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{L^^J^Bj
GJiSjy^k
G.L."Sim rrtofi^
G. L. SIMMONS MEDICAL LIBRARY
/ -7
GENERAIi SURGICAI.
%
PATHOLOGY ANdAeRAPEUTICS,
^ TEXT-BOOK FOR STUDENTS AND PHYSICIANS.
BT
Db. THEODOR BILLROTH,
isorxuoB or bcbsut or rmrirA,
nuxsLATD noM raw kuktb objuk kditioit, wira tBM encut rtuaanoF or m
AUTBOE, BT
CHARLES R HACKLEY, A.M.,M.D.,
■raexoN TO TBM nw tobk an Aim bak ihtiuubt, rEmcux to
THI nW T08X HORPITAl., rXLLOV Or THI KKW TOBK
acaukkt of xsjKODn, kc.. no.
NEW YORK:
D. APPLETON AND COMPANY,
90, BS & 04 GRAND STREET.
1871.
Emtubd, •ceordlng ki Act of CongraH, In Ibe yt*i isn, bj
CHABLB8 E. HACKLET,
In tlwOfiu of tha LibiuUn of Congma, M WublDgtaa.
\B7I
,0,.
^I^ mm°-^%
TRANSLATOR'S PREFACE.
DtTRDTa the past ten years the microscope has greatly ad-
vanced onr knowledge of Pathology ; and it will perhaps he
acknowledged that most progress in the study of Pathological
Anatomy has been made in Germany.
Prof. Theodor Billroth, hinwelf one of the most noted aa-
thorities on Snrgical Pathology, lias in the present volume given
us a complete resume of the existing state of knowledge in this
branch of medical science.
The book might perhaps have been entitled " Principles of
Surgery," but this would hardly have indicated the specific man-
ner in which these principles have been inculcated.
Most of the views found in these lectures have been floating
through the journala for several years past ; but, so far as the
translator knows, they are not eo fully presented in any book in
the English language. The only work in our language on the
subject was published many years ago ; even the late editions
are but little changed from the first ; moreover', the two works
are, in most respects, entirely unlike.
The fact of this publication going through four editions in
Germany, and having been translated into French, Italian, Ru&-
Bian, and Hungarian, should be some guarantee for its standing.
Some few notes that have been inserted by the translator
will be found enclosed in brackets [ ].
4Y WmT ThIBTT-FIE8T StBBET, JfEW TOKK,
Dee^mher 1, 1870.
,'^7990
PREFACE TO THE FOURTH EDITIOS.
AucoBT every time that it bae become my pleasant task to
go over tliis booi in preparing a new edition, I have tboogbt,
this time at least, tbere will not be much to alter ; uevertheleee,
I always found much, very much to improve, to cut out or to
add. In bo doing, I have always had the satisfaction of knowing
that even in short periods the progress of science had been quite
perceptible. We do not notice this much while swimming with
the stream, but it becomes very evident when we have before us
a book that is to a certain extent a photogram of the state of
affairs two years since. The success that this edition meets
with will show whether I have again succeeded in presenting
my book in a shape to meet the requirements of physicians and
students.
The section on traumatic inflammation has been revised in
accordance with recent advances. In the chapter on tumors,
the part treating of carcinoma has been simplified, the term
"connective-tissue cancer" being omitted, to prevent confusion.
The liberality of the publisher has enabled me to increase
the number of woodcuts by twenty-nine (Figs. 47, 53, 55, 58, 66,
68, 69, 70, 74, 91, 98, 99, 103, 106, 107, 108, 109, 110, Ul, 113,
123, 123, 124, 125, 126, 127, 128, 132, 133).
De. TH. BILLROTH.
VasvA, Nbwmber, 186fi.
OOIS^TEKTS.
LECTUBE L
IXTBODCOTIOH.
IMitiOD of Snigeiy to Internal Modicine. — Neoeuity of the PnotiBiiig PhysioUui
being acquainted with both.^-Hiatoiioal fiemarlu. — Nature of the Stadj of Siu-
geiy in the OermaD High-aohool, page 1
CHAPTER I.
snteLM mci8ED woxisds of the soft fasts.
LECTURE U.
If ode of Origin and Appearance of thedoWounda. — VarioiiB Fonns of IncUed Wounda.
— Appearance during and immedistelv after their Oocurrenc«. — Pain, Bleeding. —
Varieties of Hnmorrliage ; Arterial, Venoua. — Entrance of Air through Wounded
Veins. — ParonchymatouB Hiemorrhage. — nsniorrliagio Diathesie. — Uteiiiorrbagt
from the Pharynx and Beetum. — Constitutional Effects of 'Severe UsmoT-
«■bago, p. IT
LECTÜBE m.
Treatment of Htemorrhage. — 1. Ligature and Mediate Ligature of Arteries. — S. Com-
preesion by the Finger ; Choice of the Point for Compression of the Larger Art«-
riea.— Tourniquet. — Acupreasure. — Bandaging.— Tampon. — 8. StfpUce. — General
Treatment of Bodden Aiuemia. — Transfusion, . .... p. SO
LECTUBE IV.
Qaping of the Wound. — Union by Plaster. — Suture ; Interrupted Suture ; Twisted Su-
ture.— External Changes perceptible in the United Wooiul. — Healing by Pint In-
tention, p. 40
LECTDBE V.
The more Wnute Changes in Healing by the First Intention. — Dilatation of Vessels in
the Viduity of the Wound. — Fluxion. — Different Views regarding the Causes of
Flnzioii, p. 4S
LECTÜBE VI.
Changei in the Tissue during Healing by the Flret Intention.— Plasüc Inflltraüon.—
Inflammatory New Formation.— Betrogresaion to the Cioatrix.- Anatomical Evi-
Tin OONTKNTa
denoes of Inflaamution. — CoDditions ncdei which HeftUng bj Fiiat Intention dow
not oociur. — Union of Puts that have been eompletelj eepftrated, , , page 66
LECTURE Vn.
Cbangea peroeptible to the Naked Eye in Wonnda witli Lou of Sabetonoe.— Finer Pro-
oeases in Healing with Granulation and Suppuration. — Pus. — Cioatriiation. — Dam-
onstraÜDn of Frepaiations illnstrative of the Healing of Wounda, . . p. U
LEOTUEE Vni.
Oenersl BeacUon after I^jufj. — Sorgioal Pever. — Theories of the Fever. — Prognosis. —
Treatment of Simple Wounds and of Wounded Persons. — Open TresUnent of
Wounds, p. 81
LECTDEE IX.
Combination of Healing by First and Second Intention. — Union of Qraunlation Sur&cos.
Healingnnder aScsb. — Qranulatiou Diseases. — The Cioatrix in Various Tissues; in
UuBole; in Nerve; its Enobbf Proliferation; in Vessels. — Organization of the
Thrombus.— Arterial Collateral Cironlation, p. 91
CHAPTER II.
80XB PECÜLIABITIES OF PÜNOTÜBED WOUNDS.
LECTURE X.
Afl a Rule, Punctured Wounds heal quickly by First Intention. — Ifeedle Punotures ;
Needles remaining in the Body, tbeir Extraction. — Punctured Wounds of the Nerves.
— Punctured Wounds of tlie Arteries : Aneurysma Traumatioum, Tarioosum, Variz
Aneurysmaüeua. — Fnnotured Wounds of the Telus, Venesection, . . p. US
CHAPTER III.
aosTxmiosB of tsb boft pabts without wouitdb.
LECTURE XL
Canses of Contnsioiis. — Nervous Concossion. — Subcutaneous Rupture of Vessels. — Rup-
ture of Arteries. — Soggillationa. — Ecchymoaes. — Eeabsorption, — Termination in
Fibroiu Tumors, in Cysts, in Suppuration, and Putrefkotion.— Treatment, p. lU
CHAPTER IT.
aoNTUssD Aim LAoasATBD wounds of thb soft parts.
LECTURE Xn.
Mode of Üccurrenoe of theae Wounda ; their Appearanoe. — Slight Etemorrhage in Con-
tused Wounds, — Early Secondary HBraorrhages, — Gangrene of the Edges of the
Wound. — lufinenoes that effect the Blower or more Rapid Detaehment of the Dead
Tissue. — IndicstiotiB for Primary Amputation. — Local Complications in Contused
Wounds; Deoomposltlon, Putrefaction, Septio Inflammations. — Contusion of Ar-
teries; Late Secondary Hnmorrhages, p. ISB
OONTKKTS. ix
LECTÜEZ TTTT.
ProgreMive Snppnistion ■toiting from Coctnsed 'Wouitds. — Beoonduy Inflammatione
of the Wonod: tbeir Csuaes; Loc&I Infeotion. — Febril« BeaoCion in Contused
Wounds: Baoondarj Fever ; Suppuntive Fever; Chili; their Obiubi.— Treatment
of ContuBsd WoimdH: IniEnertion, loe-blodders, Irrigatioc; Criüoism of these
Methods . — Incisions . — Co on ter-openiiiga. — Dndoage. —Cataplasms. — Open Treat-
ment of Wounds, — Prophylaxis against Seoondaiy Inflammations. — Internal Treat-
ment of tbose severely Wounded. — Quinine. ^Ipium. — Lacerated Wounds ; Sub-
cutaneonsBuptnreof Muaolaa and Tendons; Tearing out of Uusdes and Tendons ;_
Tearing out trf' Pieces of a Limb, page l-tö
CHAPTER V.
SIMPLE FBACTUSSa OF SOmCS.
LECTDSE SIV.
Caoses, Different Varieties of Fiaoturee. — Symptoms, Diagnoüs. — Course and External
Symptoms.— Anatomy of Heating, Formation of Callus. — Souroe of the Inflamma-
tory Osseous New Formation. — Ulatology, p. 1S7
LECTDHE XV,
Treatment of Simple Fractures.— Bedoction. — Time for applying the Di^ssLng, its
Ctioiae. — Plaster of Paris and Starch Uressio)^, Splints, Permanent Extension.—
Betaining the Limb in Position. — Indications for removing the Dressinge, p. 193
CHAPTER yi.
OPBK FRACTXmEa Ä2fD anPFUBATION OF BONE.
Difference between Snbcutaneoua and Open Fractures in regard to Prognosis. —Vari-
eties of Cases. — Indications for Primary Ampatation. — Seoondsry Amputation. —
Course of the Cure. — Suppuration of Bone. — Necrosis of the Ends of Frag-
ments, p. 191
LECTÜEE XVI.
Development of Osseous Oranulations. — Histology. — Detachment of the Sequeatrom. —
Histology. — Osseous New Formation around the Detached Sequestrum. — Callus in
Sappnrating Fractures. — Suppurative Periostitis and Osteomyelitis. — General Con-
dition,— Fever. —Treatment ; Fenestrated, Closed, Sptit Dressings. — Antiphlogistic
Bemedles. — Immersion. — Bules about Bone-epUntera. — Aiter-Treatment, . p. 197
LECTDEE XVn.
1. Betarded Formation of Callus and Development of Pseudarthrosis. — Causes often
unknown. — Local Caoses. — Constitutional Causes. — Anatomical Conditions. —
Treatment: internal, operative; Criticism of Methods. S. Obliquely-united
Fractnres ; Bebrealdng, Bloody Operations. — Abnormal Development of Cal-
lus, p. 207
Z OOHTENT&
CHAPTER TTI.
ijrjvaiss or thb johttb,
C<n)t(iaioa.—I>Ulortl(ni.— Opening of tha Joint, «nd Acuta Tnmiutio ATtiealar
Inflainaiaäoii.— Varied of Covtm, »nd Beralto.— Treatment.— Anatomical
ChangM, page S14
LECTDSE X7IIL
Simple Dialocation»; Trramatie, Congenital, Pathologioal LnzationB, Sublnxatioiu. —
Ktiologj. — DitBcoltie* in BeduotiOD, Treatment; BednctioD, AfteivTreatment. —
Habitual Lnxation*. — Old Lnxationa, Treatment. — Complicated Loiationa. — Con-
genital LnxaÜona, p. 22S
CHAPTER Till.
ffVSBB 0 T-W 0 USHB.
LECTÜBE ZIZ.
HIatorietl Bemarka.— iQlnriea from Large MEaailee.— Tarion« Foimi of Bullet-Wonnda.
— TraiuportatioD and Care of the Woonded in the Field. — Treatment. — Compli-
cated Ounahot-FractdTea, p. 2S8
CHAPTEB IX.
BUB1T8 AND FUOST-BITSB.
LECTURE XX.
]. Bum«: Grade, Extent, Treatment — Sunstroke. — Stroke of Lightning. — %. Froat^
bltci : Orade.— General FreoziDg, Treatment,— Chilbl^na, . . . . p. 344
CHAPTER X.
ACUTE HON-TEAUMATIC ISFLAMMATIOS OF TOS BOFT PASTS.
LECTDBE XXI.
General Etiology of Aonte InfUmmatioDB.- Acute Inflammation: I. Of the Cutis,
a, Erjaipelatoua Infiammation ; h. Furuncle ; «, Carbunole (antbras), Pustula Mo'
Jigna. 2. Of the HuoouH Membrane*. S. Of tbeCellularTiiBue, AcateAbaceaBeii.
i. or the MuBcIes. S. Of the Seroua Membranei, Sheathe of the Tendona, and
Suboataneona Hnooua Bun», p. 266
CHAPTER XI.
ACJTFE HTFLAMMATIONS OF TBE BONES, PSBIOSTEUX, AND JOISTB.
LECTÜBE XXn.
Anatomj. — Acute Periostitia and Oateorayalitiii of the Long Bones ; Symptoms, Ter-
mination» in Besolutlon, Suppuration, Neoroaia, ProfrnoBis, Treatment.— Acute
Ostitia In Spongy Bonm. — Acute Infiammationa of the Joints. — Hydrops Acutus ;
Bymptolna, Treatment. — Acute Suppurative Inflammations of Jointa: Symptoms,
Coune, Treatment, Anatomy. — Acute Articular Rheumatism. — Arthritis. — Metaa-
tstio Inflammations of Joints (QonorrhosaliPyemio, Puerperal), . , p. 2TT
CONTENTS. zi
CHAPTBB III.
OASOSSSB.
LECTÜBE XXm.
Dtj, HoUt Gangrene. — ImmedUte Ckusea. — Proceis of Detachment. — TarietieB of Qtn-
gtvat MMordiati to the Bemote Cuubbb.— 1. Loss of Vitality of tbe TUsue fh>m
Meohanioal or Chemical Cuues. — S. Complete Arrest of the Afflux and Efflui of
Blood. — Inoaroention. — Continned PrcBRUre. — Decubitus. — Great Tension of the
Tiune. — S. Complete Arreet of the Supply of Aneiial Blood. — Qangrena Spon-
tanea.— Qangtena Senilia. — Erotism. — i. Noma. — Gangrene in Various Blood-
Diaeaaea. — Treatment, page SSO
CHAPTER XIII.
AOCmSSTMl. TBAÜMATia Am> INFLAMMA TOBT DISEAaSB, AXD POISONED
WOUNDB.
LBCTDBE XXIV.
I. Local Diaeaaea which may accompany Wounds and Other Pointe of Inflammation:
1. Progreaaive Purulent and Purulent Putiid Diffuse Inflammation of Cellular
Tiaane. — 3. Hoapital Gangrene. — 8. Traumatic Erysipolas.^— t. Lymphang^tia, p. 807
LECTÜBE XXV.
6, Phlebitis; Thrombosis; Embolism. — Causes of Venous ThrombosiB ; Various Meta-
morphoses of the Thrombus. — Embolism. — Bed lufiarotion, Embolia Metastatic
Abscessee.— Treatment, p. SIS
LECTURE XXVI.
II. — General Accidental Diseases which ma; accompany Wounds and Local Inflamma-
tions. 1. TraumaEio and Inflammatory Fever; S. Beptio Fever and Septicemia;
8. Suppurative Fever and Pysmia, p. S2S
LECTITBE XXVn.
4. Tetanua; 6. Delirium Potatorum Traumatioum; 6. Delirium Nervosum and Hauia. —
Appendix to Chapter XIII. — FoisoDed Wounds ; Inseot-bites, Snake-bites ; Infeo-
tion from disseoting Wounds. — Glanders.— Carbuncle. — Hydrophobia, . p. 851
CHAPTER XIV.
aasomo iitflammation, bbpscially of tsb boft pabtb.
LECTÜBE XXVm.
Anatomy: 1. Tluoltcning, Hypertrophy; 2. Hypersooretion; 8. Suppuration, Cold
Abaeessea, Congestive Abscesses, Fistuls», üloeratiou. — Besults of Chronio Inflam-
mation,— Qenenl Symptomatology. — Course, p. sss
LECTÜBE XXIX.
Genera] Etiology of Chronio Inflammetion.^Extemsl Continued Irritation. — Causes in
the Body. — Empirioat Idea of Diathesis and Dyscrosia. — General Symptomatology
and Treatment of Horbid Diatheses and DyscrasiK. 1, The Lymphatic Diathesis
(Beroftila); 3. Tuberculous Dyncrasia (Tuberculosis); 8. Tbe Artbritio Diathesis ;
4. The Soorbutio Dyacraua ; 6. Syphilitic Dyscra^ p. ST)
lü CONTENTS.
LECTÜEE XXX.
Local Treatment of Uhronio Inflammation : Beit, Compreuion, BMOTbenti, AntipUo-
^ticB, Derivadvea, Fontanels, Betona, Moxn, the Hot Iron, . . . page 887
CHAPTER XV.
ÜZCZS3.
LECTUSE XXXI.
Anatomy. — Eztenul Fecnliuitiea of Ulcera ; Form and Extent, Base and Secretion,
Edges, PirtB around. — Local Treatment according to the Local ConcUtion of the
ulcer ; Fungous, Callooa, Putrid, Phagedenic, Sinuous Ulcers, Etiology, Contin-
ued Initation, Venous Coogestion, DTSorasIal Causes, . . . . p. S93
CHAPTER XYI.
CSBOmC mFLAiiMATIQN OF THE PEBIoaTBÜSI. OF THB BOSS, ASD
IfBCROHia.
LECTÜEE XSXn.
Chronic Periostitis and Caries Superficialis.— SyroptomB.—Osteopbytes.—OsteopUstio,
Suppurative Forms. — Anatomy of Carivs. — Etiology. — Diagnosis. — Combination
of Various Fonns, p. 408
LECTURE XXXin.
Primary Central, Chronic Ostitis, or Cortes. — Symptoms. — Ostitis Interna Osteoplai-
tica, Suppurativa, Fungosa.— Abscess of Bone. — Combinations. — Ostitis with Cos-
eo lis Metamorphosis. — TuberoloaofBone. — Diagnosis of Caries. — Dislocation of the
Bones after their Partial Destrucüon. — Congestion Abscesses. — Etiology, p. 410
LECTDHE XXXIV.
Process of Cure in Caries and Congestion Abscesses. — Prognosis. — General Health in
Chronic Inflammations of the Bone. — Secondary Lymphatic Enlargements. —
Treatment of Caries and Congestion Abscesses. — Beacotious in the Conti-
nuity, p. 424
LECTOBE XXXV.
Necrosis.— Etiology,— Anotomical Conditions in Total and Partial Necrosis. ^Symp-
toms and Diagnosis. — Treatment. — Seqaestrotomy, p. 436
LECTURE XXXVI.
Baohiti s. — Anatomy. — Symptoms. — Etiology. — Treatment. — Osteomalaoi a. — Hypertro-
phy and Atrophy of Bone, p, 460
CHAPTER XVII.
CSBOma INFLAMMATIOS OF THE JOINTa,
LECTURE XXXVII.
General Bem arks on the Distinguishing Characteristics of the Chief Forms. — A. Fun-
gous and Suppurative Articular Inflammations (Tumor Albus), Symptoms, Anato-
my, Caries Sicca, Suppuration, Atonic Forms. — EUology.— Course and Prog-
nosis, , . , p. 456
CONTENTS. xüi
LECTÜBE XXXVBL
Treatmentof Tumor Albus,— Op«ratioiu.—B«aeation of the Joint».— GritidHiiB on tha
Opentiou OD th« Difforent Joints, page mT
LECTintE XZXIX.
A— Cbronio Benras Bjnovitis. — Hydrops AKlonlomm Chronioos; Anatom]', Syinp-
toma, Treatment. — Appendix; Chronic Diopaies of the Sheaths of the Tendons,
.Bynovial Hernia« of the Joints and Subcutaneous Huoous Buib«, . p. 176
LECTÜBE XL.
C. Chronic Khemnatie Inflammation of the Joint«.— Arthritia Defonnans. — Ualnm
Coin Senile. — Anatomj, Different Forma, B^mptoma, Diagnosia, Pro^osi«,
Treatment. — Appendix: Foreign Bodies in the Joints: 1. Fihrinous Bodies;
S. Cartilaginona and Bony Bodies ; Symptomatology, Opentions, . p. 4SS
LECTURE SLL
AnohylosM, VarietieB, Anatomy, Diagnosi«, Treatment ; Gradual Forced Extension;
OpetBtioua with the Enife, p. 49T
CHAPTEB XTIII.
DSFOBUrriBS CAUSED BT DISEASES OF THE SEBTES, XÜS0LB8. TSmiOlTa,
rABCLM, AND LIQAMENTa. ASD CICATRICIAL COSTBACTIQNB.
LECTÜBE SLn.
A. Pefonnities due to HoBOular and Nerroue Afiections : I. MurohIbt Contraotions
earned b^ Disease of the Muscolar Subatance ; II. Muscular Contractions from Dis-
eases of the Nerves ; IH. Mnstnilar Contractions from Faulty Fositiona. — B. De-
formities due to Diseases of the Ligamenta, Fascie, and Tendons : I. Atrophy of
Ligaments, Fasdje, and Tendons ; U. Belaxation of Ligaments. — C. Deformities
due to Cicatriocs. — Treatment ; Stretching by Macliinary. — Extension during An-
Rstheaia. —Compression. — Tenotomy and Uyotomy. — Division of Faaci» and Ar-
ticular Ligamenta. — Qymnasties.-— Elaatidty, — Artifldal HnsclBs. — Bupporting Ap-
paratus p. 609
CHAPTER XIX.
YABIOBS AND ANEUBI8MB.
LECTUEE XLin.
VdtUmi Taiions Forms, Causes, Various Localities where they oocur. — Diagnosis. —
Vein-atone«. — Treatment. — AnturUmt: Infianunation of Arteries. — Anenryama Cir-
■oideum. — Atheroma. — Various Forms of Aneuria m.— Their Subsequent Changes.
—Symptoms, Beaolts, Etiology, Diagnosis.— 7>wiAnMt ; Compression, Ligation,
Injecäon of Liquor Ferri, Extirpation p. C£4
CHAPTER XX,
Tmioaa.
LECTUBE XLIV.
DeflniÜon of the Term Tumor. — General Anatomlca] Bemarka; Polj^morphism of
Tiaeinea. — Points of Origin of Tnmora. — limitation of the Development of Cells to
Cert^ Type« of Tissue.- Belation to the GeneraÜve Layers.- Mode of Qrowth.—
Anatomieal Metamorphosis of Tumors ; their Sxtemal Appearanoe«, . . p. M9
xiv CONTKNTa
LECTÜBE XLV.
' EtioIogT of Tomora ; Uuamatio InflnenM. — Speotfle InfeatioQ. — Specdfio Besotion of
the Irritated TisBue« ; its Csiue ii rIitsjs ooDBtitntioiuL — Internal Iiritslioiu ;
Hypothese« m to the Cbaraoter and Mode of the Irritant Action. — Conrw uiii
Prognosis : Solitary, Multiple, Infeotioos Tumors. — Dysoraaia. — Tr«atmeiit. — Prin-
dples of the Claaaifloation of Tumors, page SSI
LECTUEE XLVI.
1. TShromata: a, Soft; i, Hard Fibroma. — Uodo of Ooaturenoe ; Operations; Ugatnre;
Sorasement; Oalrano-xtauatio. — 2. Lipomata; Anatomy; Ooourrenoe; Course. S.
Oho*dromaia .• Oocurrenoe; Operation. — i. OMtomala; Forou; Operation, p. 644
LECTOBE XLVn.
E. Myoma.— 4. Neoroma.— T. Angioma : a, Plexiform ; b, Cavemoos,— Op«rations, p. 58S
LECTUBE XLVm.
6. Sarcomata. — Anatomy : a, Granulation Sarcoma ; £, Bpindle-celled Barooma ; e, Giant-
celled Sarcoma ; rf. Stellate Sarcoma ; e, AlveolarSarcoma; /,Pigment6d Sarcoma.
— Clinical Appearance. — Diagnosis. — Course. — PrcgnOBis. — Mode of Infection. —
Topography. — Central Oateoaarooma. — Periosteal Sarcoma. — Sarcoma of the Mam-
ma, of the Salivary Gianda. — 9. Lyntphomala. — Anatomy. — Belations to Leuossmia.
— Treatment, p. 691
LECTUBE XLIX.
10. R^lomala. — 11. Adtttomata. — 13. OffOi and Cgilomata. — Follicular Oyats of the
SUn and Mucous Membranes. — NeopUsCio Cysts.-^ysta of the Thyroid Gland. —
Ovarian Cysts.— Blood-Cyst«, p. 611
LECTDBE L.
IB. Oarvittomala. — nistorioal Bemarks. — General Deacription of the Anatomical Struct-
ure.— MetamorphoaeB. — Forms. — Topography. — ]. Skin and Mucous Membranes
with Pavement Epithelium. — 2. Milk Glands. — S. Mucous Glands with Cylindrical
Epithelium. — 1. Lachrymal Glands, Salivary Gianda, and Prostate Gianda. — S.
Thyroid Glands and Ovariea. — Treatment. — Brief Bemarka about the Diag-
nosi« p. e2S
LIST OF WOODOTTTS.
10. piai
1. Diagram of ooimeotivetiBgne -with capillu-iei, . , .49
a. Biagmo of inoiMoii, oapUUriea oloaed b; blood-olot, collateral diitention, . GO
8, DUgram repreaeiitiiig tha surface of tlie iroDtid united b; inflammatoij new
formation, ....,...., D7
i. PiRf(rsin of » woond with Iom of snbBtanoe, . - . . . . 68
6. Pne-cells fh>m fresh piu, .... .... 69
6. Diagram of granulation of a woond, ..,.,, 79
T. Corneal imnaion three da^s old, . , , . , . .75
8. IndMd wound twenty-fonr hoora old, ..... 76
9. Cicatrix nine daya old, ...,..,. 76
10. Qranulation tisBue, ........ 77
11. Toung cicatricial tisiue, ........ 77
12. Horiiontal eectioo through the tongue of a dog, fort^-eight honre after the
injury, ..,,...,.. 78
15. Similar Bcction U in Fig. 12, ten days old, . . . . .78
14. Similar seotion as in Yig. 12, sixteen days old, .... 79
IE. Qranulation Tassels, ......... 80
16. Seven-days-old wonnd in the lip of a dog. Healing by the first intention, 80
17. Cicatrix from the upper lip of a dog, ...... 98
18. Ends of divided muscular fibres from the biceps muscle of a rabbit, eight days
after the injury, ......... 99
19. Begenerstion of nerves, ........ 100
SO. Begeneration of nerves, ........ 100
31. Nodular nerve-tcrrninations in an old amputation-stump of the arm, , lOS
23. Artery ligated in the continuity. Thrombus, ..... 108
88. Transverse section of a fresh thrombus, ..... 104
84. Transverse section of a thrombus nx days old, ..... lOS
!G. Ten-day-old thrombus, ........ lOS
28. Completely -organlied thrombus in the human aiterla tibialis postic«, . . 108
27. Iiongitudinal seotion of the ligated end of the crutal artery of a dog, . 107
98. Portion of a transverse section of a human femoral vein, with an organized
Taaenlar thrombos, ........ 108
99. Carotid art«ry of a rabbit, injected six weeks after ligation, . . 110
80. Carotid artoiy of a goat, injected thir<y-flvB months after ligation, . . 110
81. Femoral artery of ■ large dog, injected three month« after ligation, . Ill
xvi LIST OF WOODCUTS.
no. MME
82. Arter7 ^rounded on the side, with clot, four dajB After the iqjmy, • 118
8S. Aoeurysma traumaticnm of th« braohial artery, .... 119
84. Vsrii onearjsmatioiu, ........ ISO
SG. AncnrjBniB cuicoanni, ........ ISl
S6. Diagram of th« prooeu of detachmeDt of dead ooimeatiTe tisme in CMntused
vonndB, .......... 141
87. Central end of« torn braohiaJ artery, ...... 186
85. AvukioQ of middle finger, with all its tendons, ..... ISS
89. Avuleion of arm, with soapnla and daTiole, ..... 166
40. Longitudinal section of a fVaotnre of a rabbit's bone, fonr days old, . . ITS
41. Diagram of a ton^tudinal section of a flA«en-day-old ftaoture of a long bone, ITS
48. Longitudinal Motion of a flaotured bone fW)m a rabbit, after twenty-fonr
weeks, .......... 1T6
48. Fracture of the ttbia of a rabbit, with great dislooation, with estenaiTe forma-
tion of callus after twenty-seveu days, ...... ITfl
41. Old united oblique f^'acture of a human tibia, .... ITt
4G. Diagram of a longitndinal section through the oortical aubstanoe of a long
bone, .......... ITT
46. Diagram of inflammatory new formation in the Esveisian canalB, . . ITS
47. Diagram of ossiflcation of inflammatory neoplasia on the snrfaoe of the bone
and in the Haversian canals, ....... 180
43. Artiflcially-injeoted axtemal callus of slight thickness, on thesur&oe of a rab-
bit's tibia in the vidnity of aflve-day-old önoture, . . . 181
49. Artifleially'injected transverse section of the tibia of i dog, f>om tbe imme-
diate vicinity of an eight-day-old fracture, ..... 181
60. Ossifying callus from the vicinity of an eight-day-old fteoture of the tibia of
a dog, ..... .... 188
61. Diagram of detachment of a necrosed portion of bone, .... l99
63. Diagram of fVacture of a long bone with external wound, . . . 800
68. Amputation-stump of the thigb, with necrosis, ..... SCO
64. Traces of lightning, ...,.,.. 360
66. Epithelial layer of a oo^jonotiva affected with catarrh, .... SSS
66. Diagram of purulent infiltration of the ontia connective tisane, forming an
abscess in the middle, ....... 3T0
67. Purulent infiltration of tbe cellular membrane, ..... S70
68. VesBels(artiflcially injected) ofthe walls ofan abscess that had been induced
in the tongue of a dog, ....... STl
65. Diagram of central end of BthrombuB projecting into a large trunk, . S26
60. Fever curve after amputation of the arm, ..... 880
ei. Fover curve after resection of a carious wrist, . . . . .SSI
62. Fever curve in erysipelas tranmaticum, ..... 838
63. Fever curve In aepticnmia, ,..,.,., 886
64. Cutaneous ulcer of the leg, ....... SOS
45. Blood-vessels of two luxuriant granulations, ..... 3S8
66. Caries superficialis of the tibia, ...... 409
6T. Section of apiece of oarione bone, ....... 411
LIST OF WOODCUTS.
xvu
no.
68.
«9.
:(f.
TI.
78.
74.
75.
70.
77.
78.
79.
SO.
81.
6!.
S3.
U.
85.
Bfl.
8T.
88.
89.
M.
M.
9S.
»3.
H.
9S.
M.
»7.
98.
99.
100.
101.
102.
101.
104.
105.
10«.
107.
108.
109.
110.
111.
na.
Sclerosed tibia and femnr, .....
Point of oa0«oiu degenention in the Bpinal column of a man, .
Deatruction of the vertebral coloma by multiple periostitis, etc..
Diagram of total aeoroHis of the diaphjais of a hollow boae, .
Diagram of total necrosis of the diaphjsis of a boUow bone, with new
receptacle, ...
Fig. 72 after removal of the sequestrum, ....
Total necrosia of the diaphysiit of the femur, etc., .
Tibia of a young man after total necrosis of the disphysia,
Necrosis of the lover half of the diaphysis of the femur, etc.,
The body extracted from Fig. 78, .
Small diagram of partial necrosis of a hollow bone, .
Diagram of Fig. 78 in the later Btoges, ....
Fig. T9 aller removal of the sequestrum.
Diagram of s section of a knee-joint with fungous inflammation.
Degeneration of the cartilage in fungous inflammation of the joint,
Subchondral caries of tlie astragalus, ....
Atonic ulceration of the coniloge, tVom tbe knee-joint of a child,
Diagram of the ordinary ganglion, ....
Hernial protrusionB of tbo synovial membrane of the knee-joint,
Degeneration of the cartilage in arthritis deformans.
Osteophytes in arthritis deformaus, ....
Carious elbow-joint, ......
Os metacarpi, .......
Multiple articular bodies, ......
Band-like adbesioDs in a resected etbow-joint.
Complete cicatririal adhesion of the urticular Burfaoes of the elbow,
Elbow-jcwnt (mchylosed by bony bridges,
Tbe oapRole folded above, ......
The capsule folded below, .....
Diagram of a subcutaneoualy-divided tendoa, on the fourth day,
Tarioee in the part supplied by the great saphena van,
Cinoid aneurism of the scalp, .....
Small flbroma of the gtems, .....
From a myo-flbroma of the uterus, ....
Vessels of s onus flbroma from the thigh,
Neuroma, ........
Bmal) nodular flbro-saroomatons neuromata.
Extraordinary forms of cartilage tissue from chondiomata,
Chondroma of the fingers, .....
Odontoma of a back tooth, .....
Section of an odontoma, .....
Pednnculaled spongy exostosis, .....
Ivot7 exoetoüB of tbe ukull, . . , . ,
Section from an ivory osteoma of the skull.
Osteoma of the muscular attachments.
bony
PAQB
417
. 420
422
. 438
440
440
441
441
442
443
443
444
444
459
461
403
465
4»!
4S3
487
4S9
439
489
496
498
499
499
500
500
513
535
530
5ft6
see
597
563
56S
674
676
67B
678
679
680
ESO
681
xviU
LIST OF WOODCUTS,
no.
lia. Conglomeration of veMels from a plexiform aagiom»,
114. Mesh-work trom * oavemouB angioma of the lip,
lie, TiHBue of a granulatioa-Barooma, .
lie. Tissue of a glio-earooma, ....
117. Tissue of a epindle-oelled sarcoma,
118. Giants-cells from a sarcoma of the lower jaw,
118. Qtant-celled sarcoma with ojate and ossifying fod from the
120. Cell-globules from a sarcoma of the dura mater,
151. VireJtovi'i muoous tissue from b mjzo-sarcoma,
132. Alveolar earcoma from the deltoid muscle, .
123. Alveolar Ban»ma from the tibia, .
lU. üentral osteo-sarooDia of the nlna,
1£G. Section of Fig. 124,
126. Compound cjstoma of the thigb,
127. Periosteal sarooma of the tibia,
128. Section of Fig. 127, ....
129. From an adeno-sucoma of the female breaet,
ISO. From the cortical layer of a hyperplastic cervical lymphatic
181. Wart, .....
162. From a mucous polypus of the rectum,
ISS. Adenoma of the thyroid, .
lU. Commencing epithelial cancer of the lip,
13B. Flat epithelial cancer of cheeks, .
ISB. Elements of an epithelial cancer of the lip, .
187. From an epithelial cancer of the hand, .
188. Vessels from a carcinoma of the penis,
IBB. Papillary formation of a villous cancer of the bladder,
140. Uammary eancer, aoinous form,
141. Sott mammary cancer ; alveolar tissue of the carcinoma,
142. Frora a mammary cancer, ....
145. CoDDective-tisBue fiwne-work of a cancer of the breast,
144. Cancer of the breast ; tubular form, .
146. Cancer of the mamma, ftvm a cicatricially-atrophied part,
144. Vasoalar net-work ttaox a very young cancerous nodule,
147. Vascular net-work around points of softening in a cancer,
1*8. Extension of a cancerous tumor into the fatty tissue about a
149. Connoctivu- tissue inflltration advancing into the cutis from
cancerous nodule of the mamma, ....
160. Cellular infiltration of the fatty tissue in the periphery of
the breast, ......
161. Cancer of the mucous glands froui the interior of the nose,
152. Adenoid cancer of the rectum, . , , .
PA«a
,
, 68S
,
686
, ,
, CSi
,
GSa
.
. ess
.
ÖM
lower Jaw,
. 694
.
696
, 69S
,
696
. .
. 696
,
601
.
. 601
.
eos
.
, 60S
.
608
. SOG
gland.
600
.
. 618
.
«IE
.
. 617
.
esD
'. 681
,
6sa
.
. 633
.
683
.
. S38
.
uo
.
. ta
•
612
•
. 649
.
6i>
,
, 6M
.
646
■
. 64S
lymphatic
gland, 648
the borders of a
.
660
a hard cancer of
■
. B61
.
ÖGS
, ,
, 6G4
SURGICAL PATHOLOGY AKD TUEttAPEÜTICS.
LECTURE I.
ISTRODÜCnOÄ.
B«UlltKi at Surccr^ i« Iiilcfiul M«41dop.— NoooHiljr of tk« FnNtUa( FbfdtlftB
bda« MTttHlDied vllb botli.— HiitoriMl Bcmarks.— Natur« ot Ih« BM7 et Bar-
f«7 la tliu Own»» Bi|[b-«tli(MU.
Gextlbubk : The study of surgery, wMcIi you bcjf Ui with Ulis
lecture, is now, in tnoet countries, justly regarded as a iteoeftbity for
the prnotising phydicJiin. Wo consider it a liHp]iy ndvmnce that the
division of ^tirgcry from medicine do longer exists, «s it dir) fomierly.
The diStrruact.' l>ctwe<.'a iidemiil raedioine »ad »argay is in fact only
apiwruiil ; lhi> distinction ta nttifioiiJ, founded llioitgii It be on history,
»ad on the \M.rgc aod incretiotng Utcnilim? of geueml ra(,■dil^!nl.^ In
tlw ooune of bUia woric your attCQtioii will oftc-n bo cidlvd to tho
frequenoy with which «urgci^' must consider the genctal state of the
body, to thr «nalof^y bt;twevti the ilisniaes of ihe e.tttirnal and inter-
tnl pnriA, and to tbc lact that the whole difference dopoods on our
aeeii^ befon U9 the changes of tissue that uocur in surgieai disesses,
while we havfi to determine the affeotionB of internal mganii from the
syiiipt'jtits. The action of the looul disturbances 00 the hody at Urge
ranxt b« understood by tbe eurgeon, as well as by any one who pays
especial attention to diaeaües of the internal organs. Tn »/tori, lAe
nargtan can (miy Judge «i/Wy and comcUy ofthettatt of hi« paticiU
«Jk^nAe iä at the aanui timeajthytisian. Moreover, the phii-sician who
popotea refusing to treat surgioa] palient», iiud to attend solely to the
trcAtioent of inlenuil diseaAcs, mu»t hove Bomo surgical knowledge, or
he will tnnki' the groju«*«! bhindcrs. Apart from the fact that tlie
ootmir}- pliysic.iiiD dm-s not alwuya lisve a colleague at hand to whom
he can turn orer his surgical putinnt«, the life «f the patient often de-
pends on the correct and itutaotaneotis röcognition of a surgical dtwa&e.
2 mTHODüCriON
When blood spouta forcibly from a wound, or a foreign bodj has
entered the windpipe, and the patient is threatened with suffocation,
then surgical aid is required, and quickly too, or the patient dies. In
other cases, also, the physician ignorant of surgery may do much harm
by not recognizing the importance of a case ; he may allow a disease
to become incurable, and by bis de6cient knowledge cause unspeakable
injury, in a case which might have been relieved by early surgical
treatment. Hence it is inexcusable for a physician obstinately to
stick to the idea of only practising internal medicine ; still more inex*
cusable is it, in this idea, to neglect the study of surgery : " I will not
operate, because iu ordinary practioe there is so little operating to be
done, and I am not at all suited for an operator ! " As if surgery con-
sisted only in operations. I hope to give you a better idea of this
branch of medicine than is conveyed by the above remark, which un-
fortunately is too [wptdar.
From the fact that surgery has to deal chiefly with patent dis-
eases, it certainly has an easier position in regard to anatomical diag-
nosis ; but do not regard this advantage too highly. Besides the fact
that surgical diseases also often lie deeply hidden, more is demanded
from a surgical diagnosis and prognosis, and even in the treatment, than
from the therapeutic action of internal medicine. I do not deny that
in many respects internal medicine may hold a higher rank, just on
account of the difficulties it has (and often so brilliantly overcomes)
in localizing and recognizing disease. Very fine operation of the mind
is often necessary to come to a proper conclusion, from the combination
of symptoms, and the results of the examination. Physicians may
point with pride to theanatomical diagnosis of diseases of the heart and
lungs, where the careful student succeeds in giving as accurate a de-
scription of the changes in the diseased organ as if he had it right
under his eyes. How wonderful it is to gain an accurate knowledge
of the morbid state of hidden organs, such as the kidneys, liver,
spleen, intestines, brain, and spinal marrow, by the examination of a
patient and the combination of Symptoms I What a triumph to diag-
nose diseases of oigans of which we do not know even the physiolo-
gical function, as of the supra-renal capsules ! This is some compensa-
tion for the fiict that, in internal medicine, we must more frequently
acknowledge the impotence of our treatment than is the case in
surgery, although, from the advances in anatomical diagnosis, we have
become more certain of what we can do, and of what we cannot
The irritation of the finer, cultivated portions of the mind in inter-
nal medicine is, however, richly balanced by the greater certainty and
clearness of diagnosis and treatment in surgery, so that t)ie two
branches of medical science are exactly on a par. And it must not
mTRODÜCnON. 8
be forgotten that the anatomical diagnosis — I mean the reoognition of
the pathological changes in the diseased organ — is only one meana to
the end, which is the cure of Üie disease. 7Ä« true problenit for the
physician are to find out the causes of the morbid process, to prog-
nosticate thecourse, conduit it to afavoraUe termination, or control
it, and these are equaUy difficult in internal and external medicine.
Only oae thing more is required of the practical surgeon : this is, the
art of operating. This, like every art, has its knack ; the fecility of
operating secondarily depends on accurate knowledge of anatomy, on
practice, and oa personal aptitude. This aptitude may also be culti-
vated by persevering practice. Just remember how Demosthenes suc-
ceeded in acquiring fluency in speaking.
This knack, which is certainly uecessaiy, has long separated sur-
gery from medicine in the strict sense ; we may historically follow
this separation as it constantly became more practically felt, till in
this century it was finally recognized as impractical and was abol-
ished. The word " chirurgery " at once expresses that originally it
was regarded as entirely manual, for it comes from x^lp and ipyov,
which literally mean " haud-work," or, in the pleonasm of the middle
ages, "hand-work of chirurgery."
Little as it comes within the scope of this work to give a complete
sketch of the history of surgery, it still seems to me important and in-
teresting to give you a short sketch of the external and internal de-
velopment of our science, which will explain to you some of the va-
rious regulations affecting the so-called " medical staff" still existing in
different states. A fuller history of surgery can only be of use to you
hereafter, when you shall have acquired some knowledge of the value
or worthlessness of certain systems, methods, and operations. Then,
in the bistoribaJ development of the science, especially as regards op-
erative surgery, you will find the key for some surprising and for
some isolated experience, also for much that is incomplete. Many
things that may be necessary for the comprehension of the subjects, I
shall relate to you when speaking of the different diseases ; now, I
shall only present a few prominent points in the development of 8U>
gery and of its present position.
Among the people in former times, the art of healing was inti-
mately associated with religious education. The Hindoos, Arabs, and
Egyptians, as well as the Greeks, considered the art of healing as a
manifestation made by the gods to the priests, and then spread bj- tradi-
tion. Philologists were not agreed as to the age of the Sanscrit writ-
ings discovered not long since ; formerly their origin was placed at
1000-1400 B. c, now it is considered certain that they were written
in the first century of the Christian era. The Agur-Veda {" Book of
DSTttODOCnON.
die Art or life ") U Uic no»L important S*nscrlt wotk fbrmedinne • it
ia til« procluctioii of Stumtttu, it t-cry probubl? i>riginated !□ the lime
of the Romnn Emperor Auj^utltte. The art of lienlinjr vtm rvganM
as a whole, :l8 i» indicated by the following: " It is «iilv thff combitm-
tion of incxiirane and surgery thiit makes thi- complete pliyKieian. The
physician lavküig knon-leilge vi one of Lli««i; bntnohcs i& like a lürd
with onlj- one wing." At thnt time surgerr wiu without doubt by
far the more advanoe<l pnrt of the loedicat art. A Inigv number of op-
ccatiooB uid instrumenta urv spoken of; still, it is truly said " llicr heat
of rH instrummts is the haml ; " the trratmont of wounds giren ia
«inple and proper, >foet surgical injuries were already knon-n.
Among the Orceks all medical knoirledgc at (irsi ceotretl in J&h
culapiue, a son of ApoUo, and a scholar of the C'entaur C'biwm.
Many temples vere built to .'Esculapius, and Ibe art of healing was
handed down by tradition through the priests of Lhe«c t^rniplcs ; the
number of tho-'e temples indiioM various schools of .^^«ulapidcs, and,
altliougfa L'Vi'ry tme milvrin^ the temple as u priest bad to take on
oath, which has been handed down to uur own timed (although of late
it« genuincness appears rather doubtful), that he would ordy Iraich
the art of healing to his successors, Htill, as appeani from riu-iou» dr-
cumgtJtDCCS, even at that time there wer« other ph;t-sicisns besides the
priests. From one pnrt of the outh, crcn, it is evident that then as now
there were ph\*8ician8 who, us specinlistB, confined themselres to cer-
tain openilions ; for it says: *■ Furthermore, 1 will nerw cut for srDne,
but will IcüTr this operation to men of that occupatioii." Of the
different varietias of physicians we know notliing more accurttt« tJU
the üme of Ifippocrati'M / he was one of the last of the Aaklt>piadea
He was bom -t^O b. a, on the islaod of Cos; lived partly in Athens,
portly in Thcssalian towns, and Hie<l 377 «. c. at Larissa. We might
expect that medicine woidd be conskli<rcd seienlifieally at thU time,
when tho names of Pythagoras, Plato, and Aristotle, were shining in
Grvciao scteoco ; and in fact the works of Hipjiocrat-fs, many of wltid)
arc still preserretl, arouse our astonishment. ITie elear eJi»«ir>a] de-
BcriptJon, the arrangement of the whole material, tlie high regard for
the heahng art, the ebaip critical obscrrations, that ujijn'tu- intliö
works of HipiHii'rate«, and compel our admiration and res[v»ct for an-
cient Greece ua this limuch also, clearly sliow that it is not a ensn (4*
blind belief in traditional medioal dogmois Init that there was nireatly
a scientific arid elaborately jierfoeted nitHÜcine. In the IJippocmtic
school* the art of healing formed one whole; medirine and surgoij
were united, but there wem various daases of medical practittoDcnt ;
besides the Aaklepiades there were other ediicate<l physicians, as well
as more mechanieally instructed medical aiustanu, gymnasts, quacks,
DiTHODCCnoS.
ami workcn of miracle». Tbe pbysidant took scliülnnt to tniti in the
art of bt»liiig; luid, accunliiig to some rem&Hts of Xvnupboii, llierc
wero also ipccial army physicinn»; «pccJnlljf m tbc Persitin ware,
thcv, tugirtlier willi i\ie sooth^nycn nud fluto-ptayrrs^ liaj their plawa
Dear tltc royal tcul. It may be readily understood tJiat, at a time
wbeu M> mut^ was tbougbt of oorpoieal beauty*, on woa tlic casu
Btnang the Greeks, external injuries vrould claim üjiei'ial attention.
HiiiiK>. aiunrifr pln^ii-ians of the Qippocntic era, fractures and spruiiis
yiKTC {«irticulnrly sttxiicd ; still, some severe opi-rutioDB art: trvatcd of,
U obo numbers of iiwlrumenta and otlicr eppantliisf«. Tlivy tM-cni to
liaru liM-u very baclcwuxd regarding amputatimis; probably lite
Greeks preferred dyin^ to prolongio^ life after they xvcrc tnutilatod.
Tbe limb was only remored when it was actually dead, gangrenous.
Hie teacbingB of Hippocrates could not at fint be carried any fur-
titer, for lack uf knowledge of onatoniy and pbj-sinlog>'. !t » true
tlnere «nut a &int eBbrt made in thia direction in tbc »dentitit' flehotila
uf Alfuuidria, wbidi Soumlied for «ome ocnt^irie« under Um.* Pl'ik*-
niks, afid by (noons of wLicfa, after tJie wars of Alexander tliu (jircut,
til* Gre^iftii spirit wa« spread, ni Icflst temporarily, over port of the
Orient; but tbt> Aluxandrimi pbysteians soon lust ibotDeeUi« in phil-
osopbieal systems, aod only adroDOcd tbc scieDce of heulinff a littiu
try a few uuulomiad didooveries. In tJtis bcImm] tbc ait of healing
was at firat divided into three sejKirate parla — dietetic, internal medi-
ane, and surgery". Along with Grecian culture, their knowlmlge of
mcdicioe was also bruu^bt to Home, Tbe first Konian |>by3ieiuua wirre
Grectan dares; tbi' fr»cdnieii among tlicia were allowed to erect
batbs; bere, first, baiWre and batliers became our rivals and col-
leagues, and for a long time they injured tlie respectability of the pro«
feestnti in Rome. Gradually the pbilosopbinally-miiidM) took posses-
sion of the writings of Hipjioeratos and tbe Alexandrians, aitd tbein-
selvBS practised medicine, witliout, bowcvcr, adding to it much that was
new. The great lark of original scientific proditetion is shon-n in the
encyclopcrdial reriaio« of tlie most varied seieiitific works. The most
celebrated work of lliis nature is the " Jh AHlitv " of Aalitt Cornf-
Um C«imu (from 85-30 n. c, to 45-50 x. d., in the tin>e of tbe Em-
perors TiVrius and Claudius). Eight books of tliis, '* J)*. Medicina"
havr come down to our time; from tliese we know the state of medi-
irine and surgery at that lime. Valuable a« arc tbcse relic» from Uic
Homan ages, tbey are only, as we have said, a compendium, such as
Is often published at the present day. It has even been denied that
CVbiM was a practi^in^ physician, but this is improbable ; firom bis
wHtlngs we muscat idl events, credit C<f/!aUii with using bis own jtidg*
merit "nieaeventh and eighth books, which treat on surgery, oould not
s
ISTBODCCTIO».
have been writtco so olenrl^ by any one who had no pradicml knovrl*
edge of his subject Uunco vrn see thut, eiiicc the time of Hippo-
crcta btkI tfio AIcKandm school, surgery, Mpccially the opcmtire
part, had madu no great progress. Cdsus «peuks of pbiKliv opera-
tions ni bcmin, aod gives a roelhod of «inputQtiuQ irliich ts still ooca*
sionally employed. One part, from the Hrventh book, where he »pvahfi
of the (juali fixations of the perfect siugeoQ, is quite oelebrattt], ns it
is diamctcri^tic of the spirit which reigns in the bocik ; t give it to
you; "The KUTf^-on should be young, or at least Little advanced in
ngc, witl) n )i:tn<l nimble, linn, nnd ocvcr trembling ; eqimlly dexter-
ous with both hands; vision, sltarp and distinct; bold, uniut^rciful, so
that, as be urishes to cure his jAtient, he may not be mnvnd by hiit
orie« to hasten too rauch, or to cut Icm thnn is nccpssary. In tho
SAine way lot him do tvery thing as if he were not affected by tho
criuo of the peticut'*
ClaudiHt C<rfe«»« (13l-?01 i. n.) must bo regarded ns a phe-
nomeoon ajsong the Roiiuin physicians; eighty-three undoubtedly
gCDiunc medical writings of hia have come dovD to us. Oalert re-
turned again to tlio Uippocratic belief, that observation must form
the foundation of the art of healing, and he advanced nnalomr great-
ly ; he made dissections chiefly of asees, rarely of human being».
Galtii't anatomy, oa .well ns the CEtire philosophical systcin into
which he brought medioint', and whioli »fctned to him even more im-
portant than Observation itSL^lf, has Blood firm over a thousand years.
He Qocupies a vtay promiucnt position iu the history of inediciae. He
did little for surgvry in )>nrticular; indeed, ho pructi*od il little, for ia
his time there wer« s]ii-ciHl surgeons, either gymnasts, bather», or
bAtlwre, and ao uDfortuaatoly surgciy was banded down by Iradition
as a tne<4)aQicaI art, while iotämal medimno was, and long remained,
in the hand« of philiMophie physicians; the latter knew and ooot*
mcntcd frtx;Iy on tlie «urgical writing« of ffippocrate«, tho Atexantlt^
tf, and CeüvSy still they paid little attention to sui^iml practice.
we are only giving a Enint sketch, we might he-re skip several oen*
turie?!, or even a thousand years, during which surgrry made scarcely
any progress, indeed retrograded Of«a«ionaUy. The Byzantine era of
tlie empire was particularly uolavorabte to the adi-anoc of science,
fbrrc was only a short flirkeriag up of ttic Alexandria school. Evqd
the most celehnited phys^icians of the later Roman times, AniyUm (in
the third century), Oribagim (3'ifi-403 a. n.), Alfxander of TraUea
(52S-60S A. Di), Pauliiif ofjEgina (660), did relatively little for sur-
gery. Some advance had been nutdc in the position and scholarly at-
tainments (if physicians; under Nero tliere was a gymnasium ; under
Hudrian ao athunieum, scicnUiic inatitutioos wbere medicine also was
INTllODÜCTION. 7
taught; undes Trajan, there was a special medical school Military
medical service was attended to among the Romans, and there were
special court phyaioians, " arohiatri palatini," with the title of " per-
fectissime," " eques," or " comes archiatronim," just as, among Üie
Germans, " Hofratbe," " Geheimrathe," " Leibarzte," etc. That, as a
result of the fall of science in the Byzantine reign, the art of healing
did not totally degenerate, is due to the Arabians. The wonderful
elevation tbat this people attained under Mohammed, after the year
608, aided in preserving science. The Hippocratic knowledge of
medicine, with the later additions to it, passed to the Arabians
through the Alexandrian school, and its branches in Üie Orient, the
schools of the Nestorians ; tbey cherished it till their power was de-
molished by Charles Martel, and returned it to Europe by way of
Spain, though somewhat changed in form. Rkazes (850-933), Avi-
cenna (980-1037), ^;5mc<mm (f 1106), and Avenzoar {\ 1162), are the
most celebrated, and for surgery tbe most important, of the Arabian
physicians whose writings have been preserved ; the writings of the
latter are the most important for surgery. Operative surgery suffered
greatly from the dread the Arabians had of bloo<l, which was partly
due to the laws of the Koran ; it caused the emploj-ment of the ac-
tual cautery to an extent that we can hardly comprehend. The dis-
tinction of surgical diseases and the certainty of diagnosis had de-
cidedly increased. Scientific institutions were much cultivated by the
Arabians; the most celebrated was the school of Cordova; there were
also hospitals in many places. The study of medicine was no longer
chiefly private, but most of the students had to complete their
studies at some scientific institution. This also hod its effect on the
nations of the "West. Besides Spain, Italy was the chief place where the
sciences were cultivated. In southern Italy there was a very cele-
brated medical school at Salerno ; it was probably founded in 803
by Charles the Great, and was at its zenith in the twelfth century ;
according to the most recent ideas, this was not an ecclesiastical
school, but all the pupils were of the laity. There were also female pu-
pils, who were of a literary turn ; the best known among these was
TVottda. Original observations were not mode there, or at least to a
very slight extent, but the writings of the ancients were adhered to.
This school is also interesting from the fact that it is the first cor-
poration that we find having the right to bestow the titles " doctor "
and " magister."
Emperors and kings gradually took more interest in science, and
founded universities; thus universities were founded in Naples in
1234, in Pavia and Padua in 1350, in Paris in 1205, in Salamanca in
1343, in Prague in 1348, and they were invested with the right of
8
JSTRODÜCTION.
conferring acaiiciiiiRal Ixiiiore, PhiloAophy was Übe echnncc b> tvliU^
most iLtt<>ntion n-as pnid, and for a long tin>e Medicin« preserrod bor
p)iiK)(«(jpliJcal robe in llie univei^ilieit ; in Home ca«es Üicy adbcrrd to
Galvn's svslcm, in otlicn' to Uie Arubiiui or to neir inmlioo-pliilo-
ttnphiml systems, ond r^ffi.^t^wil «II tlicir nbsprrntjona undtr thes«
tiuuils. Ttiis Wim t)t«t grejit uhtlac-le U> ttiv progress of tlie natural
sciences, u montol slavery, from which even men of intellect could not
free tbctasclvcs. The anatomy of MonMno de IaosI (1314) differ«
veiy litÜe firom that of Galfii, in spilo of tho fact tlial th«; auUior
iNutfS it oil diascctioii» he ninde of Mune Iniiiian hodics. In surgery
there were no actual atlv-uncc» j Lan/ranchi (f 1300), Ouidoof Canli-
aeo (beginning of the foiirtv«nth oeiitiiry), Bfmtca (middle of tlie
fiftt'coth contiirj"), arc a few of tlip noteworthy surgeons of those times.
Before paaaing to the SourislÜDg state of the usturul eciences und of
medicine in thu sixteenth oeotury, we must r»Ttüw briofly tlieoomprjsi«
lion of tlw medical profession in the limes of which vre hare been
speaking, oe this ia important for the history. First, there were philo-
sophically ednnitcd physiciang either Uiy or monk, who bad Icunml
medicine in the univer$ilies or other .srliooU ; i. c, they hud studied
the old writiug» on anatomy, surgery, and spcdal medicine; thuy prao-
tisod, but paid little attention to surgery, Aiinthrr scat of learning
was in the cloisters j the IJenpfliclines espceially piiid a gn.-ut dual of
alteutio» to medioine and a-tatj practised »urgerv, althoogh the supe-
rior» disliked to sec this, aud oocusioually special dispensation bad to
be obtuioed for an operrition. The rrgular pnictisiiig physicians were
sometimes located, sometimes travelling. The former were itsuaUy
educated at sciftutifie schools and received pcrmtssioQ to practise on
certain conditions. In 1220, the emperor Frederick U. published a
law iliat theae physiciana should study logic (th^it is, philosophy and
philology) three yearn, than medicine and surgery five years, and then
practise for some time unfler an older phy^cian ; before rwieiring
permission to practise indep<>iidently, or, as an examiner lately said,
of pliysieijms who had just received their degree, " till they wcru let
loose on the public." Besides these located physicians, of trbom a
great part were ** doctor " or " ma^ster," there were many " truvelling
doctorSi^BBortof" travelling student "who went through the market-
towns in A wagon with a merry A«(lreiv, and practised solely for
money. TTiis genu of the Mxnlled cimrlatnns, which played an im«
portont part In the poetry of the natddle ages, and is still gleefully
greeted on the stage by the public, curried on » rascally trade in tltc
middluages; they were as infamous as pipers, juggler», or hangmen ;
even now these trsTcIling scholars are not all dead; although, in the
Dinetecntb centuiy, they do not ply thiür trade in the market-plaoc, but
ISTBODfCTION.
S
in the dramn^rooms as workeis of nainudetfr Mp^inlly &s Cboceiskw-
tora, licrbdocUnrK, somnambulüilB, eta Let m now iniiuire Uic rclii-
una, of iboae who practised siipgery, to tliK above conipanj. Tlii»
iHuacli of mediuae wua oix'asionallj^ resorted to br almost alt oi thr
above; Btill thure wure speciul surguons, who united into guild» and
fbnned honombk* societies ; tbcr rentirnd tlir-ir prarliral knouletlge
first from a master, under whom they sluditJ, and BuhnoipiL'iitl^- from
booln and soipntific institiitiona Surp*»! pract ioc ivna chiefly lytiifinM
to those perAorui, who wen" "mostly k>cated, but »otnetimea tnnf lied
about as " heruiu doctors^" " 0[>enttcm tor »tone" " oculist«," etc, MV
dlflU become acquaintod vtth «omc excellent mon among thesi* old mas-
ton of our Bit. Besides tho above, surgery was also practued by the
** batben," and later by " barbers *' &l»o, as it was among the Romans,
■od tkey were pennitted by law to attend to " minor sufgeiy," c. g.,
tfaey oould cup, bleed, treat &actar«(i, Kpruin«, et«. It will hf fendily
understood that somefttrifp would nrise about the rarious and aome-
tintc« indelmitc privileg<.-s of these diflvn-iit grades of physiciaUB,
«pecially in large cilio«, where all classes of thoin were collected.
Till» waa purlicularly tbe coac in Paris. The surgic&l sodcty there,
the " Collö^ de St. Come," dainicd the same privileges aa mombcfs
of tllo mMlieal faculty; tlivy werr? {>articularly desirous for Ih« Bacca-
laureate and Licentiate. The " SoriiHy of naibeni and Bathera,"
agwn, wblied to pnctie« any |K>rt of surgery, just like the members of
tbe OollÄffe dn St, C(^me. To gall the mirgmn«, the menilx^rs of the fiin-
ulty supported tlie claims of the barbers, and, in spite of mutual teinpo-
nuy ooraproiniBca, the stiifc continued ; indvcd, we may say that it slill
eontEnues, where there are pure surgeons (sur^r*^™** of tl*" first class
and barbcrej and pure physicbn«. It is only aliout ten yexr« sin«* the
distinction vm done away with in almost all the German elatea and
Deitlicr chiruigi pun iKir medici ptiri were ut&de, but only physidana
who prartised medicine, surgery, and obstetrics.
To finish the questitm of extenial mnk, we may notice that in Eng-
land alune there is still u tolerably welUmarkci dtvidiiip^Iine be-
tween nu^geons and (»li^-sivians, especially in tl»e ätie», while in the
country "general preelitioncis^ attend to Itoth medical and surgical
cases, and have an apothecai>->shop c^td ot tbe same time.
In Germany, Switzerluud, and France, ciraiimstanucs nflen eause a
physician to bare more surgical than medical praeiiec ; but the med-
ii»l etalT legally consists of phyeicians and assistants or bBrbcr>«ui^
gnoQs, who, after examination, are licensed to ctip, ble>e(l, etc. This
arrvngemmt ha« finally gone into effect in the army also, where the
so-called company surgeon, with the rank of sergeamt, formerly had «
niisernblo time under the battalion and regimental physicians^
10 INTRODUCTION.
In again taking up the thread of the historical development of
Burgeiy, as we enter the period of " Renaissance " in the sixteenth
century, we must first think of the great change which then took place
in almost all sciences and arts, on account of the Reformation, the
discovery of printing, and the awakening spirit of criticisoL Obser-
vation of Nature began to reassume its proper position and gradu&llj
but slowly to iree itself from the fetters of the schools ; investigation
after truth again assumed its claims to being the only true way to
knowledge — the Hippocratio spirit was again awakened It was
chiefly the new investigations, we might almost say the rediscovery,
of anatomy and the subsequent restless progress of this branch, that
levelled the road. Vesal (1513-1564), Falopia (1532-1662), oaAEua-
tachio (f 1579), were the founders of our present anatomy ; their names,
like those of many others, are known to you from the appellations of
certain parts of the body. The celebrated JBombaettte TTteophraUua
Paracelaus (1493-1554) was among the first to criticise the prevailing
Galenical and Arabic systems, and to claim obsen-ation as the chief
source of medical knowledge. Finally, when WiUiam Harvey
(1578-1658) discovered the circulation of the blood, end AaeUi (1581-
1626) discovered the lymphatic vessels, the old anatomy and physiol-
ogy were obUged to give place to modem science, which thence grad-
ually progressed to our times. Even then it was a long time before
practical medicine escaped in the same way from philosophic thral'
dom. System was founded on system, and the theory of medicine
constantly varied to correspond to the prevailing philosophy. We may
claim that it was not till pathological anatomy made its great ad-
vances in the present century that practical medicine acquired the
firm anatomico-physiological foundation on which the whole structure
now moves, and which forms a strong protection against all philosoph-
ical medical systems. Even this anatomical direction, however, may be
pushed too far and too exclusively. We shall speak of this hereafter
Now we will turn our attention to the scientific development of
surgery from the sixteenth century to our times.
It is an interesting feature of that time that the advance of practi-
cal surgery depended more on the surgical societies than on the
learned professors of the universities, German surgeons had to seek
their knowledge mostly in foreign universities, but part of it they
worked out for themselves independently : Heinrich von I^olsprundt,
a German friar (bom the beginning of the fifteenth century). Hieran-
ymua Bninsckwig (bom 1430), Hans von ffers(Ä«y'(8bout 1520), and
Fdix WUrtz (tl5T6), surgeons at Basel, are first among these. We
have writings of all of them ; Felix Würtz seems to me the most
original of them ; he had a sharp, critical mind. Fabry von Hilden
INTRODUCTION. H
(1560-1634), of Berne, and GoHfried iViroan, of Halberstad and
Breslau (about 1679), were men of great «cquiremcDts ; their writ-
ings show a high appreciation for their science, they fully recognized
the value and imperatdve necessity of exact anatomical knowledge,
and by their writings and private instruction imparted it to their
scBolars as much as possible.
Among the French surg^na of the sixteenth and seventeenth cin\-
turies, Ambroise Pari (1517—1590) is most prominent ; originally only
a barber, from his great services, he was made a member of the So-
ciety of St. Come; he was very active aa an army surgeon, was often
called from home on consultations, and at last resided in Paris. Pare
advanced surgery by what was for those times a very sharp criticism
of treatment, especially of the enormous use of problematical remedies ;
some of bis treatises, e. g., on the treatment of gun-shot wounds, are
perfectly classical ; he rendered himself immortal by tlie introduction of
ligature for bleeding vessels after amputation. Pirk, as the reformer
of sui^ry, may be placed by the side of V^esal, as refoiroer of anatomy.
The worfts of the above individuals, besides some others more or
less ^^fted, held tbeir place into the seventeenth century, and it is
only in the eighteenth that we find any important advances. The
strife between the members of the faculty and those of the Coll^fre
de St. Come still continued in Paris ; the great celebrity of the latter
had more effect than the professors of sui^ry. This was finally prac-
tically acknowledged in 1731 by the foundation of an *' Academy of
Sui^ry,*' which was in all respects an analogue of the medical faculty,
lliis institution soon advanced to such a point that it ruled the sui^
gery of Europe almost a century ; nor was this an isolated cause ; it
formed part of the general French influence, of that universal mental
dominion which the " grande nation " cannot even yet forget when
German science has forever eclipsed French inöuence, after the con-
fiicts of 1813-'14. The men who then stood at the head of the
movement in surreal sdence were Jean Louis Petit (1674-1768),
Pierre Jos. DeaauU (1744r-1705), IHerre Francois Percy (1754-
1825), and many others in France; in Italy, Scarpa (1748-1832) was
the most active. Even in the seventeenth century, surgery was tiiffhly
developed in England, and in the eighteenth century it attained great
eminence under Peräval PoU (1713-1768), William and John
Bunter (1728-1793), Benjamin Bdl (1749-1806), William Chetd-
dm (1688-1752), Alexander Monro (1696-1767), and others.
Among these was John Sitnler, that great genius, as celebrated
for anatomy as surgery ; his work on inflammation and wounds
BtiD forms the basis of many of our present views.
In comparison with these, the names of äie Grerman surgeons of
lä
IS'TRODUCTIOK.
tlie eighteenth c«utury urc insigiiifiaiiit ; most of tliem lirou^bt tbeir
knowledge from P&ris, mad addt^d littlu tliat was original : /jortinz
JTeitter (16S3-17SS), JoAn UlricJi ßilguer (i;ao-ir96), and Ckr.
Ant. Thedeit (ITIS-ITO?), aro relativctj the most iniportsnt. Oep-
man aargtsry only oUtaJncd grcntor eminence with U>e couimcncemeDt
of the preeeut eentuiy. Cari Ca»par wo« Si^old (1736-1807), ond
Angtat Gottlob Richter (174i-t8i2), wt-rp distinguislied meri ; tlie
fttraif r aerred a» profesanr uf ftui)^ry in Wurslnirg, thu Utt«r in 0M>
tingen ; aome of Richtet» writings are valtuüile even nov, ctpccfftÜy
KU lilüe book on rupture.
On the tliresbold of our cei»t«ry you »ee profcBBore of mx^fcij
iifirain in t\w forcgrotind, whi'rc they subsequently maintained their
[xmiliun, becMus« lh«y actiially pruutisud «irger^'. A prt-Kltwcesor of
old Bic/U«r, as professor of Bur((cry at GOttingnn, the celebrated Ai-
hert Holler (1 TOS- 1777), at onoc physiologist and poet, one of the U»t
eucTclopa^tsIs, sa^-B, *' Etsi cliimrgiae oith^lni per scptemdecini an-
nas mihi nonrmdita full, ctidiu (!ulaveribu9dificilimit.Ha<lniim!itralio»ea
diirurgicas froqu^ator Q»tendt, non lamen uiKjuaua vtvuoi lioininou
incidere suütinui, niinis no nnf-erpin veritw.." Tn us this seemg
scarcely credible, so great is the change vrniuglil by a hundred y«»ra.
Even at the couimenccmcot vf this cfaturj' the Freiivh »uigeon* rfr
inaiu«! «t the helm ; Jiotfer (1757-1833), Belpeeft (1776-1832), and pazw
rirularly Duput/tren (t7?7-lSfl5),aud Jean Dominique Larrty (1776—
184«), were almost undisputed authorities in tlicir line. Besides them
there arose in England the uminpeaeliabie iiuthority. Sir Aaliey Coop-
er (176S-1841). Z<jrrey, the constant compaiiion of Napoleon L,lefta
1ar:go nuqiber of nork»; you will hcrt^ter read his mcmmrs witb
grcfit iutfreut. Xhijju^trm was ehiefly relobrated for his excellent
dinic^l lecturea. Cnopa'ä mooogniphH and tceturca will fill you with
astonisliineDl. IVaiifilation» of the writings of the above Fiencli and
Ktiffliah «urgcona first aroiiiwd German surgery ; but soon the subject
Ha» gone into iiitiHt profnundly by original workera. The men who
induced the German revolution in aurgcry irere, amongothers, F*nMnf
von JC«m, of Vienna (I7fi0-1829), John Xep. Jitue, of Berlin (1770-
1840), Pltiiij^ von WaMfr, of Muniob (1 782-1849), Cart Ferd. von
Orat^e, of Berlin (1787-1840), Conr. Joh. Martm Zangenbecf:, of
Gnttingen (1778-1850), J6A. Frietlri,'h Ditff'enbach (1795-1847),
Ct^fOati «on Te^or (1782-1860), of Wuraburg.
The nearer we approach the middle of our century, the more tlie
n^g«M] bounds of nation ality disappear from tlie domiiins of «nrgery.
Witl) increased mean» of mmmunicatioii, nil oihancea in science
aprcad with breathless haste to all part« of the civilized world. Num-
berless writings, uationul and intemutiouul medical oongresseii, nod
INTBODÜOTIOK.
13
pGreuaal intcroouraCi bare brou^bt radical chaugci to tbc surgeons oa
well as U> othcm. A ^riomtion of surgeons, upon wlioec wurks
the profession looks mth honnr, sppcun to be now during out ; I
memBieo suob u Staniey (1791-l»tC2), Lawrence (1783-lÖ67),and
BroJu (i:8S-l86a), in England; Koiij^ (1780-1854), Bonnet (180»-
1858). Zmn/ <na8-1861), Milifaiffne (ISOft-lSöft), Chiale (tl867),
Ji>6fn (1799-1868), and Vti/mt» (1705-1807), in Fraix»; Seutin
(1793-186!^), in Belj^ium; ValefUine MoU (1785-1869), in America;
WtOter (lT8ft-l863), Sr/iuk (1804-1885), and other», in Gorinany.
Frum (luruini (^-nuritliini ul»u vru buru {»unic loftses to mourn, capu*
daily th«' impurahlf^ donth of the gift«!, indcfiirignble investigntor
O. Wiber (16^7-1867); of the excellent FoBin (-1867), one of Uio
most »olid of luodfin French surgeons ; of Miädledorpf (1844-lftßR),
th« celebmt4v) inventor of galTano-<»tistic operations. Among ibe
living we might name many on ir)ioM> sbouldore rests the growing
grncrntkin of Geinuia nurgenna, but thoy do not yet belong to hia-
toiy. But there is one point I tnuat not [«av« unmentioned, that \%, Ibc
inti^ueiion of ]inin-4iu>>!lling remediBs into siug^ry. The ninetiwntli
ueoiury may be proud of the di!iooi*Rry of the practical vaa of sulphu-
ric ether and oblorofonn na atue»thetics in all »orts of operations. lo
1846 came froin Bogtou the firct iumh-b that Morion the dentist, iit tlio
snt^cMiim of Iiis fHonii Dr. Jackson, had, in extracting teeth, cm-
ploj'cd iiüialattonä of sulphuric ctbcr, ptmlicd to comploto aosestbtrsia,
with perfect sucoeas. In 1859, Shnpso», profeeaor of obstetrics in Ed-
inburgh, [nstaai] of etlier, inlmdnc««] in surj^cal practice (-blnn)fonii,
which urts kUII better, wltiuh, after ^unous trinls vrith other .itmilitr
sub^tunc^ still prcsen,-C8 its reputation. Ttinnic« I in the name of
aaflering humanity, o. thousand tkaoks to liivse men !
In cuntinuiition of mr previous remarks reganling' German sui^
gory, I will simply add thnl at present it stands at lenst equal to tliat
of otfaa oationa, and is jjerliajH even superior to that of Franc« at the
present tima To perfect onr¥>4^tv«A in the science of mirgery, wo no
lot^r n««d to Tisit Paris. But, of course, it is nererthole^s desirable
for every phyalcian to enUrj^ his experienee and obsen-ation by visiu
log foreign lands. In the scientiKc as wi^ll an in the practical part of
■urgery, and of medictno generally, Englnod ia now more ndvanoed
tfaui any other country-. In Aiiieri<<a nl$o great advances have been
mndc in praeticnl surgery. Knjtu the time uT Hunter to the picsent
day, English surgery has niMiit it something iioblc. Surgery owes
its great revolution in the- uinetoeiith (vntury to its attempt to unite
all mdioal knowledge in itself; the surgeon who suecoeds in this,Hitd
•I«o master- the entire mechnnical side of the art, otay foci tliat liu
Ina atta^juid the bi^ost ideal iu medicine.
14 IKTRODOCTION.
Before entering on our subject, I will add a few remarics about
the study of surgery as it is, or is said to be, pursued in our high-
Bdiools.
In the four years' course of medical study which is customary in
German universities, I would advise you not to begin surgery before
the fifth semestre. You often desire to escape the preliminary studies
and plunge at once into the practical It is true, this is somewhat
less the case since courses on anatomy, microscopy, physiology, chem-
istry, etc., have been started in the high-schools, where you have some
practice ; nevertheless, there is still too much haste to enter the clin-
ics. It is true, it is one way of gaining experience from the very start ;
you consider it more interesting than bothering yourselves at first
with things whose connection with practice you do not exactly un-
derstand. But you forget that a certain school of observation must
be gone through with, to enable us to make actually useüil what we
know. If any one just released from school should at onoe enter
the hospital as a student, he would be in the same position as a child
entering the world to collect knowledge. Of what use are the ex-
periences of the child for his subsequent life among men ? How late
it is before we see the true use of the most common observations of
daily life 1 Hence, to wade through the entire development of medi-
cine in tills empirical manner would be a long, tedious labor, and only
a very gifted, industrious man would learn any thing in this way.
After having made numerous errors, we must not place too great a
value on " experience " and " observation," if by these terras we mean
no more than the laity do. It is an art, a talent, a science, to observe
critically, and from our observations to draw correct conclusions for
our " experience ; " this is the strong point of the empiric ; the laity
know experience and observation in the \-ulgar, not in the scientific
sense, and they value the so-called experience of an old shepherd as
high as, sometimes higher than, that of a physician ; unfortunately,
the public are sometimes right on this point. But enough 1 when a
physician or any one else displays his experience and observation be-
fore you, look sharply to see whether he has any brains.
In making these remarks against pure empiricism, we do not by
any means intend to say that you must be theoretically acquainted
with all medicine before studying it practically, but you should bring
a certain knowledge of the fundamental princiides of natural sdence
with you into the clinic. It is absolutely necessary to have a general
idea of what you are to expect ; and you must know sometliing of
the tools before seeing them used, or taking them in your hands. In
other words, you should know the outlines of general pathology and
therapeutics, as well as of materia medica, before going to the bed-
ISTRODDCnOS.
15
side of the jtatiLiit, Gcncrul surgery is only one part of generu)
patholui^, büuce you »liould study tiitj latter b^fuit: entering the sixr-
giool cUnic. First, yiiu kIiuuUI ^liii u olotir tiiidcnilaiidiii^ of nomiaJ
histology, at \caH of il4 gL-iiL-iul pukrta; patholt^ical atiatomr ami
histolo;^ ehould con\a n'lth general surgt-iy, »bout the fifth srra<-&tn!.
General eurgerj-, the subject of tlio present lectures, is a part of
general pathologj-, as ve bare already stated ; but it u nearer to
pracike tUaii tJtc tatter. It miiipris«» tbfl Htudy uf wotm<l», iiiftniii-
Dution«, tto4 tumors, of the <>xtemal parts of th« body, or of tinise
puts ikat may be liandle^l from wttlioul. Spe<«.-i»1 or topograpliical
Eurgcnr oocupii's itself vritJi llio »ur^uil discvut's of dilTcrent parts of
tliL* body, 60 ihat tlic inosi di)Tcrciit ti^suvs »iid orguns arc to be con-
aid(»v<l jMÄorvlingf to tlieir luoutiou ; for iuslaace, while we here treat
only of wounds, of tlieir mode of rccorcrj' nnd tmalmcnt in ^neral,
sp«ci»l suiffsry treats of ^iround« of the bead, breast, and ■b<lon)eu,
|taying R|)Criiil ntteotiou to the pari ieipat inn of llie skin, bonvs,
»ml viwiia. Were it possibli; lo ]>iir*iie iIh! study of »urgtiy for
Bcvenü years iu a larf^ bofpitul, and could careful dioiod cooisid-
cmtion r>f itKl)vi<)iinl eases be earned o» coutlntioiisly vitli the regular
Btuilie«, it would prolxibly bo uunecessary to treat of Kpccül surgery
iu teptnXc aysteraatie k-clurt-s. But, eiuce there arc ouuiy surgiial dis-
eases that periiaps may uot occur for years oven in a large hospitnl,
bat wbidi should be known to the surgeon, the Icctiues on spcdal
surgery arc by no moiuin huixTduoufi, if they am sliort and In tlie poii)t.
During my Htudent dnys 1 oco&sionally beard tlie remark : " Why
sbould I go to liiiten to sperial «urgery and patlKilog^-? 1 mn read
them more LtniTeiW'ntly in my room." Tlii» nmy be all txue, but un-
fortunately it is rarely ilone, tinle*» J« tlwj final scmo»trcs, when exam-
imtioii \a »pprooeliiii);. This reasoning is faleu in another respect
abo : the citvi vwc of tbe teiMiher, as old LaHgaifjccA\ in GottJngen,
uaed to My (and be had a ri'v«i vox in tbe best sod«c of the word),
the winged won! of the teacher Is, or slmuH 1)0, more eieitiiig and
eflcctivc than what is read, and Ibe aocompanying dejuonslratioii»
of diagrams, prepaiatioas, experiments, ete., should render llic lectures
on practical surgi>ry nnd medicine particularly raiuable fw you. I
sUw^ great rnlue to demonHlmtJon in medical instnu-lion, for I know
by experieuoe that this kind of t«a«ltiug is moot ejccitiog und pci^
maneiit.
[lesidos Uicse two sets of lectures on gciH-nd and speciat sairgi-n*,
.JTQU haw to practise operations on the caduvcr; thia you may ptwt-
le to the hist u-tnratrCK. I alwsj's like students to lake (heir
course in opcrationti in the sixth or scvciitb scmesücs» along >ritli
iheir fipecial surgerv, eo tlmt I may give tlicin the oppoitunity of uo-
3
18 INTRODUCTION.
casionally operating, or even of amputating, under my direction. It
gives courage in practice, if one has during student-life performed op-
erations on the living subject. When you have followed the lectures
on general surgery, you may enter the surgical clinic, and there, in
the seventh and eighth semestres, openly give an account of your
knowledge in Bpecial cases, and accustom yourselves to collecting
your ideas rapidly, leani to distinguish the important from the unim-
portant, and to learn generally in what practice really consists. You
will thus learn the points where your knowledge is deficient, and may
perfect yourselves by persevering study. When you have thus com-
pleted the legal tinae of your studies, passed your examination, and
have increased your medical knowledge by a few months or a year in
various large hospitals at home or abroad, you will be in condition to
appreciate the surgical cases turning up in practice. But, if you wish
to devote special attention to surgery and operating, you are still
far from the goal : then you must become accustomed to operating on
the cadaver, enter a surgical ward as assistant for a year or two, un-
tiringly study monographs on surreal subjects, perseveringly write
out cases, etc. — in short, follow out the practical school from the lowest
step. You must be fully acquainted with hospital service, even with
the duties of the nurses ; in short, you should know practically even
the most minute things appertaining to the care of patients, and
should even perform the duties yourselves occasionally, so that you
may l« fully master of the entire medical ser^'icc intrusted to you.
You see there is much to do and to learn : with patience and perse-
v'^nint'«; you will accomplish it all ; but these virtues are necessary to
the Hludy of mwlitrine,
" Sliidi'iit " comes from " to study ; " hence you must study &ith-
fully ; til«! U-ii'hcT indicates to you what he considers the most impor-
tant ; hi; may htiinulatc you in various directions ; what he gives you
M \ni!iiiiv: tuny, it is true, I>e carried home in black and white, but, to
caiuu: lliif. imrtitive knowledge to live in you and become your mental
ppiiHtrly, yon tiiuKt depend on your o^vu mental efForts, which form the
tn«! " Hludy."
Wlt'rii yon (ronduct yourself as a passive receptacle, you msy, it
ig tnn;, iic'iuirc the name of a very "learned person," but, if you do
Bot awnkc your knowledge into life, you will never become a good
*pn»''fi«iiig physician." Let what you see enter your mind fully,
wann ym up, and so occupy your attention that you must think of it
ffeqii'-dlly, tli('n the true pleasure and appreciation of this mental
Ihibmr « ill fill you. Goet/ie, in a letter to Schiller, aptly says : " Plcas-
TjBt^ «'omfort, and interest in the affairs of life, are the only realities;
■D eh«! in vanity and disappointment."
CHAPTER L
SIMPLE INCISED WOUNDS OF THE SOFT PARTS.
LECTURE II.
Mode of Origin snd Appearanec or these 'WournlB. — Various Fonns of IncUed Wouada.
— App««i«nce during and immediatclj after their Oocwrenoe. — Pain, Bleeding. —
Yarietie« of Hsmorrhage ; Arterial, Venous. — Entrance of Air through Wbunded
Veins. — Parenchfmatous iU«morrhage. — Ilreraorrhagio Diothoeis. — llttnioirliBge
ftvm the Ybaiyax and Bcctum.— Constitutional Effects of Severe Htemorrliage,
The proper treatment of wounds is to be regarded as the moat
important requirement for the surgeon, not only on account of the
frequency of this variety of injury, but because we so often inten-
tionally make them in operating, even when operating for something
that is not itself dangerous to life. Hence we are answerable for the
healing of the wound, to as great an extent as it is possible by expe-
rience to judge of the danger of an injury. Let us commence with
incified wounds,
Injuiies caused by sharp knives, scissors, sabres, cleavers, hatchets,
etc., represent pure incised wounds. Such wounds are usually recog-
nizable by the regular sharp bordere, where we see the smooth-cut
sur&ce of the unchanged tissue ; should the instruments be blunt, by
very mpid motion they may still cause quite a smooth incised wotmd,
while by slowly entering the tissue they would give the edges of the
wound a ragged appearance ; occasionally, the variety of the injury
does not become evident till the wound is healing, for wounds made
with sharp instruments heal more readily and quickly (for reasons to
be given hereafter) than those caused by the slow entrance of dull
knives, sdssois, e\c.
A perfectly blunt body rarely makes a wound exactly like an incised
one. This may occur from the skin being torn through by force n|>
plied through a blunt object, at a point where it lies over the bone.
T\sa6 you will not unfrequently see scalp-wounds resembling incised
18 SIMPLE ISCISED WOUNDS OF THE SOFT PABTS.
wounds, although they may have been due to a blow from s blunt body,
or from Btriking the head against a stone, beam, eta ; similar smooth
■wounds of the skin also occur on the hand, especially on the volar sur-
face. Sharp angles of bone may so divide the skin from within that
it ^\~ill look as if cut through, as, for instance, when one falls on
the crest of the tibia, and it divides the skin from within outward.
As may be readily understood, sharp splinters of bone perforating the
skin may also make wounds with smooth surfaces. lastly, the open-
ing of exit of a bullet-wound, i, c, of the canal which represents the
passage of a bullet, may sometimes be a sharp slit.
The knowledge of these points is important, for a judge may ask
you if a wound has been caused by this or that instrument, in Üiis or
that manner, points which may greatly affect the bearings in a crimi-
nal suit.
Hitherto we have only considered wounds made with a blow or
stroke. But, by repeated cuts on a wound, the edges may acqidre a
hacked appearance, and thus the requirements for recoveiy may be
veiy mucli changed. For the present, we leave such wounds out of
consideration ; their mode of recovery and treatment is just the same
as that in contused wounds, unless they can be artificially converted
into simple incised wounds by paring off the jagged edges. The
various directions in which the cutting instrument enters the body
generally makes little difference, unless the direction be so oblique
that some of tlie soft parts are detached in the form of a more or less
thick flap. In thesej?aj(>-wounds, the width of the bridge, imiting the
half-separated portion with the body, is imixjrtant, because on this
depends the question as to whether circulation of blood can continue
in this flap, or if it has ceased, and the detached portion is to be re-
garded as dead. Flap-wounds are chiefly due to cuts, but may also
arise from tearing ; they are very freqxient in the head, where part of
the scalp is torn off by a hard blow. In otlier cases a portion of the
soft parts may be entirely cut out ; then we have a wound with loss 0/
substance.
Hy pejietrati»!/ wovmls we mean those by which one of the three
great ea\-ities of tiie body or a joint is opened ; they are most fre-
quently due to stabs or gun-shot injuries, and may l>e complicated by
wounds of the viscera or l>ones. By the general terms longitudinal
and rfia^owo/woimds we of course mean those corresponding to the long
or diagonal axes of the trunk, head, or extremities. Diagonal or longi-
tudinal wounds of the muscles, tendons, vessels, or nerves, are of course
those dividing these parts longitudinally or diagonally. The symp-
toms in tlie person wounded, induced more or less directly by the
wound, are, first, pain ; then, bleeding and yapin/j of the wound.
SYMPTOMS-PilN.
19
As rH the tiMUM, not excepting thö epitb«1kt and «pidennoid,
are EuppliMi witJi senaorf noires, injurjr mt once causes pain.
This pain vnrira ^rrciillir with fh^ iiprv»?-s»ipplv of th<i wrmndcil
part, »od with the seoaitirencss of the putient to pnin. The itKiett
sansitire parts are the finj^m, lip«, tongue, nippl««, extenul genitals,
anil abnui the uims. Donhllest«, mdi of jrou knows from expcritmc«
thr chamctcr of thu ]xiia from n wound, ns of the litigcr. The division
of tV Kkin is the movt painful purl ; injury of the musdw and Ivii-
dons is tir Iva» »o ; injury of the bone is nlnays very juiiufiil, u you may
&ad from any ooo that hns recovered from a fnciurc; it has also bc«n
handed down toiw fipora the times when smpatations were mndc with-
out rhlorofomi, Üiat sawing the bono watt the most painful pari of the
operatioiu Tlw mucouti tneinlnanc of ike intestines, on U>in<; irri-
tatod in irarioiw way«, siiows rcry litHi» sensitiveness, as has been oeoa-
rionetly ubserrrd on man and beast ; the vaginal portion of th« ut»*
rus at&Q IS almost inacnutivc to mechnnicnl and cJiemicol initalion;
oocaaiouallvi it may bo touobod with the hot iron, as is th>no in treat-
ing certain diseases of this part, without ita being felt by the patient.
It appears that tlio nerves requiring a fspcci6c irritation, as the
nerres of epecial sense, are accompiuiiod by few if any eensoiy
fibres. The rehitlon of the senaciy nerves of touch to the sentient
nerves in thu skin cannot Ix; reganled a» decided, or whether Uiere
b« aur dc<nded diffcronoe between tbcm. In tJie do«c uid tongue, we
have sensory and sensible nerves dose together.so that in both pari«,
beudes the «p<>».-ific sense peculiar to the organ, pain may also be per-
ceiTOd. He white substance of the bruiu, altbou^ coutaiuing many
nervig t.« without feeling, as may )>e jccen in many severe injartcs of
ih^ brad. The division of nen-»-tniiik8 i« the »ererest of nit injn-
rie& Some »f you may lenii^mber the pain frum rupttirt* of a ileiitnl
nerve on extraction of a tooth. Sf^vcring of thick nervc-tnink« must
canM oveqioTCurii^ pains. Sen-iitirenesa to pain appears peculiar tu
indindiiols. But you must not confmrnd this with varioua exhihitions
of pain, aod with the psycbieal power of suppressing, or at least limiting^
this exhibition ; the Utter depends on the strength of will, as well as
oolhc lemperaiiH-nt, of the individual. Vivacious person» display their
pain, as well as their other feelings, more than phlegmatic personfL
Mu»t petsnna maintain that crying, tut well tg the instioctive powerful
teoMOu of all the muscles, especially of the massctcrs, grittmg the
(«eth, otA, rr^ndcjs the pain more endurable. Personally, I have not
beim able to vorify tijia statement, and I think it must be a mistake
of ibc patients. Strong will in the patient may do much to suppress
the show of pain. I well remember a woinaa in the Ql5ttiogen dinio,
when I was a student, who, without chloroform, had the whole upper
20 SIMPLE INCISED WOUNDS OF THE SOFT PAETa
jaw removed for a malignant tumor, and, during this difficult and pain-
ful operation, she did not once cry out, although several branches of
the trifacial nerve were divided. Women generally stand sufTering bet-
ter and more patiently than men. But the necessary exercise of
psjcliical strength not unfrequently causes subsequent fainting, or
excessive physical and psychical relaxation, of longer or shorter du-
ration, I have seen strong men of powerful will bear severe pain
without a grimace, but soon fail to the ground fainting; still, as previ-
ously stated, I believe that some persons suffer pain much less acutely
than others. You will certainly meet persons who, without any exer-
cise of vnW, show so little paiu from severe injury that we can onljr
believe that they really feel pain less acutely than others ; I have ob-
served this most in flabby sailors, in whom all the sequels of the in-
jury are also generally verj- insignificant.
The quicker the wound is made, and the sharper the knife, the
less the jiain ; hence, in large and small operations, it has always
seemed, and very correctly too, for the advantage of the patient, tlmt
the incisions should be made with certainty and rapidity, particularly
in dividing the skin.
The feeling in the wound, immediately after its reception, is s pe-
culiar burning. It can scarely he termed any thing but the feeling of
being wounded ; there are a number of provincialisms for it — in North-
em Germany, for instance, they say " the wound smarts." Only when
a nerve is compressed by something in the wound, twisted or irritated
in some way, there are severe neuralgic pabis immediately after
the injury ; if these do not soon cease spontaneously, or after exami-
nation of the wound, and removal of the local cause, or, if this is im-
pdssible, or inefficacious, they should be arrested by the exhibition
of some internal remedy; otherwise, they will induce and keep up a
state of excitement in the patient that may increase to maniacal delir-
ium.
To avoid the pain in operations, we now always use chloroform.
The method of administering this article, as well as the prophylaxis
and treatment of the dangers tliat may arise from it, you will leam
much sooner, and remember better afterward, in the clinic, than if I
gave you a proUx account of it here. Local anasthetiea, which have
for their object temporary blunting of the pain, in the part to be op-
erated on, by application of a mixture of ice and saltpetre, or salt,
have been again abandoned, or rather they have never IxJen generally
received. Recently, these attempts have again acquired a general
interest, as it seemed that a suitable method of local anaesthesia had at
last IxHjn found. An English physician, Richardson, constructed a
small apparatus, by which a stream of pure ether [or, better, rhigo-
SYMPTOMS— KSMORRHAGB. 21
line} spray is for a time blown against one spot in the stdn, and such
cold is lieie induced that all sensation is lost Even if this effect
were always attainable (which, from my experience with the appara-
tus, seems doubtful), the employment of this method would always be
limited, andnot free from danger, on account of the fireeziag of the
artificially-cooled portion of skin. [In England and 'America, the
employment of this mode of local anesthesia seems to have met with
more success, and not to have been followed by the bad effects above
feared.] For quelling the pain, and as a 113'pnotic, immediately after
extensive injuries or operations, there is nothing better than a quarter
of a grain of muriate or acetate of morphia ; this quiets the patient,
and, even if it does not make him sleep, he feels less pain from his
wound. Locally, for the relief of pain, we employ cold in the shape
of cold compresses, or bladders filled with ice, applied to the wound.
TVe shall refer to this under the treatment of wounds. Lastly, we may
give hypodermic injections. If, with a very fine syringe, furnished
with a lance-shaped, sharp canula, which may be thrust readily
through the skin, we inject a solution of -j— J of a grain of acetate or
muriate of morphia, this remedy will exercise its narcotic effect at
first locally on the nerves it comes in contact with, and then on the
brain, as the solution is absorbed and enters the btooil. Of late, this
mode of employing morphia has been exceedingly popular ; immedi-
ately after an operation, or severe injury, such an injection is given,
and the pain is at once arrested.
In a pure incised or punctured wound, hixmorrhage is a second im-
mediate S)-mptom ; its extent depends on the number, size, and variety
of the divided vessels. At present we shall only speak of hemorrhage
from tissues previously normal, and distinguish capillary, parcncliyma-
tous, arterial, and venous lueraorrhages, which must be considered sep-
arately.
As is well known, the different parts of the body vary greatly in
vascularity, especially in the number and size of the capillaries. In
spots of equal size the skin has fewer and smaller capillaries than most
mucous membranes ; it also has more elastic tissue and muscles, by
which (as we may feel and see m the cold and so-called goose-flesh)
the vessels are more readily compressed than they are in the mucous
membrane, which are poor in elastic and muscular tissue ; hence simple
skin-wounds bleed less tlian those in mucous membranes. Hiemor-
rbages from the capillaries alone cease spontaneously if the tissue be
beahhy, because the openings of the vessels are compressed by con-
traction of the wounded tissue. In diseased parts, which do not con-
SS
SIUPhR INCLSEri W0USD8 OF TOB SOFT PAHTS.
tract, even 1ia:morrliB;(c from dilated capillaries may be rcrjr ooasAer-
able.
Hteniorriinj^ from llic arteri(9 ia reatlily reoognized, on tlic one
band, because the blow) flows in n ntnesLin, wliicli sometimes dearly
sbovrs tLc rhvUimic-iiI oontmctiviis of ih<; liciirl; i>n the i/tbur, hy tbc
brightprud color i>f ill« ^lood. If then; t>o inipniivil rr^Hpinitioti, thia
briglit-red color may duiiige to a dark hue ; thuK, in upOTatious on the
neck, performed to prcvcot thrcatouing auffocutiou, and in deep amcs-
thcitiii, dark or almost blaek bkiotl ii>uy sptirt frmn tbu arteric». Tlic
aoioutit of blood escaping depends on tlic diameter of tbc tDtallr-
diridod artery, or on tlic aise of the opening in its wall, Vou must
not, however, believe that tlw BtreAin of blood or>rrpspond.i esactly to
the size of the artery; it Ih ustmlU' much smaller, for the cahbi-n nf
tJic artery geuerally coiitruots at the putut of division ; only tbu
larger arterio«, sucli us the norta, cnrotids, fcmoriü, axillary, eta, hare
BO Utt)iL> musL'uIar tibre that they voiitnict, in tlitrlr circuinferftnoo at
least, to a scarcely perceptible extent. In vcrj- small arteries, tlüs con-
traction of Ihc cut vessel has such an eflbrl that, from the increased
frialion, the blood flow« from them without spurting or pulsating ; in-
dec<l, in very »null arteries, this friction may bt^ so dccäcicd that the
blood llow'fl wjlli liilhoiilly ntid vn-iy slowly, and soon ejaculates, «>
that tho hiemorrhago is arronto«! )i|K)ntaiiooiisly. The sinuUcr the
diameter of tbc art<*rie3 b(M»mea, from iniiiinutiun of the amount of
blood in the body, the more readily luemorrlta^ will be arrested spon-
taneoualy, whilo uthorwiso it would haw to bo arrcsUxl artificially.
ÜLTcnftcr, you will orioa hare occasion to sec in tJie clinic bow freely
the hlood spurts at the commencement of an operation, and how much
less it will be toward the end, even when we eut larger veasels than
Weie at first divider]. Thus dcereaan of the total volume of blood taay
auise spontaneouR arrest of bajmonhrtge ; the \vcakcr contnictJona of
the heart have also some icQuence in this. Indeed, in internal hnemor-
rliapfc» that we cannot iracli dirertly. wo employ rapid »iMtrnction of
blood from the arm (venesect ion) as i^ ll(elllo^Utic ; in suvh cases the
artitirinl excitement of anicniia is not unfr«>(|ueiiMy the only n>me<ly
we have fur inteniul liwmorrliHge, paradoxical as this may aeein to
you at tbc firat f^lance. Uicmorrliu^jrea from incited wounds of tbc
large arteries of tbc trunk, nede, ami oxtrcmilic«, arc nlwnrs so coiH
Mdcrablu that tJtey abüoIiiU-ly n}(|iiire to be arrested, unless the opetH
ings in their walls be very nmaU. But, when tbc terminal branrh of
an artery is niptured without a. wound of the skiii, tlio iKeinnnliage
may he arrestod by pressure on the surrounding soft parts; suel». in-
juries »ubseqiiently induce other changes, to which your attention
itill be called under other circuuistanccs.
SnilTOUS-II .KUORIcn AGE.
23
Hteoiorrliage from the reins U clia-niclciixecl by tbc si«ady How of
dark Uood. Tliis ia capuciully true uf small Buil middtosijUH] reiiu.
Tbou hsBTiorrhAg«! arc rarely very profuse^ so tiiat, in onJor Ui obtua
a sufficisQt quantity oo lc>ltiug bluod from the subcdtatteoua veiiut of
the ann at the bend of tbc elbow, ire inuüt obstruct the flow of UomI
to the heart. U this were oot <louc, blood would otily Q<j\r (mm tliis
vein at the time of pimnture, fiirilior iupfnnfrhnf^ irould orjuM! sponta*
nvotislr, uule*» Iti-pt up by iriu«'iilar r<^iitra<lii«i8. Tbis is L-liiflly be-
cauM' tbc tliia walls of thu Vf ins collapse, itudcad of ;^pin<;, aa tltc
artcri«« do nben divided. Blood doc>8 not rc^idlly flow h»ck from tba
oentnl end of tbc vein, on aoraunt of the valvca ; wb rarely hare any
tbiag to do vith the vidvetfss Toins of tJie portal syslpm,
Bemarrbago from the larg« %t*nou3 trunks ia alwTiys .-i dniigiirouii
nymptom. Uloeding from the axillary, femoral, subclnvinu or inU>r-
nid jnguliu-, is usiiidly quiddy fat^I, uiiless aid nrriv« immedintely;
wivus<U of tlie veoA anonym» mny bo rf^rd<xl as nb«olut<>lr inortnl.
Tho blood does not How continuously from tlies« large reins, hut tlio
flow is givatly influcnrrd hy the respiratioD. lu opermttons about
the atxk I bare frequently ae<:n |Ktti«iit8 lire after tUeir intvnial juj^
ular vein had bi^en woiindt^d ; (luriiif:^ inspiration the nsMol eolIn]Med
«o tliat it might hare lieen regarded as a (Xinnecli%-e lissuo striuf;;
dnrinfT cJCpinttion the bbtrJt blood giuhnd up as from a well, or »till
mtro like tho bubbling up of the water from a deep spring.
Id lltes« veins near the heart, besides the r%]»d loss of blood, there
18 another element that greatly increases tJie danger; thi» is the en-
Irance of air into the veins and hearty as oocasiomilly takes place with
a gnt;gUQg ocdse, n« deep inspirotion, when the blond niahes towiinl
the heart; thi» may raitse instant dentli, though not neeewarily, [
camot now enter more explicitly into this very remarfcaltto pbooon*
encn, whoso jibyuulogioal effect has not, as it seeriiA lo ine, b<.>on sat'
iArai;lorily explained; you will a^ain Imv« your attention called to
Ihi^ «iibjix-t by the books and lecture* on opernliTe surgery. I shall
men'ly mention that, on o]>ciüu^ one of Uiu Iai;ge voiiis of tlie neck or
die oxillaiiy vein, there may bo d perceptible gurgtiuir sound ; tho
patient instanlly loses oonsci<iusa(!»8, and can mrcly bo restored to
life by instantaneous resort to artificial respimCiun, etc. Death ia
probably caused by tlie entrant of sir-bubbles, which press forward
iato the uediuiD«tsed pulmonary' arteries, and si's there arrested, and
prrrent furtho* access of bloo<l to Ibe pulmonary vessels.
Resides the aboine rarietie« of Iwrnorrbage, we distinguish the so-
aaSUid p(TmKAtfmat<niM hamiorr^aff«, v\ücii in sometimes incorrectly
ideotilied witli enpUlary hieraorriiage; In tlie normal tissue of un
otberwise bealtLy body, purcncbj-matous hnemorrhagcs do not oomo
24 SIMPLE INCISED WOUNDS OF THE SOFT PARTS.
fnim the cii]>illarics, but from a large Diamber of small arteries and
vciiiH, wliicli from some cause do not retract into the tissue and con-
IriMit, und are not compressed by the tissue itself. Bleeding firom the
«jr]>UH cavcmosum {lenis is an example of such parenchymatous htsm-
urrliageti, which also occur irom the female genitals and in the peri>
tii:al and anal regions, as well as from the tongue and spongy hemes.
Tliüse pari>nc1iyinatou8 lucmorrhages are especially frequent from
diwtumHl tissue; they also occur after injuries and operations, as so-
(uilh-d Hecutuhiry lufunorrhagea ; but we shall speak of these here-
after.
< >nM other point we must refer to here : this is, that there are per-
Hoim who bleed so freely from a small, insignificant wound, that they
ntiiy tUi! of hiemorrhage from a scratch of the skin, or after extraction
of a. t'Hith. This constitutional disease is called a JuBmorrhagic diet-
thesia ; ])eople affected with it are called hcemophilen. The cause of
tili« diseuBc is probably abnormal thinness of the arterial walls ; this is
4 oiifrcnitul in most cases, but may probably result gradually from motbid
ili'gi;neratioii and atrophy of the vascular walls. This frightful malady
is usually hereditary in certain families, especially among the males, the
females being less liable to it. In these persons htemorrhage is caused
not only by wounds, but light pressure may induce subcutaneous bleed-
ing, spontaneous haemorrhages, as from the gastric or vesical mucous
MK'iiibrane, which may even prove fatal It is not exactly in large
woun<ls where medical aid is called at once or very soon, but more
]mrliculurly in slight wounds, that continued hemorrhages occur in
Hiirh [MTsons which are difficult to arrest, partly, as we above stated, on
account of slight contractility or total lack of muscular tissue in the
vessels, partly on deficient power of coagulation in the blood. It is
true, the latter jx)int has not been proved from the blood that escaped,
for in the cases where attention was directed to this point the blood
Howed hke that of a healthy person. There have been no recent ex-
act olreervations on the state of the smaller arteries.
I slial! also call your attention to some peculiarities in hfemorrliages
from certain localities, especially from those in tiie pfiar^iXj posterior
uarex, and rectum, although, strictly speaking, this comes in the domain
of special surgery, M'ounds of the phamyx or posterior nares, made
thnmgli the open mouth by accident, arc rare, but, as a result of con-
sUtntionai disease, we may have very severe spontaneous lia^morrliage
from those i>iirts, or these may result from operations, for we not un-
fr(?(|uently have to use knives and scissors here, or to tear out tumors
with forceps. The blood does not always escape from the mouth and
nose, but it may ran down the pharynx into the cesophagus without
being iwrcoived. The general effects of rajHd loss of blood come on
STMFTOMS—H^MORRHAQE. 25
rapidly, which we ahall soon describe more minutely, but we are
unable to discover the Botirce of the bleeding, which may be behind
the soft palate. The patient soon vomits, and at once throws up large
quantities of blood ; when this ceases there is another pause, and the
patient, perhaps also the surgeon, thinks the haemorrhage has ceased,
till more blood is vomited, and the patient grows still weaker. If the
surgeon does not recognize these symptoms and apply proper remedies,
the patient may bleed to death. I remember one case where several
physicians gave various remedies for vomiting of blood and gastric
hoemorrhage after a little operation in the throat, and the source of
the bleeding was finally recognized by an experienced old surgeon,
who arrested it by local applications, and thus saved the life of the
patient.
The same thing may happen in haemorrhage from the rectum.
From an internal wound the blood flows into the rectum, which is ca-
pable of enormous distention ; the patient has a sudden desire to stool^
and evacuates large quantities of blood. Tliis may be repeated sev-
eral times, till the rectum, irritated by the expansion, either contracts
and thus arrests the hsemorrhage, or till it isfinally checked artificially.
A rapid excessive loss of blood induces changes in the whole body,
which are soon perceptible. The face, especially the lips, becomes pale,
the latter bluish, the pulse is smaller, and at first less frequent. Tlie
bodily temperature sinks mMt perceptibly in the extremities ; the jja-
tient, especially when sitting up, is subject to fointing-spells, dizziness,
nausea, or even v'omiting, his eyes are dazzled, and he has noises in the
eats, every thing appears to whiri around; he collects his strength to
hold himself up, he becomes unconscious, and finally falls over. These
symptoms of syncope we refer to rapid ansemia of the brain. In a
horizontal posture this soon passes off. Pcraons often ftill into this
state from very slight loss of blood, occasionally more from loathing
and aversion to the flowing blood than from weakness. A single
fainting of this kind is no measure of the amount of blood lost; the
patient soon recovers his forces.
Should the h£emorrhage continue, the following symptoms appear
sooner or later: the countenance grows paler and waxy, the lips
pale blue, the eyes dull, the bodily temperature is lower, the pidse
small, thready, and very frequent, respiration incomplete, the patient
faints frequently, constantly grows more feeble and anxious; at last he
remains unconscious, and there is twitching of the arms and legs, which
is renewed by the slightest irritation, as by the point of a needle, etc. ;
this state may pass into death. Great dyspncea, lack of oxygen, is one
of the worst signs, but even here we should not hesitate; we can often
do something even after apparent death. Young women especially
ao
SUFLB INCISED WOÜSDR OF TBE FOFT PAM8.
can bear enonnou» loss of blood vrithoul imnicdiutc dai)|B:cr to lifo ; you
will hereafter hiii-e occasion to wita<>ss Ibis in tlii? obstetriiitl (.-llDic.
CliildrMi ami olcl pemons can I«uit bear loss of blood ; in yoimg cfaililrea
the rrsutls of tlie Dpjiiicuüoa of a laecli are orten erident for ye^n by
a very pallid look nnd incrrased expitabilitv. In very 'iKl p*"»©«* great
loss of hinnd, if not immediately fntal, nmy iudnct- ubi^liiiata eulliipse,
wliloti alVcr diiys or wcelcs pnasßs on to dcntli ; tliis is probably because
the loss of bbod is imiucdiatoly supplied by serum, and in old persons
Lite rcriiiitlion of blood-corpiisdes poes on stowly; the (rrfyitly-dilntixi
blood proven insufGeiciit to nourisb the Lis»iic», M-bose nutrition is at
any rate very sliijrRi^b.
When the patient eomee to himstJf nfl^r severe ha;inorrluige, he
lias excessive thirst, as if the Imdy wert dried »p, ihc vessi-la of the
iiile»tiiiul canal greedily tsko up tlic quantilies of water drunk; in
8tron)(, healthy persons, the cellular ronstitucnta of the blood are
quiL'kly n-plaoed, Jt ix true we do not exartly knoiv from what »oun^;
after ii fi'w dnjifi, in a person otlienvisu liealtiir, »« can perwiive few
signs of the previous amemin; soon, too, hts sirengrth has rccoTci^
from the exbaustion.
LECTURE lir.
Tn«im«it0f1lBnierrba^.— 1. I.l^tniti aud M«(Uue r.SsntUK «f Arttriu.— 9. C^m-
proMion by ih« finget', Clioieo otth» Point fnr C>:inipr«Mioo of tlio Larger An«*
tI<!«.— TMimlquat.— AcuprcMt)».— Kuidsging.— Tmnp««.— 3. Stjiiticf.— -Ucnenl
TnURKiit tit Sudden Aiminta. — Tranafaalon,
QE3ITLEMEX : Ifou now know the different varieties of haemorrhage.
Now, what meanaluive we fornrrestingiimoreor less scrore bleeding ?
Tlie uumberis grcal, iillliough we use but few of tlieni — only those
that are the most certain. Here yon have a field of euripeal opei«UoR
wher*" quick and certain aid is required, no thnt the ii-sult niiwt be
unfailing. Still, the employment of tlies»> remedies requires |>raeticCi
cool-blontled quiet, absolute certainty, and prescnoe of mind, arc lite
first requisites is dnnjferous hrcniorrhagc. In such circiunatances a
Btirj^eOTi may show of xvhut meUil he is made.
Ha"ni09»iitii-» arc divided into three chief eksscs: 1. Clofiurc of
the voiwcl by tying it— iigntion. a. Cümpriasion. 3. The remedies
that ean*e rapid coagulation ofblood, styjrties (from <m^w, to rontraet).
]. The lifpitui-e m«y Iw applied in three waj-s, viz., as lijrnture of
the JBolatcd blcedinff veefcls, as mediate ligature of tlie latter with
tbi! surrounding wifl part«, or as ligation in the continuity,!, c, lEgtt'
tion of the vessel at some distnncc from the wound.
TßEATJIKNT OF H.EMOllRHAGE— UGATTBE.
27
These TorictW of li^tion apply almost cxclu-iirdy io arrest of
arterial hffiDorrbag«. Venous luemordiagce rarely iv«(uin; ligntioo— it
is ooly occa&ioiially indicated in the Inrgc venous Iruiiks; wl- aroid it
[vrbencver we cnii, as its restiilts inu^- lie daiigt-rous. \V« Klial) hvie-
ifUrT ia(|iiin: in what thi:} daogvr cousiate, and at pKecnt epcak only
tof llit> ligtiliun nf nrleriu«.
Let US tnippiMe tbe simp1i>st case ; a small artery spurts from a
round : yoii fiRvt m?!» Uie artery, aa innvli iaoluli-d as pussiblr, I>cst
ivcra<;ly, bctw«*>n tho brandies of ft sliding forceps; tlitu fai?t4.-u
he »tide, »ii<l tli» bl«^iii^ is stufipod. "nii! sliding furoeps axe best
IcofGrrmnn silver, as it ni5t8 less rradUy than iroa. Tbere are
Daay difTcrvnt Taiietieä of tbesc forceps, ivliidi aru all aa arraug<e<l tliat
H'hea doseil they remain AxikI in tliat position ; the meiOMiiisni ncooin>
[llisliing this closure varies greally ; the inuro simple it ik, tlie better.
It is intvrcatin;; to follow the phodes of dcvclapmcnt of this instru-
a«tit äoec the days of Ambnm Pari^ before it attained its present
iiple completcttees. Of late small spring clamps are not unfre-
[quetitly employed to compress tltc bleeding arteries; tlieso are very
serviceable, if strongly made. Uesides tlicse pinr^ttes, jve may also
use Kniall cun'e<l uliarp litxiks i^liromßdd's artej-y-liook) to Ann out
ktlii^ artery, but tliis is iioi so good a wity, for of (^^ntnw the blood
■irouJd contiouD t» spurt during the subserjuent Itgalion.
Baring sci/^d ibe artery securely, Oie next tbitig is to close it
maiieotly ; llnx in done by tlie ligature. But satiefy youiM-lf r:nit
lat yiiu bavi; not iucludvd a ncnu wiltt it, firr Itie cotueidvut li^tioa
fa nerve inay not only induoc continued severe pain^ but even dao»
eroim geueral nervous aficctions. For lif^liug arteries ue use ailk
[^ad nf varioua thickness, according to the size of the urtery ; it must
be good, strong silk, so thnt it «hsllnut breukwheii finiily Iti^d; and it
aiiQuld not really alisorb fluids. Ua\'e the forcejis, which luing from
the end of the arlery, held up, tbcn from below place the silk around
Jto ftrtory, making first a simple knot and tying it tightly just in front
ti (lie fi>nv[ui, tlieii tie a soLvaid knot. Xow loi«en tlie forceps \ if tlie
in is rightly ap[>lted, the bleeding must be urrcetett 1^ tiglit-
Iff of tbo knot must be »coomplished by puling the silk forward and
Wng it «itli the |ioiiits of both fingers. If the »ilk bo good, two
limple knots, one over the other, will suffice. Some surgeons, how-
vcr, prefer to oiake fin>t u ecKralled sui^geou's knot and then a sinipio
T7ie surgeon's knot is maik^ by passing both ends of the thread
I tlie looji. Vou üibould first try these little iuauipul»li<m<> on tho
liver or on li'^-ing aaimiils. Whca tlic liguturc is fimilv applied, exit
end oflf short and load tho other out of tbo wound tiie shortest way.
It is DOi always possible to taka up the spurting arlery and ligate
S8
SIirPLB ISCISKD WOrTKDS OF THE SOFT PARTS-
it l>j itself ; oorasioiiallj- it oontncts so simng'lj into tlie iissue^e»*'
pedalljinto the nrasolisi ori)<!n&^ opIluUr tissue, thnt its isolktioa b
inipraDticnblc. Under such cimiinKUnceii it ü difficult lo eoniplel» tlw
ligation Bcmrcly; we ore T«ry apt to iiivlwlc lli« Lindes of the Ibmcps
■a Uiv lifjulure, «e it i« diffiouH to pii^li iIip lipiitHr<' fare noujrti foiv
vard. Sueii ntaca are proper ones for mmliiitf ligntitm. After liav-
ing pulled forvrnnl tlic liliN^ling part with forceps or & IkxJi, pan a
tiarcd nccdif, hdJ in u nwdle-IioMer, around tbe Hrien-, then tic tlic
lij^ture so as to pni-irole Hip oiitirp end of tJip artery; tio tiio Ictiots
tt^ittr, IS above directed ; Uim, white closing ttic mouth of itic arlxry,
yon will endofle socae of the stinmmdinf; tJasue. Mediate li^tinii is
only to be regforded as an pxcpptioiwl proeoodiog, for the ligalod tisRue
(lif-^ or llie Itgal.iir« suppijiates tlimugh Tery »lowly, bo that tlir sejw-
nittoii of the Intler is iiiudi impeded; of nnurse we iniiet guard ag&inet
inclitditifr any risible nerve-trunk nnsr tlio arlory in tbe lij^luro. Iq (bo
pemiIaii<!o»i9 inct)iatf> ligatitiii of Jifidtlifdoiflf, w« prowed t-vvn mom
stimmarily ; we pnss a stroiigly-cur^'cKl IfirRL- ucodlc through tlic skin,
tuider and across the bleeding artery, and agnin out througli the skin;
the thread is tiedj and, besides oompressing oUjer parts, oolnprl^<I«>»l ihe
artm-; thf thread remains Iwo or three «lays. Idoiiolreoommeml this
method; it ^hmilU only Iw employed in caacs of ncccBsity, ai»! as a
profiuional hxrooittali?.
"Wlienever tlie bleeding arleiy can lie seen in the wound, tJie Innn-
orrhiige is to W nm^ted by ligutwre; but, in (biwic ratteit where the
nrt^rios« of the periosteiira or bout! spurt out blood, ligature is impiw
»ible, and other methods, such as eoniprpRSion, come into play.
If you have to deal with large bleeding nrleric», the proceeding is
jnst the same, only you must be doubly oareftil in isolating tHe
iirtery: seize llie bltfxling end and »enijH.' buck the surrYiunding
tiMue with a small sailpel, then ligate carefully and accurately; in
most eases, when you have t!io ecntral and peripheral ends cxpoÄed in
tbe wotind, you should ligate both, for tbe anastomoses in the arterial
system are so frerr that, if the peripheral end does not bleed at rmce,
it miiy do so later.
The wound from which a copious bipmorrlinge eomes may be veiy
Btnall, AS a puiidured or giui-sliot wound. Frotii your anatomical
knowlcdjjc you should know what Ittrtje vessel may be injured by »uch
a wound. If, from tho free Itfeniorrlinge or its freqiiont reeunetiee
after roDipreission, you are 8atis6ed that ligatioti is tho only oorWn
remedy for the bleeding, you have the following alternatives: eithor
enlarge the exialiiig wi^und by careful, clean incision!«, and seek for
tlie vessel hi Ihe wotmd while ilie artery is eumpressed ubove, nnd
IJgat« tbo divided ends of the arlcry ; or else, while you bare the
TBEATMEXT OF «.EMORIIIIAGE— COMPRESSIüH.
30
bleeding resse] compressed in Cbe wmtml, yoa seek the reatral part of
tbe Touet ulK^'ve tlie wound, and tlieii ligaU; in Uie contiiiuitj. Botli op*
erstioos dcmuid accimte anntomic«! knowlMgc of llic poeitioaaof Llie
uUtleS)ind ]imctic>c. MHticli of llicM'tiru operations you shall <4kx>»>
depondB oil liow jou can soonest pnulciitly attain your o^j(^-t, and
OQ irbidi of tlieoi will rcquiro the souillcr new wound. If jxiii think
jou cnn expose the artery in tlie wound williaut enlnr^n^r it much,
rlioose til» mfilioil as the raorn cirrtaiii ; Iiiit if you ixmsidiT this rcnr
dJQicult, if at tW ^-«t of ibv wvuiut ihe itrt«-ry lius deep under muM'Irfl
and h$c\Aj (^specially in very niiiRmlKr or fnt person^ iimk« a re^^Ur
ligBtinn of tlie artery above (tovtanl tin* liexrt from) tlie wound.
I fitiall not hero discuss the points clioscu after yrara of trial, od
tbeoretieal and proeticiil grounds, for the ligation of arteries. In op-
ettttiTfi siuj^ery, in the text-books on surgical anatomv, uid ejiperially
ia tJie oprtvli«'« course, you will Iw iiistniot«d o» lliis jHtinl, niid must
■ttain pfudioo in (wrtainly finding», neatly csposiog, «id carefully
UgKtinff, the art^Tv, in doitig whicli, you eiiniiot acciuiom yourself to
too inueb peduiilry and leohnicality.
2, V'>tt>pr<«»i"n, — I'rosaurc on tlio blwdin^r vessel with the fin^r
is mcb ■ gimplf, apjiareut inetlwd of nrroitiiig liiL-niorrliikg«', if we
may call it a inetliod, that it u atmnj^e tlie luity do not resort to it at
once; any penou tlmt lias seen one or two o]>eratioDB would iiistinc-
lirely liold liis (ingtrr on the blccdinp^ X'essel ; still liow rarely p4H>|>lo
do this iu a cue of aecideuul wound I Tliey prefer resorting' lo »11
eorta of home rcnnedies ; spider-web«, hair, uritie, «>id nil siirta of Hllh,
are smeared over the wound, or «lac tJioy run for some old u-otnao
wlio can arrest tlie bleeding by magic. And no ou« around ibiuks of
[iCCpipreBMny the wound.
Methmlieal onmpression may be made for one of two puiposes, oa
' pmrislonal or permanent.
Provisional ociDiptfasion, wliicb ia used tit] ve am determine
how tlie Wecdinff may \to h«*st arrested permanently, may either be
madti by pit-ssiug i.li« liloeiÜng vwtwl in the wound aj^itist n linno, if
ptesible, or by pressing the c(>nlnil part of the artery Hgainst the
bone at some distance &oin the wound ; Üic former, m wo have ul-
Kudy stated, ia to bo done when wt- propose lo ligate the trunk • the
latter, when we wish to tie tlie bleeding end of the artciy, or to ex*
acoiue the wound more csur^fully.
WlH're sluill wo compress Die artery, and how shall we do It moat
cffi-ctimlly? To coraprc!» the right carotid, you would place your*
self behind the patient, and lay the tips of the. eeroiiil, tliird, anil
(burth fingem of the right band along the anterior border of the
i«tertN>cleidomastoideu4 muscle, about the middle of the neck, and
30
iJlUI'LE LVCISED WOL'NDS OF THE SOJT PARIS.
press firnilj' agninst the spini?, while you pass tlic thumb nraiind the
nedc, and nnth the Ifft liaiij liuiid tlic [»aliviit's Iitiail goniljr to the
wountled hide and samfiuliat backward. You should di&tiiictl^ feel
the pulsotioa of the carotid arte»y. Firm pressure hero is quite pain-
ful for Ü1P paLk'Tit, for I he \ii;^ti.s nr>n,'e i.s una^'oldnbl^' »)iu|>re$iscd, And
Ihc ttriisiuii of lite purts titfci'ssitriiy Hvtfi on Uie Uirriu sud tnclica.
From til« frt-u atmEtuinosc« of ibc two oarolids, the effect of oomprea-
sion of Olio of tliem, in sm'Stin^ bliMvlin^ frain »ii urk-r^' of the livad
or fsce, is not generally very gi^at, and i»crfcct compression of both
reescls rcquirt's so niticli epncx-, lliat v,o must ^ocrallj bo satisfied
with diminishing tUo volume of tlie arti.'ri«B by incomplete compres-
sion. Compression of both carotids is alwa}-a a. very painful and ier-
rifviu}^ oj*cratioii fur the puticiit, especially ou account of the strong'
»cmmlary pressure ma.de ou tbe liu-ynx and trachea ; hence it is rurelj
employed.
Ounipreissiijii uf tlie »vhclacian artery miky be luorc frer]ucntly ro-
quirwl, e^peciidly in woimds of llii* artery in Mohrenheim'« fossa and
ill tliL' axillii. In this ojienil tun also yon amy best stand behind tbe
recumbent or bulf-sittinjc patient ; with your left hand meliuc the liead
of the patient toward the wounded (right) side, and pufili your riglit
thumb firady beiiind the outer bonier of tlie dartcular portion of the
relaxitl »teniu-<^;leido-niuslo»d muscle, po thuL yoii may firniiy CK'Ui|>res8
the artery ii^oi»»t tlic &^t rib, at the point where it pn«5cs fortvord
lx.>tu-eeii th«^ «ealeiii iniihele«. Here a.\ff> ]tre^urt? i« iminful, from tlie
liability of the bnttliiuJ plexus of nenes to be included iu the com-
pre»«i<Mi; still, by employiiig sulTieii'nl force, wc may oooijiktely comr
I>ress the arU-r}' üo us tu arrtist pulbutiou uf the nuliaL But the tliumb
800U grows tired and loses sensation ; bcnco Torious aids bare bees de-
vised— iitstnuncats by wliich tbe comprcEsion ma.y be nmde certainly.
One of tlu? most eonveuient means is a short thick ki\v whose wardfl
are wntp|H>d in a handkerchief and the handle held finidy in the palm
of llie hand; you place the waitia of tho key ovi-r the arterj', aud
cnnipres» it firmly against the first rib. I}ut this eauuiiot fully rt-pl^oe
eoinpresAJoii by the finger of a skilled it."i*i*tant,furivith the instrument
you of C(.iui»e eaunot feci if the artery slidt» away from the pressures
From it« position Ihe iraehtat artery miiy uf course be readily
oomptvucd ; in doing this, you place yourself on tbeouter side of tlie
arm, take th« aitu in your right hand, »o as to lay the secnnii, third,
and fourl li fiiigt-rs «long the inner sirle of the belly of the bioeps, about
tlie middle of tbu arm or a little above it, surn)unil the rest of the
anu u'itb the t)iuiid>, and pres» ngiiiiit>t the liuniertis with the fingens;
tlic only diiuculty hero is, ii> avoid pimullancous compression of the
mediau ovrrc^ nhkii at this puiul ulmuel cuveistbu artery. By o(Hd-
TltEAT)l£N*T OF nSMORRnAGE-COUPRBSSION.
3]
pn^aaiDg Üio tirnchu] tuicr^, wc may rcadilj* nrrcst tlic rudia] puke,
and w« may employ thU «nnprcssion i,Tilh great advantage if wo de-
. lure to ligatc cither tbc radial or uluar artery on account of wounds,
\-OT to amputate at the foreaim or tlic lower part of tlic arm.
In hKmorrhages from tbe arteries of tbc lower extremities wc com-
press Üiejimora/ artery at itx (-(immenoemciit, that i;*, immediately
iov PouparCa ti;;ntiu;iiL Herr, where it lies just in the middle \x3-
Itwecn the tuberctiliim pub» and «nterifa- infeii(>r crest of Ihii ileum,
the artery stiould be pressed aj^iusL tlie iKKÜontiil tiraneh of the puljiii.
The patient should be recumbent ; compression should be mode with
the Ihuinh, and is e«»y, because at this point the artery is supcrfitiaL
Ai Jar down as the lower tliird of the thigh, the feinuriU artery may
be oompressed agiün»t t)>c femur, but tlib can otily be done certainly
by the Gnger io very thin persons ; in most coses wc employ (or tbli
purpose a special eomjms» cftlled a toumiipii>t.
By a ttjtirniquvt we iiieou uu a]>jMnitU!( by whiirb wc prras an
elongated oval pieec of wood or leather, a pad, against au nrt<7y, and
[this against the bone, by memig of a twisting, screwing, or buvkling
mechanism. Since a long compression of ihe brac'ii:il or femoral ar-
I teries is \ex\ latij^uing, wc may advantageously cnll it (o Jiid in cum*
PpreMtn;^ the«« arteries. The form of instrument that we now employ
[is the scraw tourniquet of Jran Louitt Petit, The \ku\ vrhieli \s rnor-
'able on a buid, is to be upplit-d cxaclly over tlic point cnnrsponding
to the iirtery.and opposite the screw, under which a few folds of linen
,are In be plncod, to prevent too great pressure on the skin. 'Jlien
plniclth' the bund around tlic extremity, and by means of itie acrew nnd
ad draw Ihe pad lighter till the suhjucent artery eense» to pulsate
Md nn ampulnlion- wound, if we do not nt ont.'v see the innulh of lite
ftrt«ry, we may loosen the screw sli<;btly nod permit n little blood to
escape Eroui the arten', wliicli at once shows iU position; then acrcw
np tlio tourniiiuct at onee, and ligHle the artery. TWii is tbe great ad-
vaotage of the screw. ^VHicu the opiaratus is well made and careful-
ly applied, it a of excellent Bervicc. It ia true, thn bond »round tlie
limb imnixiidably eomprcsseit tlie reins, pspectally the aulxiutaneous
wins; neverthele^, on account of the [»d, it net» chiefly on the artery.
Witb a picr<r of brand bonda;ru and a round block of wood, or a roller
of h4nclBge and a sliort etiek, you may readily improns« sueb a tour-
t>i(|uät; still, if itiis impiDvised iippiralui does not üeourc the artery
VKxy (innty and »ecurely, 1 should advise more ecrtain modes of com*
prcMiOD, of which I shuU speak immediately. The facility of olioek-
eren consiilerable b:eraorrhages by meinfl nf the tourniquet, might
IcInJo lis Into leaving it on for a long while, unlil tlic bleediog
of itsclA and wc should thus escape (be trouble of ligatiug.
33
SlMi'LE CfCISED WOÜSDS OP THK SOFT PAITTS.
ThU iTOuld be a great error. If the toumkLUOt roiiuJitsoii bilfan
hour, tlic cxtrcmit;r bcluw it jt^ovrs blue, swells, loses scii^aliuii, and
circuUlio» in tbc piirt may bo entirely arrested, aod it will die;
tbruugh yuur whole life you would bUitue yuurself for euch na error,
which [nigl]t grratly endiuigcr the life of vour patient.
Bencc, appUcNtio» of the touruitiuet is ou\y adiut»slblc as a pro-
riaionul tiiomoKtntie. It i» almost inipmetjivablo to (■ompre.iR a large
«rlery Willi liic fitiger till IIm luemorrliJi'Tfr 8b;ill be certiinly an-ested
a|Hj[itno comply. Still, coisca muj ■rise wberu coinprcjisiuci witli tlie
fingLi- iit the only cortaia modo of am.'etiDg bb>odiiig from smHilor ar-
teriem, as in hurmorrha^s rpom tbe r^^otum ordo^p in tli€ pharyax,
when other tne.ius have failed; here, compression wiÜi tlio lingLT
niiifit Kumetim{_-9 bu eontinued half an hour to an hour, or longer, for
ligatioQ of the internal iliiic in tha forinnr case, and of the earatid in
tlie latter, are lis diuij^ruiia as they are uncertain fi>r a i>e-ri»anenl ar-
rest of It« btwjdiiijj,
Quito ret*utly ibc goninl surgeon «imI obstetrician, Slmpton, of Ed-
inburgh, whom you already know as the introducer of dilororonn,
hoa recommended a inetliod which I cannot recogniac as a perfect aub-
Btitute Jbr ligatian, but which is in nmny easoH of pmetic-al um! ; this
is t!>c compression of the lilc<!iling artx-ry by n needle — aeupretgurtt
Aeupresatire muy be miidc iu vitriüua way». Fiv Instance, iu an am-
puliitioii-fliip, yen iutrtrtluee a lung tiisect, or »ewing-neoHle, nearly
vertic:i!ly tbrmijrb ibe «Viii mid »ofl parts to witbiu oiie^|iiiirti.T or
ntie-b»if an ini'h »f the artery; turn tlie needle horizontally, bring ita
poiut elr«c over or under tlie artery, and iit iibout the sanio distance
from tlic artery you pu^h it into the soft p:irt«, and p^issituul throu^
the skin nearly vertically, so that the artery nliall l>e compressed bo-
twi-on tlic no;.'dlo and tbe soft parts, or, still better, against a hon<^
Sliould this nejmpression not aet perfectly, as it would ran;ly be likeljr
to in lar^e arteries, if the first needle was applied abore tlic art«r}',
pass n seoond one baiow it, and 8o compress the arterj' Iwtwcen the
two needle», or else press the artery against the nr^edlu by means of
ft wire loop. In amputaUoiis I prefer acupressure by torsion; I paas
the needle tmnsvorsoly through the artery, which is drawn forward,
and with the nwdle make a half or whole mlalion in the din>ction ut
the radiii}* of the surface of (he flnp, until ihu bleeding is arrcated,
and tlien insert the point of the needle into tiie »yft purlji. The
needles may he removed after forty-eiplit hours, witliout ivnewnl of
bleeding. The extensive esperii^ico of Knglisb surgeons in tbe suo*
CC88 of thie bold operation first gave mc coumgo to try it, and I must
Jicltnawledgo that in several nmput.'i(ions, even of tbe thigh,! have
seen no objcctioa to it. I cauuut quite believe that acupressure «itl
{
TBEXTHEKT OF ILEXORIUIAQC— 003IPRE£SIOK.
88
nltagethvr ilisplaco li^lion, as Slmpgon jirophcsiotL In lliu opcm-
linn, to wliirli I liavc* rcsorlccl in most of iny aniputations for sev
vral j-eare, I employ loag goMcn needles with luge bead^, bcciiiiHo
other motiiU rust easilj*, mid silver is too Rofl, and plstintim too
cxpemivif.
Tlie finn iiiiioii <>C tliu li|>s of tbc notin^l by mcaiüt of the mitun is
a. moilc of ro»nprc«sioii not iinivrnuilly hut occa.5ion»ily applicable;
fc^ra shall MOU speak of tbe suture as a meiias of closing vounili.
Comprcs^ioa aa a pamantnt tucraostafir, as it is emplnvRi] in ve-
notis lucnorrhage, bleeding fi-om jiiinjcroua stnoll «rterics, etc., «ipe-
riitlly ill so-ealled pareochymstoua hnmorrliaf^PH, must b(> mndc with
I bauthiges, ooniprcaaes, and rliarpie, aa ban<l:iges or tamixxiades.
Stuffing the hlccdinjE; wound lightly with chuq>ic, or applying a
handngv tightly around s limb, wotdd be aa itijuriuus for jiennanent
»pplirations as a tightJy-applir<l toimiiquel.
If you have a bicraorrha^ (run) tho arm or le^', that you vieh to
aiTCiit by enmprPAsicMi — if, for instnnoc, large qunatiti<>« of blo'^rd nra
V'ing jxiured twt from a dilated diaeaseil rein, or if tlien.' bu bleuding
from numerous Hniall arteries — yuu inay iipply n l*attclaKfl firmly from
the lower to tiie iippor part of th<» extrpmity, Imviniy prcriously covered
the n-ound with n corapn-'M und ctuirpie, and after applying .tevprul
thick II Bttscn of Itnni ahnig the course of the ehief artery of the exlnnnJly.
fur the lulter purpose you may aleo employ the grudunted coniprcs«,
IVbicii you will Icara to make in the course on bandn;r4>s. To this,
\«'Lieh is allied Theden*« dressing, it is well to add a splint, to keep
I Ibe extremity porf«:4ly quiet, for. the blcMlinj» i« readily renewed by
tmiisculnr «in tract ions. Tlio«o ^rmdiiiited «impresses, carefully made,
arc particuhirly serviceable on the biittle-ficld, in (rut>«hnt and punc-
titrtil -wOLin<Ls ; by their aiil we may arrest ho-morrlia^ from Uie ra«l)-
al, iilnnr, anterior nnd ^losterior tibial, and ereii from the braehiiil und
femorjii arteries. In tlioformerorsmaller arteries, by leJivin^ tliedre*9-
in^ oa six or etglit days, we may arrest the bleeding pennaiicntly,
Ixtt in the hitter it only acts as a provisional ImmMtatio; it must be
fcilIoH'Oil by ligation, if we wl^Ii to be at all sure of avoiding a ret?up>
rencoofthe bleedinfr. We may also employ compression in hiemor-
Huigeft from the thorax, a» in casp of pnrenehymatous btemorrhage
•flcr remot-al of a diseased bre^ist ; here we may dre» the wound with
roni|>re<.te^ and charpie, and retain thorn in )x}sition by Iwodages
srcnind the thorax. But, for such a banda^ to be efiiencious, it must
|bo wry annoying to the patient; on the wholf. it is bettor to l^to
itie bleedin;r arteries, even if tliere sliuuM he nitmy of them; by so
dob;, both you and yow patients will bo better off, for you will not
be worried and disturbed by the secondary htemorrbsges (ollowiiig
34
SIMPLE IXCISED WOCN'DS OF THE SOFT TS^TS.
these opciatioas u n result of hiLsty li^tion and insufficient comprce-
Biuii.
In name parts of tbc body you ciiiinot employ contpreascs, iis to
Ueoiliug from the rectum, vajpna, or poetcrior nanrs. llcrc the tam-
pon (I'roni Icmpon, plujj) is serrioeiible. Thare are many rarieiies of
tampons, «specially for ha^niorrliage from the ra^na or rectum. One
of tile simpli^at ia ua fulIuiTs : Titkc tt fuiir-eorncrcd piece of linen,
about & foot square ; placing' llio middle of this nrcr two, three, or fire
fingers of your rij^lit band, posa it into tbc I'ag'iim or nx4iim, und lill
Ute ^>ace left liy tliu ri'morul of your bund with a« muvh charpic ms
you can gel in, so thnt tlic vagiim or rectum wtU be fully dutcndcd
from witliiii, and tbns streng prt^umre be made on it» walls', when llio
hfemorrhagc is arrested, leave the tampon in till tbc next day, or longer
if neccMary, tlitüi remove it by gentlo traction on tbc linen, wbtiJi
Berrea aaaaaefor iheobarpie. You may also make n ball of cbarpicor
linen by wrapping a string araunil it, and leave a long .'^triug ban^ag
out by wbicb to rt.inuvc it; as audi a tampon may be eitlier too largo
or too email, I prefer Wie first method, in wliicli we may fill Uic linca
sac to the extent we desire.
In profuse bJecdiiig from tbc tioec, which moslly comc5 from tho
posterior part of tho iofciior meatus, and not unfroqucntty from the
poKtcrioriy-ailuat^d envernous tisRue of the lower turbioatW boup,
plugigin^ thf nose fmin llie front proves inclViwicious and useless; the
Uccdiii;; coutitiue;', and tbo blood either paues inlu tlie pharynx or
flow» out of tlio otiier noRtril, as Ibo patient presses the velum pen-
dulum piiUti against the wall of the pharynx, and shuts olT the upper
pait of Ibo pbnryiig;cal cavity. Hence, vre mu&t lie prepared to plug
the posterior narea ; wo may do this by the aid of Bvlioe'a sound. TliU
exceedingly convenient instrument consists of a cauula altnut six Inches
loi^ Knd slijrhily run'etl at uiie end ; in Uie canulu va i\ steel spring of
mucb greater length, with a perforated button-bead at one end. Yoa
pfopare befon'liaud a thick plug lurge enough to fill tlie posterior nam,
ond bavn a thread attached to iL (You may make this plug by lay-
ing tJiieads of cfaarpie side by side and tying them tightly together in
the middle with a ailk tbread) You apply this plug by passiag the
instrument, with rctrai-ted spring, tbroti^^h th<* inferior nasal meatu»,
then pushing the spring fomard till it appear« below the velum in tbo
moutli. PaNs the ibrcAd uttar-bed to tbo }>lng tlirtiugb t\\o eye in tbc
bead of tlie spring, tie it there, and dntw buth eanubi nnd spring uat
of tlic nose ; tbc ibrcud ntUidicd to the latter and the plug tjist to this
must follow, and if you draw tightly on tli(^ thread the plug is pressed
firmly into the postxrriornarcs; if the bleeding be now arrested, a» it iinu>
ally is, if tJicplug {whtdtsliould not be long enough for itseud to resell
TREATUEXr OP n.EMORr.HACJE— SHTTlCä
31V
the laiTBx) was not loo smnll, you cut loose tlic thrcud, Icnvc the plug
ill til! llio next »lay, tlur« xTitlnlniw it l>j' tlie tlircinl Ivfl burigin;^ from
the rnootb ; this is iisunllj- «isilj: <IotH:, iis thu plug is generally eovereJ
nitli nucus and is conscqucutly smootb. As this itiätronient is uoi.
nn at hand, we may use an elastic cailieter or a tliin slip at wIwIin
bit lli(* (ian>o purpo&e, intrtiducing it thniiig^li tW nose, seizing it
with ifac finger beliiiid the relum, and briiigiug- the end out of Uie
iJitHith to lie the thread to it. IJut tlie oniplojinent of this substitute
retjuires moTO dexterity than is tH^cewmry for BtUoc^a sound.
3, Slyptiai arc rcmirdies wHith act partly by causing contraction
of the tissue, partly by inducing rapid and firm coagulation. Th« uum-
bcr of rPDindies recommeniled is immense ; we »hall only mention tboso
bav-L* n pttivi'il n-iuilntion inider ixrtain cirnHnstancies.
Cold not only irril«t<.-a the arttTJcs and rcina to contract, but also
tnahes tbo ntber soft parts coiitmet and thus eompress tbe ressels ; the
curmjt of blood is grodunlly more obstructed, and may even »tngnate
entirely, wlca tbe jjart ia completely fn>zen. It scenw to me, tiowever,
thnt the recommendation of oold as a hn>mostfllio ia often oarrieil too
far; I advlM you not to rely on it loo miirh. Cold may be employed
nn foltuirs; first, vre may squirt lei-water against tJic bleeding wound,
or into the r^gins, roetum, into the 1>liid<!i>r througli a mllieter, into
the nose or moulb — here the mechanical irritation of a etrong stream
of water is lukled to that of the cold ; or you may lay piece» of ice on
the wound, or introduce thein into the cavities, or hare (hem swallorrcd
In gastrieor pulitwiinry hn-niorrhagc; or, lastly, you may fill a bladder
with ice and «pply to the wound, to be !(.'(% on for liour^ or diiya.
The a&»oiut4) quiet ia bo obecrrcd in all btemorrhngcs and tbe dim-
iuutton in size of the arteries as a result of the bleeding that has
already occurred, may often have more effect in arresting ihe hirmnr-
rlmge ttuin \ix has, \t'hilc it rcreivRs all tlie credit. I will not di^suado
you from using cold in modenitn ptiroDehyniatous luemorrhages, but
do not «x])ect too much from it in bleeding from lai^ arteries, and
do Dot waste too tnticb time over it, for time la blood — blood is life.
Tlie same is true of the common local remedies, vinegar, Rolutinn
of nluin, etc., which also contract the tisues a«d tliu» oomprcM tlie
¥essels; they are very good for arresting capillary bcemonbagcs from
tbe not^-, hut you miwl not expect any thing won<leTful from tliem.
Tlie ^ct iVo«, femim eaiidcns cnustieum aetuale, nets by chorring
ch<* ends of tbo vessels and the blood, and the escape of the blood is
arteste«! by the rcBuIting firm slough. Vou only need to hold a rod of
inta with » wooden handle at one end, nni) at tlie ulbor a smalt iron
bead boated to a white heat, close to the bleeding »|xrt, to fonn a black
cruet instantly ; indceil, the tissue occaaionally blazes up even from the
3d
SIMPLE WCISED WOVKDS OP TUE SOFT PARTS.
mtlintocl heat. A rcd-liot iron pressed on Iho bleeding spot has tlie
Bam».' fffftt, bill is «pi to ding tg llie resulting eschnr and pull il uff
sgniii. Tills iron rod (cautery iron) is usually bcattnl io tlic proper
cU^gnM? in n furauco with IjcUok's, Under Bome ciroumstancct tlic bot
inni may be very couvemenl for arresting lueinorritngR; fonm-rly, ])i>-
ftwr lif^.itioit Wii8 know», il was tliH tiioat ccU-bniU-il btyplic. Tbc
Aifibiau surg^-ons UBUAlly boated their ampuUtliO); koirt^s red bot, a
prwt'wülig lliat I'ven J'abrichi» IliUlumu extollod, althuugb Le pre-
ferred burning tlic blwtüng artorics sc-ponitely n-itb liiiopfrintcd cau-
teries, inwbicli be must have bud a» enviable cxpcrtncss.
Quite K!C4.?ntly a similar metbod bus been invented, namely, the
vae t\i plaliniim licated by the galvanic battery. Tliis ig tbe HO-csUed
gidvano-cauttic iulnxiuced into Geruiany by JfiddUtforji/, ntiiob may
Mm(>tin>e!t be cmplo)*ed with ndv^ntago. Ax yon may rr-miily imdei^
sluitil, in jiraclicc ue Imvu nut altvuys rI bund iin iron propc-rly sbspcd
fur arrfstJng bu:tnarrbnge, such aa you gcc in the surgical clinics.
Jfi^ßenixt^fiy the iivost talented Gonuan operator of tbia contuiy, wbo
was at the same timo a most original man, once, lacking oilier means,
bringnlimeina poor dwelling, arrested a lijcmonliiige MIowing tlus
cxtirpution of a tumor from the boclf, by ineaoscf the tongs whidi bo
heated in the Move. A knilling-neeille, stviek in a piece df iruod or a
cork, and healed at tbe lamp, iiuiy answer tbe purpose of the hot iron.
A remedy which not only equals, but oeeadionaily surpusaes, tbe
hot iron in its eS'ects, is liguor ferri sc^iiiehtorati ; this forma with
tlie blond such a Icatliciy, adbcrent oougiJuin, lliat it act* ex«?llently
t» It alyptif. To apply it, you press a piece of <;]iar]>ie, moistvned with
it, Hrmly ngaiiist tbe irounil ; after lia^inj^ wnsliod off tbe blood with a
sponge, hold il tliere from two to fire niinutcit ; you will ihu» be aide
to arrest iiuitu frxx* urtorial hu-morrhage. If thi; linst npplicition does
not succeed, try it a so<-oiid or lliirrl liine; this remedy will rar»-ly fail
ytAi; but it makes a nlougli, behind which tliere ia often sanious sup*
puraiion mixed with gas-bubbles; bcncc we should not employ this
styptic noedlcBsly.
The application o^imnli and blotling-pnper to bleeding wouml» ts
auokl |Ki])idnrteinedy ; the punk sticks fast tollie Uurjdaiid ihe wound,
if the bleHing be not czceuivc ; >o hirmorrliagea at all free it is use1c«a
without ».iinitltiiticous LMmpresi^iuii ; UL-mwionally it is very efHeiieioua,
and is lii^ldy praised by »ome surgeons, Dry cluir[)ic prcsse<l firmly
on the wound lins the same effect, according to my experience.
Other haemoataties are 01/ of turpentine and ayua Sindlt, in
wliieb the creosote w chielly effiracloas; concerning tlie ftmiier »luiiQ
harn I any espericnce, and I recommend it alrongly; when I studied
in Göttingen, it was also specially rc'Commcndod by my preceptor.
THEATMEN'T OF n.EJIOnitlUGE.
3V
[£<mm^awi I used it once with audi etnkingbcticnL in a doulHful case
Ithnt 1 liiirc K cortiiiti dcvfition for it. Jl ia, liowfiver, an l](.Toic remedy,
nut craly Imxmuso apjtiiciition of lurjieiiUiie-oJl U> a woiiud iiidut«s
Bcvt-n; pain, but uIimj bemuse it cxciivs hcvwc inOaniniuLiua iu ibo
«round and it« vicinity, ] will relate the case wl)cn_' I cniployed it.
A young, fei-bli* woaiiin sulTpred, after (.'onlitiL'nieiit fur niHDjr inaiitliB,
: oil dtenftivc suppuralioD bebiad tlio right breast, between the
iDuar}' ({'"■'d and tiic £^cia of tli« |>e<:tonü muscle; uuiiierous iiici-
I imd alreudj' Loon inado ihniii^h tlii> bronst, nnd about its ciroum»
ncfjto give tree access to Llic [)ii-> wtii<-li ruriDcd tnsui-liquaiititif»;
but the openings eoop closed ufipiJu, uud nciw ouvs had to bv niudv, a»
;the vround did not boat from bvluw. Froin uiki such iiictnuii, wbiL-b I
Inulc quil4* cxtCTiBltf, severe hifiiiorrliage n- suited, blow) welled up
lirDtn ifac depth oi the absecs«, and I >Taa nnnblc to Und the bitting
veaael ; it flowed enntintiousJy, as if from a spring, Pirstf I filled the
cavitjr with efau-pi« Aiid applied a 1)an(Uge; tjie blnoil soon oozed
througli tili» dn-.N^iiif; ; I rvuiovt-d It und iiijecltHl ice-wutcr into llic
lopeaings ; the bleeding modetntetl. 1 again made Hrm eompree-
'koii, nod tbe hsraiorrhago secmod anv^led. I had searecly rea(d»ed my
room in (be hospital when I wo» called by the Dutse, because the [Aowi
■gain ocMted through the dressing ; the patient bad fainted, was palo
M a corpsf, arwl the ]njl.«i> ifus very smaU. Tlic baudage ha^l to bo
emttred at once. I now thrunt pieces of ice through ttiu diflcrvnt
rdogs iototlic cavity under the hreaät; itill tbe bleeding wus not
'■msled. The |):itifut went from ono f:untinf^-ßt into uiiuther, llie l>ed
flowed with hloodund Ice-water, the paticut lay unconscious, wilb cold
limbe and upturned eyes, the nurecs constantly trying to rt'suaviliitc tlio
patient by holding uiniiiouia to the uo^e, and nibbii]g the forebciid with.
Ctdognct water. At tbc oommcnccment of my surgiral life, unnccufr
Looted to quiet »ml preacnee of mind in such ecenoSf caused by my arm
«et, I «hall De\*Ar forget tliis BituutJoii. I tbou^t it woulil be abtio-
liilrly neceasai^ to nmputiiie thv. breast at once, to find and llgale tbo
bleeidiu^ artery, but detemiined to muke one more attempt with oil
of turpentine. I sdiike*! il few vnuin in tlii« 6ul>stance, introduced
■tbcm into tho wound, and the bleeding was instantly anested. I'ha
iticut KKHi rehired ; tliu turpentine, which was left in twcnty-foiir
hours, caused inlcns« reaction in the abacca« cavitr, whose n-aJls bc>
£anie detached. Subsequent active gnmulation induwd in tlm^c weeks
. eure wbioli had fix* months been paiieiitlyand petscvcriugly sought
I» rain by physician ai>d patietil. I cnnnot exjilain to you bow bleed*
ing ia nrreste<l by oil of luq)enline nnd ereusoto; they do not <;au80
ücoliuly firm congubtion of the blood; pruUibly tbc intense irrit»-
38
SIUrLU INCISED WOUNDS OF TH£ SOFT PARTS.
tioa ihey ioducc «xcites a pccuUarlj energetic contntcüon of tbo di-
vkiui] capillurio^
You vrill nin<Iy slm; styptics employed in tlie surgical cJinic ; they
arc mtliur laroriU;a of the piactUin^ phystctan, who is not aooiutoincd
to ligate arteries, Wbore wo can ligaU* or coiiiprcs«, w« should not
use Rtyptics. Tii psuvncIijtDntous hiecdinigr from the fiiw, nocJt, or
periiinMiiii, we nmy rcaort lo alyptics with advuntagi', if it uiahcB no
tiiffi-rcnw %rliHii('r the xvound »upjiumlcB subseciiiontiy ; hut, if the
bfiiiorrliitgi* \tf- I'oiiMdenihle, and styptics fsiil, suhseciuent ligation u
much mure <lilhcult, as thv iv«>u»d is often terribly suiearcd up by tlie
pr«TJous applicntions.
Id surgery you havL' nothing to exp(K;t from tha internal admiiiis"
tration of remcdicB recommended a» slyplice. Absolute quiet, keeping
cool, narüoücs, purgatives, may oooasionally bo of great a^eistAit^ iu
cxnigesti\-e hjemorrhages, but their action is far too slow for the bleed-
iiig that wc have lo ileal wit.lt in Rurgery.
The general debility from profu«; hiemorrhn^- will, o( counc,
be most efeetunlly eorabnted by «rresting the hle<-(ling; but, while
doing Ibis, you iniiy have \\ie uasistauts, not olhem'i«: emjiloycul, try
to resuscitate tlic patient by «mdling^alt«, sprinkling with wntcr,
ote. Vou eliuuld not ^-ourself join in these attenipts, till llio bleod-
iug is frttipped ; then you niay givo wint?, rum, or bnitidy, »arm coffee,
or soup; eovertbeiMtieiit up waniily ; let himtnkoa few drops of spir-
its of otlier or acetic ether, and «mell ammonia, ete, I Imve never hod a
putient bleed lo death under my haiuls, but have met two ea««» where
the pnllinit» died, two and live hours nfLcr CJCtcnsJrc operations,
with dyspnoea and npusmodie contmctione, npparontly as a rcsultof
the great loss of blood ; tliesf> cases have decided me, under nmilar
circumstances, to inject the blood of a lienltliy person into the rein*
of tlie bleeding one. This operation, whicli in «died Tra^sfwti^n, is
quite ancient ; it originuled iiL the middle of Uie aeventeenth cen-
tury. After tlie world had been for a time astonished at its bfildness,
it wa« laid aside and derided, but, toward the end of the last century,
it wiisiignin dravni front the t:linile of oblivion by Ktigli^h |iliyKieim)i«, es-
pecially the olntctricians. After Ditffenbach Iiiid made sotuc uUempts
again to introduce transfusion into Gcnnany witliout success, Mar-
tm has of lute the credit of again calling attention to it as a mode
of saring life, while Paniim has exhaustively treated the subject in
physiological expcrinieuta, Sta.ti&tics show that the operation was
favomble in thi« great majority of eases, and was very easy to pci^
fonii, Allliough formerly lamb's blood was sticccssfiilly inje-cted into
man's vein», it is best aitd roost imdirul to elioene blotfd from n young»
hcoltby, and strong human Iwing. Tbe irutnimcnts required arc a
nUSSFÜSIOS OF BLOOD.
30
kuifc, forceps, ecisAor«, » Gii« canula, «tu] a 4-6 oe. glnta Byrittgc lo
FÜt it. We open tlie I'cin of a liealthj', xtron^ jyiunjf meu, bt tlic man-
|licr livresfWr to be de*mUei], aiul ruoeive finst iibuut four cnion-s of
lie blood in a ivtbcr high bowl, Btaiidiag- in a basin ftiU of blou(l-w)irm
iriitcr; Oic Hood, flowing into the liowl, ia bentcn with u Inirlio^
btii-lc, till the fibriiic is Bepant«d. WUilo lliis is beicfC done, the moGt
tpproeptiblc auitrutaneous veto «t tho bcnil of tttc elbow of tJic pattout
lis lo be exposed by nil tcctsioa through tlic skin; theo two «ilk thrcada
arc to be pawed umW it, tlie lower oiic is drown uii wltlimtt
Iclosing' it, so thnt uo blcod nuiy i-scnpu hy the siibatx]ucnt fine; oblique
lindnan made ia the vcia by tlip ecissots. The cnnuln la paescd up
into the now gapinrf opening in the vein, and the upper thread is
ed over it witJiout being tied ; some IjIoocI should escape tltrougll
Toaaula, so n» to till it and driro out th« »ir. älennwliilc, the h»>
irifitiiiit has cninplet(>d the venesection nnd filtered tlio whipped blood
lliniu^h a ßtie cli)tli ; then the previouKl^'-warmed svrin^ is to bo
fiUol with tlic blood inv«-rt»l mid thc»tr forLT-d uut,pluax] lirmlv in the
kConulfi, und the blood injcrted veri,- slowly, Evpetionce has tmight
tliat it is not adri&uble to inject more than four to eight uutitvs of
[blood, and that this is cnoiijjh to rcadi Ufc Wc should never empty
the sj'ringc entiri.-Iy, and ceas« (it once if the patient has <iy»pna>a.
iM'lien the injection hi eutnpletetl, we remove Üie ligntures and oaiiuU^
^and tnmt the wound as aAcr renesection. There lias l>een inucli di»>
ate, as to whether or not it is necessary to remove the fibriric from
• blood to be iojeeted. Pan um'i experiment« hiivc eleiirly ]>roved that
fibrinc i« no* new^sarj- in resuscitation by triinsfusion, and that, even
vriti) the greatest curt*, it may aet injuriouc^ly by clotting. The active
clement in tlits operation appears to be the iutroduction of blood-cnr>
. as bearers nf oxygen. PosL^ubly, tran»fuKion has a Rtill wider
ture; at all events, it might Ik worth while to try it in exi-esüive
anrnnlu, refctilting from otber, immetinies unknown, rauses, even sl-
tbougU, atxxirding iu faaum's exeellenl observationa, the blood itaelf
docs out noorisb, but ia only the beurvr nnd forwitnicr of tiourish-
Itt; The exporimonu made by KtudOrftr, <lurin<7 the Inat Italinn
Tar, on the wound««! who had beootne atwmio fi-oni profuse suppum*
tiixi, hail no brilliant results, it is true, but further trials sliould be
made of (biü operation, whieh witb proper caro is not <I»ngcrous.
I eannot here enter on the treatment of tlie Inter results of con-
xklerable baemorrbagi»; it will be evident to ymi tlul, in general, ibo
cbronin effect«, the deficient fomiiition of new blood, must be oom-
bttotl by filrengtheniiig nud nouriidiiog dtot and medicinos.
40 SIUFLE INCISED WOUNDS OF THE SOFT PABTS.
LECTURE IV.
Gaping of the Wound.— Union by PlasUr.— Suture ; Interrupted Suture ; Twisted Su-
ture.—External Change« perceptible iu the United Wound.— Healing by Firat In-
tent ion.
Aftes entirely arresting the hsemorrliage from a wound, cleaning
its surface with cold water, and satisfying yourself of its depth, and
of the character of the parts divided, in doing which you must notice
whether a joint, or one of the cavities of the body, has been opened,
a large nerve divided, or a bone exposed or injured, etc., you will
turn your attention to the third symptom in the fresh wound, that is,
its gaping, 0.i division, skin, fas-sia, and nerves, will separate, partly
from their own elasticity, partly because they are attached to the mua-
oles, which, from their contractility, shrink together immediately
after being divided, and wliose cut surfaces, consequently, especially
in transverse wounds, are more or less separated.
At first we shall consider only those incised wouads where there has
been no loss of substance, but only a simple division of the soft parts.
For such a wound to lieal quickly, it is desirable that the two edges
should be brought exactly together, as they were before the injury ;
to accomplish this, we make use of strips of adhesive plaster or of
sutures.
In wounds where the cutis is scarcely divided, as so often happens
in the common incised wounds of the ßngers, we may use isinglass-
plaster with advantage. It consists of a solution of ichthyocoUa in
water, mixed with a little spirits of wine, painted over a thin, firm
silk stufi* or paper ; the back is often painted with tincture of benzoin,
which gives the plaster a pleasant odor. As the plaster readily loos-
ens under moist compresses, it is often adnsable to paint it with col-
lodion, after it has dried.
Collodion is a solution of gun-cotton in a mixture of ether and
alcohol. If tliis flmd be painted over the plaster and the skin immedi-
ately adjacent, the ether quickly evaporates, and a fine membrane in-
soluble in water remains, often puckering up the skin. A further
therapeutic use may be made of this contractile action of collodion,
by painting it on the inflamed skin, either db^ctly, or, still better, after
covering the part with a thin, coarse-meshed col ton-cloth (gauze);
this causes moderate, even pressure. When you use collodion to
fasten the plaster, avoid applying it directly to the wound ; this not
only causes unnecessary pain, but may also induce inflammation and
suppuration of the wound, wbicli should be particularly avoided.
ÜSION OF W0UXD8 BY PLASTERS— SCTÜREa
41
U Uta cutis be dirid»df «nd tho pkstcr must ixnial any considera-
ble leaiion iu keepiujf the cil^a of the. wound loj^Uier, it!hthya:xdla-
j)l:»«;Urr proves insuiBrieut, «nJ aJÄtsir« plaaitr must I»e employ«].
Of Ulis we luve two niriuties, besiilt:« iunuraerBblu muiiilieationft, from
ntt^-innt^ to mnkc it chmparr »lu] bett«r. K.nplnstnim .i^lhu&iivuni,
umpiutlnim diiicliylon cdmprjsituin, our cuniin:ni udliL<sivt> pl:isU!r, <.'i}u>
siftta of olir&oii, lllbargc, resin, and turpentine. Wtnlo it is fluid
&oni heftt it ia painted on linen, and it is generali/ used in strip«, wbich
Art; litid oi'er the wound, and liotd iU edj^ together. When fresh,
this ptiister adliercs t-xcelleullv, but loosens after a time, if inoiHt coni-
prusacs he applied orer it. Very aunstitirc »kius nrc iniUited by tltis
pl:ist!T if it is frLxjuently nppliod; thou wc niay resort to IlicoUicr adhe-
sive pliiHtcr, the emptaatritm eenuatB (cmplastniu) odlucesi^'uin album),
vbich is prepared frotn olircM»), Htbarj^, and white lead, with hot
wiU«r, This plaster adheres leas firmly, but hss the ndrantaj^ of
smearing' the Ii[>s of t!ie wound less lluin the yellow piaster. A mix-
ture uf eipul parts uf the two piasters leescns the objections and l-ooi-
btnes llw aüranta^«.
In Ur;ge u'ounOs wo now avoid ihc^ use uf adhesive plusler jnore
tlinn foriDerly, ond in its plaoc employ the atdure more cotnmouly.
Whca wo wish to unite woun<U hy ihc suture, wc generally cSooso
between two varietie:«, the interruptiid (sutura nodosa) and the Iwüted
sutuie (sutura cireunivotutu). There Is sotna truth in tlio assertion
that, by the iulioduction of u forui^ bo'ly, su:.'li as u thread or needle,
we maintain ».instant irritation in thu «<J^.<s of thu wound, but tlij;«
cannot equal the i^at ndTantage obtoiacd by the certainty of wl*
Justmcnt of the ed^^ of tbo woimd by means of sutures. Hence,
except adheiüve plaster, almost all tnib^titutes for tha suture, in uhicfa
annient and modern surgery has eihnu^ted itself, after biting (asliion-
«blc for ■ time, have been thrown aside. The suture has not yet
been dn>ppe<l, and probably ncrer will be, any more than lif^ation.
Thiiv anj certain purta of tbe body, as tlie scalp, hands, and foet,
wbr.te we try to avoid sutures, l>iH.-ati<N! tlierc ccrioin inflanmiatory
processes, which have often been ascribed to the Suture, readily ossumo
a dangerous cltaruou<r ; but I tliink tliere is a good deal of prejudice
10 this. Wounds of tlic head are especially prono to cause inflamma-
tions of the skin and subsutancou» tissue; cxtrnstTo statistics havo
iierershuwn whether this tendency is partiouUrly increased bj* the
britaliaa from suturei, Tliej^ are many articles of faith liandad
down fnim prcoeptor li> pupil, from one text-book to another ; many
nf tJK'm are ft Mrt of Hippocratic traditions, full of pmctieol tnilb ; to
tbne I pny full re<i{ieet; others nre based on accidental obserratii ins
and coasoquciit judgments ; amon^ the latter, I olasa tlie olijeotioci to
4S
SIUPLK ISCISED WOCSDS OF THE SOFT PABT8.
sutures in ecalp-mnind«, Rcviciring; my own experience, I retnember
moT« cases of inflammution fullutving wounds wbore do sutures \rcn!
tntTodused than irhcrc tiiev w.^rc. Et 13 vcrj inip^rtant, liowever, at
onoe to recognise inflatntnationa beginning in tbe head, and to remove '
(JiP Huturpfl. TliP ftinoiiitt of griping and thi? form« n( tite uroutid (t>, g,^
a tUp-woiiiiil or not) ut vnce »howr tli« nt-wissilv for sutures. One
would never tnkc ftuy unnecossury trouble iii iutcoJuctu^ nutureft, ua-j
less urj7C<d by excess uf siir^itral z<.-al ; but wLonr, fur ttie reasons above-j
givcD, adiicsive plaster will not nnswrr, wr should rroploy Mittlres.
For til).' interrupted eucunü vre usa surg-ical needles mid ^llk tbrcndj
or wire. Surffif^tii needing differ from ordinary otim, in htiring a lane©«*
Rbn]Hi], ground point, wliich [»erccs the skin more readily ttian lliu
round p<.>int uf 11 Pt-wiinj-noudlc ; tlit-y urc ulso of sotncvrhtit softer
s\*fi.'\ tlijin Ktiglisli scwinp-ncodlcs, so that thpy do not spriitg so
raucli. Their tliidcness and length vary greatly, accnrding as weV
irislj to apply n Htmng Uircad df oply where tlwi cilgra of tbe wniind ™
are l^nsp, or only to use a tine thread (o bring- the viiges tojretlier ex- ^
actly. All npedles should, liowevi*r, have a ^oofI-si7cd eye, »o tliat wo ^k
may not, like 11 tailor, lose lime in thrvadin^ them, but do so readily ^
and quickly. Tbc needle may bo cither 8trai;rht or curved. Tho
curve (ilionld vary with tho locTility wht*ro wt* wish to st'wr; for in-
atanct?, very fine, stronylyi-urved iK'cdle-s arc rrqiiired for wiving almot
the inner canthtis of the eya ; large, &lrongl^*-i:urvod needles arc
needed for sewing up a pcrinicum, ruptured during labor, etc. The
curvBturw may citlit-r I"h> in the whola «ecilh- or ouly at t.lie pointed
end ; for instiniw, for certain upi-nitiotis, it is shaped like a fish-hook ;
the variety is very grwit. For sewing such wounds as usually present
themselves in pntctice, you need ovXy a few fine and coarse straight
and rariously-cnrved ncedlfls.
The tlireu<l 19 usually of silk, n-hose ooaraeness correitponds to ttio
aizo of the needle. Formerly I alw»%*s sewe«! with the red German
silk, which has long been used fur this purftost.* ; but in Knjjland I
found u Sort of undycd, strongly-lwUted silk, which, even when xaty
Rue, is so Strang ihul, wiUi thread hh thm as a hair, wo may sew up
wonnds nnd draw them together. Moreover, this silk imbibes ao little
moisture that it may lie fur days ui the wound without swelling or üv
rilating. Now I use onlvtlii« «o-ralli'd (TiiincRn silk. Another mate-
rial for Hutures bus been liilely «ised in F^iigbuid and Anjeriea, vit,
tUvtr or iron wir«. It must Iir very fine and soft ; the iron wire fur ilits
jxii^wsc is well nnnealed. T[ie trial of this material was first inditeed
by the long-knnwii fart that, when metals were introduced under tbe
akin or anywhere in the Inidy, they usually excited no suppuration,
but the parts often healed over tbein. Uence, it wa» thought tbat
UNION OF VrOCNDÄ-SCTöBES.
49
liQ inflAranuitiofu often occurring at the poiotd of suture might be
roidecl hy using metal instead of the animal Bubstance ftilk. la
Litb, It cannot be deiiird that tbiü siippumtioii i» \iys» xpt Ut occur
DielaJ litMi fn>tti silk Lhrcnd, still expcrimetita uf Simon liuvc
ywa that the ftujipuration from sutiin« depends groati j on the tiiick-
of tbo thrvad. From my own cxiMrricnot* I caa afGrm that fine
, »ilk threads cause as little GU|i]iurntion along ihn course of the suture,
^Bod m&/ heal in, just aa well as metal ones.
^" We come now to llie a/tplieation of tKe interrupted atUurti, Vou
do it as foUon-a : ivilh a toothed forceps ^u first sobu oiiu lip of th«
vrouad; pu« the ncvdle tbroii;;h the skiu, about Ctro lines from the
edge, tiS d^]> as the subi'nuineous I issue, and bring it oul through the
wound; now seize the other lip of the wound with the forocps and
pienx! it from the wound up ton'ard the skin, exartiv opposite the
&ni point of entrance, then draw,- the thread throufth and cut it off,
leaving both sides long enough to lie readily' iu n knot. Xow make
a ftimple, or, if tlic teusion of the borders of the ivouiid he gn^t, n
aarjcon's ktiot, and draw it tight, seeing that the edges of tlio wound
are in exart apposition; then make a »"L-oiid knot, and eut off Imth
^thrcad.i, close to Ute knot, so that no long rndü of thread may get in
^Hlc tvound,
^^ Should jou desire to use wire, you thread it its you do the »ilk on
the needle, draw s short portion through the e^re and bend it, then
make tlie suture as above desfribcd. When tbo wire is very soft, wo
» tie a knot with it nieely, just as with a silk thread; still, the
Jiole of this manipulation is iniicli less pleasant with wire than with
i;ad, and on eloäio^ the knot the lionler of the skin ta readily
J, or ther« may he twists, that render the hold ie>s secure;
U espoctally apt to hapixni with our German wire, vrhich has not
^rt attained the softness of the Knglisli. The plcosantest wires are
thoso mad© of a mixture of gold and silver nml of platinum, of which
very 61», pliable, and, at the same time, firm wire may be msdu. [Very
nice wire is made of lead, and it is supposed by some to be ait advan-
ttge that (his will break if the ports should swell excessively.] Stilt,
>w ridirulou« it would 1m? to try In mib-itilute theKo exiwnfiive articl4ts
ordiiiar^' »ilk, hy whk-li millions of wounds have Inx-ii healed excel*
itly, aod will be in future I J pass over the many ncwly-reoaratncnd-
modea of fastening the wiru by knot« or twisting; they show that
tbnsc who adrocnte mctullic sutures hare found some tmuble in
stcutng tlio knot. I fir.'it make a simple knot, draw it together,
Bake two or three short twists, and cut off tb« cn<l5 elose to the
twisted part. Wiie cut« the edges of the wound, jiut as silk does, if
ibeTei7 Gne.
44 SIMPLE IXCISED WOÜKDS OP THE SOFT PARTS.
I have rarely found the little objections to silk sutures sufficiently
annoying to make me often replace them by metal sutures. I only
consider the latter preferable exceptionally ; of this we shall speak
more in individual cases in the clinic. Formerly great pains were
taken to replace silk by other substances, such as fine catgut, horse-
hair, etc., but these attempts met with little success ; hence, for the
present, we will be satisfied with silk.
Straight needles may be best introduced with the fingers ; but
curved needles, especially when they are small or the wound deeply
Beated, are introduced better and more certainly by means of a needle-
holder. There are numbers of these ; I am in the habit of using
Dieffenbach^s. It consists of a forceps with short, thick blades, be-
tween which we hold the needle firmly and securely, and introduce it
through the skin in the direction of its curvature. This perfectly sim-
ple instrument suffices for almost all cases, and in good hands is sur-
passed by no instrument for security in holding and introducing the
needle. Complicated instruments arc especially suited for unskilful
surgeons, says Dieffenhack, in the unparalleled introduction to his Ope-
rative Surgery ; not the instrument, but the hand of the surgeon, should
operate. Practice and habit render this or that instrument indispen-
sable. Thus some find it complicaled and inconvenient to seize the
lips of the wound with forceps, as I taught you, although this is bet-
ter than holding them with the fingers ; for me, the latter would be
very inconvenient. In this matter any one may do as his habits and
inclination lead him. When I have fo sew some deep part — as the
velum, rectum, or vagina — I always use needles with handles.
Of course the number of sutures to be applied depends on the
length of the wound; generally suturea half-an-inch apart suffice, but
where perfect apposition and small cicatrices are very desirable, as in
wounds of the face, they must be closer, and should alternate between
coarse ones at a distance from the edge of the wound, and fine- ones
enclosing but a small portion of the edge.
Tlie second variety of suture, twisted or hare-lip suture, is made by
passing a long pin wilh a lance-shaped point through the flaps of the
wound, and passing a strong cotton or silk thread around it, as I now
show you. You take the thread in both hands, lay it parallel to and
immediately over the pin, that is, transversely to tlie wound, pass it
under the two ends of the pin from above, and draw on it, so as to
approximate the edges of the wound exactly (this is the so-called
Kulltour) ; now you change the threads to the other hands, and, with
the right thread in the left hand, pass around the left end of the pin
from above downward, and, with the left thread in the right hand, do
the same for the right end of the pin ; you change the threads again
trSIOX OF WOOSD&
49
make four to six similar, so-callcd figure of eif^Iit lums ; tbcn tio
. double knot and cut itie Piids off dose; then cut off tlio ciids of the
)in to aprojKT Iciigtli, fto thiit they nay not press oii the skin, but not
ichort oa (o prvvcat their being refttlily withdrown auhM^tjufiilly,
Tbcre are a great autnber of other sutures, which for the moat
arc oaly of historical interest, and which we here |>ixs over;
peculiar fomis of !^\(turo will be treated in nfiecin] surgery, under
wound« of the different p«rU, a* in wnuiiilM of the intoelioo.
Where am llie adraiita^-x of the twisted over the tutemipted
iiiuro? and when do you employ it? These indicationn ni»y ho re-
to two fuclon, 90 that i*ou wiH conaider the interruploJ suture
' cimpler and more eomnion. The twisted Miture is preTcraW*^
1. When the flaps of the wound are *-ery tcji»e; 2. When the skin-
Baps to ho uuitcd arc very lltin and without support — in short, wliem
the lips of the wound hare i leiMlcnei.' to roll in. Tlie neodle, rt>main-
tn^ iQ position in hotlt caars, renders the suture more secure and firm ;
the needle serves as n sort of «uhculanoons splint for the edge» of llio
skin ; tbejr are supported by it, and are also held more Recurely by the
I of thread on Ilie outride. In ninny caee^i, io applying «utun» io
fiuxj, the interrupted mid twi9ti_xl suturee arc applied altemstely;
tba latter servo as supporbn atu\ to lesint Icnuon, tlic fcrtner to in-
duee more exnct union of the ed(/fs qf the \cound.
I When the blccdinja: hns been stopped and Ihc wound united, all
has been done that is at first necessary. Xow let us obicrro what
I takes place io the closed wound.
^^L Immediaudy after being' unitcfl, tlie eil^s of fiM iroand are gencr-
^^Blly white, fi<oni the ]>rc!<^iire ext-rcised hy tha nitUKH as tbey com-
^Hpeas the capitliuies ; rarely the borders of the wound are <lark lilue;
^^wis alway» iudicutes great impclimeiit to the return of blood tiirou-^h
Ibe TCins, due to n loss of part of the blood-ve?*;!». It is evident
(but tba communication between arteries und %-eiiia mny be greatly
iistarbcd by the division of n Urfre number of cnplUarieis so that at
}me point in the border of tli« wound the fiii a ttryo of tlio venous
islxdl be inKiidlcient. On the whole, tliis dark-blue color of the
1 of the vrouml is rare ; it either disappears spontaneously or a
tinall poKion of the lip of the wound dies, a symptom to which we
afaail retuni wbon si>eiikiiiff; of conUi»«] wounds, i» which it is quite
-oommoa.
Even after a few hours you find the borders of the wound sli;;hltj
rollen and occasionally bright red; this redness and swetliuf^ nro
I absent (eKpeeially where the epidennis is thick), iMit occisioiiiilly,
■ooordiog to the extent and depth of the wouiul'and tension of tlio
40
SIMPLT. IXCISBD KOtTNDS OF THE SOFT rARTSL
skin, it spKa'ls from Uro i>r l.lirec Hues, nr to »9 mtiny int'lics, nrouii^ llic
wound i the usua] eo-mllu«! IocilI rv^uctiuu ubout llie wounii t»k<^ plucc
in thin spnoc. Th(! vrotincl pitiiis f;1i^l)tlv', o^jMX'JaUy on bciii;; täuKliwL
All tili« may Ijr West speu in cliiUivii aiiJ n-omi'Q »itb delicstu »kin.
About woiiiida of the fiii?c, cepccially of tbo cjclids, wc often notice
oxtonaivc ix4tfnia m twcntj-four hours; this frequontly terrifies the ^
fri^ids, but is usually frco from «Unj^er. H
Hcrp, thm, you barctbu car(liruilKvni]>l'>iii»of inflainnialton: pnin,
K«liiev, svfflliug, »nd incrojiaoii hvitty of which you may sali.ify yoiu-
Bplf l>v jilmoinff your finger oti the parts sboiit th« wouikI, then oD a
distant part of tlic boi]y. The process going on at the wound is an
inSitniiniiliou ; we call it traumatic inflammation of the skin, thut ta,
csuftpd by nn injury.
As u rule, t})u»e local («ymptoni» hiLve readied their heigliL in
twenty-four hours; if by tluit time they have not exceeded the abo\-e
bound», yoo coiibidei" thy propcis ns liikliig a norrmil eouwo. It U a
markfd jwcuUarity of traumatic injlttmttuitioti, t/iat, i» n jnttvjbrm^
it i* strictly limiteti to the borders of the wound, and dots not extend
mtAout »peeial eauae. It is not unusual for tliese symptoms to remain
at the game height the second or evoti iho third day ; but by the tltird
or fifth da^', the redness, strcllin;;. pain, and increased Icmperalurf,
should have dutappcarcd mostly or entirely. If the eymptoms still
ifirroase the second, third, and fourth daj-s, ur if some of them, as se-
vere pain, and great oirelling, rernr at this lime, or if thtM* remain at
the aaino point to the fifth or ai\th day, it is a sigii that tJie euurse
(lifTere in Bome way &om the noi'mnl. This will lie esiK^eially oi'ideDt
imn the genera! eondition of tlic jwitient. The nholc body reacts to
un irritation of one part of it, not in a perceptible manner, in small
woundK, it ia tnie. We «haJIreferto this goneml rwiction at the close
of this ehiipter. At present, we »hall consider excluslrely the oondi-
tion of the wounded purt.
The third day, often indeed on the second, you may carefully ro-
mox-e tlip pins of the twisted suture, provideii you have also applii^d
interruptetl sutures ; this le best done by- seizing the nccdlo with
Die^mhaeh^a needle-holder, and rotating it gently, while fixinfif the
twisted threads with one fiu;^r. The threads usuallv remain as a
Btirt r>f cliiinp on tlie wound, to which they are attached by dried
blood; they subsequently looscu spontaueuualy ; by furcibly detach-
ing the thread, you woidd unnecessarily strain the wound, and possi-
bly tfar apjirt the freshly -united edge». If at this time we eJirefully
feel the edges of llic wound — if thea;denmh(is»ul»idixl — we find tlieni
rather firmer than parts aj-ound ; Ulis state tyißrm it^ltr/tiion sooner
or later disappears.
üKioN OP woüsrja
47
Wli(3i you bave nj^ied manjr sütohcs, you muj rcnnve lonie of
tu, tlint liave lilüe to hold, oi) Uie tbint tUiy ; oüiers, on t]ie fnurth
, fifth. At tin- tcmdjittnrttilicü parUof Uic Hlän jt is well to leave
r«w threads for ci^bt days or more, or er^rn le^ro thoiu till Ihoy cut
througb the flaps of tlie wound, proviJed it can do any good to hold
Iter the edges nf the around, which innr be gxpEiig o])e!i. Should
be iullaiumatioii quk'bly exceed thv »orinal amount, »<• must rotnore
iUie Kuliirfs enrlier, so thai they inny not iu«renee tli«? jrrtt;ilion ; not
ifrcqut'ntly blood« thut is dcconi]iO!Mng or mixed with pus, ut the
3ni of tfac M-ound, is the cuuec of Uic untisuul irritalioiu
n.tnuvin;;f the JiiU'rrtiptiMl suture, you should tuku the fullowiu^
tious : cut the thrcnd on one side of tlic knot, where yoii can
most readily iatroduoc the tbia blade of the scissora without slietchiag-
tile wnund ; then &c\te. the thread at the knot with n dUseeling foi^
oeps, ntid draw it out towartl the aide when? it was divided, 8J a« nut
to scpoiate the eil^e» of tliu tvuuitil by the truetioii,
Shotdd ycHJ ihinif that, after removing; the suture, the union nf the
«raund b still loo weak to prevent its gaping, you may, by applying'
strips of irbthyocoUa-plaslcr trans^'crsclv over tlic wound, between Üie
points wheru tlte suturcft were, and faetcniug (he end» (not the part
over the wound) with collodion, gire support enough tn |>rerent ten-
sion uf the llapa of the wound, auch aa unavoidably occurs in ehuuges
of cxprcsbion in the face.
In Ootn six to eight days, tnoat simple ineisod wounds hare adhered
lirmly enwigh to nxiuirc uo further support ; indi^, in many cases,
this is the oase hy the second or fburlh day. If, in the couisc of tbo
blowing dfli-x, the dry hlood about the wound lie carefully wtndtcd
T, the youiiff eioitrix appears an a fine red »tj-ipe, a searcely risible
fine line, 'lliis process of healing ia called hvttin'j byßrM iuttriiUon.
In tlw course of the subeeqoeni months, the cicatrix lose« its rcd-
and hardnesa, and finally boc^inies perceptibly whiter than, and aa
soft as, the akin ; so that for years it may be reeognizod as a fine white
ne. It ofleii disappear? almost entirely after s-^me years. &omc of
3U, who left the univenity with many still lisdble cicatrieea on Iho
r, may l«oi>e lluit tliey will be ftcnrcely visible in six or eight years,
rb^n the Fhilistir.e viiuigc will become you leu than it doM the stu-
Tempora mutatitur ct nos mutainur io illis.
48 SmPLE INCISED WOUNDS OF THE SOFT FÄETS.
LECTURE V.
The more Minute Cbangos in Healing hj the Fin>t Intention. — DUatition of VeMels in
the Viciiilif of the Wonnü. — Fluxion. — Different Viens regarding the Causes of
Flos ion.
- Gextlemen : You are now acquainted with tlie chaDges, visible to
the naked eye, that take place in the wound while it is- healing; let
«8 now try to see what occura in the tissuea from the time of wound*
ing till the formation of the cicatrix. For a long time, attempts have
been made to study and know these changes more thoroughly, by
making wounds in animals, and examining them at the different
stages ; but it is only the most exact microscopic examination of the
tissue, and the direct observation of the changes after wounding, that
have enabled us to give a description of the process of healing. I
shall attempt to give you a brief r^gutnh of the result of these investi-
gations, which, until recently, I have made my special study.
The changes after injury of the different tissues are particularly
seen in the vessels, in the injured tissue itself, and in its nerves. The
influence of the latter on the process is, however, so obscure, that we
shall not consider it. We shall at once dismiss as unanswerable the
question, whether the finest nutrient (vasomotor) ner\-es, which lose
themselves in the different tissuea (for the question can only arise con-
cerning these), have any direct influence on the changes occurring in
the tissues, and in the vessels themselves ; and the rather so, as the
ends of the nerves have only been certainly recognized in a few parts
of the body, while for other parts it is entirely unknown how the nu-
trient nerves act, and what relation they have to the capillary vessels.
You will have already bad your attention called to the imaginable pos-
sibilities and probabilities on this point, in the lectures on physiology
and general pathologj'. Hence, if we say btit little about the nerves
in what follows, it is because wo know little of their action in this
special process, not because we wish to deny their influence-
Let us first consider the simplest tissue ; let us supix)se a vertical
section, through the connective tissue, with a closed capillary system
at the surface of the skin, magnified 300-400 times. Here you have
a diagram of such a system.
Let there be an incision down through the tissue ; the capillaries
bleed, the bleeding soon ceases, the wound is accurately united. Now
what takes place ?
Tlie blood congulatea in the capillaries as far as the next branches
UXIOy OF WOCNDS.
49
ifap tipxt points of mtcraectioii of tf»e capillarj' nct-worfi. Someco-
»tdil blocxl usuuUf remains uho bctwcva lUti üapa of the wound;
Fto.L
^t>
■o
o
-^ ^.■., Ci|^
■■-?
üT-
i^
JXB«niao(coaiioMlwlb>u«,wltkcaptIhri«l. Uasnifled «»-«a.
we have omitted this in Fig. S, eo as to liavc tbc amplest po«able rcp-
rcMntili'Mi of tlio chann^. Of thu i-l>atim>ls for (ho riRiil^ilioti in uur
diigntu, some liavc become impassnblc ; llicWooil must accunimuJate
it««lf to the exisliag bj-paths — of ctnirw tlib takes pUce under a
J heavifij arlrrial [)r<?3sure than previomly ; this pivssun! U grr»ater tlie
f^Te:Ll<>r ilip cibstnirtion to ih« rirculatinn, ami t^e le^s numtfruir* the
bjr-pails (t>f the po-cjlli-d cvHaferul circu'^tion). TUc result of thia
, incrpiuioti pTKUtum is the d!8t«ntion of the vwu«el« (trhioh, hovrpvor, is
f tuiully much grvalvr than could be reprvscnU^I in the diagram), henoe
itbe rtMlnc^ss alinut \hc \rotiiid, and to somn extent also the sirelliDg:,
[But the lattrr also h.-%8 anoth^T caus« ; ttio mrtrc tbo capillary wnlls
distCDded, the tliinner tbejr become ; if omler the cmlinaiy pns»
with nomuti thickness of thfir vriUI-i, tliev permit blood plasms
I pass to nourish tlio tissues, now under incmsed pru^sun^, more
Ephünu than nonnal will pass through the woUa, which saturate«
so RmPLK IKCISBD WOUNDS OF TUB SOFT VART&
^'^
a-
^1
MtftDln cif tn<1«W.~0>pIIUrlra «Ivril br hlmd-rlgil. C<>IU>ct«) ittft4lill«ii. Uag»
tlic injured tisAue, and whicti tlie latter aliscrbs by ita iJowcr of
Tili» i« a brief (•xpliiiiiiliuii of llit^ jwrccptibk- (.-Imngcs in tbo
bonkts of ihc wouitii, llio redness and inrrcuscd licat caused hy tlio
rapid de^'ctopmont of th« collateral circulftlion, by wliidi more blood
llowa llimugii the VRSsels nearer the Kiirf«eB; the fin'4?11ing is cnuBod
l)^' tlie diatcutinn of the tcäscIs und si/rcllin^ of llie tissiies, nhicli
again induoca slight comprcsalou of tbe ueirea, and lliis ex<utes somo
pain.
Tili», as it seems to mc, very simple tncclmnicil exiilnniition, would
be niufli more raluiibic, if it fully exploiuid ibc whole Mil>:-^iiiciit
oour«(>, and eniild be applied U> ul! 'piifliiniTuiitioii!>, whirh iiti> not of
traumatic or mccliauical arigio. But this is nol the raitc. Meiilicr
the preai vascular distention that occurs some tirac after injury, ilia.t
ahtiwR itiu>1( in extensive n.-diir!rs urouiid tlic wound, nur Ihc c:ipil!nry
dilntalion tliat exists (rum the first in idiopathic laßammatJons, cjiii be
referred to purely mechanical causes.
OKIOS or WOTODS— IRRITATIOS.
SI
Heoee ntlier causca that »ct as irritant« must net especially on (be
cnpillarics to compi-l tbvir dilatulion, Tbat thü is the case, may be
rouliljr sliovrii by a «iinpl« ol>scn'fllii>n, winch is imletKl difHmlt of cx-
phmtioii, dilFt-n'Dt views Ixring taken by the tniwt accomplished ob-
»PTvcTS. Vou non- soo tay ocutur conjunctiva of a pun- hlmsli nliit«,
like that of any tiorraal eye. Now I rub my eye till it weep«, an<I the
oonjunctiva biwomies reddish ; perhapo with the nnked eye you iitay %,ßo
»nmc of tlic lar^gCT vcsaels — witli » lens yon will nko sec Ihc finer vim-
8'-l*, full of blood. After five minute» at most, the redness has cntiro-
ly disappeared. Look at an eye wlioroa sinall insect, hns socideotally
jltrti uiwlcr tlic lid, IIS «o ofu-n happens; the person nihs, the eye
9, and I>cct>mcs quite rod; if llic insect be removed, in half an
liour you will [>rt)b:ibly eoc Duthiog noticeable about tin* pyo. Here
j'ou bail? the simplest obscmition how ve^M^l.-« dilute on irrilation, and
empty agmio »oon ivfter the cedsalion of the irritnttoii. AVhal »the im-
mfxli.^te eftiwe of thU «ymptom? >Vby do not the vessels cxMitnict
iQHte^Ld of ditiititi^? Time qiientions ar» as difBcuIt to nnswer as the
ohMtrratian is easy to mitkc, and to repent inimmernlil« timea, ivitli
the same residt. lite fact itself has been known as Inn^ aa nan has
oltüerred; the old saying " ubi stimulus ibi affluxus" refers to thk.
Tile incrc-ased flow of Wood is the answer of the vaaailnr part to the
irritation.
Of late, thi* proce«s indu<.-ing tliia redness is called aetivt ky-
perOfmla or artiüe conrfatton. Virchoxc tcio!c up the old name, und
nude ** fluxion and t'onyc-ition " a^iu popular.
Assbitf^ by yoiu- knowledge of ^ner&l patholojty, you will now
perceive that it is doirnble to ^ive a tlieorctical explanatioti of
»ymptoms which, ibriMj^li all time, liave formed one of the luost im-
pnrtunt objects of «itiaiilorution in me<Iieine, psrtJculnrly as tlte pro-
cess of ioOammntion is alw»}'« considered ns cUutely idlicd Co thi» ih>
tivt congestion, or indeed even ooiisJdored as alwa^*» a Becii>cnt of ihc
lattT. AntUy C'fyprr, a eelcbnitdl Gn^E^lUh wirpjnon, whose woAg
von will rtvd with pleasure, when you take up the sliuly of mono
praplu, n thoroiiffjily practical «urj^con, begins his lectures on mir-
(jerv in the fi>llowinjf words: "The subject of this evening's leo-
Itire i)t irritation ; which, I»eing the fuundatioii of surreal science, you
miat carcfidly study, and clearly undcrflland. before you can expecrt to
lutow the principles of your profession, or bo qualified to practise it
BTMlitably to j-ourselves, or with advantage to tlinse who may place
ihemsclres wndrr your cam,"
This will show .you what part the questions to-dny under ooo-
siilenition, wbidi you mi^ht r^ard as a eiiperrtuot» exercise of the
mind and tm.igloation. have played nt various timea ; you will here-
S2
SIMPLE INCISED WOUND» OF TBK SOlTf PARTä
ttfior leani, frocn the histonr of mvtlicini', tliui raUre systctuK of medi*
cane, of this px^atrst |>nct)cul importancr, arc be&c«l on livpochcses
Ibiit were fomuH] for thv (.'xplauation of this ttymptora in the refiscls,
of tliift irritability xnd of irritability of tlie tiosuM generally.
Tili« in iiot the plate to cnU-r into a tliorouj;:!' liiftU'riral (ooödcra-
tion of UiiR quostion ; I will only call to roiiid a few hy[>otbc<tes which
luve bccii nflvftUDPil lately, under iiic alrv«u1y-«xi8tin^ knowledge of
tiir. ^'cxscls and parts visiUlf tu tlie naked eye, conocniing the oocur-
rciKX' of ra»«u)ar dilatitti»n from irritation.
From Uistology and physiology, you know tliul, uutil tltcy pass
into capillimrs tlic artrjics and reins have transTL-rac aiid lungttudi*
nal uusculur fibre? in tbuir trails, oud that in gcnerul tlicac &rtt ntoro
scanty ID reins than in arteries, nItbon;;b Ibis raries greatly. Now,
sltliou^b it may be very dilBcdlt to make (iiroct obsrn'alions of the
effect of irritation on tlicsc em^illcst iirt«rifsund Teii)a,it ia rery simplo
to ftw its elTect in the intestine, »rliere we linve (•«soiitially liio sitnie
ociiiditioiis, namely, a lulie provided wiilj lonpliidimil und Iniiisverse
muacvdw fibres. Uiit,trrilat« tbe iiitesliuens you nmy, you ivill never
iruluee dilninlion ut the eotifl tripled luirt, but only ii shortening or con*
striction and a consequent motion of the cuiiti*iils of the intestine^
whose rupidity wilt depend on the fntjucncy of the mpctttioii of Üio
eontrftctiorui. But can dilatation of the capillaries be induced by such
htcrmued ra|NdtCy of motion of the vessels ajid blood ? Ceitnioly ttot.
In tltc geiicrid i>ntyi(>lo^y of Lotte, the t?e1nl>rale<l ineilicid pliilosopber
of Gbtlingen, you find tome remarks Tvbicfa toe so apt, and, like all th©
chapters on this subject, so well simn- tlie brilliant geniuB and critical
ocuiuem of tlie writiT, that I shall make iim; of his expresmuns. He
flays ! " Patbolofpsta who seek to e^rplain eoii/ji'stion by inert»a*od con-
traetion of the arteries, aa<iun)c the tli.inkle)ts tjjik of th« Danaidex;
tJiey cannot bIi«w llie fltnpper tbnt ]iri;\x'iita tlie escape of tlic blood
tbat is pumped in with so much diffieultr. Ovcr-fiiin«ES N'sultt {f
moii; i* introduced and tlie name ainounl eseajH'S, or if the saino
qiiaiitily i.s inlroduoed but leas escapes. If we buppuoeu portion of a
vessel to eontraet more eetivcly and rapidly, it will liavc as little ter»-
dency to induce increxxed afllux or diiiiiiiinhcd oHIux of bloorl ns the
Blampin;; of a pc-ntoo in a river would to nf;!ulate the iiniiniiit of
water."
Tili» refuted b^'potbe.sis, of tlie dilatalion of the captllari«« depend-
ing on more rapid and ctiurgetie coulraclion of Uic urtcrics, waa at
IcoicT, ha.ted on known observation!« ; but JLnts^'» ctplanation, on the
conlrary, is so far from all analogy, T niiglit alinc^t «ly »o metapbysi-
ciil, that we cannot attaeli any i-aUie U> it Lvhx aKserts that tlierc [5
DO objoctioii to the supposition that capillaries arc alFeoted düferenlly
ÜSION OF WOCSDS— IRRITATIOS.
63
from arteries bjr irritation; bjr nerroas influence they may cxpaDil ao-
fiirely on irritation, bjr tlicir molecules Beparaling. But this view ia
pure hypothecs, vfhich not only tms no analojrr, but is even opposed
to mviit olMKfrv ill ions. It ia wrII kiionn tliiit, villi tlic luici'OMüTjief
we c»n fullo'.v llic circiiUtii.>ii in Llie 8in>ller nrtcrira nud vuiiis, is n-cJl
ft« in th« cnpillorie* of tiio wpb in the foot, in the mr-iontory und
[tot^up of UK! fro^, or in tlie viug of« bat ; but Ute inutiodiuti; pffoot
lf}f n miiil cbcmicul or mecluinicul irritniit tltx» not at uiicu »liuw in tho
Lmpilliincfl, but firet in ootitniCtJon of tltv »mnllcr art4.'rio», ucc4ieionul]y
faiait uf itiv vfins ; this is very onLncscvnt, of scan.'oly a fiucond'a liurap
rtion, inilcrd, it often escape» obscrvntion, auJ wc then suppose lliat
lit« dunilion and jniade aru too sligbt for us to iiifuöurc. Tliia brivf
Econtraeiiun is fuUanred bv thu dilut^tiuii, uliose iutmmliale cause U
• ioiliiilinct even on mu-roscopical oljsen'atton. Wv »boll twon sec tluki
this U insufficient, that tbc fluxion is tb^ Tv»xi\t of )Mrtilyais of lb« rcA>
tteU, active b» tho symptixii ap|M>ars. Kvoi i,!n> reeeni very iiiterMt-
[iug obsPTS'atioii:« of Oolul>ew, wbo bud ibe kimbit^ss to show uie that
ttbe capiUories of tbi: uictitutiUf^ mcmbniue of tbc frofc coiktnict traoa-
I v««cly, as the result of strun'f uk^ctrical shook», did not appear to mc,
[on thinking tlio matter over, to ai>ply perfectly to tbe i^ueHlion of
[fluxion.
Virefuyto nppcani to tiiink that tite irritation, whirh is certainly tho
Ummediate cause nftlie contraction, i« fullowcd .by quiuk lati^e of
|tbe niuitele» uf ibt- vvs^cU; tbut after a telAnic eontranliim tlurrc ia a
eUvniion, just as i» imtated nerves and mitecJc« — & view vbivh
ty find some support in a cotnnuiniealioii from I>aboi»-Jiciflnond
ibnut the ptiinful tctnnus of tbo musclcA of tbe vessels iu the liead as
rau»e of beadacbo on one si<.]ti, eo-calloil bciiiicrania, tiinec tlii» sup-
posiy) tetanus of the miiseles of the veswHs, induced by stmnjr cxcito-
. nienl of the cervinil portion of tlie »yiupathette, was ciTiaitily f^jlloired
|by their retaxati(w) and ^(reut diatentio» of the ve»sela, and ahurtly by
aymptomq or »•ercliml oiMiRestion.
Uui. in tilt» vien' (by which a relaxation or temporary panily^ of
J)c walls of tbc \'i:»cls and a consequent dcercaiH; of their rceistaaoe
'lo tbe pressure of tbe 1>)ood would, it ia true, be explained ss a se-
quent of ibeir ountnictkni), we must not fur^-rt that it »s by nu means
prove«! that the niusries of tlic vessels, once Irritated and exeited to
rapid eontmetion, are indeed ]>nnilyzed, while in other musdos this
fatiipie usually oocuis only after repeated irritation. It is ueees&ary
arlntrarily to assnnti? that the iniitieW of the vosscls very readily Iw-
rome (aliftued, whirh is directly refuted by experiment. From |>!iyM-
uhigy you know iIiAt Cluudu Jhrnanl baa proved that tbc contraO'
tjons and dilutations of tlie arteries uf tbe beutl are under tho iollu-
SIMPLE IS'CISED WOITNDS OF THG SOFT TAKK,
CO« of the cenrical portion of Üio sjiiipiillictio nerve, as I Iiavc *1-
rtfnäy imiimlod. If we irritate tho ujiper cervical f^fanglion of this
iicTvv, li\ii arteiit» <.-oiilrict ; if we (Uvidn^ the n«rre, Uierp » dilatatioa
(paralysis) of the artcrk-a nnd caiulUtrics. Iliis espcHmcQt of itrh
t.-itinff llie intiftclcs of tlio rpw^U may be ofton wpfalofl, witlioHt their
|jc<x>ming (jiiickly fatigued, milt-sa the electrical nimfnt bo tooEtttm^;
facnce wc migrlit imagine tliat tlicn; is little probability in tlic b^i-pulh-
CÜ.4 of imtrtctliulo latig:uc after a »in^lc irritatioa. Scfiiff", bowcver,
lilro Lofzff assumes tlint aetive dilatation of tbe ressels ia posiublp ; lie
tliiiiks ihut lliis iiwessarily follow» from c<^rlaiii experiments; biit
tbü i» perfectly iiicoinprebi;n.<ib1c to me, for tlierc arc uo musvlv» tliat
ctHild actively dilate the vesM'l«.
If llic vL'tii;« aVnic coiitmctcd on bcia;; irritated, fitting of the ca{K
illitrics would doubtlces follow the obstruction, oud there would then
bu DO (lifftfrciieo liotween venous (passii'e) bypprtcmta aud äuxioo.
But this supposition is quit« untenable; it la perfectly incnniprcbi;nsi-
ble that tbe Ycina alone ttliould contract on inSaniuiator}' irritation.
Tiiat tbe reins eontraot on ineHtnnical irritation, you may see in tW
femoral vein of an ampiitjited tliij^li, to wliicli Virehow lias called
particular attention, and this irritability lusts neu lunger ia tbe walls
of the vein Ibnn in the nerires.
JlenU alrpjidy adranc«! the view that tlie symptotn of dist«otioD
of the vessels from irritation waa directly canned by paralyaia oC tbelr
wall.«; when Lotzf, in op|>oeition to tlii», says that it is not supposable
that there should be paralysis of the museles in a man who is cxoefr
Hively irritated and hae hi» mnsrles tense and his ftire glowing, lib
objection in not perfectly tenable. Nortloet» tlie other ol>jcotioD of
tbe usually acute Lotu appear to me eorrect »lien be Kays, " \V1iat
shall we lliinh of piileneM, of the contniLlioii of the vcp*clfllliatR-tnlls
from fri;;Iit and terror? Does that loolc as if due to ji^at muscular
action, if redness in nn^r nnd shame is induced by pandysis?*^ \taj
this proves nothin;;. Frip-bt may throw the nnisclcs into n t^tnuio
state, whii-ii is usiully quickly followed by fatigue of the muscles of
tlip vcML-ls ; iinniedialelv after a great I'righl, we p.'nenilly feci tbe
blood pftur into tlio cheeks, as snon as we begin to brrallic and ro-
oo\'Cr from tbe shock; wo aouii grow red again, at Grat indeed redder
than we often like; not nnfM-quenlly the paling from fright is oftea
overlooked, and only the »iiccee<ling redni*ss fwrccived.
Still, «port Crom these objeeliuiis, how can we imagine tlie panda's-
\ng action of an irritated nen'e ? We aeltmlly know »«ch phenomena
from phyBialogy ; ihe ohstniction of thebearl'siictiou by irritation of
' the vagus nerve, of the movements of the intestines from irrilntton of
tbe Dplaocbinv nerve, «tc: Ueru a va»o-motor »en'C-8y»tem is sup-
CSIOS OF WOU.VDS— IRRITATIOX.
B5
posed which arrests Ibc coatraction of tltc muscles; coulil not such a
TWOTOOtor ncn-e-flystem also be supposed Tor ihe vessels — iicrv-es,
irritalinn n( which lessetts the tone nf the ni)iM>lcs of tlic rt- »«els anrl
tlto» render» tlie walls less cipiihlc of iwiislitipr the prfssurc of biood ?
hTbc doetrine» ubout vnsoniolor tien-t.'? is so dilficulL to explain, that
re\-ctt a brief evjxwiUü» of tho pmliuhU) {io»HibilitieK of the process
would lead us too far ; bencc I must ooiiteat myself tr jtli having mlled
Ittention to the utalo^fous pbirstologiral prtx^essxs. Vircfiew and
lenia n^reo in th« view that the sjnnptoms of fluxion arc due to
RJs of tl>e vesiseh), although they ivfer this parnlyKts to difTcrent
on tlic wliott-, most eredenrc is attadied to the view tlmt tJic
musdc« of the vofi^el^ like those of the heart, arc part I_v under tho
influence of s^'nipathftie. [mirlly of e<>TvbTt>5pinaI nen'es, und that the
rentisc the rhythmical (oulont3ttc}aHilractionsof the vessels, and
he latter not as regulators or obstructors of tbcse contractions. Irri-
'tation of the svmpnthelie lilaiuents trouh! itierc-ii»e tlie contntetions
of the vessels, dividing; them would result in paial^'sis of the mtu-
cles of tbc Tcsscla and their conaequcnl dilatation; but (ho latter
nitfTfal also be eaufied by irritation of the eercbro-^inal obslructivQ
nerves.
The discovery by A<At/, I^rtA, and AuT^a-hf thiit ili« blood-
ipillimcs arc entirely composed of oells^mi^it c»cit«new ii^-potbc8CS
it the irritaUlily of tlie capillary cells and their tnÜuencn uo diln-
»tion and rontractioa of Ac capUlnries, nllliuu^h even this would
>t solve t!ic mediauical difficulty which opposea the idea of aaaclive
ihir dilalaticHi. In tlie aeli<jn of local irritation and oiil.irely
loeal dilatation of the vcfl-<iels wc have the ehtHc^ of considering thnt
irritation of the nerves of the vessels (or of the living ce]|*subtstaao3
Ibe capillary wiilU) directly disturbs tfieir function, or that this dis-
loe is due to rcltex irritatton.
i'üu I»ai*e now niatcrin] enough for m«Iitation. None of the
bjrpothc«es ailvaiKvd can claim (o fuUy oxpliin lite sj'mfitoms of
. althou^fli some of (hem pcrhapa contain the fivnn for future
urfrct development. Still the reeo^iitioii of this truth, the dis-
icttun of hypotheses from Observation, is useful ; it does not limit
tbc onward progress of experiment, but constantly leantmatos it
Congratulate yourselves iHut tt is permitted to you and tho coming
generation to clear up this [«oiiiL
We shall nnw leave this qusstion, nnd l!ic next hour sliall n;;puii
return to tbc Geld of ccrtaiu obaerraüon, to study tlio effect of tho
«rouodiiig on the tissue itself.
ee SIMPLE INCTSED WOUNDS OF THE SOFT PAETS.
LECTURE VI.
Changes in the TUhu« during Hoaling bj' the Firat loteDtion. — Plastic Inflltnition.—
Infiammatorj Now Formalion. — BetrogruHsion to the Cicatrix. — Anatomical Evi-
dences of Inflammation.— Conditions under which Healing by Fi»t lutentinn doet
not occur. — Union of PartB that have been completely Bcpsrated.
The dilatation of the capillaries and the exudation of blood-senim
that usually accompanies it, ■which we have found aa the first effect of
the wound, and which is most readily seen ia the living tissue, as
a]x>vc mentioned, cannot of course by itself cause two flaps that are
brought in apposition to unite organically — changes must take place
on the surfaces of tlie wound, by which the latter are to a certain ex-
tent dissolved and melted into each other ; just as you render two ends
of sealing-wax soft by heat, to fasten them together, so here the sub-
stance itself must become the means of union, in order that it should
be firm and intimate. In fact, this is the final result of the healing
process, both in the soft parts and in the bone.
Let US keep in mind the above diagram (Fig. 2), and suppose that
only connective tissue and vessels have been wounded, and that theii*
reimion is the question for consideration. As you already know, con-
nective tissue consists of cellular elements and filamentary intercellular
substance. The cellular elements are partly the f,tab\e,ß3eeä, long»
known connective-tissue corpuscles^ L e,, flat, nucleated cells, with long
processes, which adhere to the connective-tissue bundles, partly the
wandering celts discovered by HecMinghausen, which are identical
with white-blood and lymph cells, in form, species, and vital peculiar
ities, are probably formed for the most part in the lymphatic glands,
through the lymphatics enter the blood, from the capillaries and veins,
occasionally wander into the surrounding tissue (as discovered by
Strieker), there become fixed tissue-cells, or again (as observed by
Hering) enter the lymphatic or blood vessels, or undergo metamor-
phoses not yet discovered.
If we examine the tissue of the flaps of the wound a few hours
after the injury, we shall find it full of wandering cells. These in-
crease enormously from hour to hour; they infiltrate the fibrous tissue,
already softened by swelling, and even wander from one flap of tho
wound to the other. During this cell-activity, and probably on ac-
count of it, the connective-tissue intercellular substance gradually
changes to a homogeneous gelatinous substance, which gradually disap-
pears as the cells increase, possibly being consumed by them ; so that
there is a time when the surfaces of the wound in apposition consist
PLASTIC ISFILTRAnO.N.
it
almost eatirely of cwll«, held togptlipr by a very eUghl quantitj of
g«UÜnoua intt^rmediato sabstani« (which »ubscquently becwmos lirraer
iiDtl fnully gbrous).
In ifae sketcli belaw (Fig. 3), a sequel to tbc a.boTe diAgram, ytm
Flo S.
-tJ
-'l^/«*?^'
:> .
#■:
,^i .'^v
,: Mz^it
rt»n*taüax lb« «dtIVr of |)iv woiiihI nmll«d hy \iit»niMU<frj acK ft>iiaailvia.
a, plaallctnlDlniilonafilnia*. lEasnlBod 3a>'«Q.
n «V-Uon of tbc woimü now unltnl hy ncwly-fonurd tbisuf!, wbid]
tivr for alt wc sliall term inflammatory ncx formotion or primarjf
etHulir titmie. Fi'rcAow calls it gnitiulation tissue, Ithirlfleinch pfcrm-
tissue. "Pie influinmatory now fonnation results from an earlier irtalo
in wliidi tltc still filainentary connoctiTc tissue w inültnitud with innu-
Bieralil« wnndvring rall.4, n state whit^b may rfndily rctiim to tlii? nor-
tnai by alr'>[»-iy of Üii>s(! celb. This »tagn of reliuJar or pi<istie in/itfrYf
tio», in which llic tissue ttx\s finner tliaii iii tralrry ateinalont injiltrrt-
tion, n almost «Iw.iy« nt Mtno dUmnw fmm th« fdjjc nf the wound,
9» tbat ID any sueb spcMrinHTTi of n reeunt woiiikI irv may follow tbu
drv«*lopmrnt of tbc inflnminatorr new fonnntion from the pUstic
(col)uW) iolUlraÜoii, if we make microsonpiral cxntninntions from tlie
SB
RI1IPI.E »tCISKD WOUNDS OP THE SOFT PARTS.
normii! tisstic (owanl ttic nroiind. Tlic injury rcpn*s»iits an mllaiiiii
tonr irritation, whose action may ext^nwl Bonmwhiit boyoncL the Imti
diate vicinity orth« irritntioii, but the» ra[ii<llr ditniuiiiiies.
la tW gral innjority of »lscs tlierc will he al le.ist a sUglit \ay\
of ooa^lutcJ blood bctwcc-u tlic flups of tho iTOund ; iJiis also extoi*
somewhat into the iiilfrstiix's of (ho tissue of llie flap« of the
Tills blooj-clat nuiy sometimes interfere witli the healing, us vl
from its »iae or other causes, it tleron)i>0Ai>H or turns to pu^, but it majj
ttl« bwome cicatriMii! tl^suG and pprfoctly disiippw^r in tUo new rurnii
(ii-e i>f llie flap» of the woiintJ; tlii» mu*T. lube place for union by thi*
finit int^mtion to occur. W'a sliall hcrouAer 9j>cak of ttic changes tt
fmk« place in the clotted bloo'l durin;; this process.
Wf must now atU'nd to llic qtip^liun, Wliciice oonie tJie inniimor
bic wanderinj; cclb that inßltratc all inflamed tiiisues immediiitdy «ft
tlicir irritation, as they hero do the Haps of the wouiiil ? Of htlf , tliis
question lias received the followinjr «ondprful exphtnation, M'hi<;}i ten
years »gn wniihl lime been eonsidereil as the fiincy uf a niudmao:
Cohnkeim made Uic foltoiving- remarkable obsen ation : be iutroduc
fiiiely-powdercd Rnalitt Wuc into Itio lynipli-ww: iu Ibc hack of a
ttifu irritatml the sitimul's conica with caustic, and fuitnd that number
«if nanderiiig cells (lyinpli-pus eellü] containio^ niiiliu gradiiiilly
locted at the cauterized jwint; h^-noc the conchiston, «if on imVöfo
point tphite^ood corpuscle» tmtntJrr from tfu testet» into the tisstknf
thete te/iite-ftl'/od cor/i'iscit« coitsfUutc f/ie htflammatory ctlhilar i«*
ßHralion, Cifhnfif.tm then oinfirmed, by direct olwcrvatiou on tl»0l
ineBoiitOTy of a liviiiff fnjg, the discoverj- already made by Strit-X'er on
the iiielitatin;r membrane ■lluit hiid just been rcninvcd, LJtat under
dome circuraatanees the wliitc-Ulood cells wwrnler tlirougb the walla
of tilt- ressels intti the tissiins, and showed also that this oceurred to a
alill frreatiT extent in dtlnUrd raplllarlc^ and veins.
Although it vra» uftertvanl shovrn that an EnKt!»h expcrimcnterJ
Aur;. Wttl/T, bad several year« previmialy nintle similar ob«en,-ationfl]
on the mesentery of the tond antl the frog^'a tungiie, the works of |
thtr German obsen-ers, titriekcr, I'on JicctUnff/tauKJt, ai\d C'o/(i)/tf/m,|
wore quite independent of his, anil CohhneUn has the undivided''
lionor of harin;^ correctly intcqirrtcd liia obscmitions on inflatn-
Rialion, whirh have ennstantly advanced to the prcücnt time, and
of liavinf^ presented them in a form to greatly afi'cet all moderQj
pathology.
It is flifliciilt foryoii, ^entlcinrn, lo imiiirine the iinnipnse impr
made on all hiKtolog-y by these new diseitveries, which I hnv*
imparted to you ns »liinplu fiiets, because you are not acquainted with
the former point of view from whiclj the ori^ of iiifluniinatory new
PLASTIC rXFILTRATION.
a»
formattooK, and th&t of complicattxl orgnniztxl gmwUis, w»8 iv^nlml.
Frciin pnivioiu obserrttion, nur idea r>f the HlTiir was about a» foUuvi's :
It WÜ» roppospfl that thcoclU of tli« onimeetiTe tissue, of vrhkli onl/
one variel^*, tlio t'lxcil, w.i* kiiuwn, incivai;t.-d ^ri^atly by citrisioii as a,
losult oC irrilutiüci, mid ccIluW iiifiltmlion thus resulted. Ima^ne
touts^lvcs Xatiiii a few yean in n tinic when iioLliing uits kiiown of Uie
pi«uliaHlioa of young cells, of iht-ir amJiboid and lapoitintnr oo'
I antl wc only knrw bovr to dodurp ibe ciMirs« of tbe [titlhulogiciil
prOOeSB, Snrm Turious sUigi-s of tbe di3Cit.4vd, but uutdt-ud LtMwa, u is
ulUi tlie nue in tbe nornudly-dtivflopiiig layer ; Die» yott will readily
ilerttand that it w.i.i decided without lieülxticin ttiiit Um cults lying
liL'd lo;^rtlirr in tbe inflamed liftsiie were fonaed nut of one
«□otber. Bren this «lu a f*n«t udrani-c, which wus oidy possible
after the orcrthrow of the ffeaeratio terjuivoca: for, not lon^ before, the
derelopntcnt of cdU nnd tissue from Ij'nijib, eraguUted Uoo«!, und
fibiine, wus firmly believed in. Tbe Bist ob^irations on ci;>lUli\-!sion
asareaaltorsbriomial irritation were inadc on oirtila^'t by Hetijern in
EiiK)>nd ; then followed the obacrvstions of VtrcAoie and IleU on ie-
Ramod come«. In both ca»c8 it wns «ccn that after cnuterizaliou ^f ith
nitrate of silver, or after iotrodiuH-ion of n seton, the tissue wii-i tilled
with youag cells ; in tbe ori^iial Uiuue-eelb, biscuit-^baitcd, then
diKihlt? Dudfni were »aen, Eroni which u diviiiou wus decided un ; youii^
oollswcrc »am grouped together, and tb<>ir origin from the ti«siie-oelU
loeiiiad Indubitable. Ilenue arose tbe idea that intlaiumatiou was a
process in tbe tissues, which, entirely indcpendeuc of the voasols, waa
UBoebt«d with a rapid luxuriatit pmliforation of tiosue-eella, and pat^
Ual softening and disinte^r.Ttion of the inteicelliilar tissue. Von
X«eielbiffhatuen*a di-trovcr>' of the two varieties of cells ro«»Kl in cou-
DMtiro tissue, as well »a hut discover^* of the vftricd movements of
ptts-edls, might well ha.ve given rbe to the qtief>liun whethiT tho pro-
KEontJon of tbe cells, on irritatJii2 the tissue, sIuImI from the fixed «r
Movable conneclivc-t issue corpujcles, but faiknl to d'j »9, Dot now
observation U piled on observstioii ; and we are driven to the 8up|X)w-
tion that aU j/oioiQ czU» which ta tußammatton wafind aiRormatty
in th^.tinus are tcanJcrinj lehila^ooit ctü*.
Of eoursi*, from the viiriou« errora Ui whieh we nru liable in inter-
Btinj the signific-aoee of what has bweti otwer^'ed, we shotdd be rt-iy
ful about aiinouncinx general principles. The feeling that we may
again ovenhoot tho mark, invobmtarily steals over every one wlio of
\aU! cntrrs on obserrations in pitholo^cal histologr. Btit, whenever
it IiAs iM^en poMible to nxamiuc living tissm.* for a length of time, it
has appeared that the 6:tei oc«ineotive>tiasiie c«IU undergo no divt-
■ion ; that, in hot, they searoely change at all, aad that ooiksequently
flO
SlUrLE IN'Ci^D WOUNDS OF THE SOIT PARTS.
the appearances obscnrcd on dead ioflanicd tissau must bo otbcnrisc
interpreted. In cartilage alone nothing has been obscTved different
firom romi(>r aj^arances. As the hyaline cartilag« substance hos no
canaLs pussalilc for ccllit, sm fiir as we at prraimt know, there is little
left except u> Biippose tliiit the iiirrens« of cells in the oartilsgre cavi-
ties oft'T irritiitkin resiills ftriii diviwMi of ihe protoplaspi i>f the car-
tilag« ot'Ua; of this I shall herL'sftcrshowjrcnj prcpamtion» ; BlUl li^ ^M
line rartils^ has n«rcT yet been watphcJ for ilu« in n liviiij^ and im-
tilled state, and eonset^uentlv this observntioii iiiitst pivc (Jaee to tlie
.itudieH on liring eoiuie<:tive tiiUiio. ^M
ir there be uo longer any doubt that all young cells tkat infiltrate ^
the inflnni«d titutie, nnd sometimea, an vre shall bercarter E«e, esoupc
from it hi the shape of pus. »re n'hite-blood corpuscles, or, briefly,
wandfrlnff eeifa, vev htm: two (niestions tonnswer, namely, M9ly do «o
many cell« wander into the inflamed tif»ue, nnd liow eofflc these num-
ber» of wandering cells in the blood; where do ihey nrtginntQ?^H
liiere are tnro chief opinions regarding the passage of the wnDdcring ^|
eelk through the walls of the vessels : some believe lhj»t lh«'y pass at
th« pohits where the cell» forming the capillary walls eeparato^ that
ia, tlimucili fine openings formed for them ; others tliink tbnt the mpU-
l»rr walU •"titfkisl of a soft protoplaaro, through vhich the waiideriiiK^H
«•lis Ihmst themselves- There is also some donht wlietJier the imesugo^l
of the wandering cells is tu be regarded as diH* to their own act or aa
the reauU of intrarascular pressure. It Mould lead mc loo far to
discufs fully the f/ros and eowji of this qufstion. My own view, sub-
ject to future ohHervalioiiK, is us follows : the first change that wc Boe
in iiritated lintig tissue is dilatation of the vessels; the immediate re-
sull of Ihfs is retardation of the (low of blood, increased Irsnsudation
and a collection of vrliite-blood cells in the periphery of the ealihrp
of thn TCBsela; the wail of the w-sseJ gradually grows softer, pofisihl/
from the long contact with the while-blood eellR, vhieb gradually eit']
ter nnil finally pass lliroiigh the wait. Retardation of the cJreulaLion,
niid Hofteiiiiig i>r the wall of tliu v*-wsel, iipiK'iir t<) ine the neeCMnry'
requirement.'t for the extensive wandering of the cells. Whence come
the qiuinttlie« of white-blood cells that efeape during inilamniatlon,
ia a |>I)yE<iologiea] question, and must he answered by the pliysi<ik>gista,
r.ymph.Ttie glnmls nod the spleen are the organ* to whirh we first l«m i
as the «inrcc. Alllioiigh it cJimiot l>e regHnted as iibsohitoly prm-ed
that, with the cxtenidvo escape of cells, new Ij'mph'cclla are also
formed esten»i\-ely, »till this is very prohaWe ; and, a» wc know from
elinicnl cx]>ericnee that the lymphatic ginnds near the sent of an in*
fhimmalion urc almost always swollen, it is most ntiturul to nsautno
these as the source of the »bnormal <]iiaotity of waodering cells. In
HEALDCO BV FIRST ISTXSTIOX.
«I
Spite of most zt^alom «efforts, I have been unul)l(! to disoovct a.ny thUif
I alKKiL the tnoqiliDkigii^ cbangcn in ibia ccil-fonnatinn.
I mast mmtioQ one other point., wbicb is, tbat in Jnllamniatian red
blood<»rpuscles aUo not unfrequently pass tlirougb tlie »ulia of tbe
Teaaels; aoomUn^ to CoAnAeiaCa expL-rimenU, liws is grcutly iiiflii-
•eiuwd b^ tbf incTCaMt) intranucuUir pressure.
Let tu iiow return to our vroiind ftnd »eo wbat beoonn« of tlic lis*
Biic^ mliUnitL-(I with coll», of xhc inßnminatory new formnttoti, L^w the
cicatrix dcTotops from it wliilc tlic ccll-tntittrst!on c\tcmtft »lonH' Atid
I sli^gishty at eome distune« froni th« woinid : tbi* wUa in tbe Hurfuv«
of the nouTid, irbich alrrady adhrrr loosclr, ^[Tadiuilly aninnc a »piif
(lie aIiujic, tbu intercellular tissue tbcn becotuca liniier, lb« &pitiiUe-
Detls vliang«? to iix»l (xjnnoctive-iissiie opIIr, and finally the youn^
' cioatrirJal tissue assumes more and more tlie form of noriiuil, Bbroiu
DOQDCctirc tissue. That is, tbe vrliitu blood-cplLi ticcoino £x«d con-
nrctive-tisjitie ryll«, as pT»buhiy Iiikc« pliioe evm in tbo ombrya Ht>ro,
again, wc arc nivl liy vnrioii» question». The newly-formed, adlK-si\'U
intcrUfiujr tissue sooa becomes firm, especially in healing by the brst
jntMitiun; even afK^r twenty-fonr hours wi.> find its intercellular sub-
stanre quite stiff and fibrinous, tbe bord<>n> of tbe wound are also more
or less iaitlttateil witli this flliU «ubetance ; it is (xily tbe early hiirden-
inff of till* intcroollul.ir cotincr^tinjf «ul^tanc^^, formed of trsnsiKli^d
r'serara and softened conneotin^ tissue, tbat explains why tlto untou is
m> finn, even tbe tliinl dny, that the flaps of the n-nund bnhJ to^tbcr
wttbout jMjturv», fur without suth ««met live t<uU>laiiv« tliu young cel-
lular tissue eould not be so ooberent. litis sliffeninj; eonnective-tiBSUO
I' mbstancc (Fifj. 6) i» most prokibly fibriiif. which ctmMSUt of llii* Inui»-
^.adatton ccmin; from tlie vcsseU under tlir iiifluctit-e of the extinvn-
hlood-corpus^'Ie», p.-wsibly also of the waudcrinj» cells. From tbo
eiceellent experiments of .'l/f.zvfW<T &-Ami/(A it is known ttiat most
cxudatious contain tlio fio-nJlo<L (ibroiJ:enoii9 substance, wbicfa fonns
Cbrioe as we know it in the eoi;;ulated state, by eombining with the
'flbKhplaslic sututnoee of tbe hlooil iind otiMtr tissue.^. Very aeeurate
proportions of fibro^noti» and filn-ino-ploatic suhstoncc are required to
form fibrine ; these fai-omble rw^uircinonts occur in inftny inflammn-
tlnas. Sc/imhtt eonsirlent it probable t)ii<t all (irm Gbrotw tissue ia
fofine«! and maint.-iittcil by the fibrair^nous siihstaneo from the blood
bans; [trefipitatcd in a eortaia manner around the tissuc-oolU, because
they contain a Bhrino-plastic subRtanee in a. firm sbupe- Under this
hrpfith'-ttis we must suppose a spedfie tvll-actlon, wliirh woulil eaosc
the cr:a;^ilating product to a!«ume the form of muscular stri.« in one
plw and in anuthor of connoetire tissue. In our cum? this is a \-ery
■ notaiblo vitnr, for we see filamentary oooooctira tissue gradually foim
«2
PIMPLE IlfCISED W0UXD3 OF THE SOFT TARTS.
frotn lite ititonxUular «>ii;^lutccl fibrinc. It i» true llie amouDt of in*
terctillular sulieUiace iti t\w ir>w forniatioii i» iidt great, but there is
little doubt tliat tbc snioll spaces bctwctm tlic cclbt arc filluil by iL A
short ttino subsequently tUo young cöcatriciul tissue «pfKwn still to
consist nbielly uf spindto-oelU cl«sely prcs§Dil t'jgcthcr (Fig. 9); but
tlien iht* 8j>iiiill(?-cf]l» diiiiinii'b gn?atly by flutloning, many are ores
destroyed, und nc bare now a fibmituitury, coiinectivv-Li^oue substaucef
ivliicb ia to bo considorcl pniily as a proiliiot of ancrrtion, jiiirlly u
mctAmorpboeod prutoplusrn of t)».- bjiiiKlli^-ovUs; llii; ciciilnrial liiwiio
liiiidly riniiain» stable in tlunetatc. 77iursc/i^ wliu quite nxvutly boa
«gain <-tirefully atudicd tbe bcaling of rounds, maintains that ttic ap-
parpDlly ßbrinous tatcrtncdiatf> substitioe is not fibrine, but only meto-
ii)i.iir|>bixw(l c.'fnniMtive tiasiic. I do not deny tbat ibere may be ininie-
diiilc* uObcsJvu, ail iii»tii»tu(i-,?i>ua {^ruvrjn^ into cuoli other of tbc soft
flap» of tiie wound, indeed, I raeniinned ibis in the diai^mm at ibo
von imonce merit of this l«;t4ire, as the purest type of bcuUug by tbc
first tiitcatiun; but tbla tj-pc is very rare; when treating of tbn oi^
ganizstiou of the thrombus I sfaali speak of tbe metamorpfaoses of
coagulated fibriiit'. *
Meautime, wliat has become of tbc eloscd ends of the vraaels?
The blood-elot in them ia r<?aliiorbed or «rgnniw-il ; Hie wralU nf tbp
veasels nend out Rbootii which oommunicule with tlio raseuliir luups of
tbe oppoAlng- bonier of Uie ivound, and with cacb other. In this vaj-,
liowevvr, only the nitlier in-anty union of tbe opposing vascular Inopa,
wbicrit i.i at first slight, is necompHAbed ; tbexe were already fitcmcd by
extensive torl.unmlies and windings of ihe vesst^ls, whii-h liuil loo))«
ahnpcd terminations after the injury (l*'igB. 1:2-14). This u not tbo
place til go int<t the detjiila of ibis intert«tiiig development of the vns-
euUr loops; tlicirdcvelopment isiiot. due solely to dilnlntiuit, but very
much to ititcnstitiid gmwth of the waUa of the vessels. 'Z^c origioftl,
formerly-existing vasculur tinion is thus replaeed by a noirly-furmed
vaaeulnr net-work vrhich ia at first far riclier.
As a result of the restoration of eireulation through the young cica-
trix, the eireulalory disturb»nccs ratiseil by the injury are lurooved,
the redness and swellmg of the border» of tbo wound dinppear ; (rom
tbe numcrotts vessels, the cic&trix appears as a üiio red stripe. Norr
tbe consolidation of tbe eicatrix must Like plaec : this is anv>ttipliidml,
on tbo oiie hand, by the partial disnppearanirti of the newlyfürmed
vessels, whoso walls IkU together, «ad tlii;y tJius become solid, Bdo^
Gonneetive-tiEStie strings; on thi^ other band, by the int<>reellular 8i)l>-
ttaiii« lieeoming firmer and cotitiiining less water, aa above mentioned,
the cells assume the t!at form of con iit;ctiv{'-l issue corpuscles, or disop-
ftear; possibly some of them remain as waodcriDg cclle, and retura
heausg by «bst iktestiom.
•^tn into tlie lyinpliati(.-a or blood'veswls. To titto ckkkIodsiuod and
atiophjr ia due tlx; grrat contrnctilv [xiwcr of tbc cHntiictul tissuo^
bv ueiins of which I:itx0| broad cicntticos may ooouiooally bo roducod
to hair iJioir original size.
A( llie lirst glance, it might appear to jou coDlradictory, that aa
appaivntl}' oxi^eäsivc capilliu'^' nct-woric should b« formed iu the irouiig
dratrix, and should subsecjiiently he for the most part obliterated. VVe
nnnot trKiil:ii[i thi^ app«n.'iil cxcet*. still tlieir are plctily of «njilojies
in coibryoiial development; 1 wily iieciL to remind ruu that there is a
pcnod in IcetsI dvvvlopmL-iit whon, even in the riireous boiiy, there is
a oapiUar)' oct-wurk, which, as you kuou-, disapjican, leaving tcarctijf
■atract.
Xot to fatigue you with so-called iheorelicsl suhjeeta, I leave lliis
fie^ for a. short time, and, before leaving healing by tlie first inteo'
lion, OS a point fully tinderstood, I »luill inakc a feir remarks oti tho
. eaoees that may prevent this mode of healing, even when the flaps of
the wound are in appiwition.
nctding by I'lrat intention does not take plaoc: I. \Vlicu tlic' edgeti
of the wouod are brought together by pU^tem, or »uturcR, but their
ti>naion or tendenoy to »epamte again h very great, tender tlieso
cirouniAluioe^ either the plnoters do not keep the wound ikccumlely
doecdl, or the suture« cut ihrouj^h tlic flaps ; [»crhaps aUo the tension
of the tis&ues obstructs the flow of blood in the capillaries, nnd thus
disturbs tht! cell d'^velojitnent xnd fmriniilion. How great iJili leit^un
BiHiit be, und whni raeaua we liave fur rvlicvittg it, you axn only lenra
ia the cltuie.
2. A furtlier obstruction to healing' Is, n large amount of blood
pottrcd out bciwcrn the cdpres of the wound ; thi» interferes with the
i iNtXttM of healing, partly as a fbn-ign body, and partly, if it deeom-
pooeSa by the influeooe of the process of decomposiiion.
3. Oilier Circign boihca, us sand, dirt, aLUaliue urine, fsx;ca, ctCL,
also retard the healing, partSy me.-hanically, partly ehcmtcully. Hcaoo
these sub.ilanoeHRhoiiUI be tntrefully reinovoJ before uniting the wound.
Is wounds of tbe urinary hlattder, it 19 not u:iiial to attempt the clo»-
nve of the akin-wound ; the urine would force ita way into tbe sub-
mtaoeoita eelluliir tissue, or into (lie peritoneal aar, and excite t4>rrib1e
tDJur>-. Hen-, under some drcum^taneeK, it would be a d:-nded fault
lo unite the wound, althougli of Into the views on thi» particular poiat
dUFer somewhat from those of former days.
i. l^vttly, from a contusion, whose eOect on the iliiiw of the wound
vm may fuil to observe, there may luirc been an cxti'twive dUturlwinoo
of circuUtiun and deetruetjon of minute tissue, which has iiidueed tJie
pftrtial death of certain ports or of the whole surface of the wound.
6
64
SIUPLB ISCISKD WOCSDS OF THB SOFT PAP.TSL
Tlien, ma there is no wlSronnation in Uw edgps of Üiß woui«!, but (m\
vthcTV. tbc tissue is still livin;;, ^rc tiiir« small t«;^ of tUe dc»lrojcd
tissue ljin;^aa foreign bodies iK-twec« tli« islge«) of the wound ; Üseea
mtist prevent heating br first intenlion. If llii» inortilicxtiuii nttack
only niinutc particles, tlir-ao may possibly quickly iiodcrgo molorultur
disint4>gmlion »nd absorption ; this may occur not «iifrwiuont ly. We
uliall »pc'Hk niorp exteiKtvply of tills mortißcatioo of the tissue, and of
it« (lelu-faruciil from the hciiHliy parts, when trcBtio^ of contuaiona.
Experience, arising ftom many ob^M-i-atii-ma in judjfin;; of wounded
surfari*!), wi)l hcrenflor unubl«? you in most cases 1o kiy \\ litrlliiM' heal-
iijg hy fintl tntpnUon may be exported or not, aod you will also learo
ivfatm it iniir bu uKcful, even iu doubtful case«, to try to uid this uuiou
by apply in;; drpssinga.
You will oL'casioiiully hear of wonderful cases where parts of the
body, ocimplctoly st^iiaratcd, bav« again become united Thid appenn
to bo iictiiallv tlie «nso. I hnve nevir had l1)(> opportunity of maklug
any ubaer^ations on such cases; «till, even in late days, very trust*
worthy mcQ have asserted that tbey luive «.-on small portion» of eUin
again uiiilo after being rwmovod friMn the fingers by a blow or cut,
then carefully replaced and fustent-d on with iidlicsivL- [)Wtcr. For^
merly I cqii tended against tbc possibility of this heoUng, but must now
admit it, niso on theoretical grounds, afti^r it bos become imaginable
that, through the movements of the cells, the detaehed porlio«», if not
too great, may soon bo njstored to life again by Itie ciitnuicü of wan-
dering cells. That vfti may siiccessfuHy transplaiita twig, cut fromono
tn*e, into anolhcr one, is well known ; but, as the ciiriilatiou in plants
is not by pumping, but the sap run» simply by wlhitar forrc, the anal-
ogy is not very close ; it was more reiniirkable, it is true, that a cock'a
spurs could tx' tran'^plaiited to hi« comh, hut between birds and men
the iliflcrenccs in the formative process «re al&o very great, and any
immediate transfer of observations is inadmissible in practice.
LECTURE VII.
nip!i pnrMpilMn Us iho Nkk«! Eje In Wounili witli Lau of SubBinnce. — Fintr Pra-
eat*c* In IImUdit '"'llh Umniihliou oni Suj>[tiimtlnn. — l'u'.--'Cu>atriulioR._Deni-
ontntiDnnf Prnpatat.Unu UlDUrktlreof tL« Uettling orWouud«.
It now remains for ii» to inquire what becomes nf the wound, if,
under the nbove cirounL^tanoe«, it does not heal by first intention.
!iPR, a« the flaps ga)>e, we have an open wound twfnre uk; and
circtunstAnces are the same as if the gaping wound Ii.id not been
HUUNO Br GRJLNOLATIOV.
65
dowd, or OS if u piocc hod been cut ouC, ns in a wound n-itb l»ss of
subsUnce. Accuroto observation of eix^ u-oonds, which ore usuallj-
cnrerpd with «omc unirritating bodj', as vnth a fold of liacn dipped in
oil, with oiled nr dry diar^iio, etc, sbovrs tlic followiug changes — if we
tfXAioitie it daily, this ia not necctjsary, it is true, and may ercn bo in-
jiirioui; after tirenty-four hour», you fiud the border» of tlic wounii
sligJiiljr roddciied, soiuewbat swollen, Hiid scmitivc to tlie tuiich ; llie
eamc ejrmptoais ua in closed wotiutls, Aa ia bcBliof; hy first inten-
tion, Üic«o sj-mptoutö may Ui vary iusi^^iii Pica lit or eutin.>Iy absent, as
in old, nzbscd, flubbv »kin, also in strong »kin with thick cpidcmii&
Wq obecTTC these srinptoau best in the skia of healthy children. An
extensira and increasing redno«, BxvcUing, and pain about the wound,
nuke ui suspect an abnorraat course ; jost «s, witli the sainc symptoms
in » wouod healing by ArAt iiitcalion, \-arioiis indiridual circumstanocs
ore to be eonRidCTed, und the vibrations from the normal to the abnor-
mal ar» so numerous, lh»t the dividing line is often difTiaiU to ik'ter»
minv. After the tirsi ttveuty-four hours, the surface of tlie wound has
changed but little ; all orcr it you cnn still recognize the tissue« quito
disttoirtly, although tliey liavo a |>eculiar gelatinous, grayish appeal^
ance ; you also find a coiisidorablc nuiubrr of yellon-ish or gmyish-red
Bmsll particlca over the surfiice; on close examination, you find ih(«ie
!o bo small fragment« of dead tissue, which still adhere, however. Tlio
second day, you icay already nuLiae k trace of reddish-yelluw, tliin
fluirJ over the wouni], tlic tissues appear more regularly grayish red
sod goUtinous, and tlieir boundarii>s besomo more indistini't. The
tbinl day, the secretion from the wound is pure yellow, somewhai
tbiekor, most of the ydlow <lca<l porliolea are detacheil and flow off
with the secretion ; tlte surface of the wound bcoomes more eren and
rcjgularty nsl — it ci^an» <i^, as we *ay technically. If you had not
boand up the wound (a stump from nmputution, for instance), and had
fvetived in a. bii*in tlie se<M<(>tion that fi^rmcil, the first and scniHid day
you would find it bloody, brownish red, ihifd of a ge1ali:ii)U8 <lirty gmyt
tiim dirty yellow : at the points where the accretion flows from the
wound, fibrino not un frequently stiffens in drop«. If you examine core-
fillly with a lens, even tlic third day, you will seo numerous red nod-
ules, scarcely as large as a millet-seed, projecting from the tissue
— dinnll gninules, grttnulationt, flethywaet«, My the fwirth or sixth
day tliese linre greatly docelnped, and gradually join inloarme,granii-
lar, briglit-red surface — the granulaiing tur/ace ; at thesomc lirae, the
fluid flowing from this surface becomes thicker, pure yellow, mid
of un'ainy eonsistcnco ; tliis fluid is piii, and, when of the quality hero
described, it ts good pus, jm* bonam et tüudabiU of old authors.
Of this normal couree there are many varieties, which ehieSy de-
6«
SIMPLE IKCISED WOUNDS OF THE SOIT PARTS
pcnd on the parts iojun.'d, and the mode of injury ; if iarga slitv<)s of
tissue from the surface of the wonnd dio, thft notnid ig longer in cIcAn-
ing oUT, uikI lli<.m you titny someliioes sec tli« wbitc, Adhoruat shruds of
dr^ tissues still clioging for days to the surface, most of which is al-
rendy grnnulating. Tendons and fascttr arc pnrtitrularly a]>t to hare
ihaii circulatioQ so impaired, eren by simple incjaecl wounds, that they
die to ui unexpected extent from the cut surrnci-, while there i» little
kws of loose cellular tissue or nuscle, Tliis i» undoubtedly duu piirlly
(o dofiHent vnscuUrity of llie tondinou» pnrta, partly to lln'ir lirro-
iicsa,nrhlch(locsQotpi-nnit rapid co)[a1vm)dilntul-iun of the vessels: the
SAino is true iu injuries of hone, especially of tlic cortical suhstoace,
where there is often death of the injured bone^urface, that r<M]uiros
a long time for detachment. Other oVistaclcs to active development
of granulalions «ro constitutional eomlitions; for instiincc, iu veiy
old or debilitated persons, or badly-nourished chUdren, the develop-
ment of granuhitlons will not tiitly l)c vr^- nIow, but they will look very
pnlu and Hubby. Hencnfter, at the ehmü of this (^liupter, I will frivo
yoo a short fp\-icw of those nnonwlies of grunulntion whioli are doily
oceuireiineK in larf^ wounds, and, to a eerlain extent, may be regarded
as noniial or st least customary.
Uut, to return to the obsenrafion of tfai; nonnally-dovclopia); In^-cr
of granulations, with the continued secretion of jiu^ you pcrecive
thai the ^rniiitilntions liecome more and more elcratcd, and sooner or
InliT iUtu.tn tliu Icrel of the skin, and not unfrei]uentlr rise ohove it.
With thin priwesa of growth, the individual granulcB become thicker,
and more confluent, »o that they can hardly be recognised as separate
Dodutctt ; but the entire ^urfucc ussumes u p^liutsj', f^latinous appeorunco.
Occnrionnliy the pninulntion« remain for a long time at this »tnge,
BO that wu have tu use «iiriuus reitiedles to restniiu the jtruUfenitiiig'
ncofilanra within bounds that are requisite for recovery; oa the
periphery, particularly, the graoolations should not rise nbovo tho
level of the »kin, for the rieatrizntinn hns to oomraenee at this point,
llif following metxmorplioaes now |;niiluully occur: the entire surffu-e
contract» more and more, become» smiiUer; on the border, between nkin
and gmnulstions, the sefretion of |>us dimtnishcn; first, a dry, red
border, about half a line broad, fontis ami advuiioes toirard the ccat4%
of the wound, anil, as it jirojrcf'scs ntid tiiBVcracs the {granular surface,
H is followed closely by a bhiiab-xvhito border, which passes into nor-
mal epUlcrmü. TIk^c two seatmi result from the devclopraent of
epidermic, which advance« fmm the periphery toward the oeotro;
etfatrizafion htfg'uis', llie youn^ cicatrical border advanecs half a line
or a line daily; finally, it covers the entire granulation suifane. Tlie
youngs cicDtrix then looks quite red, and is thus sharply defined fn>m
CICATßI7„inOS.
or
the liealthy skia ; it tenia irm, mnrc ro lluin Lbe cutis, and is still
very intim ii(«1}' connectiNl nllli tlie «iibjaoent part& In the roUR^e
o( xom6 tnontlis, it graditallv ((rows puk-r, »uftt'r, tiioni iiiovtibh;, uwl
Bnally white ; in the course of months and y<yirs, it f^rows still sittiUor,
but often nMnainti wliit(_'r lli»n thu cutis all thruitgh life. I^te
strong nontniction in tJic cicatrix often cuunut traction on thu neigh-
boring part», an effect that is occasionally desirable, but sootetimes
vorjr imweloome, as, for ia&tance, irhen such a cicatiix on tbs cheek
draws the lower eyelid dovrn, causing' ectropion.
Vou n-ill occasionally see it asserted that the cicatrization of a
granoktiiig (iiirf.toe ra,iy sometimes bcjfin from several patches uf
cpldrmiis fonnini; in its midsL This is only tmo of canca where poi^
tions of cutis vrith rctc Miilptnliii linvc romaiitcd in the midst of t)>c
wound, as may r(>adily hiip]K-ii in gnn^ronous vrouiidii, ag the caustic
agrnt may pnnetratc unequally deep. Under such circumstinras, epi-
dermia a^ain foftiis from some remaiuiu^ ))ortii>u of tliu papilhiry
Imyor, Ui-ii has Hie alightpst possible covcrinff of cells of the rcte MiiU
pigbii ; at Uieftc pointA wc hare tlie same cimiinstancca as vrbeti we
faatt; nüaeü a wniclu uu the skiu by caiitliaridt^, inducing; by the rapid
exitdiitiou an «•le^titinn of the epidermi« from the miiraus layer of
tbeakio; llii« 'm follunrcd by no gmnubttions, !f you do not continue
to Irritate the siirfare, but homy epidermis a^in fomui at once orcr
•thenueous layer. But, if there be no such remnantof retoMalpighii,
wr never hare these islands in the cicatrix, the formation nf epidermis
only takes place gndually, from the periphery »f the wound towanl
tht centra. I belieTe thia so firmly, that I think sur|;;coniS who *ay they
haw seen otherwise, miKt Iw mistuken in uime way.
After harini; conaidenxl the CKtenial conditions of the wound, tlm
dorolopmcnt of ffranulatioas, of pus, and of the cicatrix, wc must
now turn n^ain tu the moro minut« cfaan^OB hy which theso external
symptoms arc iitduccd.
It will be simplest for us, ajain, to rcprosont ■ relatix-ely simple
capillary net-work in the conneotire tissue: suppose a eroB«mtin piece
to be out out of it from above; first, there will be bleeding from Üie ve^
•els, which will l>e arrcütcd l>y the formatiuu of otots as far as the
next Iwiiiiflies. Then, then' must be dilatation of the renels about
tlie wound, which u due partly to fluxion, psrtly to increased press-
ure; an iocnwscd transudation of blood scrum, or an exudation, la
also tt neoMsary result of the capillary dilatation, from cause« aboro
p*cn; the transuded sienim contaiui some fihro^n^nous suhstaofe,
whii'h, by the inlluenrc of the ncivly-formeil ct'lls in tl«; most suprr-
fiebl layent, coai^iUies to fibrine, while the snum, mixed vrilh blood
pluini, Oowx off. The rascuUr net-work would assume tlie foQoiring
aliape:
eg fiiMPt.K I^■cD^En wousds of thk soft farts.
Pm. 4.
-ftO
1'
ro
'.">
V
.^■c
I>lJi{;Mmof a n-oatitl, nlUi Iiiu u[ labaunu. VMdUiiiiIIlalAllon.iiiasnIQedSnMtOllniM.
Ill most cases, from itiMifficient supply of blood-plasm, at lltp eui^
face of llic woudJ, more or less paiiick-a of tis^uo nil! die; *s tlte
Stoppnj^ of vessels inu»t, uf course, deeply alTivt llio miutUon of U»»
sues not very viiaoilur, atid, nlicrr; the tisMii's nrc vl-i^' stilT, ililalntion
of the rcsscU wili l>n interfered willi. Let ua stipposc tliat ttc upper
layer, sbadcd in the diagram, is dead from the i-Imiigi^s in llie droula-
Uon. Whai will now take place iii llie tisRite itself? Essentially,
the »tniu clian^s ils iu the unitod cdgts of n vouiitl; wattdvniig
of white-blood cells t.lirougl) tin? walls of th« TP*sel«, their collection
in tlie tiesne with the sücotidary action tliey iiiduei-; jtU^lic Jnliltn-
tioti, ami inflanimalorv new ffirumtioii, But, sJnrc there i» no oppos-
ing wonndod surface, witli wliicli tlie new tissue can oonlesee, llicn to
be quickly transfornied to coniieelix-e tissup, the cells, fseaping from
the vcsscIb, rcmniii at first on tbc surfucc of tlie wound ; the cxwlcd
6bmioiis iiiulvri»! on tbc eurfucc of tbc wound bccomee soft and
gf Uiliiiutis ; al tlic same lime, Ihe infilLniU-d tissue of the stirbt« of
tlio \round aBSumea the same peculinrilic»; the »oft coniicctivo tJaniie,
into n-hich tlte young Tewolä ahoiily grow, cTcu if onljr present in
GBAN-ULATION TISSIT&
00
«moli qimutiticit, bolus l:o;r^bcr tbc cclU of tbc itiilumtuatory new foi^
matioii, wlifcli ooiistaiitly iiicrca&u in uumbvr. Tbe yraniiUUion tissue
is thus fonuccl ; tliis is, ifacrcfore-, a tiigUj-vuscular iaä«nunatoi7 new
fonnatioi). At first, it grows coosl&ntlj-, tlko dircciion of its growlh
is Qmn the bollom of Uic- Yroimd (o^rard the siufoce; t))f> ti.4su<> i*,
bowerer, of diffprent consistt^no? in tlie varioiw laj'er», ils »u)K'räL-ial
surfact: e9])ccially is sofL, nud tnost äupcrficiiilly of fluid cuiisislc-uoc,
for hcpp the intcrcrllulnr siilMtanco hw-ome« not only g^atmoH&, but
dititl; this upjH-niiost tliiti lluiil liivcr, wlik-1i 'n ooiuitiiiitly flo^Ting
■od bi-iti^ i.-uustiiiitlv n^ncvrcd from tbc )*cauulatioa ti&suc bj ocll-cxu-
dAtion, is pus {Fig. C).
Hraioe, pus is lliiiil, as it wctv melted, diitsolved inflamnuiloiy new
Ibmiation. ^ylK■^e \)\ia is present iii c|uimtitv it iiiiü>t li^ivt- oonie from
KXne «vrt vf grsiiulution tissue or (mm tscate other bif^ilj-Tgufculur
and unnlljr iii^ily-vclliilar source; tliis eourc« uood uot iWayslwB
surfiKe, ma ia ihr prvM-nt cuse, but iiinv lie deep iii the tissue and form
A ca%'ity ; tbo ccntrt: of on ULQaiuioatory new foimntioii anywhere in
the tissue may bn?nk down into pus; tbeo we liavc an aAaw**.
We shiül frequently have ocrasion to »peak of tbis rclaUon of pti.«
BTiij gmiuUtioiis to ench other ; Wld East to Üie idea of f^iiiiltitioi»
Iteinir tiitffu«^ (not granules), and of pus beinji^ fluid inflammatory new
fomialion, aud \uu will hereafter rt^dily umkTslnnd many |iroe«Me%
especially cfaroaic inBammntioDs, whose Tsriablc appcnraJOL-c you would
Otfaervrisc find incomprehensible.
Let u3 now say a fen* words about pus itself. If left standing in
s Teasel, it separates into an upper, thin, dear layer, and a htwcr yel-
low one; the fom>or is tlniil iitlercvllular substance, Uie latter uontaios
ebiofly pusK'orpuM^lea. On simple niitvoseopie eiaininatiou these are
mumi, ItiiL'ly punctated ^obub^«, of tlie sizu of wbtte-Iilood coriniKlea;
Cbcy couluio (brec or four dark nuclei, which bc«)ine quite distluot
rni addition of aeetie add, bceausc it dissolves the palo grsDulcs of
tbe protoplnsm, or at least swells tbcm so that tltcy become trauspar-
üqL Tbe uudei arc not solubk* ta aoclio ocül ; tbc entire globule ü
readily dissolved in alkalies.
no. s.
Pb*hmII* tnai (rMk Ml. mttnUlNl M Umm. «. rtea'l «illioatwMIUan: A, th« umi ep|Utfti>t
aiaUlMi ut dOMk kU ; t, nriem bmn Uut IWIuk piat<aii» mttaata la Uiclt «uMuU
70
SIMPLE IXCISED \VOCNDS OF TBB SOFT PAKTS.
At a And b wc see Uie pu»-celU as thej usiiully ujipour wlicu we
cover a drop of pus irilli u lliiii rIiiss, anil wiUiout uiiv midition cx-
tttnioc it untler tlio microscopt-. Thv atiOToaiciUioncd «■l>H?rvatioti3
of Von Itfei:lingAaumn hare shown that only thed^sd oelU liiLtretbis
rouniJ »bapp ; if wc ohsprve the piis-wlU in the nioist chainhtT on r
wariuwl u!»j«'t-tjiblc {nct-ording ty Jtf, Hc/tultte), nv »ce ill« nm^lbntd
iROVoriivtit (if thi.*« yv\h most lifntitifully. Thp«e niovemenlA, «i-hitih
oa\y go on slowly and slu^^lslily ut blood-heat, becumc mon) rapid
at a highor tcinprratui»-, and Its» so at n. lower. The num1>cr of piis-
cpIIs in pus in so groiit, that in a drop of pun? pus, under the niiero-
Kcopi*, the fluid inlercellular substance Ik not nt ul) perccJved. Oieoii-
cal «xamitiHtion of pus is dtlHcult, first, Ixicniise the ourpiiäctes can-
not l>e oomplotriiT sopnr.tt«ii from thß fluid, iilso, bocnusc the Lirge
qiwutitics of (IHK obuiosble for t-licuDieul examiiwtiun htid nlivady
berii-a loii^ time- in the body, niid may h:ivc chauf^cd moqiliolojjfirally
and chemically; and lastly, because c!d<;fly prolein siibstaitccs arccoo-
tainod i» pus, whofit- pprfec-L et-paratiun hitherto has not alu-aya been
possible. If wc let pus from a •Kound stand in n ;;la.<s, llic clear,
briglit-ycllow ecrum usually ocoiqiies more apaoc ibon iUe thick, »traw-
yellow s^xiimtmt, which eonloina lite pu«-enrpusclc«. Pu» contains
ten tosirtocn [inrtsof iirni constiLuents, chiefly chloride nf sotllum;
the ashy constitumta are about the same aa those of blood-aenioi.
Reoent examinations of pi« have ghown tliat myosin, poraglobulin,
Protagon, fatty acids, letidn, and tyrosin, are ronstatit constituents.
Pus collected in the ho<Jy does not readily nnilcrgo at'iil fermenta-
tion; pure fresh iLlkulinc- pus soon become« roup, however, if it I«
left sbtndinjj for a time even in a rnvcred glass.
Let ufl luiw return to the gntnutation luyer, where we have fttill
an imporfant point to consider, namely, the numcrou» vc«*!«, which
five ilK rv(] ujijicnmriec. l^ie extensive vascular l<>o])s tliiit must
ibrm on ihe suriawi of the wound, and which in the difl^raru (Fiff. G)
we too ainall and too few, commence, with the growth of the eurround-
ing granuhitinn ti»iue, to elonjrate tiiii beromo more tortuous; tow-
anl the fourth or Gftli day new vessels develop aa fiiie lateml capil-
lary cominuuiuatioi), ua Id healing by iirit iiiteution, and the lisäue is
noon traversed hy an cxocs^ive number of resacls, which have to
much fftect oix the appearance of the entire graniilaimn surface that
it is liurdly recognizable on the cuduver, whei'C the fulnc-ss of Ihtr vcs-
gela is wanting, or is at leiist lea^ marked than dnnivg life, nod the
tissue consequently ap{ieant pale, relaxed, and much Icsa Ihiek. The
iiucstion arisca. Whence come tlieficrciuorliablc, small, (ftadually-coa-
Cuent red nodidcB, which are visible to the nuked eye? Why does
not the surface look even ? Indeed, this is froc|uently ibe case ; the
ORANOLATION TISSUB.
u
grtatvUr^ are by no mcüns attvaj*« distinclly tloßn«! ; biit it is not ea»y
to expUtri the cause of their fonn. It is usually assumed that Ihc
gnutitlfs arc to be regarded as unitationB of tliu ciilnacous papUho;
but, indcpcr>d<Mit of Ihr fart that it is inroiiipn-heiKiLlo why such
structures should be imit:it(^l in imiM-lf^ and bone, and that tlic gmn-
ulc9 ntc usually ten times as lar;^ a» ill« cutAiHK)us [upilla', this is
no real espUnation. TTic appearance of the granule*, doulnle;», do«
pflods oa tb(> arratigrtnt^nt of t))L> \-uscular loops iuto tufi», on certain
boundaries belwern tlir: diffrrt-nt group« of rcsscla. Hence «c might
tupposc thst the nsculnr loops acquire this form without known
cause. Still, it se^ms to me natural to compare them to the Hrcum-
scrfbnl ciipillarj- district», alrewly foriiirti in tlie normal tisiues, of
*rh>ch we have numerous cxamplos, oiipeeially in tba skin and in fat.
Ton know tliat every sweat and fcbaee^us gland, creiy hair-foUioIo
and fut-lobulc, baa its nearly-closed capillary net-work, and, bj? the
enlargement of such capillary net-work?, the peculiar closed vascular
forms of the f^nules miglit arise. In faet, in tbo eutnneous and
fntty tLRme yon will find llie bidividiial flc^Lby gruwtbs, particularly
sharply naJ clearly defined, while Uils is more rarely the case in
tniisde, where theae Imnnded eapillsr}' diatncls do not oeour. It csn
only be deeirJed by artiRoiat injeclious of fresh granulations, whether
tbta explanation is com-rt ; till Lhcn, it mnoius simjily oti attempt
to refer this patholofpcal new fonny tton to normal anatomiool con-
dition.«.
The followiog Äketeh, in whirli, on account of the great enlarge-
ment, and the small rnjtired difttrict, notbinf^ can be seen of the ,i>ranu*
lar layer, may serve you a» a iltu;TRun of the development of theprun-
ulatiun tissue with its veuels, iitiil of ils n-latton to pus and to tlie
subjaecnt matrix, a« it l>a$ developed from Fig, 4. AVitli' the for-
mation of this rich new oourse of eireutalion, \he redness of the edj^
of the wound, caused by the enllntoral circulation, diuppeam, tlic
eymptoroa of fluxion having' previuusly oeased soon after the injury.
It has already bi>en stated ibnt pus i.i inllammatory mivr formation
whieh has become fluid ; strictly speaking, this is only tbo cos« in
purulent melting down of inGItrated tissue^ in formution of granula-
tions and uluk'css. Hip secretion of pug from thegranulatinjf surfiice,
(a which tlie latter lust's no substance by giving off pu.<i, i« to be
rC};aTded a^thc oontinuul c&oapc of numerous pus-ecll» on the siufuco
of ibc gntnulations, in part directly üom the granulation tissue, partly
from the vascular loops. Thus ihe secretion of pu» on the griui datjcm
surCico becniDCs quite nnalnjjfoii» to the Mxrction on the mucous nnd
■eroUB membranes, and particularly to the inercaecd secrcfio» from
mucous membrane in eatarrii. This also fully shoivs the diflerenc«
12
SIUPI.E IXCISED WOCSDS OF TBE SOFT TAKK.
bctvrccD eocrctioQ of pus luid pr^^cssivc auppimlivc aoftcoing of
tissue (suppumtiuu luid ulccratioD),
i^P^
rukfl.
0
^0:?j
1 /
o
0^ .-^_
Do) V_df>
"Q ty Bivik will. lo ilWiiitfulih Ihe pn>-<clli In ttio BfuK DUHC ucumtcljr ftua lb» Knog-
lUIoD ri'lli. UBcnllleiiaooUoailliiinclcn.
If the growtli of (he ^nniilntions whs not nrr<>st(?d nt some |w>int,
n conBtantly-gTOwiiig granulation tumor wotilii be forme*!. Fortu*
nnlcly, tills ie nL-rrror wry nnXy the case. Vou olroMly know, from
the representation of the extrmnl ronditiorut, thdt. irhen tlie granula-
tions ha;'e reached the level of the culi», or even «ooner, they cease
to grow- and are roatcd wilh epitlcrmis, anil rctrojrnuJo to n ciratrJx.
The foUovving cliatigr-g occur in ihc tissue: At first, in the granuln-
tion tisfiiie, as in the edges nf the wound in healing hjr the first inten-
tion, tIii?Te lire nuinemua rrlln which arc dostrcij'Rfl. Not only the
millions of pus-ccllfl on the surface, but nlso cells in the depths of the
gT-anuliilirin timie, disaiipcnr bv (lisinle^ration aiid renlMnrjition ; it la
very ptehaWc thnt relU from the gmnnhtticn lissue mny pass bauk mi-
injurefl into l^ic vessel«, aa we shttll see, when treatioj^ of the organi-
zation of ibrombosc« of ttte ressels. Aa the coUs retrograde, fine lat
KKSULTS OF GIUNULATIOir.
19
I gnuliially rorm In Lhem, not trnly in the raund but also in
thtr spuidle-sluipccl ones ; »ucli cell», ivliLch are composed nf rety fine
fcl-(jlolmle9, an gcncmll v cnllo<l gnxmilar ctlU {Körucbcuwillcn) ; Htvy
oeoiir in tlio pmnulaliona, ns nbore dwicribcfL Wlicn the f^rtn-
lacinn tissue is tliim tümtni.sb«! by »Lropliy, nod escape of the cvUs,
^t Lhu Bainu tin)« tbe new fbnnattun of cells ccoaca, soaicthiag tm-
must happen, that is, tbc ffmdual consolidation of the gelat-
intertvllular tissut* to »triatcd coTinectiv«' tis-iu**, ivhioh in
it uWiiL by llict a tcadily •increasing \(t»s nf nal«r, tliat is ciimvO
' by tiie TCssek «nd ertpomtcd from the surface ; then the rcmaio-
■tooce aMiim« the abnpe of Ih« ordiniiry wmnoutive-Lti^tte
AcoorJIiig- to the view of other obör-rvt-re, thir ori:;inul
iteix-clluliu- substanc« cnürßly cliMpjK^M, nnd il« place i» silppliwlby
ti>> pmt'iplium of grnuulution cA\6 whitili transforms into fibrous tia-
»IT. With these ohanges which take place frotn the periphery low-
tbe c«utre, tbe Be«r<>tion of pus on the surEtce ceases ; at tJie veiy
Ircnmfotx.'noo of the vound on the eondciudng ßrantilntinn tisMic
epidennia forms and c|iiict(1y !if]>mLe-^ into hard <.>])i<leni)ic and mucous
ftyeis ; ncicnn]in^ to J. Anivhl, llii» ft»nuiition tuLcs place by tbc di>
iriaion of a protoplasm, at first cntitv>ly Kiuorpbous, in tb« imntciliat«
ielnit^' of the exiKtiag border of opidunnis. I^utly, the »uperlluoas
iries tnii^t be obliterated; few of them remain to keep up the
itioD throuf^h the cicatri-'c. With thoir obUtoratioii the tissue be-
ooraps drier, ti>ngl>er, conlnirts more and raort'T and often the cicatrix
mot acquire ita pcnnaueut fonn and oocuisteucc for years.
Tbe wbolo procoM, like all tbcao modes of IumUd^, contains much
tt t) very remarkable, althougli recent in\iHtigBtio:t3 have ex)>laiiied
Duny »f tlie mim; minute morpliological chaii|cea. The jHi&üibility,
oay, tbc necesait)', under otbcrwis« norntal circumaUmcca, of orriviox
fti a typieal termination, is the chief charaeteristio of tlioite new fonrni-
tin» Uiat arc Indiux'd by an inflammatory proccM. If Uiis natural
course of bralin;; diw» nut t:iku place, it is bi^auac either coiistilu-
aal or local conditions indirectly or directly inU!rf«w,or Iwcausctbo
attacked is bo impurlaut to life, tb» diaturbaucc to tbe entire
\y so severe, fhnt there la death of the orjpin, or of Iho individual,
that the functional disturbance of tbe fonnc-r causes the death of
till" bilter. Every new formation, due to infUnimatioii, always has the
endency to reach a cerl'itii point, to rctro^^nvJe, and pass into a sta*
Jonary iitatc, while other new foriuatious bare no such natural termi*
ition, IxjI usu-'dly i<oiitiniiu lo grow.
Different as hcaliii": by the finrt and second intentions af^ars, at
be first fflancc, tbc morphological chan^ea in the tisane arc in botb
\ Ibc same ; you only need to divide I**ig. 3 at a, to hare tlie samo
74 SIMPLE INCISED WOUNDS OF TIIE SOFT PARTS.
picture as Jn Fig-, 0. Observation teaches in Ihe simplest manner that
Uiia Ü actiiiilly so; if a wound almost licalod bj first intvation, but fl
Dot yot con^olidntod, be torn opim, we liai-e n gmnulalini; wouikI ™
wbich »oCMi suppurates. Von ivill iKTcartcr Ijo frequently cioDviiicc><J
of tills in practice.
The above process of >ic»ling bj' iniinvili&to adhesion ntid bj gna- ^
tiUtion vee faavi* tenQ(>(1 traumatic inßammation, and have found it fl
itirntinil iviUi «oxaf. otiii-r forms of inßnroination ; it has ntso bcca .
ütntod tlint It mafko'l p^^ruHnrilr of traumatic inilanimation is, that in
it, u'illtDut «ome fiirllier cause, llw irrilnlioii In the liMire doai not
extend heiroDtl the irniiiediate vii^iiiitj uf the injury. But we »liould
here mention that, in onüitary mc«)icAl intercourse, it it not umöt to
BAy tile wound i» iuSumeil, if all goes on nonDutly ; but by inlhininia*
tion of the woudJ, in ordinary sur^pcal tnnj^age, is meant a progrvs-
waa of the inflamniatioa beyond Uio ordinary cxicni. Wc ^1 ft
wound inflamed wh^n the borders swell greiilly, and beeorae very redj
ami p^iinfiil ; in «n trnmrilialely united wound, litis is not a good »Jgo« '
for cjttenjMVtf Riixion is often accompanied by «eeasi^-e suppuration.
We ghitll hcrenfti'-P speak of the great inipnitanee, under rcrbiin wr^
oiiiii8tiLnn.'s, of this progressive inllHinnmtion, wliieh i» jKirtieuIarly upt
to flocur in eontuscil wounds, ond of its causes ; here I ouly witdicd to
call your attention to a form of speech which is not quite correct, but
is common.
It is not tlic object of these iRCturea to show yon on preparaUooSt
fttep bystcp, the moTpholo^cnl mirroseofüt^al changes in grounded li»
Riie— you will »e« these, in (lie pmclical l(>*soiis on patholo^ifnl histol-
ogy— but I will shrtw ytiuu few point», sti tlmt you may iir-t lliinktliat
the proocsAcs of which I have spoken can only be demonstrated on
diagrams.
The ceU-infiltratian of tissue, after irritation by on incision, is bcrtJ
seen in the oomca. Four days ajjo I iiiftdc nn incision, w^■lit a hmoc-
shaped knife, in the comen of a rabbit; yesterday the ineision wns
visible as u fine line witli milky cloudine;». I killed the animnl care-
fully, eut out tlic eomcu, luid let it swell in p^TuUgneoufi nejd, till thia i
morning; then made a M<ction tlirongh the wound, and eleareil it upl
witli glyivrine.
Now, at <t a (Fig. 7), you may ecc the eonnccting substnnrn be-
tween tlie edges of the wound, in which there has been & considerable
cotlcctiu» of cells, bL'tween the l3melhi> of the cornea, where the eor-
ncal eorpuscles lie. These cells are not so evident in tlie meiliod eiu*
ptoycd as in that, where canninc is used, still the intermediate cub*
stance between the edges of the wound is Tery distinct. As you seo^ ic
PBEPARATI0K8 SHOWING HEALIXO OF WODSBS.
W
almost eDtireljr of celts ; the cells alone vould not, hovrever,
eadcT tho union sufficiently Grni, if tbcjr were not glued togetlier by
Fid. 7.
r
A\^
^nm
^^
^
loa, Has"UM 300 dLHWi«*«.
a fibrinous cctncDt. Tlio young cells probably como out of tlie edges
' the woiind from llip fiMiitv^» botweoti the contenl lAm«IIic, and p«ib-
\Ay du lint i.>ri^iiiiitu iu tin; coitiR'ctii'O sulistunua bctwi'va tlio edges
llie wound ; on tlit; cotitraty, tbo Utter 13 Btially formed frotn tbcto.
>iyt mc remnrk incidctttslly, tlicfte 6i)o oome«l cicatrices subecqui-nt'
cletu' up, Ko as lo leave scaioely ■ tnu». AU tlic oells that you
cm a«? in tlw prrparatioii romo from the tascular loops of tbc coo*
anetiva ; tlic nunnal EtuiUtc oorood celU »ro not vbiUe \tvvc.
Hufg (Pig. 8) you have & tranBVPrso section tbiougli ii twenty-four-
«ir old, frcsbly'iiiiiied vromid \\\ \\vt cheek of a dog. llie inriaion is
rell nuirlceil si n a ; tlic oil-;cs of the vrouud ore separated by a dark,
intermedtntc subitanre, wliieb curuisis pnrlly of while oelU, partly of
red oorfiuacle» — llif latter belong to tho blood, escaped between tbc
odgM of the wound, after the iujury ; the cooncctivc-tissuc fissures
crowed by the wooiiü, in which the conni.'ictivivtissuc cells lie, are
atnsaily filled with nutnerous newly-formed cells, and tb«»c oells IwTe
already pusbci into the cztravAsatcd blood between tlic edges of tho
wound. The preparation bas been treated witb aeclic aci<l, hence yon
no longer seo the striation of the coniioot ite tissue, but see the young
cells nioro diatint-ily, Look p«rtieutarly iit eerUiiii f>lnng8, rich in
ooUa, that extend from the wound toward both sides {bb b); tliesc
afQ bb30d-ires>«l» in wbt«e slieatbs niMiiy cells are inliltratcd ; this is
apparently beeauae here mniiy wbitc-blood cells have passed tbnntgh
PREPAiunoss SHOWISO nEALiN'o OP wouyoa
77
Flfw sections rannfit he made of f^rnnulauon tiuiie, just ulcen
from a wound ; it i» generally a rerj difllrtiU subject for fine prepara-
tiona. If ruu hard<.>ii U)u ji^muliLtion tissue in iilooliol, color tlic »«.■<•
tJoa with rurminc, then d«»r it up with glyceriiM", you have it epcol-
nurn likt^ Fig. lOi
Fio. la
Onniilitlimimv. UtgnlBadfnOdianiütcTB.
The tissue appears to ronsLst Mololy of cells und vt-ssels, with rery
tliin walls ; tlic wliolc tissue is shninkcn bv tl:c alcolio), so that \rn
here aee nothing of tbc mucous intcrccUul»? sut^stanoc wUcli is al-
ways present, even if only in sinsll qtuntilicii, in licatthy, freth gninu-
laiioQS.
Wv sc« the tissue of lliu youn^ cicatrix particuLirlj weU in Uie
fullow-ing prepurutinn (Fi|^. 11), whioli wax taken from a brond ctcn-
trix, fuUowing grsDuIatian and suppunitiaa, in ifae bock of a clog^
about fuor or five weeks after the injurf.
o-
Pui.ll.
^
i^.
»
ify.
78
sniPLB mcisF.D vovxos of the soft p^bts.
Hw preparation bas btrcn Ifcstcd wilfa acetic acid, to eliow tlie ar-
nngcmcnt of llie cotiucvtive-tieeuc cells, that have fora>cd from tb«
granulation tissue ; a a a are partly obliti>rau>d, partly still pcniieaUe
blocxI-vcxM^ls ; tl>e roniut4:tive-ti}«ue reib are »lill rclnlivcly I»T;^,9U(y
culi-iit, »Del distinctly spiiidlc-eluipctl, alUI the iulcrcellulor substance u
riclily dovelopeil.
To study tlio slate of the Llood-vcescis In the wound, wc mnst
make injocUons; tbis is quite difBcult, and ciuidc ^ucccw oftca dcpcodl
oil a luoky oliuDUb
lHjl'T'
the 111- . L,r 111.' -,
Limpina ot III" vi
Hon of UiuliK>|ii Idiu ilic louuuiUmi iuIibUoM.
I" iDrfto*, mint* wltli a broad knlb.
4 a. tuinniMiUatcnilMUiiorlwi'nFea
Ill ihiih bcmlonodbonoinul; moiEiitacliiit «toiupi*
On this «ihjr*-! wo hare the wcent work« of IVytfcJioff' nod
TfiiertvJi, wliuse rraulta in the main ogro« parüy with one another,
partly with my invrsti^tions on this subject. Wt/teQdiO^\ who op-
erated OQ dogs* tongues, gWvs a series of represcuutions of the coo-
SURGICAL FETER.
81
mnatnry tie«- funiiution, where ihft primnrv oelluJar tissue fonns, tlie
ipb-vc&sels arc moslly do§ed, jiurtly liy librous ooaf^iitions, parüy
new coll fonnatioiis. These obacn-ationa Kare also been cODlInDct)
uite recenilv bj- LUteh, of St. Petersburg, by cxauiiiatioas of trau-
»tlcallv inlJained testicles.
LECTURE Viri.
I Reatllon after InJaiT.— Swxi^ Forcr.—Tjisailni of tbo Fcmr.— rnt^tttntls.—
n«alRuni «tf Simpla WoaaiU and of Vaiaid«d J'uanna.— Opnn TraimiMM of
▼ound*.
Gkstt-BMIW; You now know the ext^^nial ami internal minute
la t))c hvaling of wounds, so far as it is jxissJblc to follow
ibcm ffiUi our prcacnt micmscopes.
Of the ifoun<Uä pfr*on we liavc not yet upoVcn. If you Iiiive crit-
tcally pxiuiiiue«! his condition, yaii «ill Iinv4> noüoe<] clinnj^», which
>y not Im cxploitieü bjr i^^ll-koowk^ilgu (mit «^eltetiwmheit), and
»pa not at all.
Ponibly eren the first lUy the p«lient may Imve been restless
inl evening'; he may hure felt hot, tliinsty, with no appetite, some
lie, wukcful at night, and dull the next mnraJn^. I'bcsc sub-
Iro Bymptoms tncreuse till the cn^in^ after the next day. If wo
bI tl»e (lulse, wc finJ it more fretpKnt lliaa oorrual, the mdial nrt«ry
tenser and fuller Üian before; tlic &kin is hot and dry; we find ih«
bodily tempottaure elevated ; the tongue is coated and readily becomes
You alrcudy know what alls the patient — he has fever. Yes, he
kfcver; but what is fever? wheiioe comes it? what coniiccUon la
kbctween the diiFereot temarlcnble subjective and objeelire synip-
But do not iiftk any more qiiestioiu, for I can scarcely answer
' «Iready proiiosed.
By Uie name " fi>vi>r " va- doajjifiiatp the eonibination of symptoms
pIiu?]i, tu a thoiiMLiid dilTV-r^-iit )ih;i}»i>«, uhiinsL always accompanies in-
tlanunatory diabases, and is geuendly ap[wreȆy due to them. We
^w ila duration and ooursoiniiiriousdiseJisea; still, its nature is not
illy imdentood, altlioiigli it i» belter known than furmcrly.
'V\vs different fever »vmpttm« appear with \\^ \iiriublc intensity.
Two of (he«c symploma «rt.r the mo«t eonstant, viz., the increase of
• and bodily temperature; we e«n measure both of them, the first
coutilio^, the toUcr by the tbennomcter. TTic frequency of the
irl'3 l>cat depends on many things, especially c*n psyeliical exeite-
it of (dl Krtii- it shows sliglit differenec« in sitting, lying, »landing.
es
SmrLE INCISED WOCKDS OP TUE SOFT PARTS.
walking. Hence, tlierc »re nuiny tilings to whidt n-c must atleud, if ve
noulil uvuul crrur. HowcrtT, vca ntujr uixiiii llicac mistakes, bdJ for
centuries tli« ^n^qucncy i>f the puUc has Iteon used as a nicaAiirc of
fever. Examitiütiuii u( tlic pulfiu also sliutvs olbcr tilings iiujiortsnt to
bn knaim : tbe amnutit of the blood, tL-nsioii of ttc artmcs, irregu-
larity of the hcart-boatf etc. ; and it eliuuld not he ncglcctc<] even now
that we have other modes of inwisuretnent uf the fever. This otiier,
and in some respects ecrtninh" lietter, mode of iiiraMirin^ tlic amount
aud diuttlioii of llic fever ia delcnninatiüu of the bcxiUy ttiuiKtature
n-itli ciirefii1ly-]>re[iftrod thermometers, whose scoleRure divided, aeconl-
iiig to CdtiM, m one linndred degrees, and each de^rcre in (en ]xirts.
Thv introduction of Ihia mode of meotniremeLt into jtmcticc is duo to
Yon BJrrnsprtin;/, T/vtu6e^ »od Wundert leA ; it tins themlvantagc of
gnipliioally presenting ttie mensurutnentA, whlctt are usuiilly nuulc at
9 A. u. and 5 r. JL, as curves, nnd tntiking Ihcin iit once ciuiil/ ruud.
A series of observutions of fewr in the nonnid course of nonuds
Bbou's the following points: traumiitic fever oecasionally begins imin^
diately after an injury, mora frequently not till the second, third, or
fourth dny. The higheet tam|»orature alUiued, althuujfh nirely, is
104..'iT.-lM..'l''; as a rule it does not rise mucli above l02''-iö3\
Simple Irauinaticr fever doe» not usually Iftst over a week; ia umsi
OMC* it only continues from two to ävc dnys ; in many cases it is en-
tirely absent, as in most of the »nixll supertieliil inci»ed wounds ttt
vrliich wc spoke sbove. I'niuiuatic fevirr depends entirely on tl>e «lato
of the wound ; it is g^norally of u remltliiig type; tlie dcelinc may
lükv ]>1aee rapidly or stowly.
From tlicsc ubservatiniis wc »linuld naturally suppose tho fever
woukl I« the higher the more severe tiic injury. If tho injury be too
insigtiiliount, tiiere is either no fever or the inei'ease of temperature is so
slight and evanescent as to escape our modes of measurement. ]t has
been thought that a scale of injuries might be constructed, aecordinglo
which the fever would last a longer or shorter time, and be more cr
less iiilense, in pr))|torlion to Uie length and bn'adtli of the wound.
This voiiclusion is only approximately correct, after inuking vety
iM>nf!d[>mt>le limitation». Some persons become fererisli after very
slight injuries : oilier» do not, even after ficvcm ones. The cause of tills
diS'crcnee in the occurrence of truuntiitic fever depctiila partly on
whether the wound heals with more or less inflainmntory »lymptuiiiK,
partly on unknown in6ucucus. Wc cannot avoid th« supposition that
purely indiridual circumstances have some iuflueace: we see that, from
simihir injuries, one person will ha mure disposed lu fever than An-
other.
Uefore going on to oxatninc liow the state of tho wound is related
ELEVATFOX OP TEUPERlTTEtB IX IXFLAHIUTIOK.
83
to Uie gPDPnil cnndition, »-c nitist exnmiiie Üic latter ft little more
cwfully. The moat proiuiiiciit and pliysialogicallj the inost remark*
able «^mplotn of tbc fever is the elevation of the temperature of the
hlcxid, rikI tilt* t?oiiML>(|t>Dut iacreaso of the bodily tenpenturR. All
the modem theories of fever turn od the explanalion of thi» symptom.
Tliero i« no ground for supposing that iii fever auy ubaolutelv new
element must he added to the recjuirempnts artinj^ for tbe prp«*rvation
of a constant lemperatur« in tbc body, but it in|>ni)>al>li> tlinl the fever
temperature is caused by »oinc cbaOKe of tbe noniiid ri-quirementa of
ieni|teniturc, whioh vat^- readily ivitli clreumstaoeva. When you re-
;ii)ber tbat men nnd atiimuU in tlie varied temperatures of sunimer
winter, in bot und lmIiI eliinules, have about the same tem|ier»turo
of Ibe blood, you irill se» tlmt tlie eoitditionsof produelion and glvinj^
off of beat are suseeptilile of gn>at TnodiÜcalion, and tbat within tbeae
enmlttion» tbene may very pnnsibly be abiionnitics of the re5ultiiig
bodily tcmpemlure. It is pri^lent a priori that an increa»<> of bodily
temperature miüv de|>i^»iJ eilla-r on diminution of tbe uniiiunt of buat
given off, the prCKlucliun remaining the same, or on incrcaacd produi>
tion, the Kiss of beat remainin;; tbe same (other relations of those
fiuitors to each otlier are poesibk-, but I shall \mi& over them, to avmd
eomfuMn^ jou on lliia diflicult question). The deeiaoti of this eardiual
queation duos m>t tteem pos.Hible at present ; it \vuulii be pusäible by
diftemiiniiiif awl eomparinj^ tho qunntily of hnnt prodiiiwd in fever
and in nonnal eoiidilloiis, by the »>catled adurinietrical esjurrinient»
OR nirn and Inrgc nartn-hlooded animals; but hitlicrto there havi; lieen
gremt difficulties in tlu! way of llicsc cxpcriniente. Liebirrmtitter and
I^jden 1ia\'e invented methods of calorimotry, that seem to me cor*
reel; but ibe methods and eonelusjona of LiebermeiM<T hare tiecn
«neiget icallv «imbate<l by Senator. Ilenee, in rpgaid to the above
f^uefcliona, we are still, to a great ertent, thrown on probability aod
bypotbesis. As tbe production of beat de)>cads diicfly on oxidatioQ
of the consiitticnts of the body, incrense of tbe latter wonhl neeessarily
be followrd by increase of the former if the loss of heat reruainod the
tame. Now, since tlic amount of urea is re^rdcd cliioily as the result
of the buminjT up of the nitrojfenous hndiea, and na the nnvount of urea
eicreted in fever i."* uHually inrrpaaerl, and tbe weight of the body
fapidlydeercaaea,aa appeare from the ex(wriinwilsof Ö. lfW«w, /.iVAtr-
mci*tirf Sehnttdfr, and Lfydfn, thi», \i-ith Ibe above-mentioned ealori-
metric experiments, is considerrMl strong {woof that in fever the con«
«umplinn is jfrratly ineTenscKl, and that consequently inorrr wnnnth is
milly ]voduocd than in tlic normal state, more than can In; disposed
of by the body in the same time. Trau6e pves another view of the
ocdurrcnre of fever-beat : be asserts that every fever begins witli caeiv
64
SniPr.R INCISED W'OUSDS OF THE KO}T riilTfi.
getic contniotion of lite ciitancoitR vessels, especially of (In fiinaller
art^cs, »ikI lhii( llitw llx; giving off of heat totlicuir iAdcii-ir».''(;il,&nd
more hcAt tt>ltccti-<l iu the kotly, witliuut its nctukUj [:nxluüug UHirc
Althuuffli tlib h_yj>uth(?«iit t» ndvaiicciJ hy its outlinr witli wcitidrriut
dliility aaii aculcaesK, aiul is a{^i|iaTc»t1j- suppurlcd by tlie noth of
Sc/iator, I, willi mist patUologisif, cannot agree with it, crprcially as
the premise«, the contmctioii ol' the culaneovs TCCficl«, can only he uc-
knowledged in the fnnt. Iieginitig u-itli chill ; hul lluB diill Js by no
meniid « constant symptom in the tcvtx. Hence, in what followF, wc
shall «tort from tlic ])oint thnt in fcv^rr there is incroost'd production
of heat. Tlivn ariiüL-H llic qui-»lJuii, Ikm ilocs iiiCnmtRation generally,
and trnumutio inflanimation |:iirtiLiiluily, lCccI tlic increase of bcdily
tonnpcnttiirc ? Tlti» question i» answered in vtkridkift ways :
1. At the point of inllanimatian, as a rceull of the livirly intert-hnugc
of tissur, heat is produced ; ihc blood Üowing through llic infonicd
part ia warmed more, and dietributcs the abnormal annount of heat here
an|uired, to tie whole bo<iy. That thu inllamed part is warmer than
tlie nnn-inflamed is readily proved, especially in snperficial paits, an in
tlie ekin, but this dots nut prove that tnuru uaxniLh i» produced here
than is usual, but is probalily simply due to the cireulaticin of more blood
through (lie dilated mpillnries ; if the inflBmed j>iirt he nut u-xmirr (Iiuu
the blood fion-ing to it, it is iint proliable tlutt iL sliould produce hi-aL
Tlie fnvcstigalioos on thia point are nuincrous and oontradictory. Tho
thennometrieal measuremenls of O. Wtber and //»j/icAwnV( hare given
inrious results; usually the temiicrature in (he woutul nrd in tJic rco-
t\im (whicli has about the vr&nntb of arterial hlooil) were equal ; ocea-
Munaliy the former was higher than tlie latter, Küineliiue« the iwerB<?j
the diBcrcnen was never great, not being more llinu a fuw tenths of a
degree in any case. Kecently O. IVebef lin» hit on n new method of
mensuremeiit, the ihenuOL-leelrie; by his very diffn-ult invi?Btigutiotis
Uie fjutation seemed to he decided that the inflamed part is alwaya
warmer thnn the arterial blood ; indeed, that the venous blood coDüing
from the »eat of inflitnimntioa is warmer than the arlcrinl hlood gtüng to
it. Quite recently these invcstigalinii» wrre repeatrd in Königsberg
by//. Jacofison^ M. ßa-nlHirdt, aud O. Laudk», with the final re-
sult orsliowingno inereaBe of warmth in the inflamed [wrt. I'Vom the
contmdietion of the n*>ult.s of oli.sorviitjon it \% iiii]Ki9S)hk' In fnnn a
jutlginenton this point. Keveitheles-i it seems oerljun that in Ibv la-
flaiiii'il ptirl there is not enough beat prudnectl to cle\'atelhc tempera-
ture of all the blood in the body »evenil degrees.
3. The irritation induced by the InSamniatiou on the nerves uf tlie
inflamed part might Ih> >^up{Ki8ed us advimeing to the centres of ibo
vasomotor (uutricnl) uen-w»; the exciteniejit of the ocul«« of tbcae
ELEVATIOS OP TKIIPERATCIIE LV ISFLäMMaTIOS,
83
Dt^m» would indt>ce trKrensc of the geiionti chitn)^ of tLssuc ami coin
«Kiuf lit iiKrease of tlie pro()u(>lioii of Wiiniilli. Tliis hyitutlieais, which
IS suppurUtl by soinc factsi, such a^ the fcroat dilTcrcncc in febrile ini*
taUlitr, ixad which I fonni-rly tnuinlaioci); no longicr uppea» to mo
Llvaati'e; il is oppo6«Ht bv thi- (.-siioHiiicntHl reseaiches of Itreuer aaä
fCftrobaK.\ wbirk prove tliat fc^Tr* ooTirred even when all tlie nerves
nrrc tliviilra], by uhidi tlicrc ooulil be aiiy eonduotio» frum Uic pcrt|)lf
era] injury to tlie nonre-centTCB ; llie rf>rcnt inTesti^tioiui of L*yden «Uo
oppose thü h^'potbeus, siacc iJiey prove thnt there is no consLniit r»*
btion between the loss of lütrugonuuä DUtiTi;il, or ooiuuinption, aad
^^[levelopotent of wanntb.
^H 3. Since, from tlio nature of the pmce8S> In the iiifliinieil purt some
^^n>f the tisBue Is deairuycd, vrliile »uiae new tissue is funned, it is uot
^n>npn>bAbIe thiit Bome ot the prtxlui^ of this destnictinn enter tbo
hlood, piLrtly through Uie hloocl-rejuelft, partly llirougb the lymph-
l>ri!ftsclE ; Kuch materia] net« as n femicnt, excites chnnge iii tbo Mood,
a coneequence of VrhioU the entire aoiount of hlood may be warmed.
Te might also admit n mon? complicated mnde of derelopment of
(«armth; the blond cliAngrd by takin;^ up tlio product of irritation
sight prove irritant to the centres of tlie vasomotor nerves, and thva
finciiice inereased pmduotion of warmth in the manner describod in 2,
[lOr arcordioft to Traube's hy|»Uicais. The dcdsion. bet^Tccu these
SflereDt bypothesc« is difficult ; they are all nHout equally justifiable,
all bare the eommon fnetor of pollution of the blood by tnatorial
the sent of inflnmiiialion or the xrouud, which U recogntxed ta
baring nn elTcct «a the producCion of hi^t; thi.'se substanees tnu»t
haro the effect of exnlinp fercr(njjyw>_7«i'»t«Rctioii). Tliisw^stobe
proved. It has been proved by experiments of O. Wel>fr and in^-sel^
I can notier only briefly here. In moet open wound», especially
I contused wound«, threads of tissue arc always deoomposed; in many
Siointhic inflammations, the circulation ifl arrested at diSercnt points
tbc inflamed lü^ue, mid tlien; is paTtinJ deoonijMisitinn of these dead
portioos. Dccomposinfc tissue, then, was an object to be examined in
n^nrd to it« pyroj^-iKKM action. Uyou inject tilterod infusions of this
abatani:c into tlic blood of animals, they Iiuvc high fever, and not
ifrcriueotly die with symptoms of debility, of »onmolcnce, with eoitw
(dent bluoiiv dinrrha?». Tlie same elTcet is induced by fresh pua in-
cted into the blood ; a weaker effect follows the employment of juice
Hftnd pw serum pressed out of llic inriaiiiod part. Ilenoo tho product«
' deMNniMution, as well as those of new furmatton, have a p_\-rogenouB
tiim in tbe blood. Tlieite products are of a ii'ry coniplicttcd and
■ble luitiire; some of tl>o cbormoal subttonoca in Lliein Iihtc boon
adently tested iti regard to their fin-ercxciting qualities: vra
S8
SIUt'LB rXClSED' W00ND3 Of TBB SOFT PARTS.
may Indticn fever by injecting leuein,Kuli)1iurett«<l hytlrogcn, sulphide!
of onimoiiitiin «ml carlwTi, luiit "llicr clii'mical 91j1)b1«iic»_'*i rosiilliiiff from
tic dfc^m position of tissue. Henwj Ihprw are no »pocifi« forw^oxdting
eubstjiticm, but tlie nurol>er of pyro^tious irwterials is innuiaembte.
Decomposing; vp^table mutvrinU ilIso hare a fuviTr^xritin-; «(FecU
To prove tliat the blootl is nctunlly than^j«! in fcvrr und rctaiiv tl>c
poisonous Ku'iutancc furntiiiif nl loxsl, O, H^rfter iujc^i-ted the bl(>od
of a feverish dog into a bcaltJiy one, nnd thus iucluucd ibrcr id tlic
second one.
After the pyrofp^nous effpct of thp producta of inflnmmalimi nnd
dt-cuanp(i)>ilii>ii lui<1 Itot'ii abüolulWy coultniH^i, it reMiaJnril lo Ix^ proved
that tliia material could b(« («ken from tbe tissue into the blood, and
lo ho rIiomh) how this tonk plaw. For this purpose it was injn?tod
int« the nubL-utiinnjiis «-«lliilar lissue, where it »prnwl around iii tlie
meshes of thf li:»&uo — th« effw:!, as to fcvor, wiis thu suinv ns wlion the
injoctiun u-ns iijiidi! directly into the blood; hence tho pyro^nm«
mateml is absorbed from the cellular tissue. Htm there Is anoth«-
obscrrattrni to bo made ; after a tlmr, at the point where df^^npoalojEC
fluid or fRFsh puB has Ijfcn ir.jectcd, thore is scv(.*ro and not tmfrnjtteiitly
r:Lpi<lly progressive infUminalion. For instimco, I in}cct(!d half bd
uuiKv of d«cotnpo«ng' iUiid uiU) the llii-rli of a horee ; in twcntr-four
hours the wholo }eg wa« swollen, hot, und pninfnl, nnd the nnimul rpry
revcrish. I did the smne thing with the eiiniif result, with fresli (not
decomposing) abscess pus. In ii doff. This action of |>U5 and putrefy-
iug utattcr in exciting locnl inHanimation I cnit phloyogeHOU», All
pyrogeJiDUs suhstaiiM-s nru not at thtf ssinc time phlo;;oi;t>noiis; sotno
iirc more so tlioji others, and, especially in the putrefying fluids, it
makes a great deal of diffi^rence whether the poisonous power, trhich
vre do not kuoir accurately, is present in greater or less qunntiües.
It is not certainly dctcnaincd whnrthcr tlie pyrogcnous materials
enter th« bloo<l through the lympli or hlood-vessels; they may vary in
litis r<>ft]tc>rr. i^~>mo points are in favor of the reabsorption taldi^
place chiefly through the lympliatirs.
Then* i» «till »omr-tliing to be Mid about tho <otirM of tlie feter
artirii-iuliy indui-ed in iLnimnls. Thn fevw hi*f^n» very unun, ofton
even in an hour alU-r the iiiji>ction ; after two hour» there ia alwTiys
oonsiderable elevation of tcmpenit urc : for ioMiuice, in a dog whose
tennpemtiire in Iho rectum wa» 103' !■"., two hour« afiernninj^wtioaof
pus it may be lO-'i", niiil fnur lioun afWr the injection lOJ*. It is im-
matcriul whether Ihi; substauce be injected directly into the blood or
into tfio cellular tissue. The fm-er may remain at its height from one
to nrclrc lioiira or even longer. The defi'rresccnn; may be cither
giwlually or by orifiijs. If wo moke ddw injections, the foi*or ioereaaes
I
FROQXOSIS or SIMPLE IXnSED WOPKDSL 87
■gain ; hy repented iojiKitiafu of putrt-fying material we mxy kill the
Inrgvftt nninial in n few dajs. Wbctlirr an animal »ilinll <lie (nm\ m
sin]*Ie pxporimont, dep<?nda on iIip amount and poisonmis quulitiCR of
the iQJe<7lEHl msimul in illation lo the ahe of llie animal. A im^lium-
aüc^l do;:, iiArr Uie injection ot a scnipK* of filtcnnl decixtifw.-'iii^r jlui<I,
HMV be fpvcrisli ft» a fow hours, and bp perfectly well af;'?r twelve
bout». Hpm«.' the [MMSoo nmy I« eliminated by the I'^hango of ti«£ui>,
Atid the iliaturbfinccs tuduccd l>3' its pir'avnt'e iu iJic blood may ngain
•obMdc.
I will nuu' tenniiiatu thes« obsvn'ution«, and only hope I may have
nuidR this impnTtaot subject, to which wc shall frequently «iturn,
coniprcheiisiltlv to you, I feci coiiviiircd that trauntatic fever, Ulic any
inflanniatory fever, cBsenlially dt-pc-nds on a p'jisuncd stale of llinMood,
antl may 1m* indur<^ by various material passin;; from the .■4(*at of in*
flttmnwtton into the blood. In the accidental traumatio dbeuca wo
shall again take ap IbUi question.
Jfow o few woTtU about the proj^iiosis niiil treatment of suppurat-
ing wiiunilx.
The prii^Mosts of simple inrinctl woundi« of tlie soft parts depends
cllielly OQ the phrsiolo^rit.'al ini|X>rtiiiiec of the wounded )>!Lrt, both as
rej^arda its importanee in the brKly and as n>;^nU the <lt£tiirbance of
Auietioa Id the part itself. You will rcndily understand that injuriea
of the medulla oblongata, of (he heart, and of lartte arterial trunks
lyinr; dtwp in the «iritios of the bodv, should be absolutely fataL
Injuries of the hniin hcjJ rarely; the same is true of injuries of th«
apiual ineilulla — tliey almost always induce extensive pnmlysis and
prove feital by varioai secondary diseases. Injuries of Inrpe nervous
tninlu te^ult tn paralysb of tlie part of ihe body lying bt>)<>u' the stiit
of injury. Oi>cning» into the cavities of I he hoiiy are always very
■eiioas wounds; ahonld tliey he aoeoinpaiiied I>y injury of the lunj^,
tnlcvtine», U^■CT■,«pleen, kidney, whlnddir. thedangiTincn'nse»; many
of these injurica are absolutely fal«!. Opening of the lar^- joints is
al*o an injury which not only often impiiin« the funrtion of (he jmntf
butts often dangerous to life Irom its secondary efTccts. External
draamBtaoces, the constitution and tcnipemmcnt of the patient, have
«Iso a certain influence on the course of cure. Another »oinve of
danger is the aeeessoiy diseases which subsequently arise, and of
which unfortunately there are man/; of theae we shall lierearter spcjik
ID a sj^pamt« chapter. You must f»r the lime l»eing content your^
selves will) thesic iodieations, wlione further elucidation fornts a very
ooDsiilerable part of cliniral surgery.
'We may give the trt<ttntcnt of simple incised wound» very briefly.
Bü
SIMPLE INCISED WOCMDS OF THE SOFT PARTS.
Wu have lUrcady spoken of ilic unitiag of wouncU witbout losa of
subsUni.-«, und tlic proper lime for reinov-inji; ihe sutures, and ihut is
abitut rII Üiul \vi'. oiin re^anl il'« diret^tly nfTocting the prooe^ of beul-
iag. Still, as In »U mtitiunl thcinpfuLics, lieru it is most iiiipurtaat ;
1. To prevent injurious lofluviicca tJiat may iulcrfcrc nrjtb the Dt^nid
couräc; 'i. Curcfully tu watirli tlio (Kintrrerico of clcviiitions from
normal, and to combat tUeto »t tlic right time, if possible.
If we, lintL of alt, limit oursolTcs to l<ical treatment, wo have S^
remedy for decidedly »liortemng the prooesa of dealing hj first inten-
tion or by suppuration, say to naif it« time or leas, NeTCrtl^eleM,
most wounds requin? ct-Ttain care, althoun^lt innumentblo slij^it n-ounds
bcal willicmt Iwing soon by a aurgcon. The first rcquircntont for nom-
inal ]ii?iUng U abiioluie re«! of (he ttijiiri'd [Ktrt, «^specially if the
wound has cxt<;ndcd tlirou^^h the akiu iiita the muscles Ut-nec, in
wounds at all deep, it is very ncce»tary tliat the pniient should not
only keep his chambor, but that lie sliuuld remain in bed fur a time,
as il 18 evident that the morcm>riit of injured parts, cspeciully <»f in-
jured mitides, must interfer« with the process of healing. Tlie aw
ond iinpoHant point U cleanliness of the wound and its viränüy.
Formerly il was always considered necessary to cover tlie vrouiu), nod
to apply dresnaga in all coses. Of lute I hsrc grown doubtful if this
bft indeed neocssary ; indeed, I would go so far as to assert that in
many eases it b well nut to apply any dressings. In iroundH ihst
lure Uvan si-trcd up, it has often been observed tltat it does no liano
to leave them uncoverad. If w wi^li tu cover sutured wminds, on
account of pain, redness, and »«rellius, or because they arp iu a part
of the Ixidy upon which the puticnt luust lie, wc may aptily various
kinrU of dn?ssin|7; wo may smenr the edjjes of the wound with pure,
fine oil, hirst with almond-oil, and lay on a fold of linen dipped in oU,
wliidi ahmdd be changed diily, till the «titiircs are removed; or olso
wc may apply a linen compress three or four layers thi«k, and tJio «in
of thn wound, wet with water, and coi-or il with «lit-ailk, gutta-poreha
sheeting', or ]>archm?nt-paper, a.nil >n:ilte » few lo-iäe turns of a Imiid-
age over it.
We are somewhat more careful in 0]>en, non-united wounds.
After the bleeding is arrested, most surf^^ona corer tlie surface anil
cavity of the wound with dry eharptp.. In large wounds, it is better to
apply lirst a pieon of Unen fid] of holes (a so-callnl fenestrated eom-
preas),nud over thb the charpic; this lias the advantage tltat tritli the
compress yo« may at once rt'move nil the eharpie, while otherwise
pieces uf it wouUl stick in |)1hcvs itiid n-tpiire the Tenin\-a1 i>r the indi-
Tidual iNirticle». The bliKfd dry in« and the fir^t MN:Tietion from the
Wound cause the charpio first applied to adhere £nnly to Iba
TREATUEXT Of SIMl'LE INCISED WOüXDä
SD
^ound, «iiil you »rely nocd to remove »t before it bpoomcs loose,
^Kdiirb is lutully tlic third or fourtli d:iT, wliü» plenty of puH appears
^^■il tliP iviiund. Shoulil thn wound bavc Ued »uhdeijuetilly, aiij the
^Bbirpi«^ saturated with decomposed blood, smell baJly, you may
^ttmlna« it with water, and reinnve it carpfully without strotuliiii^ tlit!
^iinMiiMlaitilliurtiii^llie [);itit;nt^ S'lovilil llie truiiiiJjiruretulcral>lyclR;iD
^Kftcr the rcmoi'al of the chafptc, it ii guhjcquently simply nrn^äsiuy
^^> dress it djily witli cliar^iki, »flor prrviuusly cli.'«u£iii}j> it uf pus. It,
. aftrr rnmoral of tbt- first cliarpi.-. »lie wound la Caiiad cmcnTil wJtli <le.
ipQScd blooil, and nutncroiu a!nxrd» of uecrosed ti^suu arc &i.MlU;rcd
jet iljVou may adraatageoiuly dip tbe cbarpie, subBoquently ap-
lad, io clilorino-watcr, or solution of chloride of liin« (one dmolim of
hlortdc vt Hme to a piut nf vvat«r), tbeu vrriug' it out aiid apply
irt. Usually this will quickly arr;>it the prow^^ of decomposition
. the u-uuiid, which is rarely of nnicli importance in »itnple wounds.
JL> tliii drratfin;; till the wouiii f;rtuiulatcs actively) and Hup-
!Iow often you «iii-tt renew the diarpje on a suppuratiug
id, depeod« on tlm quantity of pus secreted ; ftoinetimm it
oat hi twioo a d»y, again only oqcc in two «lays. For ayrin^n^
the wouni, we may either use a simple wound-syringe, or iSr-
rcA'« \roun J>4loui?)ie, whidi consists of a vci>sc1 ten iiiclio» liigli, and
ur and u lialf irit;brs in diameter, lu tlic huLtuin ot wliicli tliL-re is a
hole with a 8l>ort tube throti^i it, to which n nibhcr tubo with ft
inge-noszle is uttacbed ; as the reswil is olevatwd by a Dursc, the
rxtuii ai-.Ls as syringe or doiicbe,
I just rem;irko(l, 1 have recently booarac conriuccd tliat it is bettor
tapply (hv^^ings tu freäb wounds or to Uioao suppumtiog freely,
to take pnxiiulions for tlio blood, pus, and sanies, to flow into
pUocd hencatli. Thus we make iho uoeapocteO discover)- that
< blood and scrum at first es^^j^ing has Tio smell of its own, when
nor has pure pu»; and, mikreot'er, that, at the ordinary l«m>
tturc of the room, this seuretiou may aland for twelve or twenty
boun witliout developing slinking gases. This is surj)ri«in;;, bo>
wv know that every dreKtinjF, saturated with bluud ur pus,
lotls worse when removed from tho woimd, and that this oikir can
^Ij he orercsmo by beeping tlxj wound constantly ooverod with so-
Ird an'iseptic or disinfectant solutions The reason of this is, that,
the secretion flows off, it coc^U so quickly tiutt it dccotii|K>se(i
let» readily, while the same Bccroliou decomposes very quiekly
ben on tbc wound at a lemjierature of 101°— 104^ K, and the water
anot cra|knnitc from it nn acciiunt of the thit-fi drt'ssin^. It is niso
sible that the cmuulc orgjinisms, which induoo the dcc:>inposiUoD,
ire a more Gtvotahle soil when the seetetioa impn^alos llic dresir-
00
SIJIt'LE IKCiSED WOUKDS OK TUE SOFT FARTS.
■ng thuti n'liLii it w received in a vi>skc1 or dries into a scab on Üie
vrountl ; nv shiill notice this in the ilcvclapmcat of tbcsc small organ-
ism«, wlik-h oc.t'usioiiiLlIy giv? tht- pus a. 1>lu«-^rcco color: of this more
lereafter. Clinical obeen'atioii, as well as QxperimenU, »hoiv» Ui.tt the
lenbsorplion of putrid and purulent S4XTeti(>n 1» greatly Givoreil whra
tbe evacuation or escape of the Kecretion is mcdiBDionllyoppoftCd ; oa
tliiK ground also -wc cannot sitfliciciitl}' »rge tlmt the guape of the te-
crelion fniin tlic wound etiould be pL-rfw-'tlj free. It is true that in
tili» ■nxy crust* form, and Uie tround do*s not look so woll; but tliis
objucLioii is sHglii as cuiiiprtred witli tlie advmitagos of the open treat-
ment of wounds. If the wound granulat^'S pcrfrctly, cicatrüation
begins, ami the secretion grows lees, wc may dress tlie wound us
usual without injury. Iii fivfjly-iuppumlin;» wminiU, npplit^tions of
chiirpio \mvr the n<.1i,-antagc of nl)»orbing tlit; pus ; \nil tlds is adoubt-
ful ndvjiiitagc, if vre bear in mind the i>i>Mibi]ity of more nrady dccom-
)HK«itioti of llie pus in llii> chiirpii.!. Many surgeons dress only iTitH
Kitiall r:igs of lincu or cotton, muny tvitli wadding; blotting-paper and
other articles have also been euiplorcd. It dors not. make so uiuoh
difference what the material of the dressing is, if it only be «oft uod
somewhat bibulous. In hospital sen-iee I prefer fresb wadding to
cliar[>ie, whiffi i-f ni;idu by the paticiil» or nurses, witii dirty fiii^i-r»,
from badly-wflslicd bits of bandage ; if it be nCLt^sary to use the lat-
ter, it is lH*st to dip it in some disinfecting Quid beforebntid. Fur this
purpose dilute chlorine- water, solutions of chloride of lime, and of per-
miinganate of potitüh, alcohol, solutions of eulphurcts of 1)>c alkalies
{Pollt\, lead-water, acetate of alumina (alum 3 j, aoetato of lead J j,
water S f iij, Iturote), arc very good.
In many cases nctbiug more i» neccsaary; Uio wound heals without
further treatment. N'everthelos.*, iiiflependent of eerl.»in dlMases of
tlie granulations, of which we shall speak nmre |a.rticularly hciüafter,
it frequently happens tbut under a continuance of tlie same trrstmcat
the healing i< arrested ; for day» the process of vtenLriiUtion does not
ndvsiice, and the granulating surface assumes a flabby appeareneeL
Under sucli circumstaaccs it is advisable to cliango tbc dressing, to
irritate Ihegranidatingsuifaeeby nowremoöiee. These teinpomr^ ar-
rests of improvement occur in almost every Inrgc wound. Under
such eiruumstanrcs you may order fomeii tat inns of wann i-kamointlfr-
tea; several compresses may be dipped in the warm tea, wrung oiitj
and from time to time .-ipplicd frpsh to tlie wound, or yon may pre-
«rfibe lotions of lead-water. Von may also ]Ki.iiit the wound friini tiiao
to time with a soSution of nitrate of silver (two to live grains lo tbe
ouni-e of water). If the wound-surfuce be no lunger large, x-ou may
lioally niiJi« use of audves ; Ibcac should be spread tltinly over cfaarpie
nCAUNG OF WOUNDa
91
or linen; tlie most suitable uc tho basilioon^intment (comjxnind
rcsift oLiuti;), consisting of oil, wax, reäin, au«t, and tuipenliiic — and ii
■aire of nilrute of silver (one groin to n rlrochm of any salcc, with tlic
wlditton of Ptrnivian biJsam). If tlic cicalrizntlon ha nln-ui!/ fur :iO-
vaaccd, ffc inay employ zinc-salvu {ziivc. oxiU« 5 j, ung. oq. rosw 5 j),
or let the dry «ifaurjuu adlion-, anil l)»vo Uio In«! |)(>rtiuii of tlio wound
beal ander the scab.
ßegarding' constitutional treatment, \ra can accompliült fli-^rro)y
any thing vrith internal remodies in preventing <>r cutting short tlie auh-
Seqiieiit fever. SliU, certain dietetic rules arc neressar^'. After the in*
jury, the patient should not overloa'i his stotnacli, but, us lon^ as he
baa fever, must live on low dtet. TliU he tuually docs sponLiueously»
as fever patients rarely ba^■e any apjietile ; but, oven afu»r subsiden«*»
(it the fever, the patient should not live too high, Iwt only eat as much
as ho con dtgcätf while lyitig in hoJ or confined to ha chiuabcr, where he
Itaa tto cscicüp. If th<! fever bn big)i, and the patient desires eoine
daago of driuk bom cold walvr, which is (^enirrally prcfemMl by furer
patients, you may fwdcr acid drinks, oa lemonade or some medicinal
oultftUKe; iho patients soon grow tired of the ordinary lemouide;
tbfiy bear phosphoric or muriatic acid in water with fi-uit-juioe, nuip-
bcrtj'-riuegar in water, apple boilc<l in water, toaslrwaler (infuMun
of toasted brcAd witli some Icmon-juicc and sugar) ; some patients
prolbr nltnond-muL-ilagi;, wat«r^oe dissolved in water, oatmenl gruel,
barli'v- water, cUz. Wc may give the taste of tlic patient full play ;
but it is well Cor you to attend U> such things yoursclC The pbviü-
oian should know as much about the cellar and kitchen as about tho
apothocaty-shop, and it la even well for liiiii to have the reputation of
being a gourmand.
LECTURE IX.
Co(a^hifttIou«f llcaliiij by F1r*t and Second lM«nd«n, — Dnloa of 0 raaoUlIon SiuAcm.
Iliallii; ania ■ Ssab.—nrviulatiao DlMan«*.— Tbs CImItIx in Tarigos TUanos; In
Hiwclei ta Mcrr«; Iti Ka^lfb; ProUfemloB; la TeaMk.— Ori^KnimiiM) oJ tlie
TlirombiM.— AntrlaJ Collaicnl CinuladixL.
To-tMY I luivc Gr«t ümply to add a fow words about certain de-
uiatJuoB &0U1 tho ordiuaiy coiu^v of henling, which occur so fropicnlly
that t1iey must very often be counted aa normal ; nt nil evcntfl, aa vciy
U is not at nil unfrequcnt for the two forms of healing above de-
scribed, by first and seeotid intention, to combine in the same wound.
Q2
PIUPI.E INTISE» WOL'KDS OF THE SOFT PARTS.
For inütaiK», you unite a wound otMnplelulj', and may sometitnes ob>
serve timl »t ftome placefl Ihrrcr is healing hy tito lirat intpiition, while
at otlM^is, afl«r removnl of the sutures, tfac «round gapes, and &uhso-
qucntty licaU by MippiiraLirm.
In the same way it not imrrL'<{u(.'iitly hnppnis tlu>t thti liixp part
of tlio wound heals by first inlcnlio», vrhJIc uflcr rcinonng the sutures
tile cuUtieous edges separate, »ail afl«rn-unJ bexl by BuppumUon ;
or, on till* other hand, the mfanrous surface iinitfs hy first intctition,
while pus ifOZL-s up frum the depth of the M'ouud, and the cuUiiicuua
«Igos, which have becoine adherent, again partially separate. These
two hitttT en»'» cccuT psrticuliirly in iimpulat ion-stumps »f tbc ex>
irciiiitirs, when thn unund is uniti'd hy suture.
Whv, in such cases, even perfectly smooth incised wounds do not
always heal, eim sc.^rceIy be certainly decided in every Bpccial case.
However, when }'oii consider liow eomplicaled tlie rondilioiis of tJils
proeeas, how muoh they depend on tho nntun? of the injured tissue,
OD the arranger ni'Ht of the vessels, on the tension of the edges of (be
TTOund, and ilicir irioro or loss perfect npposilion, on rest of ibe parte,
oo the clcaiilinoss of all instrumouls and dressing« employed, on the
general health of tlio jinlient, ami, (inally, on many things that wo do
not exactly utider*taii(I, xve cannot be astonished tliat such distarb-
atKCS occur in tlic process of IicalJn;^, and would be dvltghtvd if notb*
lag worse could happen to llie patient lliaii failure »f liealing by Iho
first intention, which, in simptc incised wounds, except in plastic ojK-ra-
tions, is really only important from iho time lost. The histological
conditions, when a wound at first closed subsequently opens partly or-
entirelj-, may be wadily understood fw>in the description I have giren
you ; the »hole diiTerence in the healinj; 13 cöseiiliiiUy thai the lufbim-
maiory new formation in the one caso is trno^fonned directly to cott*
Dcctivo tissuo, and in ihe other case must puss tlirougli the stago of
granulation tissue.
Thera ia still another mode of adhesion of the edges of wounds,
which consists in the direct tinion of two adjacent granulating; sur-
facea. Iliis mod« of healing', which you may call healing by tlic third
intention, is unfodunutely ver>- rare. The reaaoii of this b evident ;
pus la constantU* secreted from the snrfitre of the grnniilatiuns, and
while this govs on the surfaces arc only appareiillj- in contact, for
there is pus between them. Occasionally, it is true, wc may, by press-
ing the two prannlation surfaces together, prevent the further formation
of pus, and then the two snrfnres may adhere; wp a<'oomplish this by
drawing the Ihips of the wound firmly together with giKxI ndbesivc
plaster, or by tbe application of secondary BUtures, for which it is wdl
to omploy wirv. UnfortuuBtely, tho attempt to hasten the cure bjr
BEjaiXG OF WODXDSL
89
theae ncaiu so rarely sunceecb, tbat ihey are only excepliminlly em*
plajrcd. Tbc best tveutts am obtainrd from sct^tKUr)' euliirts nlitrnt
six or »«nil lUys after tlw? injury, they are applied nbout four or five
lioes frum tlie edge of the noimd, ht'ouuse thp tissue is llivii xaara
düaac and tinn, tuul Hi*: Mitunr» rut llirougli U-»8 «[uiclily.
There is still onolhcr mode of hcuhn^f, vix., healing of a eu[>cHidal
wound undüT n scab. This only occur« fixy^iicully tu small woundR,
that »cfrrtc but litl k- pus, for in ihrse «lone doca the pus ilry <m ib«
wounU lo a firiuIy-xttachiMl ^-ab ; iii prufusc guppunitimi it in Iniu tbo
tuperftciol hiycr of the pus may dry by ev-apointion of the walirry
portion, but, nhile new pus !■» conMsnlly t^in^ socrti«! uiitlvr it. it
cmnnut funn an lullieroiil, cunsi^lctit seab. When such a »cnb has
fixiDed,thegramtlalioii li»;Micik'vt>h)))« lu only a very small amount un-
der It ; perhaps because on account of the slight pressure of the fctth, ihn
gninuliitiun tissue is Ices tnuoous, so tbat the epiclennt» cvn more
readily n^'jenentte under the scab; sucli a small wound nuiybc wholly
cicatriju'd when iheccab Mk.
The gramilatkin EurfACO msy assume n totally (liflerent ■])ficamnce
from tliat above dcscrih<J, cspL-dally iu larpc woands, 'llicre are
cvrtoiu tlitt<ut* of the yrttnttlation», vrltose nutrked forms I hIwII
brii'fly ski'lcli for you, altliou|!fh the vnrictics «rr so numerous that you
will only Icnrn ihcni from individual observation. Wc may dh'lde
graiiulatinn surlnccs ns follows :
1. Proliferating fungniis gnmulalkins. Tlie expressio« "funj^ous"
mouu nothing more tlian " spongy- ; "^ hence by fungous granulations
we mean those that rise above tlio level of tb<i skin, and lie over the
oA^t^ of the wound, like fungi« or sponge. They are usually very
soft ; the pus scereted » oiik^our, gbiiry, tenaeious ; it ctHitains fewer
ctrlb than {^xxl pus, and imnt of th<; |Ni:vretlj4, like granu In I ion-cells, are
filled with numerous fiit-f;Iohulos und mucous material, which is alno
more abundant tlisn normal as intonvllular substance; ami in tliese
gnnulatioos Jiin^eUeh also discovcn.-d collcctious of Virchovy'a
mticuus tissue, fully developed, Tbo devolopmcot of vessels may b«
very prolißc ; tlie fragile tissue oflen bleeds on the slijj^blesl touch ;
Occasionally tlir praiiulations arc nf a very dark blue. In other cases
the dcvt-lopmcat of vcxkIh is very scanty, ofteu to »uch a degree that
th? surfaeo is light red, or in spots lins even a yellowish, gelaliuous
■piwaronee, in very snurmic pervin», often aUu in yuurig children and
my old persons. Tlie most frequent ntufc of dcvclnpmciil of such
prollfemting (tranulatioos is any local impediment to the healing of
the wound, such as rigidity of the surrounding sfcni, so tliat the eon*
8-1
sniprji INCISE» wouxds of hie soft parts.
IrHctioii of the cicatrix is difficult; a forcij^ bodjr at the boltooi of a
tubuluTf^nmilutin^ wound (a lUtula) ; this almomial proliferutli»] is
also pnrliinilsrly npl to occur is Large» wuund», nbich cao only coiilnct
sluwlv; il «pnears ii» if (lie nctivit/ of tlte tJssiie wis occA*iiuiui)ljr ex*
hauBtciJ, »nd iio longer aipiiblf t>f «mlinuinK tlic requisite condensa-
tion and cicatrizatioo, so that it only protluc^es relaxed, spongy granu-
lations. As long as there aie grauulations of the shore cfaarader,
rising ubijve tiie cd^i'8 of the skin, cicatrization doc» not ufiially pio-
fiW9A, The ivoiind wnuld probaliiy heal, but not for a very iong tiiuft
We htivs plenty of rerae^lics far Iiaiilcninj^ the licaling uiulor »uch cir*
cumstancc-s ; these arc eeyeciaily eitu?tii», by irliich wo partly *ic«tTpy
tlio grunulutioQ surface, and thuA oxcilc a slronjfcr groirth from tli«
depth. At first yoti may canlL-rise ibv granulutiiig surface daily, es-
pecially alnnjr tbc edges, with nitrate of silver, Wrhcrcnpon a white
slouch will quickly form, which will becoma detarhed in twelve to
iwotity-four hours, or even sooner; repent this emitcriziition as re-
quired, till the graniilating snrrnce in cwn. Anotlier Avrygood rem-
edy is sprinkling the wound with powdered red precipitate of mercury
(hytirar. oxyd. mbruni), wliicli also Blionld bo repeated tl&ily, to im-
prove the granulating surface. Compression with adbesivc plasters
also aeis very well ocr-nsionally. U the graniilaUons he exeecdinply
dense and Iarg^^, wo often niay succeed soonest by cutting sooie of
tbeni off with the scissors ; tJia eonsequcut hsemorrhage is readily
arrrsteii by applying oharpie. Where the proliferation is less, as-
triiigeiil lutiiLiiis, suc-h &8 dococtioD of oak-bark, ciiicbona-bark, lead-
water, etc., may answer to excite the sluggish cicjitrizntion.
2. Wy tn't/ntic granulation» we mean those chanicteHied by great
])atn on the tslight«9t |>rovocu(ion ; they are iiauidly rcry pnilifcrant
gninuIatioMs, whidi readily bleed; it is a very rare conditioo. la
excessive erethism of the graiiuliitiuns, they are so sensitiv« that they
cannot endure tbc slightest touch or any dressing ; a less degree of een-
Bitiveness of the granulations is not so rare. On what it depends, u not
very certain; granulatiun tissue itself has no nerves ; iu most cases
touching it causes ao scnoation, only ihe oonduclion uf the preaanre to
the subjacent nerrc« causes sensation. In the above excessive sensibil-
ity, probably the «nils of thw nerves at the flotJr of the wound are degen-
erated in u [HjcuUnr manner; {>erhaps there »re nilniiilure tliickcnings
of tlie fineitt ncr\-c-end9, like those that wc shnU hereafter sceo» largo
n«rve>tTuiiks. It would be a thankworthy task to tnalce a careful ex-
amination of this question, Wc occasionally obserre similar condi-
tions in the cicatrices in large nerves, ond shall speak of tliis hereafter.
For this verj- painful sensitiveness, which not only interferes with
healing, hut greatly woniea llie patient, you may first try sootliiug
DISEASES OP TUE GBAN'EU^T10X&
S5
lUnents, almotiil^, spennHccti-ointment, or simple cataplasms of
>iled rntmcal or linseni-fiwal, or waT[n><vat<?r ootnpresses. Tlie dm^
^otic ocMnpreases or citlapWui», iniulo willi the additiou of belluloniw
or byo«ej«iiiti»-len.ves, am nf IJttJv liciicfit. If tfac«e appJiontiotis do
lot uii^wer, do not cleliiy <I<fstroyit)^ tliu entire gisnulating surläcv, or
It Iciust tlic painful part, with caustic (nitrate of silrcr, rnustic potanli,
or tbe hot iron), with the patient «nicsthotizcd, or else oxoising the
entire surface with tlie knife. If the great paiiifulnras bo due to Hy»-
terto, aiumiia, etc., you will n^tt attain much bj any local remedies,
but sbouM try to assuaj^ the Rcaeral irritability by internal remedies,
Mch a» nierian, anafoetidn, in-in, ()uiiiino, wann batliti, etc.
3. In larf^ wounds, esfK'uially in fistulu frniiiuliitiotis, a ri^low rind
•omctimcs forms on port of t))c gfanulation surface, wlikb may be
readily dt'tacbud, and un canjful examination is found to coDKistof pus
eelts, very firmly 8ttacbe<l together. Altlinngli I liare soinetim«!»
{bund coa^atin^ fdament« betneen tiie velln, tliey Uo not always
oomr, hence wc murt suj^icm that the cell-body, the prntojilasm itself
Is tninsfunne^l into fibriae, as occurs iu true croup, niid espwiidly in tbe
fonnalion of ßbriiioua de]x»it5 un Kcruus mtTnbmnL-s, Hera tltcrc is
•Im ft etY/Up of the ffranttfalio»*. The croupous nipmbran* reforms
erm k few hours after its rt^moval, and this is n.-peated for serend
days, till il either disappears sjiontAneoiisly, or finally c«ases oit cau-
torintion of tbo affect«! part. \' cry similar wldtc spots ore ooMSion*
ally found on Isirper pnimilaUun surfacvs, which are prwljably not
BU»td bj fibriuons dcposils, but by loral obstructiuu of tlie blood-
Uodcr peculiar, unfavorable conditions, both slates may re-
It in destruction of tbe gmuuIatJons, in a true iHpfitfivria o( the
und, whicli we sliall horcafUT treat of as hofpUnl ganijrfiie. For^
luiiatcly, [towcver, it rart;1y goes on to this disoase, but the state of
tbewutiiid improves again after a time, and the recovery takes the
OMialcouisc.
If disease of the ^mtnulatiug surfiice be accompanied by swcUiiig-,
great pain, and fever, wo hnx-e a true acute inflammationof tbe wound;
then thu mucous graiiulatioii substance sonictimcs congutat« llirtnigfa-
oat to B Gbrioous mass ; the wound-euiütcc looks yellow and greasy.
I shall treat of tbo causes of these secondary inflammations under tbe
heatl nf rontaaed wounds. Usually tb» croupous inflammatioQ, which
haa alFerted part or the entire Hurfare of a wound, ends iii slouglunf;
of the diseased granulatious, whereupon new f^nulationä spring from
he di'plhK.
It cannot be deiucd that the perfectly local, superficial, and intcP'
atitiid deposit of fibrinc strongly support« the view that P'TtoAo»
has propooed for croupous processes f^crally. It was formerly gujv
Oü
SIMPLE ISCIKKD WOC.VDS OF TBE SOFT PARTS.
pciiwxl thxt in all inflaiDmatury croupotu prucess, «apcHÜall^ in Uie
nniiiiary funii of ncutu infUimtDatmn <4 the lun^ and plcurm, tbe
blood was ovfp-rioli in fi)>rine; timt thpiv was a Bbrinotu crnsi» in Üic
bloo«I, as a result t>f wliicli, tlie exix'sjiive filirine esntjiiug Trum tlie
capiUaricfi, coagulates pitrtlj- on, piirlly in, tUv inflaim-rl surfarr, and
so led to the formation of these pwjuJonjcmbnmotts dcpoeils. Fir-
(■/«)«•, OTi tbc «ihcr hand, ]>rojiusLHl tlie idea ihat, by tlie infUinirintory
pmcL-KS. tlic tissue may be plai-cd in a rnniUtioD to niii»r cnagnlntii)»
of the tibiit»f-n» »ohitioii inliltnilingit. I cannot iictv »'(itvr more par-
ticularly inlu iJie various grounds on wljicli Virc/ioie Iuiscr tlii« view,
but ftliall nnly call attcntinn to the fart ihnt in llie c-asi* in (picstion
(uf librinous exudation ou the f^rauuta.tinf^ Miriaci;), nt Ic-ast then: can
b<* no rapidly eoniiiif^ and PvanpRCi'iit fibi-oiw enoiis of the blood; but
L'vidi'nily it is a lo<-al process whiih may n'adily be mnovwl by local
rtrmcdicA. According to tJic rcpealcdly-nicnlionod obsrirationB of
A. iVMnitW/, wu miiy inft;r that in certain <|iiaiititutivu and qunlitalire
irrilations of the tissue, more fihmgpnons tissuß llian usual fscajwe
from llio cnpillarieA. Virc?40tf had even pnn-iou^y called nttcntioa
to the fact Ihnt, frciii rcpcntod in-ittilinn, sinipln ktous oxiidntion may
bücumi? librinuuü or uniiijHiu!^ li' yuu »pply u K{>imisli-lly blister to
the skin, a vcsirlc Riled with »crous fluid forms — tbc superficial layer
being lift<rd from llic tcte inucosuui by the rapidly-formiu^ aerOus exn*
dution; \S uo n-niovc the v<>Hiclc and reapply the blister, in maay
cases afl^T a feu- limm we shall lliul tlu- snrfaee covered with a fibrin-
ous Inyt-r, nliich <-ont>dii8 iimuntumbli; ueH'ly-fumKrd cells ; indtred, ia
almost entirely efnni»oiicd of them. 'W« may altntii the same n.«idt by
applying the plaster to i*kiii already iiiflmiied, or txi a young eicatrix.
The treatment of croupous iiilhimniution of the granulations is
purely local; we );honld ewrefully et-ek for any causes of now irritA-
lion, and try to ranore iheiu. Daily neinoi-o the fibrinous rinds, and
niuterijse tlic exposed surface with nitrate of silver, or ]>aiut it wilk
tincture of iodine, and ynu will soon see this abnorfnnl stato at the
granulating surfafd disappenr.
4> Besides tlie above diseases of tJic grnnidationp, there ia Oocb-
rioruilly a state of perfect relaxation and eollapse, in which they pro-
sent an even, red, i^mnotli, ahiny snrfare, from which the ixxlular,
gTunuliir sppenrariec has entirely ili^ipiH'ared, und, i[i&t«<£nl ut pus, a
thin watery Benim is secreteil. This state almost always ucctirs in
the gmnuktions at the end of life; ait alretuly mentloued, you always
find it in the eadaver-
It is still necessary to add noniethinfr about the cicatrices, con-
eeminf; eertnin Kiihsequent eluuigcs in them, their proliferation and
their shape in different tisanes.
CHAKCES IN CICATRICES.
»r
Unear eimtrices of wound«, tliAt Imvc li«n1cd hy firal intention,
mrvly iindt^rgo eubaoqiiont dcgpncratioo. Lor^^, browl cicatriow,
esix-ciallr wlicn they lie imninliatrly on Hie bone, often t>p4?Q agaia;
lO opidcMiiU, wliicli is tender »t first, beinfr *t>m oil" by nvolioii or by
least blow or friction, ami thorp is siip^rücinl nimphy, an exnorin-
ion of Uie cinitrit. Someiimcs ilie ycnng- fiwdcrmiu is elcvaiwl like
n.'sictc, by cxiK)utio<ii from Uic vl'sk.-I» of tbi* cicatrix; llier« may
be Honi« htemorrba}^, to lh.it lUt- ^-eciele will Ih? fillini with bloody
funi. Tlicn, »ttcr Tcmoviug the Tcsiclt', you haw an uxcurintioa, u»
simple nibbinjc off of (^idermis. 'Shit opctiiQg of the cic«trix,
if often rufWitMl, inny prove very nntioyin^ to llic ])iitJi<nt. You pre-
rcnt this most readily by caiisiiijr ib- pntic-nt to protect th«; young
licatrix for a time with va'Min)!^ or a bandajfc. If lb« excoriation
,8 takfa place, opply only mild fUcsaings: oil, glycRrine, 2ini>-^ve,
'., or «•inpln.struin cent»a. In these case^ irritating »alT'eii t>nlarge
tlie wound, uimI coovequeutly eliould 1)e avoided,
^^^ If ibe f^mnulntinff surfor« l»o oiioe perfectly covered with epidcr«
^^bis. Ait already stttt«), l)w rctrogre«!ii>x^ rhau^^'S to »olid comicctJre
^^Räwue take plure in tbc irituilrix, und it atrophies. But in mru caaes
^^Dm «nitris prow» indoi'MMidculIy, und «h-velops to a firm connective-
tiasuf luiiiur. Tlits is sct.'n almost i-xcluttivt-ly in Hinnll wounds tliat
haro lon^ auppuratcd and been corerrrd with Rponf^' ffrannlatinns,
0rer which the epi<lermi3 formed exceptionally. Vo« know it is the
custoni to pitTPe the «-ar-loho» of litll« g:irU, so that they may wilxse-
jfpiently wear ciir^riugs. Tiii» lillle operation is iloiic with i» wiun«;
by tbe mother or the jeweller, and a «mail car^-inj; i« oX onoc
trodun-d through tlio frv^h puncture. An ii rtilft, lhi>; puiit^turo Houn
Is — the ring pR.-\fnting the dwsuix^ of the tiiN.-iiin;c> I^nt in othtr
cwet tbcrc arc ncttvc inßanmuition tod »tippunition ; indoetl, if the
suppurBtion cnntiniie, tbo ring may cut downward tbruugfa Llit? lobv;
pnnulntions dnrlop at the openings of entrance and exit; finally,
tlie triitl is g^vcu up, and tlie ring removed; then the ojKoing often
leals quickly. In other Fanes the grnnulations cieatrixe, the eicatrix
tinnea to grow, and od both sides of ibe lolx^ of the ear small
nnecti%'(.-tiNiic tumon>, small fibroid^^fonn. 'llK-tM- Untk like a thick
irt-butti'>ii dmwii tUrou^ the hole of the ejir, und tliev grow inde-
dently like a tumor. If you examine these tumors, on section
<a ftud tHcm of pure white teiidinoita appcanincc, like the <:icetrix
itseIC Microseopieally the tissue is found to consist of connective
with numerowB cells ; it w («imply a pmliferation, nn hyp«'rtropby
ilie cicatrix. I have fteen this twice in (he enr; aiiol her 019c Ls
mentiooeil by Tßiffftmbafk in bis operative surgery. I onoe ttw
«nülar tuiuora ou ihc Imck of the nedc, whore tlioy hail formed at. Ihc
06
SIMPLB INCISED WOL'SDS üf TUE SOFT PAfiTS.
openings made for a setnn ; they were about tlic ftiie of a boree*
cbcstaul. Tliey »Iiould l>e carefully reinovcil with tl«s knife, and any
subsequent grnTiulmioiis ki?pt in Rubjftctinn by nitnte of silver.
[Tbu Iniiisliitor Im» «wmi llic; alxiv« tunuira on the lobe of ihe ew
several time»; in all bitl Lwfi instance» Uiey occurred iu mulatto
fefualc« ; tii one case the Luinvr had ititumetl nftcr a prerious
moval.]
In ihc aboTo d(>»criptic>ri of the fonuHlIon of frraiiiiUUoas «iid cira^
trioc», for ihü Bake of »iitipUcily we have only referred to tlie process
M it is found in connrative tifütti?^ but must aovr sjieuk of it ns it
occuix in ciL-atrixiitloii of otber lissiif]*.
The dcatrix in inusdu is at fint idiumt entirely cooneotirc ti&suo ;
PUI.IT.
Clcalrlirroin l)i'i?D]ipi:rllp(iriti1<iir. a, rnnii'rcllTcil'iiiiiKrilici-irainx. Thr dWUiil mnimlaf
rtbrM ■TO ben! atrnjihlMj. Tur ■ »bort dltlttact, bail Icrmlutle Iu • caulcal «liaiic. JJa^nl-
llRd 90C illBinotcn.
in the ends of flic muscidur fibres tb^ro is at first dcslrvi^tiun, then at
N certain bouodaiy a collection of nuclei ; then there is luuiiding off
trf the fibres, eoni«tinies club-shaped, hometimefi of nioro conical form,
tnd the stumps of the musoulnr fibres unit« with the oonneetive tissuo
of thi< dcalrix just lis tliL-y du with the teaJoim ; the mu!«de dontrix
beeoracs nn inscriptio tcndinco. 1 mj-sclf have only ohscrvcd them in
wounds of iiiusclo that bad healed by fust iutcntiou, and have norer
there Keen any thing that 1 could decide was a new fonuation of miis-
culiir liwue. In nnppiirating ends of muscle, O. Weher lias -witnesseil a
slight fonnatioi) of now iitiucle; this uppears to occur cliicUy iu fui>
mation of gmnulslion» on muaci« nnd in eertaln tumors.
Weber is of the opintoa that young muscular &l>re8 ty|>lcalty form
CICATRICES IN MUSCLES AKO NBS'rB&
6d
bom the cells of old ones, but cottsidcifl it impossible to prore that no
muscular wDb originate frmn other younj^ ce3!3. Ab ■ result of bis
examiiution of old musoular Hciitric«», he »Iao mnintaiii« tliitt the re-
gmeratloo oontinues a loii^ time, und in must cases ia inonr compk-t«
than is generally supposed. Maaioicaky has affirrncd the mctamof^
FM.-t&
'm
iSf-
S*ordti1iMiDiu«l*rtbr««rKim ihrblcrrmninKkor ■ nbblldcMttari'aneriluilDjaiT:
ai*. oU natralü flbra*: a. i\ir r-inirviUr mbaUinc« iMeA vp mil bällnH MBOthcr: TM
•«m* invt* IlMboBÄa «botu J; ihoianic vlth tbetarculemm« ilnwnoiil lo*p<:^nt; ir,
Inln iha palDWd cani(l->liaiH><I nircoifiiinii liitirrtlonilmtiii^rliMitrffliiTis iiiimciiUt nnfii>I.
bHweclB vbi4 Itictv |4 Tcrjf drilmtc 1FntL4vi>T«fj rlrldled vuHituife; *, tbc «Aiu« ^l(h
fiMiic. rrvo nuMdiM«tl> - /. inn r<^ni: rllibun-llkf icuni-iilu Olainiuu ; p. IbCHmeofml-
j^KHis of vraiKV-ring cells to Diuscle-oells ; but I c(m»kler the einstabar
met/toil cmploTcd br him na insufficient to prove: tliia aKscrlion. [Oo-
nnbar or rermilion injertcd into tho blood is tal«n up by white «p-
pusrles, and may nftcrwnrd be discovered on intluntwl tissue.]
If !i nerre be divided, it« ends aeparate, from l!it-ir elasticity, they
•well sltglttly, and subsequeatly unite by development of a new fonna-
tinn <if true neri-e-tisAue, so that the nerre i<i again oiipable of conduc-
tion tlinnigli the ciralrix. In targ;e »upcrlictal dcatri«?», new uervc*
duTvlop ; when you havt cxctsvil periions of skin und liuve brought to-
fjfetbfr am) united [nrts lying at a distance, new uerves grow tliroi^b
Ibc riailrii and perfect power of conduction come« nfter a time, as
may be alteo obecrred in pUittic operations, "nicse lacts a)<<: %-cry
100
StUI>I.P. IXCISED WOCXDS OF TltE SOFT PARTS.
ivmarksblt?, anil pliy»iukigi(-Hll/ are still catircly inoxpUrsblc. Just
think how wondrrful thut tliL-Ku ncrTC-fiiucneuts, sCiisory aiiil ntotor,
sbouJd find «uth othur jii iJm new wUmsioii, ntitl tliMt even, as wc miist
Bupjwse, the stumps of the priiiiJtive fibn» HhouJil umlc u tlicy hmd
been united, so that correct coaductioQ aod IrfcaluatioD lui^t rceult
as they actually do I Wo ctnoot hero go more oxactly into tlii« sub-
ject. I will only mention that the nuire Riinute process, which hw
beeu very ciirefully f<dIowpd hy •Scfiijf\ Jljtit, and otbera, is geocrally
Dfl follows : [inf., in th^ stiiinp or the nen-e thr>re is a destmctioD of
the nerve-ftheath, possibly also of the axis cylinder to a certain extent;
ot thv same tiin» in the netirilefiim» tJit^re is a i-olloctioD of celb,
which proceed» to iho d«rolopnicnt of spindle<«hnpcd eells in the mih-
slitncc lying between the ends of ihv nenv, and ext^^mliiig into (he
stump. From these cells, just tis in the entbr^'o, neir nerve-tibriltie
do\-elop upward and doimwaitl ; the filaments, which arc at first Toiy
pale, subsequently acquire a Kfaeatb,«ad then cannot be distinguiobed
from ordinary ncrvc-iilaments.
Pn.».
Pio.ttl.
w\m.
'M
%
J»'fi
fi«y«nf TDflnn (ifnurTML Pis. ID. from « nhblc Hfinnii Omj% adiir dlTlnInn ; ytnxin ipindlcMll«
III ilw end «r tliuuunre 4tr(l«pcd Troru tlie eiiuncGil'o tlatn« ■n4 Iiiilmaiclr conaMWd
vltb tlia Dniirlloniinil. Fl», 30, (Toni Iho froH l*ii nnak« atler dlvMon; ilovckipniBIU Of
foanjt D4ivir«»II> firaiu Ibc ■pibdie caUa, MiKOlltcd SXl dlUDVlcr», anoi IQ4I.
The most rccciil investigation« a» to th« significance of wnnderii^
oelbi in new fonimtion of tissue, as well as the speeiul studies over
till? formatioo ofuerrcM in portions of ladpules' tails rcgeneratcd after
injury, bare made rac doubt the formor >icw, that young rcgCDCratcd
ncrve-iilnmpnts werw ooTuposml nf spindle-cells. It seems to me muvh
more |m>hab1c that the divided axis cylinders grow out into young-
REGENKRATIÖX OF XKRVEa
101
EDerTe-&laiiicDta, aad that the (.'looxBt*-**^ spindlc-ctU«, which uuloubt-
etUy esiüt in tbe uprvtMnllus in ccrtaiii stugus, crilliar buluiig U) the
oocuicctivc tissue o{ the tKrunlcmtna ur arc d<-tadtcd portions of yoUDg
nervo-filamenU nniiiaiiiiu)^ nurJei,
In the human bftiij^ the rfgeiicration iif ncrveü onlr tak<!» platfe
within cpnaiii Unitt», which, il is tni<>, (.ruiiiut be very accumtoljr tle>
6nod. The couipK'tc rcgeocrntioa of Utrgc uctre-truaks, os of ^c
criatlc «r modian norvrs, dor» not oMur, nor doc« it tnko pl*co after
«xdston of largo jHjrtioiiK of iiisnc, if the ends rciiiui», 9»y thret» or
foar lioca npnrt. Vcty upcumio »pptuitioii of the ends of the nervo
iä netx«8hry, for apparently th« tnosfonuatlon of the ncwly-fonued
iolcnuediatR subfitunoc to Dcrvo-Kulislaiioo cau only take place hy
LOH'nn-i of thr> iirrve-Atump, oliliniigh tltcrc am dilTcTent opiiiioiifi aliout
^th<? mod'? of llii» i»n>cc»» ; we shall »tf siiiular coodjlit^ii» iu the hesJ-
ag of brokwi UnicR, where bony union only follows apcumte coapU«
'iiou of th« fmguii^uts, Nuw, hov is it in lliis n-äi>eot trtlh bniiu nnd
spinal tissue? Iii tliu human Itcing thorc a uu n.-ffi:Qvnttiuu here
■npT injury, or after loss of siib«tA»ru from idio|)athie iiiflnrniniiliou, or
at least Dot sufGcieut to n-storn the power of conduction. In BuinuÜA,
indeed, as Broten-Sf^uard has ehowa In pilous, after diriding the
spinal mnrmw, there may be rcpeuQnition witJi diaappeamni!« of tho
picalyKift, which has ufi-üurKe ijcuiirn.><l in all purU lieloiv- llie ]>oint of
liri^DO. Unfortunately, this power of rcgcucratioti of nerves decreases
'hi proportion to tho higher development of the verl<?br«te nnimals.
Olid it is least in man. As is known, iu young salamanders whole
pxiremitira grow a^in when they have been amputated, ^^'llat a
pity thi» ia Dot so in maul However, as regards tho ncncs. Nature
occastonoUy necms to make a fruitless attempt at regeneration ; for
|itito oh^a the ncrve-enda in ainpiiulion-stumpe, iiisteacl of simply
rdcvtiizing, develop to dub-shsped nodules, whioli arc occasioi>ally cx.-
cessivdy painful, niid miuire siiltsequcnt cxciKioii. Tticsc nodules oa
itlie nerves consist of un eiitunglenicnt uf the primitive ner\'e'filanicat5,
iwhidi develop fixim the stump of the nerve as if tbcy would grow to
I'Bioet opposite nerve-ends. The cicalrices iu the eonliuuity of iKn-es
>utftametimcsno«lular &xHn the formation of convoluted [Kimitive
Ebmento. Bucb small nerve-tumor« (tnic neuromata) are occasion*
' klly exnesKively painful, iLiiil must b«^ removinlwith the k:nifc. Hut
titers are also traumatic iieurüinata, which are nut Hi uU painful, as I
bavtj eeeu in old umputotion-stumpa. In general, tbcso proliferations
of nervc-oicBtricc« arc to be oomparod witli the previously-mentioned
bypeitropJiy of conneetJve-tissue cicatrices, and with proliferating
bone, wlticli, olthmigh rarely, is formed in great excess in the licslitig
' broken lioaes.
103
SIMPLi: L*;CI£ED nOUKDS OF THE SOFT P.\»TS.
The process of bonlin^ atiet injur/ of great rossole, espcct«lly of
arterial tniiiks, tiaü lienn cnrefuU^ detemained hj^ experiment. If a
laige artery be Itgstcd in an nmpiitalioii or tor tliaease in (Is continu-
ity, as tlic lig&turc is drawa tight, tin; tuuica intima is ruptured, and
Vtat.»!.
■ho AmUolial Uuneuiual Buau. C-uiilvd adci Frvmp. "SurctcalCopptirpMlc»." Bil. L.
tttltt.
the tiinl(« 1111114 nilnTis and ndi-cntitia are so ccnatrictcil IhM their iitiicr
surfaces foldi^d up lie in nxact apposition. Von may siitisfy yotiniplvcs
of the frequent although not ncwwiirilv iiiiiverHiiI niptiire of the In-
ternal tunic, by lif^ting- a large arttrriul trunk in tie raduvcr, for you
Dot unlivqucitlly experience a slight grating or cmoVliog under tho
finger n-hen tight(*iiing the ligaturo ; rou miiy altso bpi> it ou cutting
open a ligatcd art<'iy afior ilrlarhmcnt of Hip lijarnlurc. From the
point of ligiitioi) to the next, hrancli leaving the art-en', both at th« cen-
tral and pfi'lpheral ends, the ealibre of Iho vexftcl ftllR with roogiilated
blood, tlie eo^nilled (hrotnlnu (from A idpofii'toc, tlie Mowi-i^ot). Tlie
VDvelupiiij; lif^tun: kills thi; eticloscfl tissue, vrhich (n^dtuiLly Inxmkä
down into piiüt, nrid wht-n this process is completed the lij^inro (nlh,
or, »s vf c Itvhiiically express it, " the ligature has cut tlirough," " comes
away." Wlicii this has taknn plaee, the calibre of the artery must bo
pormanently and ecrtiiiiily closed, or there will at once be another
hmiorrhage. ITnder unfa vom ble ci rem instances it may certainly hiippen,
in small as well as in arteries of medium or large size, that the ligature
POftlCATIOX OF TDROKBUSL
103
Fl«. ».
through too soon, and Uif» dangerous, suddoti secoudnr^ hfemor-
: oocun ; Uitit is especially upt U> occur if tlic vull uf the orterj
VMS diseased or tltc tlirombiLS b«s euppiimtcd as a result of profuse
ftuppuntioii; artent-s that liave tiiudi cal{>are«iia dcpnsil in theta
often tannnt be ligiit»], as ibe ligature cither does not oomprem tlie
cclibiv or else cutd tbxougli it ut ouce ; under audi elrcumataiiocs, wiucli
wc mny occisionslly recognize beforehand, it is impossible to operotS
Buoocasfullv. Stilt, fiirlunuU'l}' it tit rare und tiocurs chiefly in old pei^
iu wh<)tu hiTpv ojicniliutui are, aa n ruh-, ofduubtfu] n^sidt.
Passing MOW to the considCTation uf wlutt has taken place ia tbe
' the vessel from the coaguUtioit of the blood till the lirm closure,
leiita on animal» and accitlcntat ob^en'ations
0« man hare gii-en the foUowing: the btood-clot at
first Ijringlooe« iu Üie v<Muiel gntdunlljr ItecoiiieK iiiuro
Grmlx Bttadied to th« wall of the virssel, and ooo"
tanlly;rri>w» lumlvr, but stil! ri'miiiris red for a long
ame ; it dues uot luse its color fur wovks or months,
and tbea does so first tn the ventre, so that the rest
of it still retains a slight TcUo^Ti8b tinge. After the
dctaohroent of the ligniun', tlii> thrombus is su bard
and 9u firmly nttatTbed to the wall.i of the ve.*»cl
that the calibre is entirely closed. The prvparatiun
(Fig. i'i) shon-s you tliu thrombus foniialJou in nn
artery after ligation in ihc coutiuuity; the lower
thrombus reaches to the point of departure of the
Gist branch, the upper one not so far ; the former is
rale as laid down iu most boak«, tlic latter is a
. uncommon ciccptiooL Plugging of tlic artery
- a blood-ctot, whiob becomes firiu, is, bowerer, only
provisiiKial state, for the lluombus does not remain aa for all future
line, but the cicatricial tissue slirinki; and atraphira; this takes place
the oaane of moutba »iitl yean, at which time the closure of the
^WMry at the point of divixion hoa lieeome »olid by adheaion of the
walls of the vessel If you examine !«uoli ao artery a feiv luontlis after
iha ligation, yuu und nothing of the llirombiiüi; but the artciy tcnni*
nates in a c<*nii-Al point of cicatHeinl connective tissue, as vo we in
miniature in divided muKculsr fibres (see Fig. IT).
The above <h«nguB, which ire may follow with the naked rye,
■how tliat in the blood^lot there is a chango which msentially consists
in Us increasing firmness and eoheren«* to the w:»II of the vessel; we
11 now study witli the microscope on what this intusfoniiation of
he bkiod>ctot depends. If you examine the recent blood-clot, yoa
Sud it to consist of red blood-corpitecles, a few colorless blood-oeUs,
Art«i7 tInUd in Ui«
ountkiulir. TliuD^
biu; All«r JVttri^S.
104
SIMI'LE INCISED ^VOVSDÖ OP THE SOFT PARTS.
«tid of fine SLamentB imd oc«Kuli>t<'d fibriac, nrnioged in irrc^sr net-
Work. If you trtke a UiroinlMis two dnvs »fWr the li^tioD of a smnll
or medium-sized attcry, it is ünntT llukii iit lirfit, and is broken up with
diSicuiiy ; the red hlood-orlls arc little rbangcd, Ihc whitr oocb aro
greaÜjT iiioreii9cU; lliey have somctinioa two and thrf-c nuolci ati pre-
viously, »uTin.-tinH>s »in^le palo, ova\ niivlei with nuclef>li; some oT
these cuUft are almost douÜv the siaeoCvhite bloocl^elb. Ute fine
Elamctits iä tJic fibnuc am united to uti almost homo^rcDcuiu mass,
irliich ia dioioult of diviiiion. If you a^in v):nmiuL' ii liiminbiia six
days old, the red blood-cvU» have almost disap|K-arcd, the fibrioc is
more Gnu and homc^neous, anil ei'cii nior« difficult to 6«ftiirato than
previously; a large number of epindle-sliaped cclla with oral nuclei,
fthnvviiig distinct dii^siotts, ajipear. From llie above, it appears
iliut cveu ({uito early a number of living oelb aiificar in the Uood-
clot, vrhose further development will be *een front what followi.
Sinco IV« ubtiiiii a more acourate understanding of the c'hang<% in the
thrombus aud its relation to tlic arterial vrall», by makiiif^ trunsrcrso
sections of the thrombosed artery, we shall proceed to do this.
Iliis pre]>aralian sbows a traosvcrBe section of a recent throm*
bus Id a small artci-y uilliin tlic delicate mosaic ibrmcd by the crowded
«d blood-corpusole«, among them a
fmv round trhitc blood-cells (which
have been rendejt-d visible by lap-
mine) ; next cornea the tunica Intima,
laid Logctlier in repftilar ftdds, in
which the blood-elot clings ; then the
tunica musculari? ; then tlie iuuim
advcutitia, with the tiol-worlc of clas-
tic fihrca ; to the ri^liL «omp adherettt
loose cutiiiectirc tissue The nest
preparation [Vig. 24) is Uie tranavei»
section of a himiaii artery, closed with
a thrombus for nix days ; we see no
ted blood-cells ; the white ones are
greatly increased, mostly roimd; but,
in the tunica advcntitia and »urmundiiig connective tissue, tJiere has
already liecn some cell infiltration. If we nowcxainino a Iviwhij-old
thrombus fixjui n large nuisculnr artery of the tliigh of a man (Kig. 25,
a), we find italrcadyodntaiiitngDUiucrousBpIiidle-oclla, wtiich are partly
ammged in strtw (subsequently vessels) ; the iutorcellular subetanco
is lilamcnlaiy, herercmdered tnuis[iarent by aoetio add. Finally, Uicn
ts ulso fonnuliou of bluoJ-ves&ela in the organized thrombus, aa you
aee in the following preparations (Figa, äfi aJid 37).
I
Fm, !&
Tniuvpor Mtilcoi of > Truh ihrombul.
Xai:>Utd WOiUaiQPicrt.
100
SJUPLE ISCISBD WOUKDS OP THE SOFT PAltTS.
Tbe prooeaa of liealiu^ iu transverselyniivided vein» uppean »i
iho first gUnp© to be much simpler than in tlie arteries ; cvrn in the
lu-gs vcinÄ ur Uie extremities, the divided ends fall tojfcthCT, and »p-
pesT to beal ut once, ui soon ua Ute blood has bi?cii obsLnicted st tbe
Flu. »
i'OV
^
''-'^A.
f.t ■. Ill
r^^
^V
^■VT
/wi.
OampliitPly-oTjiiMli-iiiI IhrniTiIm-
'. r.,,.. ,,. c „i ,',.■ :..i.:iLi: A. ii)oU>aoi)Bor 111« unla
U^T L t^'.*'! bv iimii.ii'i.- tuiiUCXIlTc liwuv dnd «iMilk fllo-
meuU; d, TnJüotadroiillUa. Mat^iaialWOillBinciuri. MUit Ktu^ßÜnA.
next TslfC obove ; *t these valves clots form, and they aro often mucb
Ur^r than ie dcsimhlc ; thiit fonnatinn of cJnts extending tonrard the
heart will honmfter occupy our earnest iitt<?iitirtii. Hut I have of tat«
observed thut the tuaicu intiinu of thu divided rein does not by any
means so fuld togclhr^r and ndhcrv, bnt that her« also thorc is a dot,
although a nniall one, which is organized lilte the ortcriiil thrombus.
If j'oii draw conclitsions from ilif^v |)re]miiitionfi, prcac-ntcd iu such
a fragrapntary wny, it nppenrs that in tbe ctottod blow! thorc is a cel-
lular inllltratinn, which here Iniids to clerelopiiient of eonncctive tissue;
in NJKtrt, (hilt tlic thrombus becointüs orgnnlzal. Tlie thrombus 14 not
a permanent tissue, but jiradually diMi]>pear» again, or, »t loost, is re-
duced to a miiiiininn, a fnto vbicli it shares with many nevr formationg
rcaulüng from inflammation.
rüBHATION OK THROMBUä
lOT
Peculiar rcasoiu cauxctl diu to iDvt.'^stigate more accurately tJie ot>
gsnizatioa of Iho tbronibus, Tbc importance of tbia process is rutUur
pM.ffr-
^
'7^.
K ,!->!'
r-v>^
>
ItiHUMi fM^lonor llwßtaudeiiilotiDB cramrnnnToradra. KltTitaroRerlirilinn:
haanmtiatuitOMtod; a<t.(tiatfa tniifa* und ma,1U:9BL lODlaMvontUli. ll«gtiiflad
sire; a poiut on whicb jou cannot at prceent Jutl^ trell, but
hereafter be in a position to «estimate fully, when we ooine to
It of ili»eases uf the v«k»cU.
From mj invutU^iioiis up to lb« pr«s(>nt time-, I do not tbtnli I
■■ rettsct tbc oescrtiua that coogulatcd fibrinc may, b_v aid of cells,
be tmufunnotl into <'un^(<(.'livc•til^suL■ iiiti*rcullutar substaii«?, althougli
cannot deride whether this bo dut; to true mctaroorphnsi», or to a
luul subotituÜoa of cell pn>lupUstn for disappearing- til>nuL-, äoiue
ive atttiinpletl to rpfor tlie origin of the «jMs, wbir-h npnear in onn-
stanLlr-inore-asiii^ numbers hi llir tlimmbus, lo tbe vraM of tlie vessel;
^tbe arteries, aa well na the veins, are corilnl t^ith a. lining of cpitlic-
tum, which to aome Oltcnt n'preBonts the tnocrrmu«! lamalbi of the
lica hitiina, Tliese epitJielial cells and tbe nuclei of tbu striated
108 SIMPLE IS'CISED WOCKDS OF THE SOFT P.iBIS.
n«. Ml
I." ■-'
p
^-IK
A-J\
AN
:0
Vi
fi^
\"
^•i/'
Pnttlnnof «(iMMtOTW'cll'iti i>r It trnnMQ niinaial vatn. «rlili «n nri>iiiilfi*i1 Tiviilnr Ihrmnbiu,
IH lUr* «JtarampDlalluii of the rlili^h : ri a. Tiiaica IdIIeub: t h, ■».'■lU; c<-, iidti'cillliii; </t|,
mvclciiilng C^ut«r 1Ihu<^: /<t. un^iiilEcil ihraiobqii Hiiti vriiali; rhi^ lacnrlng at Ui»
flfciri(i«MMUi4lbElnctl; vLtlblvin UiupertpbeFjO't lli«tlirumbu>. Uijpitaod (OO dluiwihm.
lamcllic of tlie Iiitiitiu linve bcL-ii cininted a priori bj,* Boinr authors, bo
ihat Ihcy eoiiW let new cells be fonncd from tliem, and gitm- into the
thrombus; in liis last work, Thirmcfi also inclmen t« this view. I
&<;krnjwle(l)r'^ tliat I myself formrilr etroii^Iv comlmlcd i\w Mjjiposi-
iion that llitf blood cwiild of itself become orgaiiixud to coonectirc
tissue wiili vessel* ; but from examinntions of transverse 8e(<lioiu) of
tliroiiilwsed iirlfrie«, I mil satisfied of Jl» eonwincss. After Imvln^
abandoned tlie idea of prolifenttion of stable tisitte-ci.'lla in tnflanuna-
tJon, wc ejiii 11» lod^r tiilk uf a pruliferatiuu of the intima in the old
sense. But wlienee coine, then, these newly-fntnied t^IIs? I htt\-e no
doubt that lliey oiipnate from ihe white blcKid-eell«, which have been
purtly enclosed in the thrombus, partly may have wondi^ri^d into it,
aecordln^ to the olncnatinns of I', lleckliiiffhaugen and Hubnoff.
As rcßsrds t]iu red bluod-oelU, it seems lliut tbey^radimlly unite witb
llio coagulated fibrine, lo»c their »hnpe, beeotnc iaterecllnlar substance,
FORHATIO>' OF TTiROMUl'S.
100
and lose tlieir coloring tnaltcr, whWi is sepsrnWd a« gmnulos or crj"«-
tals of [ifinntnidin, Littl« a» wc know wb<'nre blood-cclls cuuic, and
vrhillier tbey gw, still it Ls ccttain tl»t tlip vrliit« cell» ontcr the Mood
from th« Irmpjiiiti« toawIa, ami that they ent«r th« latter £rom the
lyni]ili:ilic glands or ouniiet-tive linitue pIsewlK-ro f tUey nw poll« tluit
orig^inatc dlro<ctJy from connccltrtMiaauc evils, ur fruiii n pmluplusni
aoalogou» to coonwuvc tisWK. Are tlic«c c*;ll» «lil! viable wlicr» ««-
doaed in a blood^'lot ? After coming; to rL>sl lu-ro, vnn llir-y trsiisfonn
tlictnselrca to tiiuup ? It is inipossiblc to affirm or di-iiy iliesc
<lue8tioua alt&olutely ; sinve Jlulmoff' baa »liowu thnt ^raiideriDg ccUa
enter the lIiromlnEi, aad may there oontinuo their iiiovpmonla, there
b DO neccMiily fur supposing tlutt til« wliit4< l)1üO(l-<.-e]ls (whii-li are
idciiliml with waudcriii^ cell«) cricluiK^l in the tlirombitis on coaf^ln-
lioa, no longer move, and cnnoot be Irangfonncd into tisuie. Hith-
erto there have been no investigatious as to uhetlier wandering cells
paaa thivugfa the wnlls of artrrins as rr-adily as tliroiijrli tliow of veins,
as Sti^off^» iuwälitilutii.'tta oiilj reft/r to voiious thrombi. Some of
my investigations in this direction showed ine that minute eiiinnhur
graaulea pas«») thrmigli the rHnrt.iiI of n do|j; into the thrombus, but
I DCHild not tsntisfv my&vlf that they woru n-plunMl by wundt-rin^ n-ils.
So at prvscnt it t» iiiieorlaiii whedo«.' tlio iiunieroiis wamliTin^ tt'lls in
an nrganiziiig arterial tlirombus origitiate, and hoiv tlif-y enter thcr«.
Tnchataioff, in a very carrfiilly-Rtiidiod work that bos lately ajipearcd,
calU attention to the faet tbnt a ^real portion of Urg« Lbronit» are
destroyed by diKintegrntion. 'V\\t9, in very triio, )Hit lie gnea too far
when be entirely denies Ibe provisioniil or^niution of the tbrumbua,
and eiippoeea tliat the disintc^ratiou of the clot ia imnio<liately fol-
lowed by the adhesion of the walls of the veiisel, to which 1 have
called attention aa tbe deßiille lenninalion of the whole proeesa.
As I l»vo alrt'ady staled, poitjliarly favorable coiiditionH are re-
qaifiite for the blond-elot (o beeonie nrg»uizc<i. It is. an nbaohite Uw
in ibo human organism, that non-vasntilar tiünueN. whiHi are iuinri»1i«<l
by meaua of cclla altine, lutve no great extent ; tbe artiruliir cjirtiloj^eri,
ihoooRicn, the tunica intltna of these vessel», the tlMtucs, arc all in thin
layers; iiiotlito-wonU, thoeelUof the human body c:itiiiot, like those of
plants, carry nutncmt fluid U* any given dialaucv, hut are limiu-il in
tlieir conductive power ; at oertaiu distaiices new blood- ve&io la must
appear, to supply awl carry off the nutrient fluid. 'Hie hlfK»d-eIot^
oomtBting of cells with »lagulated filiriiie, la at first a oon-vaseiilar
celluhir tiasue, wbiik uin only niaintain its exJstcnee in lliin layeni,
lliia appears from obeer\'at>ons, which we shall hereafter often have
oocasiun to mention ; nan»ely, that largo blood-elota am not organized
si all, or only iu tlicir |teripheral laycn, while tlioy diflintegratc in tho
no
SIMPLE INCISED WorNDS OP TUE SOFT PARTS.
ccntiv. From thi» it appears (licit, io liealiiig bj tli« Gnt inletitioD^t
siiiull nimiiint vi blucul Ij'i»;; Ix'lwocti tlio r>i!^>!i of th(> wrtuml does no
hurin, while ii lur^-r Biuutmt iiitcTfi-rcs with liL-nUiig, or prerenia it
allogctlior. Vou will 80oa Iw Me to \cnty tliia obacn*aliou ia the
clinic
Let us novr look nt the Gntc of ihe circulnticn «ftcr lignting» Iftr<gc
arterv ia tli« continuity. Suppose that, for a hiBtnorrliage in the leg,
t)i« ft^nioral Ribcry has bccti li;;atnl ; liow docs the blood now rc»^
tbe Il'R.? Ituw will llip circulation go on ? Just as on closure of capU-
Inry distriots, under increased pnsaure, llie binod preKscs tlirou^ tlio
next i)cniw«l)!e vt*&8»?l8, whicli am thereby ililntetl ; llie same tiling
occurs 00 closure of small or mvdium-si/^d aTtcrics. Under iacrCftAcil
prt'SKurr, lliv lil(X)d flows throujfh llie bnincbos cloev iibovt' ibo
thmmbua, und from tho uumennis artt^iiU uiastoinoscs, both in tho
Vut.ia,
Ab.«
Fi)
HjIBtlMi. A (let At/a
SS novilw allot li^UoB. A.U
ter iWn-
loog axis Mid viitious tnnisverse axes of the limb, readies otlienirleriis,
thfotig-Ii wliich it soon agniii streams into the ]HM-ip1iiTiil cud of the; liKst^
rdTC«sc1. .fVnartenal coUatoml circulation isostublisbod to tho «do of
the ligatcd and llirttnilxisml ])ortioii of t-heurlt-rini trunk. WiÜiout this,
the pari of the body lying bi:lo\r this puint would not icccirc sufli-
COLLATERAL CIBCCLAnOS.
Ul
r». u.
)
jcDt blood BDtl irould die; it would dry up or putrofjr. Fortunately,
•nastoinosus uev so free tlut, cvl-q alter ligstioa of a large
try, like tiic axillary or fcmoni), such a case ie not apt to occur ; in
seased arterie», however, which do not distend Bufficit-utly, toortifi-
Cfttkm of the afTrctcd extremity may occur. The iiKidefl tn wliich
lh«se neiT VBst-uW conncotiooa form vary greatly. YiMn ago. Porta
made very pmfound researches on this point, and from hix iminerous
tuperimeots slated tJie foUowin^, as the types of collateral circula*
]. Direct oollatond cirrulatiou is estabUsbed; L c, there are
agly-dorelDped vessels, u-hleh pasa froco the central end of the
artery dircrtly to tlie peripheml cad.
Theos unitiog vessoltt are
hiefly the dilated vasa \-aaorum,
attd the tTsaels of (he thmnilius ;
mi<;ht happen tliat one of
lese uniting ve«s(4s should di-
late so much as to acquire the
appearance of being simply the
trunk regenerated.
% There is an iadirrct col-
latcnJ circulation ; i. v., the
cnonecting branehcia of (he next
lateral arteries an> greslly di-
lated, aa in the GoUovring case,
Fig. 31.
Tlie iiio^i itlrildng examples
of both varieties of collateral
rirculation h&TC here been cho-
sen ; but vhen you oxamiuc the
numerous shetclics of Porta,
and youisclvcs rejieat these ex-
periment«, you will find that in
most eoM-K direct and inilErect
ooUatcrsl circulatiou an: com-
bined, BO the only valuv of the
ufiraticn is to group tlte
Iflerenl fonna in some way. ""«^ "^ il^ *aSÄS* '
It is SQ excellent anutoini-
eal exercite, to represent for yourselves how, after ligntioo of tl»e
diSBmtt arteries of one or both cxlieniitiea», or of the trunk, the
blood will reach the parts beyond the point of ligation ; in this you
wonldbewt^l assisted by the plates of arterial aoastoDiosis in AVatm's
9
;
«tol S loontbi
112 SIMPLE INaSED WOUNDS OP THE SOFT PARTS.
text-book of anatomy. In the surgery of old Conrad Martin Xan-
genbeck, these conditions arc carefully described in the chapter on
aneurisms. The reversal of the blood-current, which not unfrequently
takes place in these collateral circulations, occurs with wonderful
rapidity, when the anastomoses are liree ; if, for instance, we lignte the
common carotid in a man, and then divide the artery beyond the liga-
ture, the blood escapes with great force from the peripheral end, that
is, backward as from a vein. In all such cases, where the artery to be
ligated lias free anaetomoscs, if a piece is to be cut out of the artery,
we should first ligate both central and peripheral ends, to be insured
against haemorrhage; this is an important practical rule, which is
often neglected.
CHAPTER IL
JOMK PECULIAItlTIES OF PUXCTUHED W'OUIfDS.
LECTURE X.
Ä* ■ Hnl«, Pmictnrtd Wound* lioal qulcklj bj Flntt leitrntion. — Nvedl« Punottin«;
Itvpillea rMiuintiif is tli« Bodf , tlieir Eilnurtinn. — PiitiFtUTcd Woutid* of tli* NorrM.
— PtiBciurvdWaiRidii<iftii*Aitcriei: Anrut7iiiiia Tnnimatteum, Vniooauai, Tiriz
jUMniysnatkn«. — PnM(ur«<i TTmtitd* af ih« Voliu, VenctcoUoa.
MoxT ptnrttircd -ffoiirKls »re fimplo wrtiimi», anil iiRtiallf lienl hy
fiist inUmticio; manj of them are at the? s:imr time inaseil nuiiiiilH,
rlvn tlii> piinrturiiif^ iostnmicrit liaH a iTrtain bmnHli; f)ome liitvc
bv L-bnmct eristics o{ contusi.^ wounds, wbcii the [lunduriuK iiuitru-
sent wii« blunt ; in llua case thcro is gpnonilly more or let» euppiira-
)n. Wi; maVc niany punctured vounds with our »ur^enl tustni-
fVcDtfi, as witli a^ipunctttre needlea — lin<>, long nco(]k«, that wo
oenuionally employ to cxainin<> wh^^lhor and how deep below a tumor
nr ulner the Ikone ixilestroy«?«!, etc, viith acitpreMtuif nftdle», whinh we
OS« foraireAliiig lurmorrhaf^; with the frocar, a dagger with a Uircc-
liclccl point, fumUlu'iJ with r <«lo**Iy-fittin^ canub, an inirtruinent for
twiiig of! fluid from caritiüs.
Dirk, sword, knife, and Iraronct punctrucs arc often ümultani-ouaij
Iadc«(l and contused wounds. If those punctured wounds Ik> not
aocompanied by injun,' of large nHf^rieii, I'ein», or boneR, and do not
riil'T any of the cavities of tlie body, ill«/ often heal mpidly and
witLuut treatment.
Tlie most fK>r)tH<!nt puiiclurod wounds arv thoso ma<lo with n«M0»,
nperially in women, and how rarely a doctor is cnllod for thrtn !
Sitcli an injufy ie only cninplicatod by a ncnlle, or a part of imc, ci^
tering Uie soft p«rtH so deeply that it cannot readily be extracted.
^Ita omiiiinn3.ny tjappci» in different part)) of the body, as from a
penon Mtlinj? ur fulling on a nredle, or iKimt^ such aoddenl. If a
iwedlc ha« eoteror) d«-p under the ^n, the »ymptooia are lutually fm
lU
SOWK PECIJLIARITIKS OY PtTSCTCßKD WOCSIlS.
üÜßlit that Die pnticats rnrcly huTc any dccidei3 sensation of it ; !i>>
deed, Üi€f orten caiitKit MV \vbctlicr the nwdlc liaa really untonxl,
anil nbere it is. And in th« soft p«ris this Imdy iDtiullv induces do
extern«] sytnploiu», but may \ie ramt-tl iii llic budv for months, yev*,
or even ■ liictjmc^ iritliout trouble, if it do not cuter a nerre. Tbe
need]» rarvly ivniiiins stutiumiiry at the point where it enl^M-iyl, but
wunden about ; it ib shovud along to other pnrts of th« IhmIv by ctnv-
tractioQ of tlio muscles, and thua may come to light a long distaooo
from the point of entrance. Cuspb hiive been ohsi-rved whore hyster-
ical women, from the pectiliar ranity of attroetinf? the attention of
pbysicinns, \»ivc iiiflcrttMl nunirrtnia »üciUc« in iliflcreut parts of Üio
body; theso ncodW appear»«! now hen? now there, Evcd wlien
needles have t>een »wallowt^l, they may irithunt dnnger pass through
tlic wull» of ihu stoitmcli an<l intestiiicit, mid come tn the sur^ne at
any part of the abdominal walL M. von lAin(/e'il<cfc foitnd a pin in
the centje of a vosieal calculus ; on more careful inquiry, it wnn found
that, when a child, the patient had swallowed u pin. The pin may
have pitiwcd through Uic int«6tine into the bladder ; here triple pltoe-
phalcs were de)M)«ited around it in layers, and Uiia was poesibly tbe
origin of the calcultut,
Wlicn the needle has remained for a time in the eoft parts without
exciting pain, or when needles, passing through the Iwdy iri>tn within
outward, coiiio to llie surfaw clo«e under lln* skin, they utiuiilly excite
n little supimntion ; the piercing feeling bcLOnie» more decidc<l; we
tnake an incision at the painful «pot, lot out n little thin pus, and in
the pus^arity find tlie ueedle, which may be readily removed with
foroqps. It is dilBciiU to cxpluin why this body, wbicli for monllis
bna moved »bout iu the body, should at length excite »uppumtien
when it arrives under the skin ; you must here Batisfy yourM>ives wtüi
a simple knowledg«? of the farts. Tlie following iutereitting raftc may
reader the coutm; of tlie^e injurtca more dear 1o you: In Zürich a
perfectly idiotic female d«if mut**, thirty yeitra old, waa brought to
tlio elinie with the diagntisia: typhuK, Nu hialor}- of the case couM
be obtained from lbs patient or those about her, who were idso tadt-
ing in intelligcnee. The patient, who often roiaained in l)ed for days,
had ooniplained for a abort time of pain in the ileo-wecal region, and
bad moderate fever. Examination showed a swelling at this point,
which increased the following diiy!i,Bnd was very painful on pressure;
the Hkin reddened, ductuultuii became cindent. It wag clearly nut a
oaac of typhus, but you may imagine wimt dilTcrent diagnosca there
were as to the scat of the suppuration, for there was xmdoubtedly «a
nbicess ; it might be inHumtuation of the ovury, perfuration of tbe
vermiform process, au abscess in the abdominal trolls, eta, etc, ; stjll.
NEEDLE W00SD8.
115
srnnclhing could be said aguinst all iht^sr. lirp^LhcsCfL After n. Icvr
ixy» the reddened skin bcc-aine very tliiii, (Ite ibsoess pointed aboot
die lif^iglit of the aatcrior »upcrior spinaus prowss of llip ilt^uni.a fewr
fingCf«' brcndlhs ubuvi: tVujiurt's liKsmoiit, anil I auidc ao incisioa
tlitOBgli Ute skin ; tliore uns Dvaciiuted n gneey, browniKli, üanioiis pus,
riith a »trorid ft'cal odor. As I examined tlie absccss-ea^-ity witli my
Sn^r, I felt a bard, nnMike, Erm Itodj iu the depth of tlic a)>»oeAS,
lud pnijecliiig §lightly into it, I began to extract it, and pullwl und
puUcd till I brought out a knitting-need It; almoüt a foot long, whidt
was somewKat ruftty and ix>iiited dowu toirunl the pelvi». The ab-
■ecesK'änty tras elotbm) u-ith flnbby graniilationx. "^nien I trit^ to
eiamine tlie oiwniiig tlint ihe iiM-dle must have left Whind, I (tould
tu> lon^T lind it ; it had dosvd a^^iii, and nnu i-orcretl by the f^ranu-
lationg. Tlic alMtcess took o long time to hcnl ; it at lost did bo
without fiirtlier »ecideQl, so llint in four weeks the pati&nt was dii^
missed. As [ &howe<l tlir unfortunate cretin ilie rxtrarted needle, she
^^auj^hed in bcr idiotic way ; that was all we could make out of lier }
^Hierhaps this may bare indicated some sliglit recnllnetirin of the needle.
^■t ia nxwvt probable that tlic patient had innerted iJic needle into the
^^Y&gina or rectum — procedures iu which even woiiien not idiotic and
•oine incredible pleasure, il8 you may see id Mt^'f-nbactCt operative
stugeiy in the chapter on cxtroc-tioo of foreign bodies. It is not im*
{WMJhIe that in this case the needle possetl by the side of the vaginal
portion of the uterus through the espcum, for, from the gas-eoiitaiiiing
^jius of the abscess, we may decide that there was at least a temporary
^^Bomnunicatiou with the intcattnc. It is true this canuot be regarded
«a absolately certain, for pus in the vicinity of the intestines by the
developmeDt of slinking gaM>s may putrefy, even when no conimuni-
oatioQ with the interior of the iutestines exists or has existed.
The extraetion of receJitly-entered needles may be very difficult,
npecjally as the patient« nre not unfrequentty very uiidudde<l in ihcir
iafornmtion about the lucatiun of the body, ntid omifionafiy from
shame will not acknowledge how the iioe<tIes (in the bladder, for in-
stance) obtained entrance. We should, with tlie left hand, ßx the
tpcA where wc shall most probably Bnd the foreign liodr, cnrefuDy
mdeavnring to press the skin to^^hor in folds; we must at tho same
ttttw bo careful that the needle does not again change its position
while ire are making the incision. Sometimes we feci the body more
or \fm distinctly, and can cause pain by pressing on it ; these attempts
miBt decide the point of onr incision. After dividing the skin, we
ipt to seize the nee«lle nntii a pair of gooil dissecting forceps;
tense bands of fascia may readily deeeire us, especially- about
fingieni, for with fbreeps onr sense of feeling is always uncertain.
It«
SOME PECCLIARITIES OF PCSCTCKED WOL'NDS
If wc cannot find tlie neeillc, wc may move the \>!irla some; tho
dclhHc! is till'» KotiicHntL's imjvi'tl into a ]}a<iilioii w)ien> il may be
8ciiU!(] more retidilj'. The L-xtruotimi of forcij^n Ijodieb requires a cci^
tuia atuouat of practice And manual dcxtcritv, i\-hich ve acquiro oulj
i^'tlli tJiiRt sud prac-tico ; here niittiral kii!U.'k is ciT grvat »crvioe.
Punctured wound», made witli mstrumeuts not vcrjr Kliarp, an
ocrasiomilly ititciniploil in Üicir process of healing. ExIcniaUy tbejr
hexl by first intciitiini, lm( nft^r a fewdaj*s there are suppuratiuo and
iiiflniuin4ti(in in tlie deejwr parts; llie wound cither oix-ns, and llie
wholu tract of the wound »iippurulir», t>r thu pua brcuks tlirou^ at
Bomc otlifr point. This ocmr« piirticiilurly in nasea wh<je a foreign
body, as tlio point of a kiiifi^, n-rnaiiiii beliiiid, or where the vrouitd
wii» nindc- trith a iilunt instiuinoat. lu cxaniiuitif; tlit; wound, you
shoidd ftlways bear in mind the possibility of n foroicrn body reniaio-
ing behind, anti, if possible, see the instrumeut willi which the injury
v/a» donrr,iiiid lind i^xaolly in what direction tlic instrument passed, so
that you tuuy know about what partd are injured. However, even in
unfaroroblc cuKe« tberc arc occasionally very littlR intlnmniatioD and
suppuration. A short time ainci' a man cuine to the clitiic whOfB few
days prcTiously, bad fallen a moderate height Eroiu a trc«, Ugfatiug ou
bis left artn, while vnga;^l elipjiin); the suiidl bniiiclte^ On the dur-
sul siirface, a ft-w iiiclies below the elljow, the ann was swollen; oil
tlie volar Burfuce, just above the iriist, there wim a slight excoriation ;
the arm could be extended and tloxod witlioiit psin ; only pronatton
and supiuutlou were impaired »ltd piiinful. Itiert- van no solution of
continuity of the bones of the fon>iirni ; th<r bones were certainly not
broken through. At the rwoUcu spot on the dorsal side, an inch
below the elbow, immediately under the skin, we oould, bowe\-er, feel
a finn IkmIv, whieh could be pressed hack somewhat, but it »t one«
rctunicd to its old position. Il full just ns if a piece of bone had
been broken off lengthwise, and lay close under the skin. Inoonipro-
heo&ible as it mu^t seem for such a detachment of bone to occur by
simply falling on the nmi, ^nthout fjBctttrc of the radios or ulna, I
nevertlielcM hnd the pulient iina'sihelizt'il, nnd again made the at-
tempt to press into ]H)»itiun tbL- suspected frugment ; but it did CKit
miooeod. As it lay ao close under tlie Kkin thnt it would tux^ssarOy
liave perfomted ere long, I made a small incision through the skin to
extnwTt iU To our great »stonislnnent, I diTw out, not a fragment
of bone, but a small brunch, five inches long, which U'as quite Unnly
hold by the two bones of tlie forearm. It wan ineijnipnehensible bow
this twig could luire entered the forcann; but, ou more curaful
cxnminntion at the nbove-ini^nlirmed excorjftted spot on the volar
Burfacet we found n linear, slit>likc wound, which hud already cloecd,
PFKCTURBD WOrSDS OF ABTSUIEa
117
tliivugl) wlitch tlitt body liud appftrcatly {Missed so quickly tlia,l tlio
ptilioiit Lud uot iiotk'L-d its culrance. After ilü vxtncüon tUe very
modiTxtc strcllitig cutircljr subsided; lli« small wound di»cbaipN]
Intt little pua, and wu entirely closed iii eight day».
These favorably conditions of punolured uouiula ha.vo given rise
to tbo «walled tuhrutatieoiu opecntioiis, nltidi wem introduced into
surgery utore particularly b}- Stronttyer aud Vifffetihach^ uud consist
in jMUwiiifi n priintcd, su-row Icnifc under llii> «Icjn, itnd dividinff teo-
doiu, muBc-lf^ or nerveK, fur vnrioiiK |)ur[K»K« of treuüneiit, wiiliout
nokiii;: iiiiy wound In llie skin otlier IIiilo the lunull punirturcd wound
bro»}^ which the tenotome is introduced. Coder tltcse oircum-
tctiinces the wound almost «Iwnys quickly closes by Gist intention,
rliile in open wound& of tondons iliero is slniiist ulwiiy^ mi|ipurKlioii,
II cxIcuBtvc dcutli of the lendoo. Of lliis we »liull speak furtUcr
tlie itlmptcr oo defornütics (CJiapter XVUI.).
[f the puni-turc haa entered one of the cnritios of the body, and
e»u»cd lajury there, the prü^osia vrilJ always Ix- doubtful; there is
more or Ipeb dnnger, ncotiiding tu ihc jihyBiulogic-al importance und
Tulnrra1]ility (tbc greater or less susceptiliility to dangt'roiis inllAuf
■nation) of Ui« organ implieated. Sue-b h punctun-d wound i» not m>
dsn^nit» nn s gunsliot U'ouad. We shall not at present pursue thi«
sulijeet further, but must now »iiy Boinethiiif; u1>out punetunid wounds
of tbc nerves aod nrtori« of the extrcmiLiea,
Punctui-ed wounds of nerves nntumlly induce, according to their
(l«ut, [aralysis of variable auiounl; otlienvibc they have the same
feet as inr-ised wounds of tbc ncTvrs. Itcgcneration nrcurs tlie
readily when the whole breiidthof th« nerve has not been J>unc-
Th« case is different when a foreign body, as tlie point of a
tie or a bit of glasa, is left in the ncrvc-lrunk ; they nuiy licul in
pre as ill oilier tioäues. The cicatrix in the ncr^'c whicli couUin» tliii
Imdy may teuiain excessively painful at evejy toueh; there may aUu
□euRiIiria or nervous [ains extending cxcentricully. 3Ioicui-er,
ic severest iMsrvous diseases, ncutc or cbrooic, may be induced by
foreign bodies. lLj>iirjA»J\rrm tjxum«^ with an aura, a paiu in
be rimrix preceding lite sjuu^iu, have been olKK.-rv'cd after such in-
t; aouie surgeons also assert that Inmmatic Manui may also be
Ddn<>nl hr thi» nen-oua irritation. This appears to mcveij-douhlful,
lit of tili» hen-after. The iirat of chesc diseases, the 5o-4?al!nl reflex
epsy, may u»unlly be curvd hy the cxtraetiou of the forcigu body,
I*unoture<d wounds of arterial trunks or their large hrancbea may
indure various resultt«. A very Kuitill ]>uneiuru usually ckwes by tlie
dastkity and rantraetility of the cuata ; indeed, there it not always
, bdnnorrhage, any more than there is always escape of tsK<x* from
-118
SOME PEOrUARtTIES OP prKCTTRED WOrXOa
& small puncture of the inteetiDc. If the wouml he fllitr«hnp«d, tlie
bleeding may alsu be insignilifant if the opeiiinf^ f^VOa Init litUe;
but in other mses scrrm arterial haincrrliHge in tlio immediut^ n'inilt.
If comprcenion be at once made, mid a ImiKlagc arcnratcly applied,
we shall uaimlly KU(!Ceod not otily in «rr^stinjf the hBttifiirluigc, but
«Uti in clodinglhe pimpliire in iht* nrterj-, just us weehuiiltl ont» in the
«oft pari«. If the blccdinj; be not arrested, ta already stated, we
shoulij at oi>M Hgntc th« nrtcry, after enlarging tbe wound up ootl
downward, or at a higher point iji the continuity.
Tlip Hosure of tlic arterial wound take» phiott aa follows: A blood-
clot foitna in the more or loss gaping wound of tlio arl<;rial wall ; this
riot projects slightly into the calibre of the T»»el ; but externally it
is «SHulIy somewhat larger, and looks like a tnusliroom. As described
in intra-vBSuutar tiiroitibus, this clot is transformvd to coDoectire
tissue ; and thus tiiere is p<>miftnenl ot^nic closure, without citange
of the ealibrc of the artery, litis
RCMina] course may be coiuplii^ted
by layers of new Shrine from the
cimJating blood, riepositing on
the part of the plug projccliiiK
into the cAlibre of the vessel, und
thus closlnij it by a plot, (firming a
complete arterial thrombosis; but
this is rarv. i^honld it lifipjien, wc would have, the finme result as
after a iLrombost» follo^'ing Hgntion — dcvclopmcnt of collateral cir-
culation, and eventual obliteration of the vcbspI by organization of
tlie thn.)mbu^.
Puucttin-il wounds of the arteries do not always t<ikc so favonblo
a course. In many eaws, soon after the injury-, wc notice a tumor at
the seat of tlie young cutaneous eicatrix, whieli gmdually enlarges
and perecptibly ]>ulaatc8 isocbronically with the sj-stolc of the heart
and with the nrtcritd pulse. If we place a Btetbosoojie over the
tumor, we may hear a distinel buzzing and friction sound. If we
compretss the chief urterv of ilic extremity above tlte tumor, the pul-
sation snd murmur cense and the tumor diminishes somewhat. We
call such a tumor an oiieiirigrn (from avfiftiyu, to dilate), and tliis
particular form, nri»ng from wound of uu arter^', we cail anc'irüma
^ntriiiin or trauinatii:unt, in contntJistinctiou to tlie antKrUma
verum, ariMiig spontaneously from other discARea of the artefy.
Whence «.-oniejt this tumor, niid wlitit is il? iLs nri^n is as fol-
lows: The external wound ia closed by pressure, tlie blood can no
longer flow out of it; but !t forms u way through the opening, wkicli
is not yet firmly closed by the clot, into the aoft purls, and winds
Pia.».
Arier? «romrilMl un Ibe ildo. With riot, tar
lUj« sRcr lUc Isjorjr ; an«! ArA>.
ANETItrSH FROM PCSCTÜRKD WOCXDS.
ng
Fl«, ta
abciut smong them u long us the pre^fliireof tlie Viloocl b »irongcr tlinn
the rrnstaooc of tbi: Üksucs ; ■ caritjr filled with blood is fDrincrd in
ttnfliedUte oommuniriilion yrith the enlibre of llie artery, ymrtot the
Uooct aoOQ coHgulates, antl them is slight inflnnirnatioii of tlie tissiw
about it ; a p!»«tic ia£ltrar
tratioii, u-hicli leads to »a-
nectire tiHsite new fonna-
tioD, and this thickened
tissuA forms a Me, into
and from wlto.«^ civitytlie
Mood llon-ii, M-hilc the pe>
ripheiy of the onrity u
filled with \ayvn of clott^
blood. The buzzing and
friction tliBt we perceive
in the tumop arise piutly
from the bb>oc1 flowing out
through the narrow opvo-
ing in Ihn iirtciy, partly
by its frictiou agiiinst the
ooagulunif and lastly by
the regurgitation of the
blood into the aitery.
Siich • tniiiniatic an-
oirism nuiy also occur in
another, niort' cwundary
way ; llic arterial wound
Ht first hcnls, and subeo
qitently, after removal of
the pressure tiaiulagi', tlie
young cicatrix giree way,
X'-'
nvrtrp, '■ SarslMlÜoppctpUl».
ilteon oTiSe ftrarhlal artrn: «nof and then for the first time
the blood e»c»]tes.
l^timatic uu^urisnts are not always caused by ptiK'tun.'d vrouuda
of »rtcrie«, but rupture of tlicir eonts by great twixion and eontUKion»,
iritbout any citirntal wound, inay result in their development. ThuA,
in lits ftur^citl lectures, A. Conjxr tells of a gentleman k-Iio leupcd a
ditch while out shooting, and at the time felt a pain in tlie hollow of
Icnei*-, which prevented bis walking. An aneurism of the popliteal
■rteiy »oon de^-elopi^l in the bend of tlie knee, tlinl finally hud to be
opemted on. 'J"he artery was partly niptured by the ioiip. lEuptitro
of the tunica intima and muuularis is siiflicitmt to |>eniitt the forma*
tkn of an aneurism. Should the tunica udvcntitia remain uninjured,
130
«IME PECULIARITIES OF PUSCTOnKD XVOCXDS.
tbe blood mny dotacli it from ihu tunica iniHlta ; this fanos a vnrie^
of aneurism rallctl anatrisina diateeaoM (disaccting anourUm). 1'jisos
of punctured wouada nitb subsequeut aiieurisms occur imiiJculüHy Id
military practice, but not unfrmjuontly also in civil praclioc I t.aw a
boy witb an aDvurism, us lar^ ax a heu*»*«^^, uf tlio fumoral artoy,
abuut tJic middle of tbc tbi;;h, tluit bod been caused by puncUne witll
u pvn-kiiift.', <]ii vrbifb llio buy fell, A eliurt time Bince 1 operated on
nn anetifi&iii of t\w railiiil artery, that had dt^reloped in u sbocmalccr
lifter an uocidL-ntal puncturL- vrilb an nwl.
Alt aiieurl*M is a twr%of ccinmunieatinff (Urictl*/ <rr indircc4Ij/
%tilh tfie calibre of a» artery. This is ibe comiuou doGniuou- The
coaimtmicatiwi is immediate in tbc case just described of a nmple
trnuHiutic «neumtii. Still, tbe aualomicul conditions of tliis tumor
may b« mom coinplicattHi.
For instiuicc, in a veiii!»eptioo at ibu bend of tlie elbow, that is,
Jiom tntciitioDulIy punclurinf; a vi*ia fur tin.- ptirpom; of alMtiwHing
blood, besides tho vein, tho bmcliinl art<'rn- may be wounded ; this tt
one of tbe moat fnwjneut causes of truumati».' unpuriam, or at least wna
BO fomicHy, wbcu blrcdioji; was mnni {»mmon. In snob a ca«e, besides
th« dark, venous blood, wo may readily perceive the bright, arterial
Wood ; tbe »bole arm ik nt once bound up and the arterj- compressed,
and in Bome cases tbe opening» in both vessels bt-jJ at oiico without
further eun&equcaces. But occ-jieio'ially it happens that tbia accsdeot
in followed by nn nneurism ; this may have the simple form above dc-
acribed ; bill the opening in tbc two vcssela may so frmw toother that
part of tli« artvrial blood will (low diioclly into the vein as into an
arterial braneli, and must then meet the struam of väuuuB UuotL This
TahH
[tPTrn-
:ll!i(!-1
vaMx uwilHMtlOOS. 1. OnclUal «ncrr: «lUr luli. yr\Tii», "Uiik1c«1 CountnUlM."
Bd.i[i..TiEna.
ASEÜBISH HtOM PDKCICRED WOUND&
121
causes obstruction of the Tonoua current and consoqucQt snoculations,
dilaUitioaa of the calibre of thü voiu, wliicli wu g<t.Mi(rr&11_v tvrai tarf>
ca ; ia this particular cast- Ihc xanx. Is caillcd varie ancarUrmüieuMt
bccsuse it comniuiiiiütU'A with mi trUsry likii an nuoarism,
Another case niav aria« : au aiiL-urisia funtm tM-'ln'Miu Uie artery and
TCta, both of irhicii comiuuuicalu with tJic ancurü>mal &ac
Vm. 30.
^'^
-■■i'
ivKTkoraB. a, BncUal irttiTi (.»«dbti rrin. Tb» •nmrisiii«] we ti cat opts t
»tuttkntf- i>Mlep, "SomUilCopiwrptUn." M. IIL. TiIKS.
M'c coll ibis aneuruma vancttsum. Tliprc iiinj' »Isn be aonie
ivtks in tlic relatioo of Uio uneurianuu sac, reio, and artery, to cuclt
Qtber, which, howevor, arc only important a» bciiij; ourioiis, and change
neither the »yniptoina Dor treatment, and fortunately hnvenopaniouhir
names. In all Ütcae cases where arterial bhmd Hovrtt dircutly or indi-
rectly tlirouj^li an ani^uriamn] iiac into the ^*ftina, there i* distention of
tbe rciiis and a tlirill in thoin, tvhii-b iniiy he both felt mid bonrtl, und
may even be occasinosUy porc<:ivct] in tlic arteries ; it probably results
from tlie meeting of the carroutd. However, tliia thrill in the veaaets
is nul chanict'i'riAliti of llie »Ixive xtiiltr, fur it loay sonii'Umea l)e in-
ducted simply by prthtsure oa the reins, and occurs in some diseases of
^^bo heart. Wc also oocsfiionally boo a vcak pulsation in veins dis-
^^koilcd by the aboTO causes, which would even earlier give a conicct
^^EafrnrioiiL
^B Anoiirl'uns of the arteries, in whatever form tbey eome, if they
only remained small, would cause no grout ii>coiiv*oni<'-ncc. But in
most eases the aneuriunal tats gron' larger and larger; functional dts-
torbance» occur in Uie afiioctcd cxtruiuity, and finally tlio uiieurism
nv rupture, and a profuse hicmorrha^;^ t^nninato life. I» moot case«
tKilmait muBl coauisl in ligutitig the aaeurismal artery; but of
122
SOME PECCLIATIITIES OF PCNCTÜRED WOCNDS.
lliia licrenlter. I Imve considercil it pmctii»! io explaia lo you ho«
the (IeveIopm«nt of traumatic nneiarisms, «s in pmrtice they are mosUj
line to i>uiicliireil wound»; «hile in oilier t«xl-bookx you will find Üiein
Bystoiuiiticnllj trt?ul(;ii uf nmorig diiMMu»» of tlic arteries, Wc fthnll
sppak, in x separate fhsptcr, of »pontsrK'ou» fttieurisms and tlicir tPC»t-
tiient,
Punriured wound* of veins lical just Iflco IIiobr of arteries, so Umt
I neeJ a<ld iiotKing her« to what was said nbovo; wo need only re-
mArk li(*rc llmt extensive ooagulaiioiis form more readily in veins than
ill tirt^ries; tmuinatir. vfnotai thromboaia »fler vcneseetion, for in-
etuucc, is fur mor« frecjueiil tban traumatic arivrial thn>nilx)eia ait«r
I>imclur*;i.l wound» of nrterie«, and, what ig far worse, tlic former variety
of thro III bo»iit hus inucli more serious n:»u1l!t thuii the Inlli-r; on this
poiot you will perhaps hcrcuftvr hear more than niU hv a^rccoUc to
yoiL
Wft hare frequently mcntionod renetttrtton, nrbicii is a very frequent
nnall »ui^ifiil <iiH'ration. AVe shall liorc luiefly review it» performance,
■Ithouf^ you Pom)irc-hend Rurh thitiflpi f[iiicker and Iwtter by once see-
ing tliem than I coii!<l represent tliein to yoii. Sliould I attempt to tell
you under what t-ircuii>stAni«8 veiiesedJon should bo performed^ I
should hnre to enter deeply into the whole suhji-pt of medicine; <]uite
a large l)ook mij^ht Ik? written on the iadicalinns and uontiaiiidicatioos,
tlie ndmissihility, Uie beitefita nnd tnjuriesuf veuescetion ; hence I pre-
fer to say Qolhiuf; on these jMJints a» oo so many others which you will
p)cl< up in n fi-w niiimten at yotir daily räits to the clinics, and for
whose tlieorcttcal exposition withtJijt sperial cases wc should require
hoursk In regard to the histoiy, we will only mention that, while for*
mcrly venisection was performed on any of the duWutnjieous reins,
now it is only done in the vrjns of the lietid of the ellxiw. If j-ou
wish to bleed a patient, you firet apply » prfssure-bainhisu to llic am»,
to cause olietruction of the periphfrnl rein«; for this piirpoM we em-
ploy a i>r<i]«>rly-applieii handkerchief or the old-fnsliiontHl srarlet bleed-
inp-rihljoii. n linn bituilof^ two or tlirec fitiRtT-brL-ndths wide witli a
biiokle; when this i« firmly applied the veins of the forearm swell up
and the venu eephalica and basilica with their oorrespondiDg nie<linn
vein» nppesT in the bend of the dlmw. You choow, for opening, the
vein whieh is inogt prominent. The arm of the patient is flexed atao
obtusn angle; with the left thumb you fix tlio vein, with the lancet or«
very pointdl stmiglil «calpcl in the right hand you puncture the vwn
and slit it up lon^itutliimlly two or three lines. The blood eecape« in a
«trpnm; you ullow sufKcient to flow, cover the puncture with your
thumb, remove I he bandage from the ami above, »nd the bleeding will
cmise spoutaneously ; the wound should be oovtnxH] »"ith n small com*
VEXESEtTIOX.
13t
I and a bandage; tfae arm ülicnild be kept quiet three or four days,
Ütc wound will be bealed. Easjr aa tliitt Dpt^ration is in most
'cases, it BtiU r«qiiin>s pmctier». l*uiicture with the Intioet or ecolpol i»
to be prt'fcTTL'd to the »iwiii^Uiiwt; ttic lalliT wji» furmirlj' vltt po]»-
ular, but U now »-cry jusÜjr pamg out of lushiun; the sprin^lancc» is a
iSO-i:«llcd fieuin, which is drivi^D into the vein wiüi a Gpiing:; \ro allow
H! instnnuent to operate, insteiul of doing it ouraelves more wrtaiidy
'with the hand.
Various obstacle« may interfere with veneseution. In \-ery fat per-
ns it is oflcn difficult to see or feel the veiiut thnittgh th« skin ; Oien
compressiaii vre employ unolhur iiiejiii», that is holding the
in wann vratcr, wliJch incruuM-a tlic nßluxof blood to this part
of th« body. Mornover, after opening therein thofiit may impede the
escape of tlie blood by fnt-lobulen lying in Ch<j ojwninff ; these sliould
be qoickly snipped off wilh the utissom. Occasiomilly the flow of
blood is mechanically obstmctcd by the ann being nutated or bent ut
n different angle after the puncture has been made, so that the open*
iug in ihc vein nn longer correspond» lo tliat in the skin; t)>!s Is to be
met by disugiug the {xuitioii of the ana. There are other i»aacs for
the blood not flowing pmpnrly; nufh as (he puncture being too small,
a fmiuent fiiiiU with be^punera; the voinpresüon is too weak, thin may
be improved by tightening the bandage ; or, ou the contrary, thcoom-
preesiOD is too great, so that tlie artery ia also eompreaoud, and little
or no blood Sows bom the ann, this may be obviated by loosening the
mtCMü-tion bandage. Aids for iiicreatttn^ the How of blood are: dip-
ping th« hand in warm water, and having the patient rhj-tiimically
open and eloee Ihi^ hand, so that Ui<; blood may bo forwd out by the
moacular coii'.racttoti& Wc ahall speak further ou this pcünt, as op-
pottunity offers, in the clinic
CHAPTER IIL
COITTUSIONS OF THE SOFT PARTS WITHOUT
wozrjvxts.
LECTURE XI.
CauBOS of ContuBioiiB. — Nervous ConcuaBion, — SubcattmeouBBuptoTOofVeiselB. — Rup-
ture of Arteries,— Bureillatlons. — EccbymoaeB. — Kcabsorption. — Termination in
Fibijous Tumors, in Cysta, in Suppuration, ami Futrefoction. — Treatment.
Bt the action of a bluet object on the soft parts, the skia will
sometimes be injured, sometimes it wilt not ; hence we dtstinguisb ood-
tusiong with or without wounds. We shall first consider the latter.
These contusions are partly caused by the falling or striking of heavy
objects on the body, partly by the body falling or striking against a
hard, firm object. The immediate result of such a contusion is a
crushing of the soft parts, which may be of any grade; often we per-
ceive scarcely any change, in other cases the parts are ground to a
pulp-
Whether the skin suffers solution of continuity by this appIicatioD of
force depends on various circumstances, especially on the form of the con-
tusing body and the force of the blow, also on the nature of the parts un-
der the skin ; for instance, the same force would cause contusion without
a wound in a muscular thigh, that applied to spine of the tibia would
cause a wound, for in the latter case the sharp edge of bone would cut
the skin from within outward. The elasticily and thickness of the
skin also come into consideration ; these not only vary in different per-
sons, but may differ in different parts of the body of the same indi-
vidual.
In contusion without wound we cannot immediately recognize the
amount of destruction, but only indirectly from the state of the nerves
and vessels, and also from the subsequent course-
In contusion the first symptom in the nerves is pain, just as it is
OOXCCSSION.
128
in wauDds, hut puti of a duller, more undefined cluracter, although
it tD^y be v«ry 5cvcrr. In nuinjr cases, csprcially vchea he hau stnick
against a luinl Ixxl)*, Uie psliciit has a. peculiar vibrating', tltrcatcniiig
fieeling in IIir injunid pnrt; tfab fiwlinf^, ^rhich pxlcudu immo diätanee
Iievoiiil tbe seal of injury, is cau«?d by tlie concuMton of llie no-nT«.
Fur instmicu, if wc strilit.' tbc band urliiigL'rquttcbnnJ,ouly a small part
ia actually oootased, but not uiifrwpwniüy thtTO is eoncn«sion of the
nenv^of ibp wltule hand, with grvnt tmnbliiig, dull pain, ou account u{
chicb UiR fillers cannot be movvd, and tbncv in almost complete loss of
eling for tbc moment. Thiflocuiditionpaescsoff'quiclcly, usually in a few
. then a buraiog piiin U felt in the contused port. The
we have nf thit temporary eymptom ia tliut the
n(irre-iubditanne of the ax» cylinder suffers tnoleculnr displacement
from Üie blow, u-liidi spontaneously passes off again. Tbcse ityRi]>tom8
of roociBsiun (ibc commotion) du not by any mcana aoooinpuuy all
contiMion«; tbcy fiiil especially in casM where a heavy bo<ly come«
. n liinb at rest, Init tboy an> not uiifn.<cpi€iiüy of greitt signifr
in cnntusioos of the head ; hero eommotio cerebri is not unfrc-
itly united Mi\\)x<o»tHiio cerebri, or the fonncr appears alone, for
tiwt>nn>, in a fall on the ft^etorhuttocks, whence the concussion U prop>
agated to tlie brain ami may induce rery scntre accidents or even
death, witboutany pn^ceptiblc anatomiad cliungi». OoncuasioD ia es-
smtJAJIy a ehsngi< in the ncrvou» system, beneo wo speak ebiefljr of
oerdnl or qiinal ooncus<iiot>. But the peripheral nerres alao may be
concoBBea nith tJic aliorc sjkinptonia ; but since in stirli cases tho more
localized oootusioo is especially prominent^ this neirous state is per-
haps too much neglected. Severe oonoussioa of the thorax may in«
duce the nuist ching:cruua symptoms eimply from conciis»ioii of tlie
canliac and pulmonary nerves, whereby the circulation and rc»|^ration
are disturbed, although for the mast purl only tein|>oimrilr. Nor can
a reflex aetiun of tlte concusee«! iwrve, cttpecinlly of (he sympathctiu
on tb<> brain, br- enl irely domed. l3ouhtl<>f)« »omc of you, when wrestling
ur boxing, have retvived » blow in the ulKlonum ; wliiit terrible pain I
li feeling of fointDCM nlmust overcomes you for a time ; here we bnvc an
Elion o<) the brain and on the heart ; one holds his breath und i^lhcrtt
I strength, to prevent sinking to the eurih. Coneussioo of the uliur
nen-e often occur», when we strike the elbow ban! ; most of you proba*
bly know the hca\-y, dull pain, exteudiug even to tliu little finger.
Oompression of sensitive nenes is aaid to cntise conlni<^iion of tlio
cm-bral resaels, aa is shown by reocnt experimenta on rabbits ; possi*
ily this explaina the fniutneM &am severe pain.
Ail these aro symptoms of oonoussion in the peripheral nerrea.
Vow, a» we do not know what specially takes place in the nervea, we
120 C0NTC3I0NS OP THE SOFT PARTS VHTHOCT VTOCNDS.
caoiKit jud]^ wheth«r these cluinfi^ liave any cSiiil, and, if «o, wbjtt, on
tl>c Eu1>£i'((iioitl courae of Ui« coiil-uüioD, nnd of tlic contused wound;
bcncc wc cunDut iicre study tbe nerves nay furtlicr. Some luum*
poadiabla ohaamiioot «ceta to prove that tbU concuMion of pcriph-
enl nert'es mny induce motor «iid sensory [iikralyiüft,aswi>llasstnij>lty
of tlie muscles of a linib ; but tliu conocctioo bctwrcu ciu»o and effect
is often difficult to prove.
Contuiion» of tlic norve» nnj di3tin^igh<>d from ooncu«»ioBs by
the &et that in tiiem certiiin ports of tlie iicrv-c-lniuk», or their «rbole
thickuess. is destroyed, to the most rarird extent and de^'rce, by l]is
fosce applied, 60 that wc &iid ibcm motv or lofts pulpy. Under ibcso
eiroumstanoes, there must be » piinilysU corn.«{HJudiH^ to tliu injur)*,
from which wc detonninc the iier\'e aOecieil, aud the exteut uf the
efibol. On the frhi>le, such coiituHons of iicr\-rs M-itkout wounds are
rare, for the chief »er^'c-trunks lio Atttsi^ between the musclwi, and bo
are IcM apt to be injured directly,
Vontuaion« of the vessels must l>e tnueh more op|>areiit, aiiice the
walls of the smaller vcuxeU, o*peciftlly of the subcutaneous veins, arc
destroyed by the eoiitusiii}^ forei?, and blood cacapea from tbcm.
Henc*, Knhtnitineoiu hfumitrrhaffe is the almost conatant eonscquenoe
of u contusion. It would be much more considornble if in (his variety
of injury the wound of the vessel had Nlinrj) edj^, «iid gtt[K^l ; but
this is not usually the case. ConUiAal wuuudtt of tlie vessel are
roujrl>t uneven, rafcffed, and these im.'^;ruliirilie» form obstacles to tbe
escape of llie blood; the frii^dion u tio great that the pressure of Ute
blood w unable lo uvereouK- il ; librinous clots forni on thes« inct|iial>
itics, even ejctcadin^ into the calibre of the vcsael, oaiuinf<r inechaaioal
closure of the vessel, or thrombus. Contusion of tlie wall of a ret'
sei, with nheralioR of lis structure, may alone rau»e eoafrnlation of
the blood; for JtrOrAx liua jiruved that a livio)r, hvultliy intiuut of the
V««tel is very important for the fluidity of the blood within tho Teasel.
We shall again reluni lo this snbjeet, under contused wounds. The
oounlcr-prcssurc of the soft ports prevents an excessive escape of
bloofi, for the muscles and skin exercise a nutural comjiression ;.hencef"
these subcutaneous hemorrhages, ffveii when from a large vessel of
the extmmitJce, are very seldom instantly dangerous lo life. Of
eoune, it is dilferent in hicmorrliii^cs into the cavities of tlie body;
here tliere is liirfo besides niondjlu parts, that can offer no sufficient
opposition to the escape of the blood; hence, these luL-inorrhagcs are
not iiiErequeiifly fatal, 'lliis maybe in two ways: partly from tlio
amount of blood esiuping — into the thorax or abdomen, for instauec —
partly frnni the pressure of the blood on the poirts in the cavity— on
tlie Imiin, for instance — which arc not only partly deatrayod by tlie
COXTUtUOXS OF BL00D-VKS8ELS.
IS7
Uöod (ton'ing from laT;ge vessels, but »re cacapreaaed in rarious dire«-
tjcoiB, and tbcir functions thus impaired. Hence, luemorrliages in (he
brain caiiso rapidly-occurring panl}>scs, and 4^^«», nlsn, disttirbonoo
of Uic «diuLOfitim. In tlie bmi» vre call tliis escape uf bluoJ, ua well
US Hus sjinptouia induced by il, aiMptcxjr (from &'T9 iwd ^Ai^aw, to
knook down).
If alsi^ artciyof ancstJcinitybccoDttiscd,tlic conditions are the
eame u in a ttitdiLHl ur comjjir.'ssud [niticturvd «vund. A tmumatia
aaeumin, a pul>»ttuj;r tumor, fumut, as described in the lust lecture.
Dut tbia ia rare as cocipared iritb tbo numerous tiontueions ooLurring
daily, and la bo, doubtless, because tlie Inr^r arteries lie qiute deep,
and tlie arterial ccaU\ are firm and elaNtii", ro tliaL tbey t«ar lar 1«S8
i«adily tbon the veins, altl>oiig:b a »liort time since, in tbu clinic, wo
iaw a subcutaneous niptuic of the anterior tibial artwy. A strong,
muscular man bud n fracturu of the Ivg; the skiu vras iminjurvd; the
DIU wa£ frnoturcd about the middle, ihc fibula rather hij^hcr. The
«idcrablo tumor ifaat at onco formed at the seat of fraoture pulsated
dbly aod jierceptibly to the touch on the anterior surface of the Ic^.
Dprp was Tcry evklent biiioing sound in it, whinli I was able lo dc-
jostriite to the chi^ The foot was dressed with splints and band-
■gca ; we avoidt^ the application of an immovable dressing, so tliat
miffht watch the further course of the tjnuinntic aneurism that had
ridently formed here. "Wo renewed tlie dressing cvoy three or four
lys, and could see tlio tumor gradually lH?<.'orning smaller and puleat-
lesa strongly, till it finally disappeared, a fortnight after the injury.
he aneurism had been cured by tbe comprosaion from tbo bandage,
was tlifl recovery of the bmrture iat« mipted; eight weeks after
he injury, the patient bad fiitl ui« nf Iüh limb.
The iDOftt frcquvut subcutaneous hicmonbagcs in contusiooa are
nm rupttire of the subcutaneous vein». These effusions of blood
luse risible symptoms which vary, partly from tlie quantity of the
blood, partly from the distribution of tlic'blood in tlie tütaue.
The more vascular a part, and tho more severely eontuwxl, ih»
greater tbe extravasation. Tlie eztniTasaled blood, if it escapes from
the veasds slowly, fonns a passage-way between the connertiTO-iisaua
boodlea, especially tbo»c of the subcutaneous connective tissue aod
Biiiscles; this must cause inültrntion of tbe tissue with blood and coo-
ik swelling, These düTusc ami subcutaneous hipmorrliagea we
, giijfffiUalions or ntffuaion$. The more relaxed and yielding, aod
Bier to press ajwrt tbo ti;t«ue ts, Uic more cxloiisir« will be the
■tinn of blood, if it flows gradually hut contiauBlly from the
T«saelB for a time. Heooc, as a rule, we find the effusion» of blood in
the oyelids and acrotum quite extensive, because tbe subcutaneous
10
128 COSTDHOSS OF THE SOFT PARTS WirOOUT WOtNDS.
conn«otire lism« there is »o loose Tlic titinncr the ^o, the more
readilj- and quic-kljr wl> sliull rvcoguize the su^gillntion ; the blood has
a hlim color througli the Klitn, or presecA into it aiid give» it a eteel-
bluc color. Under the oonjuactiva Ixilbi, on thö coutnirv, Uic blood
nppettrs qiiite rpcJ, as this membrane ia ho tliin and transpareat.
ßlood extravasations In the ctitU ttsdf apprar an red spots (putpun)
or tlriic (vibJccs) i but lu ibis fonii ihvy arc rvrj' nirelj due to conttt^
sion, tliey are cnused by »|x>nlaii«nii» rtipliiw of the vessoU; whether
because the walls of llie vcasrls an.* parttculnr! v tliin tn some persons,
as in those alrcudj mcutioncd as beta); of hnsmorrboj^ic diathcfiis, or
bc'CHug« lin-y aru i*s]H<L'iällv' bnttlo and tt-udt^r Crom some unknown
condition of the blood, as in scorbutis, some forms of typhös, morbus
maculosus WorlhofU, olc. Contusion of the cutis may usuallr be rrc-
ognized by a very dark-blue color, passing into bmvn ; nUo by Mria-
ijou of the epidemiia vriih so^jilled diopt^ or, as tliey or« tcvhuicBDy
termed, eixoriatiotif^ llnyiiig of lliu »Iciii,
If much blood escape euddonly from the rcfsels and bo effused in
the IcKwe cfliular tissue, a more or less bounded carily is Eoraied.
This form of effusion of blood is called etx/^/moȟ, eeehymomay ktn-
matoma, or blood-tumor. Whether tho skin be discolored at the
same tiiuo, ilepeods on liow deep the blood lies under it In de«p
effusions of blood, difTusc us well us circumscribed, we often find no
discoloration of Uio skin, especially soon after the injury* ; no only
perceive a tumor u'boee rapid tleYelo|iiii<.'ut imiuediatelyuftL'r an injury
at once shows its nature ; thla tumor feels soft and tense. The cii^
ouniscribcd effusioo of blood offers the very characteristic fecliof; of
JtucUiation. You may most readily t>btaiu a clear idea of this feeling
b}' fdling H bladder frith waiter and tlicu feeling its wall:<. In surgical
practice the rvco^nition of (luctuatiou ia very imporUmt, for Uiere arc
innumerable cnw« wliere it is imporlaiit to determine whether we
have to deal with a tumor of firm cou»i:<teiioe, or with one cmilaining
fluid. Vou n-ill be shown in the clioic bovr it is best to make this
examination in difi'erent cases.
Some of these effusions of blootl have reoeirod particular mmoa
according- to ilie localities wlien^i tliey o<vnur. Thus tiioae cmuing on
the heads of the newly-born, between the various coverings of tho
skull and in it, are called wphaf/imnatotna (from unftaXtj, head, luul
itfULTÖu, to ttiüil with binoil), cepfanlio tumors of the uewly-bom. He
extravnsations in the labia majoro, tmm contusioos or the spontancou«
niplun» of distended veinik, Iinve roetnved the neat iiiLnie of f/tisiofuvma-
toma or ephtarrhatjia (from ir^riatov, the external genitals). EITu-
•ic«is of blood in the pleum and perioardium have »Iso special desig-
nations: heemaioihorax, hosmaiopericartliumj ete. On the whole.
COSTCSIOXS OP BLOOD-VESSEIÄ
139
"We attacb Uttle impoHanco to Hies« cuplioiiioLiiUiinnil Greek names;
bot you should know Otetn, so ns to understand Diom when reading
k-siedical books, tad not seek for any tiling niystoHous Ix-hind lli^m ;
■«Iso tbftt ^"ou miky use them cu tut to express yourself quicker, and bo
cadily undcnlooH.
Til« eubecquvnt coum© sod Symptoms are very diaraoterielio of
ihcs« subcutaneous cffusioofi of blocxl. I..ooking firet at the dilTuse
ofluswnfl of blood, immediately after the injurj-, we arc rart-Iy nble to
decide baiv extensive the bleeding iuui boon or still U. If you ex-
smino the contused part the »econd or tlijrd day nflcT llie injury, you
»tice tbal the discoloration is more extensive tlinu on the lirsl day;
liU uffpeo-n to inprease »ulm^iieiitly ; that i«, it booomcfl more fiet-
ceptüjc. The extent is Kinietinies astonishing. We once had io the
l^diuio a man n-ith iracturcd ecajnila ; at Erst there veas oaly slight dia-
Dmtion of tJic skill, alrhough there wiis a larg? flucluatiiif;; tumor.
On (he eighth day, the whole back from the nefk to the gluteal mus-
cles iras of a dark »trcl-blue, and prcflentcil a pet-uliar, uluKist comical
»pearatire, llie skin looking as if pointod. Siicli widely-spreadiiiff
[tnTHsaitnn» «re particuWly apt to occur in cane« of fncturwl bonei«,
cialiy of the arm or le*;. But fortunately this partly dark-blue,
partly bluisb-rcd color, along with which the skin is tiot scnsitire and
^scarcely sn-ollen, does not remain sa, but further changes take pisce ;
■firsl ibere i» further change of color, tlie blue and red pasa intn mixed
blown, then to green, and finally to a bright Ictnoa yellow. Tliw pecu-
liar piay of colors tuw given rise to the oxpresuon of "beating one
black and blue," or ** giving one a blade eye.** I'ho Inst ccJor, the
cUow, usually remains a long time, often for months ; it finallj dia-
[ii{i{mn, and no visihlu trnee of the cxtr»\-a«atioM remaiiu«.
If we ask ounelrea whence come these Tsiious oolorings of tbe
rekin, uid if we have the opportuttity of examining blood cxtravasa-
Mnos in various stages, we find thai it is the coloring matter of the
which gradually posses through llie metamorphoses aitd shades
color. '\^'hen the blfNxl lias escaped front the vessels and entered
I connective tissue, the fihrine coagulaleSL The serum enters the
DDDfctive tiiKHue, »lid iheiic*' passes bxck into tlie vessels; it is re-
Thc culoriog matter of the bluwl leave« the blood-cOqiua-
elcA, and in a state of «olutioin i» diicirilnited llirongh the tisstie. Tbe
ififarine and blood-eorpusclett, for ihi.^ tno«L part, di&Lntegnite to fine
Bolc^TuIrs, and in tliis state are reabsorbed by the I'cssels ; as in llic
ibufl a few v bite IJo(xJ-(vll9 may attain a liig(»er development. The
Dtoring matter of the blood which saturates the tissues passes through
not thoroughly understood metamorphoses with change of
r, tfll it is finally transformed into n pcrmUDeat coloring matter,
130 OOSTCSIONS OP TBE SOFT PABTS WITUOt'T WOCKIÖ.
vrbicli u DO longer soluble in tb« fluids of tbo body — h«mat«üiin.
As in the thrombus, thin is partly granular, partly dystaUine ; in ■
jHirL- stulc it. is ümiig:e-oolorei], and if scanty givea tltc tiaaun a yeOov-
ifib color, if plcatiful » deep orange Luv.
JteabsoTplion of lite cxtravasulian nlinost nlwAys Inko« plaoo in
difTuse suggillations, as the blood la very widely distribuUd tlirmig^
Llic tiseut's, and tlio ves&e\f tiiat bavc to acvomplUli the rcahsorptioii
iiftM! not been affcoifid by the ooiitueiou ; it is the most düsirablL-, and
uudvr favoniMi.* circiiRuitn.nr«» the mast frequent result after uibcu-
tancous and iDtmiiuaculureOtistons of bloocL
The eti«e is ditforent in circumscribed cfFusionj^ in «»Aymocat
Hero tbe finst queatiuii is as to tbo extent of llie effusion, tboa about
the state of the vessels Biurounding it ;. the marc dcrcloped ihc latter,
the less they have boen injured by the contusion, the moto hope tliere
iü of early reabnorptioii ; but its occurrence is nlimys less coostaot in '
Iftrge eOfiisioas of tlita variety. Tliore are vanoua fartoiB which inter-
fere ivith it; iu the first place, there is thickeuiug of tiie oonneotJ%*e
tissue ftjound the efTueiou of blood, as aroitnd a foreign Ixxly (as in
traumatic nueunsm niso), by which the blood is entirely encapsulated;
the Cbrini^ of the effusion is depoutcd in layers on tlic iaoor suriaoo
of this sac:, the tiuid blood remnins in the middle. Tlius tbe vessels
about the blood-tumor can t^ke up very little fluid, as thny arc sepa^
rated from tbe lliiid purt uf the bl<Ktd by layers of fibrine, which aie
oft«n quite ihJpk. Here we hnvo the same «mditions a» in larjre
Ubrinoits exudations in the pleum ; there also ilie fibrous deposits on
tho Trails greatly interfere with rejihsorption. Tlris can oidy take
place perfe^'tly when the fibrine disiiilegratefl to moleeules, become«
fluid, and thus absorbabl» ; or when it is organized to connective tis-
eue, and supplied with blond »nd lyinpb resaela Tltis is not bo very rans
in pleuritic deposits. But there i» also another Eute for ftuch extrava-
sation!). The fluid portion of iholdnod umy be eomjilett'ly reabscwbod,
and a (irni tumor cotiiptised of concentric, oiitondikc laj'crs may remain.
This results oi:ca«iotuiUy from cstramsatinns in tho labia, major»; a so-
called ^rou« Itimor is tlius fonned; in the ravity of the uterus, olso^
auch fibrous tumors occasionally develop. Some hxmatomnta majr be
partly organized to conoootive ti»»ue, ami gi-adunlly take up üraesall«
and entirely ealäfy ; a rare termination, but one that necura in effii*
siona of hinod in liirge goitres. Another mode is the tmosfonnatkNi
of the blooii'ttiinur tu a ci/at ; this is S4-en in the hniin, and in tKift
tumors. Besides other modes of origin, some cysts in goitres may owe
their origin to such effusions. By a cyst or encysted tumor we mean
sacs or bags oontaining more or leas (luid. llie cnnleniä of thefle
(^ta, icsultiag from extravasation of blood, are darker or liglitcc ao-
STPPURATIOS OF EXTAATASATIOXß.
191
cording to their age ; indeed, the blood-fvd may totaUj dinppcar
from llwin, and tliv ccmtents bccooi« quito cIcjip or only slightly
eloud<T»l by fat molt-culcs. In larf^e circumscribed (rxtniFasations yon
will find immemuA und beauiifully-foniied hemaloidiu cry»Ula more
rmrrly than in anull difTusc ones, lor iii the former fiitty disintegration
of tlie dements of Uie blood predomiiutes, hetice excretion of cbole«-
tcrinc crystabt is monr cominan iii tLcm. 'l^c capsule enclosing these
old effusions ariM^s p*r(1y from organization of tlio poriphoral parts
of the blood-clot, partly from the circumjacent tissue.
Suppuration of circumscribed exiravasatious is far more frequent
tlum the tn-o lust described metomorpboses, but is not so common as
rcabsorplion. Tlio inflammatJon in the vicinily, and the plastic pro*
ens in the pcripbcnil part of the extravasation, from which, in the
two preceding cases, tlic thidtcncd conoccUrc tissue was developed,
which encapsulated the blood, a»mmc a. moro acute character in tlie
cos« we arc about to sprak of; a iKnuidaiy layer is formed here also,
i not slowly atid (rradnnlly ha in the preceding cases, but by rapid
I-fortnation ; plastic intiltmttou of the tissue doC9 not lead to devel-
öptneot of conoective tissue, but to suppuration ; tlic inflammation
^^•Acr a time attacks tho cutis, and it sitppunttes from withtn outward,
^K^ is finally perfoRit»d, and the pus mixed with blood is «rocuated;
^^pe walls of the cavity come together, cicatrize and grow together,
^^ptd hnling thiiH take» place. We shall speak more exactly of this
mode of Itealing wl»en treatiug of abscess; Vre caJl »ny pus-tumor,
^^L t; dreumscribod ooUeclion of pus under the akin at any depth, an
^^BKor&s: bcnce we term the above process the conr^rsiou of on ex-
^<rava»iitioQ of blood into on abscess. 'His process mov be very pro-
tracted, it may lust tltn^'e or four weeks, but, if not datigurous from its
location, it geucsally runs a fitroniblo course. ^Vo recogoizo the sup-
puration of an extravasation of blood by tho iocrcasitig iufiammatory
r«>dne6S of the skin, tho growth of the tumor, iucrou^ing piiin, oceo^on-
ally aorompaiiietl by fever, and finally by ttüniüng of tho skin at some
puini, where il is fnuiUy ]ieriumtcd.
Lastly, there may be rapid deoomposidon of tho extravawition ;
ftiKunalvly, this is run*. Then the titiitor •^run'S hoi, Ichmt, and very
the fercr usually becomes oonsidcrnblc, chills and ulhcr scrtiru
lOral symptoms Taa.y occur. This termirkation is tho worst, and tho
ity one that requires speedy relief.
Wlietlier there Khali be reabsorption, suppurution, or putrefaction
of an cxtnivai>Btion, depeixb not only on the auiouut of the «ffiiscd
blood, but rery much on the grudc of tho contusion that the tissues
liBVo suGTercd; as long as these may return to their uonnal slate, re-
absorption will bo probable ; if the tissues bo brokcQ down and pasa
1S2 00NT08I0NS OF THE SOiT PARTS WITHOUT WODXDa
into disinteg-ratiuQ ot decoDipostlion^ tliey mil induoe suj^iumtion
dci;oiiipositioii of ttra blood ; bridly, tbe eSiised blood will hare the
staao ^t« at! the oontiised ttssu«.
'Wbilp tlic skia i» iininjurcd we eiinnot judge ftCMimti'Iy bow nmoli
Ihe tnusc'lcs, tendon^ nnd fusctii:, iir» injured ; ovcasiaanll/ tbc »ise of
the csljav(untio& ma^ give Mine mid oa tbls point, bul it U a wry
uiicortain measure; it Is better to lost the amount of functjotial ac-
tivity of tbn aSeot«d imisclps,biit even tb^ n'sults tbws given must be
carefully accepted; tbu amuuiit of force ihut liuit acted on Ute port
may lead to on approximate e.'ilitnntin» of the exigtiii|^ subcutaneous
dcatniclioii. In contusion of inusck-». aii in wounds, bcolmg^ takes
plucc fruni the crusb<»i nuuoulor elements umlcxgDin;; molectdar dUin-
togretioD Bud bcin^ nbsorbetl, or bv being eliminated wilb tbi> jtua on
suppuration of tbe extrarasation, but then tbcie is Dew formation both
of conucetiTfl tissue ami innaclc
Tlie birgest extravasations, either diffus« or cireuinwjibed, are
usually ncconipanii^ by iiijitri<tt of lb« Ixmes-; but it will be bKlrrto
consider the injury of tbe bone iu u ftcparntu section.
1/ a portion of the body be so crtwltod ns to Ijc entirely or mostly
inoijiable of living, it becomes eold, bbtitih n-d, brownish red, tlieu
bliicU ; it bcxbifi to putrefy ; tbo product* uf putrcfiuHion enter tbc
neigbburiiig lisäues and tbc blood; Uie local innumiu&lioua, as well as
the fever, nü.Hume peculiar forms. As Ibis is the same in oontusiona
with or \ritbutit wounds, we ^Imlt speak of it later.
•
Tbe treatment of contusions wiüiout wound bu fiir its objeol tbe
condiietion of tbe process to tbo most fnronUe teniii nation possible,
that is, to n?nbEoTption of tho extraras&tioo • wben this takes pbioe,
Ibc injuries t« tlie oUier soft parts also progress faronibly, as tbe u'bole
process remnina nuboutancoiifl. AVe here refer eolelj tu tbosc cases
M-hcrc (lie contusion of tlic soft part« and the extravasation are the
oidy objects of Irealmcut; whuro the bone is broken it should bo
treated first nf all, tbe cslrarfuuitjon of jtdclf would scarocly bo on ob-
ject for special trcstmeiit. If called to a contusion tbat has just oo-
cttrrcd, the imlicaliun may be to arrest any still continuing baimar-
rbagc ; this is best done by oomprcesioa, which, »here oonrenient, is to
be made by cvcnly-applicd bandages. In North Cereiany, wbeo a
diUd falls on its head, or knocks its forehead, tlie mother nr mirve at
once presses the bAudlo of a spoon on the Injured spot to prevent the
Gmnatioa of a blood-bniis«. This ia a ver^' auitablo popular remedy ;
bv tbo inDtnntnneouB compressiou the further escape of blood is fain-
deicd, as is also It« ooUecUon at on« point, boc»u»e il is compelled bf
TJlKdTlJEST OK DLOOD-KXTRAVAaMJO.VS.
133
kv preutire to tlistribute it«elf in the surrouoding tUsu« ; an ecch^
I jtutt formiog may thus be tranfitormcd into a su^gillation, so that
be bIfKKt inay more readily Iw altsiirbe<L You may occuaiüiuilljr at-
tain tbc same oli>jcct by a wcll-a[>|)ltij<J bituduj^.
But wo rarely see the injury »it trar\y, unci in tbo great majority
of nuea there is also au injury of a bono or juinty auj iJic trcalmcot
of tlio blnod-extraviuuitioa is a accondary object.
Tbc UM! of cdd, in llio sliepR of bladders or rubber bags R) l<y) \rith
ioe, or of cold lotiotu» to wbicli it U an old custom to add vinegar or
latd-wntcr, is nwortcd to aa u mncdy in recc-nt cootusioaa; it ia
Bftid to pren^nt uxccsstro Inflammulion. Ktit yoti ninst not r«Iy too
Bmcb oo tbese remmlii>s ; tlia means that most aids the reabsorptiun
of bicxxl extrovasalions is rc^:ular compression anil rest of the part.
Hance it b bc»t to envelop the extremities in moUt bandage, and
ovor tJiein ajtfily wet doths, irhieh are to bo renewed every Uiree or
fiwr houra. Other reniedie^, which imually act well in iiiflunnnations
of tite akin, nioh as mercurial ointment, uro of little uac here. But I
tnuBt not forget arnica ; tlils remoily ia ao honored by some Eamilii»
Mid ph>'^(^ians that thry would cunsider it unpartlotiiiblt; to neglect
{iceecribing loiiuns o£ iul'usioo of arnica, or of wat<^r with the addition
of tincture of &mics. Faitli is mighty; one believes in arnica, an-
other in lead-water, a third in nnegnr, as the potent external re«b-
aorbcnt. lu all macs tbc cflcct ia doubtlcas simply du« to the niuist-
lue and the variation of tompenture of tbc akin caused by the com-
press, whereby the ci[Htlaries are kept active, now brouj^lit to ooolroo-
tioD, now to dilatation, and thus placed in a belter state fur reabaorp*
tioD because they are active
IMSuMi bloo<l-extra\-u»itions of the akin mitli moderate contusion
of tbc soft parts arc uaunJIy absorbed without much treatment. If a
circanuoribcd extravasation docs not change considcnibly in tlic course
of a fortnight, there is ncvcrcbeloss no indication for furtlK-r interfcr-
ice. We tlien paint the swelÜng once or twice daily with dilute
iiicture of iodine, compress it wltli a snitabte baudagc, uikI nut unfrc-
itly SCO the swelling gradually subside after several weeks,
lid it become hot, and the skin over it grow red and pninfnl, we
Hint expect suppuration ; then even the continued application of cold
wQt rarely «hange the course, though it may alleviate ic Then, in
order to haalen tlie termination of the »iippuralion, which cnnnot b«
aToide<l, we may apply wann fomentatious, eithvr simply of folded
mnslia wet with warm water or cataplasms ; now you quietly owoit
the fan her eoursc ; If the general health be not impaired, but the ptk-
ticot feels pretty well, you calmly await perforation ; it will perhaps
be wecl^ before the skin gradually lx;coiiie3 tliinuer at some point
13* CONTUSIONS OF TBE SOFT PARTS WimOCT WODKM.
ttitd fiiiall/ opens, ihc pus is CTTKniatcd, the vraUa of tfac large cnvit/
&U together, and in a abort tiute tlie parts tue all bcsletL At tlto
oommcooement nf this lecture 1 montioned a case where, iritli r fra«>
turetl scapula, Uiere was an enonnotis jtarrly OilTuso, partljr circum*
scribed cxtniTasutiuii ; Iicrc tlicrc mud n sltvii};Iv-llucluiLtiiifr tumor,
which was not rcabfiurUuil, while tho ditTuse ofTiiiuon n'as rapidlj^ re-
moTed; the suppuration did uut end in perforation till th« fifth week,
Iheu one aad a half to two quarts of pua were evacuated; a week
later this cDormous cavitj was healed, and the pntient left the hosjM-
tal welL Why we do nut here interfere earlier and aid Nature by an
incision, vc shall consider lucirc closely when wc treat of nbscrasc«.
Should the tension of the swelling rapidly increase, howe\-cr, du>
ing the suppuration of the extravasation, ami high fever with chilis
occur, U'c may mppnüe that the blood and pus arc decomposing, that
there is putrc&ictiou of the endoaed fluid. Fortunately, tbis is rate,
and OMtuTS alma'iL eicoliisiively whore tliorc is great eniahiiig of the
musülea or splintering of the Ijoite. M'itb such s^Tnptoins uf ouune
tho putrid äuid should be quickly evacuated ; thca you tliould make
a larfff incisinn tlirough tbo skin, unless this bo forbiJtk'n by the ana-
tomical position of llie parts; in vrhich caw* several small incisions
(tbould be made ut puiiit« wlicr*^ tlie fluid may escai» freely and easily.
Tteac incisions greatly alter the aspect of the casej you have cluinged
the subcutaneous coDtusian to an open contused wound. How otlier
condition» come into play, whicli wc shall treat of in the next lecture.
M'« must »am mciitioa that^ if extenaivo putrefaction of the soft parh)
follows such ooDtusions, amputiition is indicated, although this unforto-
DUte case rarely happens wEtbout coincident fracture of the boaes.
GÜAITEK IV.
'CONTUSED A2n> LACEJIATUD VTOUiWS OF TUB
SOFT PARTS.
LECTURE XII.
d« of l)««iiTTmic« of tbaw Wwndi ; ihair Appeanmc«.— Slighl Itofnoirha^ in Con«
tiiu4 Vomda.— Earij' &«Miiid*i7 ItainorriiigM.-^Gtnpvii« of Lbs Kil|,t« of tbo
VomKL— InfluraoN Ikn «flkct üi* Sloim or inwe K*pld Dttwibmont of Ui« UttA
Ttora«.— IkdiMttom for Priiaar^ Amputation.— Loo«! C4int>llfl<itlODa tn ConliMed
'W«Badi; DBMiBpoitiion, Putnftctloiik, gcptio Influnnutlont.— CMAiutoa «f Ar-
(«nta \ Lalo Steondary IIiiiiDorrliago«.
Tbk atoses of coatiwtxl wchukU, of wliicli we liav« to trt-ul to^BTi
UQ tiw Sftme IL8 tboec of Muiplo contusions, ooJy in tbo first casefl tbo
fbrce {s uauall/ greater tbao in the Luttcr, or ibc bodjr by wliicli Üicr
»re induced ts vi suc-b u fomi as to divide ibc skin Bud soft paita
easily, or elw iiarts uf tbi) bo(]y tiare been injiir«! wbcre tlie ^o is
particularly thin, or lies orcr porta unusually firm.
The kicJt of a lior&c, Mow from a elick, bite of on anitual or a man,
beinff run orer, woundiiij{ vitb blunt knives, savR, etc., ore frequent
eauaes of contUMxl vouiida. Notliing, bowwcr, causes more contused
vonods tbaa mpidly-morinjr wheels and rollers of macliincry, cutting-
jDa^iiiKfl, drcubir-fiatvs, epioDing-jenaice, aud tbo various maobinea
with cog-vhetHs nnd books. All of these iiiHtnimeats, the product
of adraocing inclu^ktry, do niucl) injury among the operative». Men
and women, adults and children, vritb crushed fiiij^n, niasbcd banda,
nggud, lacerated wouixb of Uic focviirm and arm, ar« now amon^ the
eODStant patieDt« in the tuirgicitl n-unls of hospitals in every large
city. InDumcrablc {rcisoDs are thus maimed of fiiigcns Itands, or
arms, and many of these patients die as a result of tlicir mjuriee. If
to tliesc you add {what recently ia becoming rarer, it is true) railroad
injuries, Ibooc caused by blasting, baikling tunnela, eta, you may
ISA COSTl'SED AXD l-iCEBiTED WOUNDS OF THE SOFT VABTS.
inugiae, nut cnilr bow much sweat, but bow much blood, cUogs to tko
numy evidences of inndem culture. At the same time it is not to be
dciiH-iI lliiit iIk' clifcf CJiiise of lliese ncciiii'iit» is ilie ranrlcasness,
often tbc fooIbunIiai:»s, of llio workniim. Fuiniliuriij vritb tb« dan-
^roos objrvt rciiclc-rs persuDS at Lost cnrclcKX and rash ; some pay for
this whb tlicir liT<%
Gunshot wounds aUo cssoDtlally bcloDf; to contused wounds; but«
as they linvo some jicculiiintics of Ihvir otvii, no shall treat of them
in a spei'ial cimpter. Laccmtßd wounds, and tcarin^f out of picoei
from llic limbs, we shall coa&tder at the ond of tliis chapter.
Fractures of hnm» nf Ibe most varied and djuigcrous TirintiCB no-
oompan}- conlusvd wounds from hII the above cause«; but fur tbe
preeent we &baU leave these out of oonsidvnitian, aud trc«t only of the
Boft ports.
In most c««e8, the Rppi>nraiH>e of a wound indic^tfis wbetherilwax
due to inciffi'ju or eonlii.sir<n. Yoti ulrt-ndy know llie cbaracLer of In-
cised wounds, and X have alluded to some outes whoro a oouluscd
wound had the ajipcnninuc of an indMxl one, nud the nnrcrs«. Con-
tused wounds, like inrised, may be aerompanlcd by loss of subsbuiee,
or there may Iw fiiriiply solution of cx^ntinuiiy. Tbc ttordcre of these
voimds are gt^nenilly uneven, ospeoiully tho edges of the iJciti; tbs
mnsctee oecasioitully look iis if t'hoppi^d; tugs of tbv soft parts, of
various sizes, not unfrcqucaliy large flaps, bsn^c in llic wound, and
may hav* o bluish-rcd color, from the blood stagnated or olTused ia
thetn. Tendons ore lorn or pulled out, fwiciffi are torn, the skin, for
some dislanee nmund the wound, is not iinrrrrjuni'tly detached from
the faseiji, e^p^ciallf if the eontUBtns force was combincU with a tear*
ing Bud twisting. The griide of lliU doslruclion of tlio soft parts of
course THrics greaUy, and its extent cannot always be accurately d»
tcnntncd, as we ennnot always ere bow far the contusion nod tearing
extend beyotiil thv wound ; from lliu üubserjueut ouurso nf the wouod
wo often satisfy ourselves that the contusion extended mueli further
than the size of the womid indicated ; th.tt separation of tnuscles, dj-
viaions of fascixi, and elTusiona of blood, extend(yl under the dein,
which may have bnen but little torn. It is iiTirortiiiinUf that the akin-
wound ^ivc3 no means of jndg'iiig of tlie extent und dcjitb of the con-
tusion, for it renders it very difficult to eom^ctly enlimato suoli an ia-
jury al the first exauiination ; while the apjii^aranco of the womid
give» the laity no idci» of dniigcr, the experienced surgeon sooD «ee«
the gravity of the case.
Sinoe the injuiy, espwehilly when due to maohinerj', is verj- rapidly
done, tlie pain is not great; and immediately after tbe injur}- tliepaio
from ooutused wounds is often \-ery slight; the more 80, tbo greater
n.^vonntiAQE pro» contused wocnds.
137
lie iajurj and cndbiaf^ of tlic port«. This ie readily explained by
[tlio norrm in the wound bciiif^ crilifvly niusliod and destroyed, cons^v
'quently inciipabic of ctmductinji; moreover, what I told you in tlic
last lecture about local coiirut<sion of nervc&, tlie so-<»lled stiqwr of
I the injured part, comes into pl&y.
At ftnL Higlit it Hceras rallier rnmarVable that tlieae contused
troauda bliM^l littJ<^, if any, even if lurg« vi^ins or nrtciii-s be onishwl
or tom. There arc wcll-obsen-ed «isos to thov that, after complete
crushing of the femoral or axillarj- artery, tberu n-as absolutely no
prinuiiy bicmorrhagc. It is true, tliiB is raro ; in many cas«8 where there
is ooinpleto solution of cuntinuHy of a large artery by a contusion,
although tbt're is do spirting strenin, there is eonstant trifltling of
blood; this, coining from tbe femoral artery^ would speL-dily cause
deolli. I have already told you how this arrest of hairaorriiage takes
pUce in small arteries, but mil make it clearer to you by an inuatra-
tion. A railrond hand wa.<i ran over by a loroniitlive, so that the
vrbecl poMBtd ovvt his kTt tlii^h jiisl Ik;Iow the hip- joint. The unfor-
tunato was at once brou^fhl on a litter to the hospital ; meantime he
bad toet much titootl, and came in very |uilu und au:vmit!, but [XTfeirlly
eonsdous. After cwmpleto rcmovTd of tho tom clotbioj;, wc fuuiid a
[liorrible manj^linj^ of tlie ^in and museles. The bone was enishcd to
the inu$elL>:* were pmrlly mnslicd to pulp, partly bung in tags
the wound, tbe sJdu was loru up as fur as the hti>-jotitt. At no
rpoint of this horrible wound did an arterj' spirt, but from tbc depth con-
[nderable blood constantly trickled out, and thogeneralstatoof thcpa-
r tient cJeaHy »howcil tlia t he had already lost much blood. It was nvidimt
that the only tlitnfr to be dune litrre wa» to amputate aL the hip-joint,
but in tbe coudition tho patient tlien was, this was not to be thought
^Df; tJie new Ineta of blood &ora this severe operation would undoubl^
' have been at onee fatal. Hence it was, first of all, nwewary to
ftt the h.Tuiorrlia|;v, vrhieh evidently came from a nipture of tho
I fitmoral nrtcr}'. I ftnt tried to find the feinonl in the wound, while it
^waa cutDprc»Bed above; but all the miucles were mi displaevd, all tho
i>fenatomieal relatioBS were so changed, that this was not [)uirk]y done,
bcnee I pioecoded to Ugatc the artery below Poupart'a ligament.
.After tilts was done, most of tbe bleeding ceased, but not entirely, on
jnt of the free arlerinl anastomosis; and as no regular drceainj;
luld Iw applied, on aecownt of the cxif^tinj; manghup, I surrounded
^the limb linnly with a tourniquet^ clueu below where I projxised
to cxartirulate. Now tlie bleeding stopped; we gave various
inmcdies to revivify the patient ; wine, warm driuks, elv., were ad-
ninistered, so that, toward evening, be bad so far reeorered that his
Unniientture was again normal, and llic nidiid p«ike was again good.
ISa CONTUSED ASD LACERATED WOCSDS OF THE SOFT PARTflL
I flltouM have j>rcferre<t postfiontng ilie operation till the fol
daj, il^ in »pite of lif^AtuT« mad toontiquct, with tltc strevgthemng i
tbe liearl's beat-, there liad not l>een some bleeding fronj the nouml,so'
that 1 fcarDiI the piiUciit might blot'd lo ck-stli duritij; tlio ui;;fat.
Hraoe, with the able help of mj nssistants, I cxnrticiilated tbe thi^h
as ra|>iJIv as possible. During llie Operation tbe abeolute loss uf
blociil ivas not groat, but it was t«o murli for tbe »Iready-ilebilitHte'I
patient. At fint nil seenied to go irell j tbe opirtiiig TesscI» were nil
ligaleil, tlio wound cleiiiiKcd, and tlie piitioitt placed in bed; soon lie
suffcrtHl &0III rMlles^cie?» anil ilyspna'ii, which increas«], finally con*
ruIoioDE occtirrcd, (lad the patient di-partcd tiro Iioim nftcr the opera-
tion. Kxatninat ion of the fL-moral nrlery of the crushed extremity
sIioiFcd the following : In the upper third of the thigh there waa a
crushed and lorn pari, i-oin prising about oae-lliird tbe cnlibre of the
artery. 'Hie tag« of the tunira intimn, »» well as the other coat« of
iiessel, and the coimeetiv» tissue r>f tbe Klieutb, hiul rolled ii|> into tbe
calibre of the artery, and the blood could oiil/ cseapc slowly ; the
siUToUDding ti£suc was completely saturated with blood. In this tAae,
no dot had fijrmpd in the artery, aa the escape of blood was still too
free to permit ihi.^ ; hut, if you iiniigJDe that the contusion bad affected
the enlire ciroiunfcrenec of the arteiy, you inay underaiaiid how the
tags of the eoatu of tho vessel pressing into fl« calibre froiti nil side«
might have rendered the escape of tbe blood more difficidt, or even
impossible ; then a thrombus would have formed, and stopped the
resftel, and gradually hare become organized, so as to cause permanent
rlosurerjustnuafler ligation. If no biemorrbagehatl followed t)ie partial
cnitthiiig of tiie artery iu this case, if, for iiiatancc, Ihc criisliiiig bad
ooeurrcd without an external wound, possibly a clot would simply have
formed nt tbe part roughened by the onntusion, a thrombus forming
from the wall; in this casc there might have been crusltiiig of the
artery with preservation of its calibi-e, a result that is said to hare
been observed.
If you ajiply the above^descTihed eoiidilion of a large cnishcd ar-
tery to smaller urtcric», you will undcistaad how there may liere nxtro
readily bo complete spoiitaiieous plugging of the calibre of tbe vow^
partly by in-rolling of the fragile, torn tunica intima, partly by con"
tnelion of the lunica uiusculans and hy the tags of the ndvcntitia,
and that consequently bleeding may fail almost entirely in fnicli con-
tused wounds.
There b another factor for limiting the hurmorrliagca in eiteusirc
contusions, that is, the weakening of tbe beurt's action caused by the
injurj', probably due to reflux action. Persona badly injured, besides
suffering from loos of blood and injury of the nerTe-ccutrcs, arc usually
HEALING 0» CONTTTSED WOUNDSL
180
for ft time in a state of nuislmesA or stupor ; tbe irord most commonly
used lo rxprcss lliid stat« of dfpn.'K&iuii is " slifKk." Tbc fright from
tlio injury twd all Utougtits nlwut it, wliivli rnlloir in rapid Bucccesion^
unite lu producing' great psychical di^prctuiuu, which lias a panilrnaj;
effect oo the heart's «ctioiu Still, even in persons out greatly af-
^fccted psjchicully by tlio injury-, «8 old eoldicrs who havo often been
-vrouoded, or wnr pUegmalic pcrstms, a teveie injujy is not entirely
without this effect, so tliat wo must sup|>ofic that there are purely
physical oaiises for shwk. Coutnsiotis of tlu' sbdomon have an even
more dopiTSsing rffrcl on the nerve-centres than do those of the ex-
liemilice, ns I bavo already told jou. In this connectioo tlie so-oalled
bmting^xperimcnt (Klopfrcrsnt^li) of Oois U rery interesting: if «c
repeatedly strike a frog sitarply on (lie belly with tlw? handle of a
scalpel, lie bccomt-s aa it were paralytic ; as a result of paresis of their
tralb, tbe abdominal rcseols distend greatly and take up almost all the
blood, Eo that all the other ressels and even the heart become blood-
letB^and ihe latter only ronlrnelA feebly.
Wlicn the pnticut tiu» rcoovereil from this »tatc of psyclucal and
ttysical depression, the henrt begins to «et wiih iis fonner or even
'greater enei^y, tlicn hiemorrhagea may occur from ressels that had not
pccviously Wed. This variety of socondary Licmorrbago occurs after
.operation», wh«! the effect of the an;eethotic has passed off. Ueocc
patient should be carefully watched at tliis time, to guanl againat
'such Bccoodnry boBmorthagcs, esjxH'ially if, frt>iii the locitlily of the in*
jurr, there be r«&eoo to suspect that a hirgc ftrt>*ry has Itecn injured.
Now we must again examine somuwliat more attentively the local
changes in the wound.
Although doubtless the processes that take j^ce in th« contused
womd, the chnngcis on its surface and final healing, must be essentially
the same as in Incised woimds, still in the nppearaiKes in llie two cases
tbcTO arc coDEidcmblc diffcrcooca. One vcrj' important circumstance
is, that in contused wounds the nutrition of the edges of the skin and
soft parts is more or less extensively destroyed or impaired, or, to ex-
press this more anatomically, the circulation and ncr^'e influence in the
borders of contused woun{l.<t arc more or loss lost. Tliis at once pre-
vents the possibility of healing by first intention, as this require« pei^
feet vitality in tlic surfaces of the wound. Hence contused wounds
Iwayfi heal with suppuration.
This observation causes as to introduce sutures or tiy Gnn unioa by
Btera verj- rarely; you may consider this as a general nilc. Tbero
excepti'ina to this rule, wltioli you will only learn exactly in the
and of which I shall only incidentally remark, lliat occasionally
I uutfiD large, loose fiape of skin in their original position, not bo-
no CONTUSED. AKD IJiCERATED WOrSDS OF THE SOFT PARTS.
cause we expect tlie'm to unilc hy first mUmtkin, but thai tlie^ may
not from tlie iirst rvtract too iRucL and atrophy to loo great an ex-
tent
GranulatioQ and suppuration ure esealiälly ibe same as iu wounds
willi loss of substonco, except tliut they a« alowcr, nod wc mi^bt »y
more uncertain at many plawa. In inciswl wounds with loss of sab-
Stanco «iso n tbin superficial layer of tissue is occasionally lotit, if H
Im: not wry \\v\l uoitriNljeil; but tbis is insignificant as Poinpiin:<l witH
tlic extensive lo»s of tisaue-ttbreds that ocoum in contused tvounds.
Many dnys, often fur week», tags of dead (neiTOse<l) skin, fa8<-in,and
tendons, banjr to the cdgua of the wound», while otber parts arc
luxuriantly granuktin^,
niis process of detacliment. of the dead from the living tissue
takes place asfoUows: A cell infiltintionand formation of reascis, lead-
ing to dercloptneat of granulations, start from the bor>dera of tlic
new tiiwue; gmmilations form on llie l>ordpr of the hejiltby tis^uc,nod
tJieir aurfai'e brexkii down into pus. With this change to the fluid state
as it were tbc Bolution and melting of the tissue, of courEC tbc cobe-
sioo of the part» must cciue, and tlie dead shrede, wliieh previously
were in continuity with the living tissue by tbeir filamentar}' conneo
tioii. n)ii»t no\r full.
}Ience part of the surface of contused wounds almost always b^
eomea ntcrosfj (from vtKpo^, dead), ffonffrenoiig (from rj ydYyptui-a
from ypatfu, I consume), wliich arc botli expressions for piuiA in
wbicli cireulittion luid iuncr^'ation biivc ceased, ur which arc entirely
dead. Tlic part wlierc the delaelimcnt takes place is tedtnieally
called Ibe line of thmareaHon of the gangrene. These technical
icrms, which refer to every rariety of gangrene, no matter bow it
occurfi, you must only notio« provisionaDy bore, I will try to render
this process of detuebment of necrosed tissue by siii>pT) ration more
dbtinct by means of a diagram.
In the portion of connective tissue represented, 8up]>o*0 <?, tli«
Ijorder of the wound, be so destroyed by the injure,' that its dreulation
is arrested and it is uu longer nourished ; the blood is coagulated in
tfao vencls u far as Uie ebading extends la the diagram, Now cell-
inGltiBtion and inflammatory new formation begin at tlie outer eilgc of
the living tissue, at tbe border between «and b where the vessels terml«
uate in loops; tliesc va&culur loops dilute, grow, and multiply ; tn tho
tisEUO llie infiltration iseonslnnlly incrcngod by wandoring cells, asif
the edge of the wound u-crc hen; ; granulation tissue is formed ; this
turns to ptts, on tho »urfaoe, that is, close to the dead tissue, and
then of couiso tho necrosed part falls, because its cohesion with the
living tissue baa e«ased. Hence detachroeut of the necrosed sbrods of
BBALLKO OF COXTUSED WOUNDS.
141
tisftue results (wm mflamtn&tion wiüi Hiippunitmii ; wlicii tlK.- dead pen«
tion of tiȣiio liM fdko, tlie subjacent, su))puraliti]7 lu^rrr of granula-
tioiis comes to light, liovinf; Ih?cii aln^ndy «It'i-oloped befoie tho
detachment of tlio iiwroiseil jwrt. WIiaL jou here see in comiectire
tiasae is true of tl»; otlicr tuBum, booc out excepted.
tn.m.
r^
«<
''■X
^«
[JHlgnM or ttm pfocNH or ddatlmiiinl of Anid Miin*cilT« Hud« Iq conloHd tTcnnitri. MBgU
■edSMdlBmoWni: a. cmabrd orcrowd part; b, llrloK IImik ; c,nirf3C0(ittlrairo«iid.
In many cases, nn the fresh borders of tlie wound wo may nee
about how niuirh will di*', but by no means in nil vase», and we can
nerer deoido fro» tiie ftnt na to the bordering' line of the dead tiunv.
Completcljr cnulHxl skin usually bu a dark-blue violet xp[>eiininoe
and fetrU cold ; in other oafics wc at first evti no cbnngc in it, but in a
ficw dajs it is white, without sensation^ later it bcoonics gray, or, when
quite dry, (rravisli or brownish black. These Tarious colors depend
iiicfly tm tbr araottiit of coag^dated blood remaining in the vcMcIa or
iSltratcd ill the ttasue ilarlf by the jMU-tiAl rupture of tbc veasds.
!ie healthy skin is Ixurdcred by a ro»c-rod line wbioh loses itself in n
iSime redness ; this is dtie to collateral diktaliun of the capillaries,
143 OOSTCSED AND LACERATED WOCNDS OP THE EOFT VAKTB.
and i» portly oIbo a symptom of fluxion, of wliicli tro bnve bofora
spoken ; it is the reactioo redness about tbs wouwl, whit-li wu have
already described ; for the livings wound^infecc onljr begins where
the blood still iton-s Uiroiigli tli« capiltaricB.
In mtiieclpit, fnsQiPf and tendona, we nm d(>cide far less frequently,
and oftvii not iit nil, from the ttpj^exranfe at fir^t, tiow far titey will be
detached.
Th« litne required for the dciid tissue to be eopArnted and dctaeb«d
from the living varies greatljr with tliu different tissues. This dfr
pcods first on the vascularity of the tissues ; tho richer a tisauo in
capUlaricis the so^^r it is, tlie more readily cella spreftd in tl^ and thd
richer it is by nature in celts capable of development, no uiuob the
more rapidly wit) the fomuitinn of granulalini» and the detauhmeot
of the necrosed parts Come about. All then; circumstunDCs combtao
best in tlic siilwutanoous cclluliu- tissue and in tlie niuiicles, It^ast so in
tenduiis and fnsciie; the cutis stand:« in the middle in Ibis rcspccL
The circumstances are the most uofavomblo fur the hones ; conae-
quently the Beperation of the dead from Ibo living takes place most
^owly. Of tliis nions hereafter. Rich supply of aonrcs seems to
bsvo Utile eOcci in this protn^ss.
But there uro infiHTotlior influences thut hinder the detaelirncnt
of the dead parts, or, what is the same thing, that retard the forma-
tion of granulations and pu» ; sueh as continued action of ooM. on t2ie
wound, as might be effected by applications of bladders of ice. He
cold keeps tlie vessels oootracted. The cpll-movements, the escape ot
ocUs from the vessels, go on Tory slowly under the influence of low
temperature. Treatment by continued warmth, as by the application
of cataplasms, lias the opposite effeot ; by this nu>flns n'c ioorcaM tbo
6uxion to the capillario* and cause them to dilntr.-, us you mny readily
Bcc Eiom the redness you induce on the healthy skiuby upplicnlionof a
bot cataplasm ; It la known that the high tom|>enituro also hastens
the ecll-activily.
]t is entirely impoAsiblo to tell beforehand the inllucnoe of the
general state of the patient on this local processi. It is true we may
say in general tenns that it is energetic in the strong, stout, and young,
more moderate and sluggish in weak persons ; but on this point we
arc often deceived.
From what has alrearly been said, you msy euppuso that contused
wounds need much lon^rer to beal than mom sitnple incised ones. It
will also be oridcnt that there maybe circumstances under whiob
amputation of the limb will be neoensnry ; all the soft parts being en-
tirely mashed and torn, llicre are case» where the etift parts are so
torn from the bone that Uiis alone remains; so that on the one hand
IIKILKG OK C'OXTCSED WOUSM.
143
Gwatrisktion cannot ocmir, oii tliu otlicr, if the extremity did lical lu
montlis or year», it woiikl be jwrffctly usck-w, »iitl hcnco it would be
bettpT lu reiiiui'O it at uncu. Still, wun tliu simple L\)inp](.>to dL'tucb-
lent of ibc skin from the greater part of an cxlrrniity may some-
, thou^ rarely, reiiJcr uiiipulatiou tiecc-SMiry, an lu llie fullowiiig
A girl about ten yearn old caujrht bt>r rij^hl hiinii hctu'ceti tvro
jllets ofa spintiing-macliiiie ; slie drew Ikt unii i^uictcly back, m ihxt
tnix'hl uot be entii'ely mosttcd bvtwuuD the roUun. Iliv baud came
jt agaiit, but tho skin from tliu wrist tu lliu cndti of llie fingen re-
maioiHi between the roller« ; tbe skia was torn right around tbe wrist,
and ibcii druvm off like a glove. WLcji tho ]iaticiit was bn>ught into
tbe hoa^ital, tbo injured hand lonkini like an anatomical preparation ;
]rou cnuld see the tendons |>lay in tlieir «liRatlis on erery motion oC
fleuuD and cslfiiAiotif wbicli were uriiui^minMl ; no joint wn» opciietl,
no boDC brwk«n : what wa» to be douo Iktc ? Uonsiiltruhtc experience
m tfai<6e injuritrs by lusohinery bud shown tnv that ßngiTS which are
entiirly deprived of their skin always becomo gangrenous ; here tlicrc
rctnAÜi«<] a very strange etump of a band, whidi in the mo»t IJavor-
abtc CTiAC wituld pre^'ut an immovable «äcatrioial rlunip ; it was oven
doubtful if a |)ennuneiit solid cicatrix woultl form ; nmiiy months
would be wntstcd, tiyiug to obtuio itucb a rvsult ; under sucb circum-
Btanocs it would be bettor to amputate eIo<w alMiV4^< tliu wrist; this
was done, and in four weeks the patient returned home ; ber employer
had an artificial band, with »imple iiiechaiii»ni, mode for tlic patient,
t»i ovcreoroc the injury as far as possible.
Fortunately such cn^n are not frtfrjueiit ; in similar injuries of sin-
g^o fingers wc mostly Icavu the detuchnient to Nnturo, so that no more
IS lost than id absolutely iiicapuble of living ; for wc should always
nnaember In maiming tbe band that every line, more or lees, is of im-
portanee, that especially single fingers, and porticularly the thumb,
»liould be preserved wbeucver poaaible, for such lingers, if only »lightly
capable of pprfoniiing their functions, are more useful than the best-
madp aniAcial band ; for llw foot and lower extremity there arc otbor
oouaideratiiKut, of which wc shall hvreuftcr speak, wbcn we ootnc bo
com plica t<xl tVacture« of iKMies.
\^''üuld that this maiming and slow healing, lud as Lhey are, were
tlio only cares wo had with our patients having contused wounds I
Uofortutiately, there is a whole series of local and general oumplicn-
tions whidi tlirectly or indirectly endanger life. We shall first speak
vf the cliief local oompUcatioiis ; for the more general, the "* accidcotol
diseaac» in wounds," wc preserve a future chapter.
CcuiKi'lerable danger may arise from tlie decomposing tissue on
tbe wound infeeting the hÄiltby partsi. Putrid matten» act as fer^
1]
144 COSTl-SEü AND LACKßJiTCD WOUNDS OF THE SOn PARTS.
mcnts DO uthiT or^iiic coinbinitioiis, cttpvciull^' on Buid» r»nta!nin||r
them; (hc,TiB<]ucc profiTCwivc decomposition, Wc might wtiiidcrllnit
Euch t^xtutisii't^ dix'omjtusiliuii of the jiart wliich is iujurLiI, if killeil,
sbouM noi oftTiT more frequently thnn it actiiallj doos. But in ino«t
cases ccU-action occurs m> quickly on the border of tbo living liasue
tluit a sort of living wall is ramed; Uiis new fonnatioQ does not read-
ily penult tliL' {).t»s»gc nf putrid matter, and the emulation Rurface,
if oncp formed, is partindurly rceistaat lu eudi in&ucaccs. In many
places it is a popular rcinody tu cowt ulcon with vov^lun^ sjtd other
dirty ihinjrs ; this never rauses extensive puti^fartion« on gnnulatiD|f
wotitid». Ittit, if you apply Midi sul)stanccs to in:tii nound^, aud liind
th<'m firmly on so that the tissue may Iw meohanically impregnated
with putriil mailer, tliey will iiHiially herome gangrenous to r certain
depth, «lid then uii imerjjftic rt-ll-fonnation opposes the putrvfuclion.
This i» most remnrkablo in lilholomy : if, for the purpoKeof removing
■ stooe, you ope» llie bladder, u'liHlier by the [lerineal or uppor Be^
tion, the urine, which in such cases is usually alknUnc, nntumlly
escapes directly £rom the bladder through the opening made; the en-
tire surface of the wound almost uiiivenially becomes gangrenous^ but
only to a »light depth, perhaps half a liuc to a line. In favomble
OBSCä, after t<ix or eight dnyv, the white necrosed tag« fall »jvoutsne-
ouslj; bcnoHth lliem Bppeur Btronp>, well-suppurating graoululiona,
although the urine continues to flow ; tlie wound contract», and usuaUj
lieals entirely in from four toMs weeks. Should the urine not escape^
but be pressed deeper und deeper into the eellulnr tissue (us is the
case in so-cniled infiltration of urine, as when an opening is suddenly
formed in the bladder or urcthm, without Hiuiultaneou» injury of the
skin), nil would become gangrenous with ivhich the nlkalino urine
ceitnes in vuntaet. If yon tom[wrc the slitte of contused woimds, on
which shre<Is of tissue arc decompoBing, you find an unalogr to the
circunislance» in lithotomy ; the sanies flows from the tissue, Iienoc
the gangrene only extends to a eertai» depth. Even tliis is not
nlways the rase, as in most of the slirrds nf tissue long hanf^ng cm
the wound, tttioh aA tendons, baciie, or skin, from tbe natural dri,*n«ss
of these tisKueü. the pulrefnetion romes on rIowIv and at a lime when
the hc-althj- tissue is alreudy bounded by cell infiltnktion nnd gmiiu-
Ution. 'flic rcniiDn why decomposing matters act so injuriously on
fresh wound«, »ml so »lightly, on granulating ones, I eonttider to be,
that Mii-y lire chiefly absorbed by the Innphatie vessels. If «"ou inject
a dmclim of putrid fluid into tlio subcutaneous cclKdnr tissue of a
dog, the result will be inflammation, ferer, and seplieiemia. K you
make a large granulating surface on a ring, and dress it daily with
cbaipie soaked iu putrid fluid, it vrill lia\-e no decided eßect. On the
BEAIIKO OF COKTUEED WOO'DS.
U$
borders of tlitr iiiflxroniKtorj- »cw furmittion the lympbatic vessels rk
cloAml ; DO tint ^tninulutin^ fiurfac« tUcrc arc no open Ijrmphatic vco-
saIs, bcDce no reabeorption takos pläoo (livro.
The inon* lite tissue is saturated n'itli fiuld, the more it is disposed
to decompositinn. Hcncr, tlii? mws where grent cedoinatous 8wdl>
iag iKcun nfter rantuaiona ore the niA»t 4lkiif>«rou8 in this rcrepcct;
but litis «iHkiii» (Htiiies on rvry rvmhly us lltn rt>iiuus eirculation is
obstruct«!, frojii exUinsivc ruptiu-c unJ cnuhing of llic vessels, which
intlecij often oxt<Mid f»r beyond the borders of the wound.
Imagine a forearm paugtit under a stone weiphinfr several hun-
dred-weight; there will probably- be only a small sit !»• wound, but
cxteiitüvc <xusliin^ of the muscles, tendoiii«, and ^cii« of the fuiuinn,
and masbinigr and ruptuiv* of most of the Teins; ^rcst a>dematous
swelling will speedily reeult, as the blued from tbe arteries is driven
with greater energy into the eapillaries, and cannot escape by its eiis-
tomary passage through the veins, and lien«e, under the increased
prcature, Ute semm escapes tliroiigb tiie capillary walls into the tissuo
in greater niimunt, \Mmt a tunuilt in itie ciri-ulatioii and in the
whole nutrition ] It must soon appear where the blood can stil) cir-
culate, and wliore not. In the wound, at first^ under tbe influence of
tlie otr, dceompoeition uF tlic parts iitnipublc of living begins ; this
adrances to the stagnating Quids, and, in unforttumte cascs^ it coa-
stantly progresses ; tJie whole extremity awelU terribly as far as the
abouliier; iJie skin becomes briglit red, tense, painful, covered wilJi
TestclfSB, from die escape of seruni from (he cutaneous capilliuics
tnder the epidermis, Tliese sym|>1omK usually appcnr with nlnriiiing
npidity tl>e thinl day aOer the injury. As a result of this disturb-
ance of cin^ulation, the whole cxtrctnily may bcconjc gangrenous ;
in other cases, oidy the fttscifl^, tendons, and some shreds of »kin die.
Tliero i» oell-inliltraiion of alt tbe connective tissue of the estreuiity
(of tlie subcti la neons cellular ÜDsue, the perimyHiuin, neurilemma,
l^eathfl of the rcssela, periosteum, etc.), which leads to suppumtion.
Toirard the stxlh or eighlh day iho whole extremity may be entirely
saturated with pus and putrid fluid. Tlieijretioully, we might imagine
socb cases cumble ; that is, we might imagine that, by making sidt-
able openings in the skin, tlie ptis and dead tiMUC might be evacu-
ated. But this rarely occurs in pmclice, If iLc caau has undergono
the above distention, generally only qmck amputation can save the
patient, and even this is not always sudoessfnl. We may term lliis
TaHcty of Infiltntlon saitio-srrous. There is a eeltulaMissue inSam-
mation, caused by local septic, infection; a ««fXii phl<(fmi>n, whose
products again liave great tendency to decoropoeition, but which
fioally leads to exicnsivc 8uj>]>uratioa and necrosis of tissue if tbo
I4Ö COSrCSEP AND LACERATED WOCNPS OF THE SOFT PARTS.
pnticnt lives tlirougb tli« blootl^nfectioD which alwajB aocotnponieB it.
Thv (.■»tIiit BiKh processes limit themtelTn, the betl«]- the prc^nosis;
with ilif.- ndviiDcc of tlic lucal symptoms Uie (lunger of deatli of tlic
piiticnt iucrcnsce.
\Vitb thu tictachmuiit of Ü4.<u(l portiuiis of tissiu.', wi> must again
return to tlic arteries. An urter^ may be contused, bu u« not to be
fuüy <lirid«d, AuU tbc blood contiuuea to flovr tiiruufcli it »Itbuuf^b ymii
of iu wall i* iiK'iipabl*» of living, and beoompg d<'lAcJ)c>(l <m iIk* sixth
to thv iLJntli dav, or vwa lal^-r. As soon as this oircur«, tliL>ru nill be
a hirmorrba^ tn proportiou to the size of tbc irtciy. Tbcso laic
seooodar^' hiemorrhofics, whidi tisuallr come od suddenly, are exceed-
inyfly daiigeroiiN, as the^ attnrk tbe jiatieiit unexpectedly, sometimes
irliilc sW-piii^, and friniufiilly reinatn unnoticed uotil much blood has
escaped, Bcaidt» tbc above manner, Into ortcml »xondary haanor
rbagc may also result from euppuration of tbi' Ihroiubus, or of th«
wall of the axterj'. I obaerred a case of ibis kind late in the tliiid
week after n s<:^1;^R ojienLtioti in tlie iminaliikte vinnity of the femoral
artciy, in whieli, however, the artery was not voundvd. llie bleeding
began at uigbt; n« the wound looked jierfcetly well, and ttie putient
had for soinc time slept the wliole niffbt, aud fur some days bad
boea pTomi»cd pernitSMon to get up the next day, tlicre wa« no nure«
in bis primte room. Ho woke in thu middle of Uiu iiiglit (tliv
twenty-second day after the opemtion), fouud himself siHmmiii^ is
bhK>il,Htid rung at once for the nurse. She instantly called tbe Meisi-
ant phj-uirian of the wiird, who f<}ua(l the patient unconsciouR. He at
once «>ini>re»«*tl the artery in the wound, and, while I was bcb^
called, every thinf^ wus done k> restore the patient. 1 found bim
pubeloM, unconscious, but l>rejithitif;, nnd the heart etill beating.
^\1]il« I mude ready to lif^te the t'l-raonil artery the pittieiit departed;
he barl bled to death. A very siid case ! A n>an otherwise healthy,
strong, in the bloom of life, near recovery, must end Ids life in tbiA
miserable way ! liarely has a case 50 depressed nie. Still there was
no blmnc anywhere, as it hapiXMied all the «Irruijistances had beca
TCty favorable. The nureu was uwakc ia tbe next room, the ph>'slciai
wa» only down oiio fliglit of stutrs in tbcsiuiie house, nnd was with the
pati«nt in three or four minutes ; but the bleeding must liave existed
befom he woke, lie was proliably awalvciicd by the feeling of wet-
nesa in the bed. On autopsy, n small spot of the femoral urtcry waa
found stippiirnl«! nnd perfomtcd. Fortunately, it is not always a
fcniunil that bleeds, nor does the bleeding alwnys come so precipi-
tately, or at uighl ; hence, wc sitould uut become dLuiiti^lied with ottr
art Etom such • rare case. Uxunlly such urteriHl hsnnorrbngc« frciiii
suppurating wounds are at first insignificant, and soon cease tinder
gECOXDARV H-EMORHnAr.E.
147
plies or compresnoo ; but aftto- » fpw cUj-k the bleeding oontes oo
Dm actively, and is moTe dilllcult to arrpitl ; fimllj, the hiBmorTli«ges
more and more fiuickly, and the pntioni c^nstAOtl/ boconm
tme. Til all Movere arteriul liftMiiorrliagu inKtantaiicous conipr^-ssion
is tlie fint miicdy. Every nurse should uRdL-mUtul cnii>prr«$ing the
ri»l trunks of ihc extremities; but ihcy eooa lose their presence
mind, as iu llie u.bu%-o case, atid, in their first terror, run themselves
lbs soTfccon, instead of comprrssing tiir rcsscl and sending some
fllec ConiprcsfioD is only a pidiiuUre reiue<ly. Tlie bleeding
By cease sfter it ; but, if it be conndemble, and you are sure of ttg
igin, I strongly advise ymi at once to ligatc tho «rtery at thu point.
elecLioi), fur tliia is the uiily certain remedy. Vou isliould do this
ner tf the jinlicnt bo already extutustcd ; remrmber that a sec-
thinl suth Weeding will surely cause death. Hence, in the
I tqficrftlira cuursc, you should particularly ptactisc ligatin; the arteries,
( so Ibal TOu may find ihem so certainly that you eo\i\d opemte when
^half Bslepp. In ihsse particular enw^ much time is imneeessarily k»t
^^B nppV'"? Ptyptios, vrhieli usually act only pjdliatively, or not nt all.
^^Knition of art«>ries i» only a tnlle for one vho knows anatniny tbor*
^fbghly, and hss employed his time well in the t^mtive eoiirscs.
Analomy, gentlemen I Amttoniy, nud again iiuatomy] A bumSD
Npc oAeo bangs on tlie certainty of your knowledge in this braocb.
P While treating of seeondary hiemorrhagefi, wir shall speak of
parmeAymafOMs fiirmorrbagfi'. Ttie blood rises fmm tho grantila-
^Inas OS from a spuugt; ; we nowlK-re see a bleeding, s]>irtiog ves»eL
^^BiP whole surfncc bleeds, especially nt every change of the dressing.
^^Iits maybedue tovxrious causers: great friabjlity or destnidibilityuf
_tiic gnunilatione, that is, their defective orgiioizalion, may be the fault,
ad this mnlorgnniEition of llic granulations again may de|>ciiil on con*
titntiunal ili&eas«« (taemorrhagie diathesis, scorbutis, septie or pysKuiic
a). Still, local causes »bout the voimd arc imaginablv, ne, if
"i*xt4>nsivv coAgulalion graduallT formed in the surrounding veins, tbe
cirmlation in the vess4>U of the gianulatiocts would be so affected;
, the pressure of blood would so increaee that not only tbo serum miglii
I CKSpe from them, but iliey would rupture. It is true I have hitherto
^ had no opiKirtuiiity of conltniiing this by autopsy, but T have seen very
^^kr of these porcncliymntous bann orrh ages. Hie latter explanation
pV>u»ils very plsuAiblc ; so far as I know, it Originates with Str^mfytr.
Be calls such h:etnorrhages "h^tnoatatic.'* According to tlie catisea;,
[ It may be more or less difficult to arrest such hicmonbuges ; in most
Mses ice, oompresHion, and styptics, will be proper, or, in severe
rautex, ligation of tl>e arterial trunk, although this oocaFionalty fall«,
fonn of hcmorrhagt' occur« oliielly in vctt>- debilitated |)cnKnis,
148 COXTtrSBB XSt LACERATED W0CND8 OF THE SOFT PABTa
wUq Imvc been cxbjtufttod by suppuration and fvvcr, and licnoc iuu a
bad ni^ificnnce for the general Btabe of the [wtiCDL
LECTURE XIII.
Pro^rMiive SnpptmUiiia Martin^ Jhrni Conliiiipcl WoiumU,— Seoonduj ItiflunmitloBl
or |]i« Wonad: Uitlp Cuum; LoosI InfootioB.— Ftbrile RcmUoh in ContOMd
Woundi: 8«sftt»d*f7Povtr;Sap[tntaiivo F*v«r; Cfatll; thoir Ctnuoi,. — Tnotnmt
orC«BlaMil W«iuii(la: lunienion, ta«-b1ai!*l<ni, Irri^llon; Criti«iiia «ftliSM
JilatUodjt: — Indslen«. — C«untc r-oponinga. — U ni n «^ •,— CiUpbwD «. — Op«it Ttmt-
inunt ofWoanilB. — Prophjliuiu Kgbü»t Pitr"nilnT InHnitimatirrrir,- -tntitraiil Trrat-
inontof lluHia ■«vortlx VTounucd. — Quiniao. — Opinn. — Lancsted WoooJa : 8ub>
oulMDoo«« Bupluro of MmhIo« aiid Tsod«M i T«aniif mtt of MiudM MidTmlooa;
Toariug out vf I'i««« of ■ Umb.
The gramitating surface tliut dovclops on n coiittised wound b
(^•ucmlly VV17 irrogular, and oflt^n lias numerous angles and pockcta j
thpro is guppunition not only of llie surfaco of the wound, but o( the
surroiindiikg contuw^d psrtA luidcr tbt» uiiiiijur«d sIcId ; lieno« tlw
aeigliburing iskin oftca appears undermined bj pus. Tlio iufliuuii>ar
tion and auppuration oftou unexpectedly cxtond betm-(>pn the mnsdo»,
along the boups, uihI in tliu shcatlis of tlie teudiiii», bentuse these
jMrtit were also uffcc-tnl by tbc injury. Tlit: process of inflammation,
0DC1; cxi.-itcd, creeps along, especially in tbu fibcatlut of tbc tvndoua
and ill thu cellular tissue; nvw collucliuns of piM form, >up«rlioial]y
or in tlicdrptiis; tbc injured part remains swollen and trdcmatoua;
vu the surfaui tbc granulatioiu aro emrary, yellow, swollen, aad
spongy. Whea we press iti the vicinity of the wound, the pus Qows
slowly from smxiler or larger openings, wliidi b»vo formed sponta-
noooBly, and this pus wliieh Iioa remained for a time in tltc depth is
not infrequently thin and bndly smelling. Should the process con-
tinue long, tlie patient becomes mora miserable and weak; be has
high and I'oiitiuui^l fevor. A wound, which perhaps ut first uppwrotl
insigiiilieant, perhaps about the hand, has extended Itorribly, and in-
duci>d serore general dislurlNincc. The sheaths of tbc tendoas about
the liands and feet arc particularly favorable for the oxicnsioa of daop
suppuration«, which readily attack the joint«, while, on the other
hand, articular inOammations of the extremities readily attack the
ehoutbs of Ihe tendons, "niese states may take a rory ibiigcrous turn,
and yoq should he constantly on your guard. From the ooDStant pu-
rulent infection, as well as frum llin daily lo«!t of ptis, even tlio Htron^
est man may enuiciato in a few weeks, and dte with symptuma of
febrile manismus.
lNnjt.)UUTIO» OF COXTTTSED WOUNDS.
li»
We no»' knovr two funiia of iiillumtnation vrbicb may ottnck oon-
Fius(?d >T<>uiidii : I, liApiJ, pKigrcNtirc, septic tiiftainiiifttion, wliicli
be^Ds »bout tlie wciuihI duping ihe ßrsl tbree or four days {rztvly in
leas tlian tweolr-foiir boure, mul jii»t us ranAy xfter xhe fourth dii>'),
kod wbidi i» cuuncd by looul iuft-ctiun fruiu parts tlmt tk-cucipoec in
tb« wound, i. I*rogrc«ftivc punilcnl intUktnniAtion, whtcH is pitrticu-
larlr njit to octnir in wounds of tbc baritk ur fci't during tbo cl«uuin^
nf tlir wound bam necrosed sbrods of ti&sue, widiout linnog cuictly
• septic cbanoter, >
Itiit, r>vf>n when th« woud<1 has entirely cleaned off »nd p^nu-
kicd, vrben tbe iiitbitiiiiiiLiioi) is brjutided, sud tbe wuuiiJ begius to
dcatriie, new inllommatJOD, with sctctc rcsulte, f»<iy begin. Tlieso
HOOOilary progrcuipe intlmtintuliotis of siippuraliiig wounds, ocour-
lu^ even aevcnl vrecks uttvr tbc injury', nud som(--tim<--a coming as
uacxpect«dl)' aa ligbtoiug from a cl&ir sk^-, arc of grca,t intportanoe,
uid »re sometimes very dangerous. Tbey arc abno&t always of sup-
puraiire nature, and may b(? fatnl from int«n»>e, jililngisiLlr, coii.stitu-
lioaiil infection, ju&t aa ofteu a» tlie prttuacy progreosive auppuiaUoua.
In Botne cases, also, tlt^y prove ciang<?roug from tbcir locAtlon, as in
vounda of tbe bead. Tbcsv caiiee are so sinking and tragical tbat
we must giro tbnni special coDsidcrn-tion. Suppose you bavc brought
a ease of serero crushing of tbc leg, with fracture, euoc«ssfuUy
titruufjb the tirst daugeis. The palieut has no ferer; the «ouud
inulntcs beautifully, and haa tvvu iM'giin to cicatrix?, i^uddenly, in
üc fourth vrcck, the wound begins lo swell; the graQulatious arc
cmu[H)u<i or spuugy, tbv pus thin; tbo vbolo limb swelb. Tlio pa-
tient again has high fever, perhaps repeated chilla. 'Ilic symptoms
BUy pass off, and every thing go on in the old track; but it often
turns out badly. Id a few days tlie strongest man may become a
ooipse. Some time »tince such a cast; ocruri-t-d in Zürich, in a fellow
atudvnt witli a wound of the head ; it may atrrvQ you us a warning
exampk;. TIi« young man rucoircd n blow over tiio. left vert4>x ; tlie
bone was injuicd wry superficiaUy ; tlie wound healed «quickly by
fint intention; 011I3' a email »pot Lxtiitinui.'d to !tu|>i)urat(.'. Aa tlie
pAtictit felt quite well, ho pniil no attention to the littl<t wound, and
vent about as if perfectly wclL Suddenly, in the fourth week, after
a watk, be bad »cverc headacli(^ and fever. TIic following day thero
vms about a tea^poonfiit of pus collected under Ih« cicatrix, which
ovaruated byau incision. Thisdid not hare tbedesired beneficial
Beet on tlic geiterul condition ; the fever remained! the same. In iho
reniiig delirium begao, tlien sopor, 'itie fourth day the previously
man was dend. It was c»gy to diagnose (lint there had been
itivcmcniugitia. Thia was proved on autop&y. Althui^hatÜie
IM COSTl'SER AKD LACERATKB WOCNDS OP THE SOFT PJJtTS.
ii]>i>t, as big as a poo, yrheK »li^t suppuration had been so long
ke|)1' up, tlic bone was but ülifftitly (Ii.'u<n1on?fl bv purulent infilLnitjon,
still llie suppiirHtioii oil, in, uiiil under llic iluin miLl«r v^ts gn^Unt at
tbc pait exactly ooireepondiiig to this point ; so that the new i&flom-
mation iind'jiibtodly Etnrtml from tht* woumJ. A sliorl t.ime siiip«^,
Ticjc in Vienna, in prirat^^ iirartipt-, T jtaw a perfectly similar case, nbo
tutitlf in a man wbo rn-civcd au a]>]iareiitlr ituiguiüamt wouiitl from a
piece of a ftodu-wntcr bottle that butst, at tho upper part of tlie fore-
bead, along tlie margin nf tbi'liaiir scalp.
The inflsm mat tons uocurrinfr uu'lcr audi nruumetaDcrd, as alrcaJr
rcinarkc<l, are usually of a difliiscly purulent cbnractcr, but otbct
fonns BCfompnny it, or occur spoDtancouslj', Burh as dipiithcritio in*
ilnnimution of Oic pranulationa ((rtiumadc r/ip/iiArrin^ /timpital gan-
gritif), iiillnmniatirm of llie lymphatic Inuik» {fi/mjifiati-filis), und a
qwcific form of capillary lynipiiangitin nf tlie skin, eryripela* or ety*
aipelatonn inllnmmulion ; and, lastly, iiiftuniuintioii of the ^-^iii» {phU"
bitis). Not infrequently all of tliesc? prwi-sst-a may be *evn inix<»I
togcthcT. AVo i>linll boreafter study thi>8o dieeas«« nion.* aix-unilvly,
under acciiWntal intuniatii? iliavaNes. Hut h«^re ve must consider tbe
eartae* of thc&i; secnnduiy influinniations, before iiassin*; to the treat«
ment of contused wounds; and, in so doing, n-e imiKt nitlicipata
BomewhaC, All of tlicjie form» of inflammation, and ttifir tväex
action on Uie organism, are so intfrtn-ined, that it is impoe&ibte to
^Wak of one witliout mentioitiog tbe otbcr.
As causes of sccondury inflnmmation» in and around suppurating
woiuids timt Imve begun to heal, we may metitton tbe following; 1,
Exc<c«Bire flow of blood to tbc wound, such a* may be induoed by too
mucb mnlion of lb« part, or by great bodily exertion, as well as fay
vxcitiDg drinks, mcntul agitation, in short, by any git-nt rxcitt-mrnt ;
ia wounds of the bead, euch congr»tions art^ particularly dangerous.
Congestion, as caused by too ti^^t bandageti, may prore injurious in tlie
same way. 2. Local orgeneral calcliing cold; about rat«-bing cold a»
s onuso of inltanunatioii vre know little more Iban Uie »iuiple fact that,
under certain cireiimRlancfii, wliJoh mnnot l>c neenrately defiiierl, a
«uddea change of lenijwmture indncrs inflammations, eH[ieeially in a
foetM minori« rvsülrnlitv ot an indinduol; in a wounded pcrsou the
wound is »Iways to bo ccnsidored as a Jortu minorh rfaificnti<^, Th«
danger of catrliing cold after injury was nrtainly over-estimated
formerly ; 1 hardly know of any certain example«. 'A. Jfec/ianital
trriiation of the wound. This is very itiiporijiul, Tlie puj from the
wound is nerer reahdtorbed by the uniiijoo>d gmnulations ; but, if they
be iU'atr«ye<l by mechnnicut iniinipulntions, as by imprup«-r drcMiii^
cniH'b probing, etc., wbiob cituac the wound to bleed frequeutly, new
l>"FLAiriIATIOS OP OOXTFSED WOrSDSL
1«1
inRanitBatioos may bß induced. Aay forei^ bodies in the wound
mipht provf* n'rifni» in tliU way, such as pii-oea of g\aBs, IpriI, or ipoo,
ur »birp Sjilinter» of bone; for the first cliiuigcü uhirli tiik« pliice in
^■he wound, tbc vicuiily af «uch fordgn bodies ia leas impartaQt, but«
^Rrlieti, From inii»ciilar movement», and llip motion ron^muiiioAt«?«! to iho
^ni«:iii> tma\ tlit> Artifrieo, the sharp aiif^li^ »f s fon-ign IkhIv kf>f>]> up
^HiiD»tant frirlion in a port, aerene inllamniatioii mxrurs after a lime.
^"4. Vhemi^Ml fermenU ; here E metitiDn Eirat soft forcijcn bodies, suoh
as pieces of elothiiip, pup<7r ^rsds, wliieh have enteroil tJie ItMue
mgti i^unshot wounds ; tiw^c siilratancca become impregnated with
ke »ecretions from tiic vrmitKl, then tlio organic material (paper, wool)
9inpo«ieK, and oets aa a caustic and ferment in the vround. I am in-
iiiwi to Ijelit^vr thai m*enwed upltutiT* of hone also act rallwr a» clwm-
k1 tbun us mei-hutiicul irritants ; in tlic Eliivt-rstuu cuiiuls, or me^lutlary
cavity, tbcy alway» ooDtain Bomc organic dcootapoRiog substance \ all
leh pieecfi of bone have a putrid Bmoll \rhen extructrd ; if thtf aui^
Hindlng granulation» were partly destroyed by tlje sharp angles of
«»ch a fragment of bone, the putrid matter paasos from it into Iho
■open lymphatic rcsseln, or possibly even into the blood-vessela, and
Id induces, not cmly locn), but, at t!ie Mime tinne^ cofistitution&l infeo
onn. Necrosed ta^ of tendon and fuaeia at the bottom of euppu-
miin^ wound»; müv induee ttiu Mime rpftults, allliougli this nirL>ly haj>-
pens. In bospitabi, especially, tlierc arc some rare eases where wc can
End none of the above cAuses ; such occurrence» naturally induce pc-
culiiir niami, am) attempt» have Itccn made Xa explain thpm by ctirtain
injurious influene»^ of llie hoKpitnl ntmosphere, esi^ecialty «iich as \%
^^lled with the smell of pus. Many circumstaiicca spcali a^inst the
^Wew that the injurious substances aro gaseous; by good rcntilation
the air of the hospital may be kept pure, but this is no protection
^^against the affection in question ; moreover, we cannot excite inflam-
^^Bation« by any of the gases dercloping from pus or putrefj'ing sub-
^Htanoes, unless, perhaps, by sulphuretted hydrogen, when dissolved iu
^prater and injected into the subcutaneous cellnlnr tissue. Putrid fluids
and pus from oth-.-r patients would not intentioiuilly be brought in
CMilaot with wounds; wo have previously shown that the vicinity of
thR wound may, under some ctrcumatanecs, be infected by pus from
thQ wountl, and excited to new inflnmmalion, ITcni'« there is little
left but the suppo-^ition tliat the injuriousty-ading sub*tan«>>s nrc of a
itlecular, duMt-Iike nature; they may flont about in tho air of tbo
oital, but tln-y may ulsu adhere to the bandages, charpie, com-
fs, etc., witli which wc dress the wounds, or to the instrument«,
s, pn)be«, sponges, etc., with wbieb we touch the wound, Hiy
ey not be fungi, or other organic gent», whose nature wc ilo not at
16» CONTCSKD ASD lACERATED WOUNDa OP THE SOFT PART8.
present know, like Oiok we know to excite fermentation? Thi» is
poseibk-, for in evirry cubic fool the »ir liokl» quantities of »ueh gennit,
and in the liospitul »ueh orguiiic genns of onimul or vegetable nalure
might dureloji in tti« secn-tJuns from wounds, iu tlie B]iutuin or
cxcrcniriit, anil the more so in pro)H>rlion as the rendily-dccompOMO^
sceretiuud und cxirrttion» are cu]lccl«<l in hospital», or in baUl/-
built unter-eloRPt» and sewers. On this point wß can only liu-
ard conjuctun.-», while wc nifty ninke cxperitnents with dr>- potrid uil>>
stances and dry piu, by powdering thvin, and tben tntroducinfr tbcm
Into the healtliy tissue of aiiimids. ^uch eipt-nineulit h»ve Iilh;» made
by O. Weit-r aud myself, and they hare shown that botli aniioal and
vvgelabh) putrid, rlry aubstancv», as well as dry pu», iinliice inflani-
matioii ; if wc pulrcrize these aubstanccft, atir them up quickly with
water, then inject them iulo the subcutaneous M-llu)ar tissue of aiii>
mals, they will excite jtroKT'CSMVc inÜammation, just as putritl Saids
and hesh pus do, Xow, it must at onee bo acknowledged that in a
hospital itiirh injurious dust^like boilies inay readily olinj^ to dressings
and bedolutlies ; jiosKibly, aho, to iiDttruinentp. In »liort, il is poesible
that the direct injurious influeni'o of hospital air oti a wound ma.y be
due to line dust-hke particles of putrid or purulent matter oouiing in
contact with it from the dresaings or instrumenta. Tbere can be no
doubt tliat suck injurioua mutcriala may enter tke hoity in otlier waya
hcGides through wouud«, a« tkrough the lung« ; indee«l, we explain ibc
oceurrcnce of all so-called infectious diaeaBes by the eiitfauoeiu iheor-
ganiam of substances which liave a sort of fermenting influenoe oo tbe
blood; but, whether the morbid matcri«!:» which CJicite the infectious
dioeascsehietly occurring in the wounded lie different from thoae ariidii^
from tlie wound itself, may be a disputed point, so far as we at preseat
kjtow. We »hull retuni to this ]H>int when »peaking of accidental
trnumatie discnsoA. Vou will suspect mc of contradicting myself here,
because in yesterday's lecture I said tliat no moleetdar body could eo*
tcr tho tissues through an miinjured granulation-«urfaee. I must still
daim this as usual; a strong, uninjured gmnulatioD-surfocc 14 a (k*
cided protection agaiiiot infei^tion through liie wound. But, when the
infecting material itself ia very iriitatiug, so thai it destroys tho
granulnling nurfocehy causing decomposition, a passage-way ia opened
for the poiiKiu to enter the ti»iSL]L>s. Still more, there are certain xulw
stauoes which are curricd into tbe granuktiun-tiitsue, and perhaps
OTCn furtlicr, by the pus^oUs. If you sprinkle a granulating surface
on a dog with finely-puwdered ca.rmine, some cellü take up the small
carmine granules and wander with it into tlie gmnulntion-eubstaace;
after a time you find cells with curmine in tlie gratuilatioa-llfisuc. I
consider this an abnormal retrograde moTcmcnt of the pus-cells, wbidi
wriiAiiiiATioy or costcsed wounds.
153
we genctmlly brlkrvo to poaa fmiu Uio grniulalinn-tioaue to the surface
of the \f ounil ; it is true, oo unv bus seen this. Xevcrtliclcss, {com the
tbaw experimeni, it is evident tliat cTen molecular 8ubstances may
piM bum iritJiuut into the tissue of the edfi^-s of the vound, aiid, if
ihesc pnlwtjimH"« ho viiy <U>roinpoiuiIitie f>r cAUtenint, they viU excil«
active hifiaminntiun. From ihesc cotiKitlcraCiuits^ ^ou uiJl be much
terrified about the fate of the nounded, as absolute prevention of euch
injuries »eeina iuiposaible. I mufit elate at once, fi>r jour ramfort,
thai all molecular organisms, millions of which an» coiitHincd io the
atmospherr, are iiot talceu up bv the woiuid, nor do they all induce
inflammatioD. Just as ccrtaiu fungous ipcrm», under certain condi-
tions, sometiiacs rerj* limited, are neeesaaiy to indueo fennentation in
certain fprnienlable fluids, no it. i^ not crcrj* animal or vp-gelable germ
tliat can excite iiitluuimation in th« wound. I do nut believe that
theM sutetanccs, whetlicr lifelea« or liiing molecules, arc always the
EMMA, but I think they »re very niimeruu», us are thu causes of in-
flmunation generally ; tbcy may oil linvc certain chemical peculiarities
Id oomnon, a« we might suppose from their similar action, ulth«ugh we
knoir nothing about them, except llUa action; tbeyat&o differ »oinewhal
lu their mode of ac-tion t>Q Uii» or that tissue ; the ab«orlMbitity of stic-Ji
HulMtance» may vary with the part of the body, and puaeibly, also,
with the individual ; but the lar»v number of these injurious subatances
ia, in bet, small as compared with the innumcmblc variety of cngiuifo
aubstanceti generally.
JP^riie rtaelion is usually greater from oontused than from incised
WDunda ; according to otir view, tliiK is l>ecau)ie, from tlie deeornposi*
tioo, whkfa is much mure cxtt:iuiive in crushed tlian in incised porls,
Car tnoro putrid matter enters the blood. If in »ny ca»c the pulnU
matter is particularly intense, or very much of it is taken up (e*-
}>ectidly in difTu!« septic inflanunntionB), the fever assumes the charao
t«r of »o-called putrid /ever ,* the state thug induced is eaU«d tepti-
etmin ; we sliaii heri>after stwly it more closely. If the >^u]ipunitive
inBanuiiatioii eiu-nds from llie wound, there is a oorres]K>ii<ling eou*
tinucd inflammatory or suppurative fcvvr; this has tbecliaracter o£
remittent fever with very Htecp curves iiiul oonasional exneerhntions,
moatly due to progress uf the inflammation, or to circumstances that
bvor tlie reahsorption of pus. If we call the fever, that often, but
bM always, accompanies traumatic ioHummatioB, simple traumatie
/«e«r, we may term the fever tliat occurs later " teeondary ftvtr^'' ot
** mtf^ntrative fercrT' This may immediately succeed the tramiiatio
fcrer, if the traumatic inßammation progressea regularly ; but the
traumatic fever may have ceased entirely, and the w^tuiul be already
healing, and when new aecondaiy inflammations, of which ive have
iSi COSTrSEB AKD LACERATED WOUNDS OF T0E SOFT PARTS.
fully trealc<l, i>tt«<-1c tlio wouihI, thoy are fflocamparüffd by oev auppo-
nilive fever; in slmrt, inllaiiitiuitifni ani) fcvLTgcj parallel. Occadon*
ally, indL-eü, ibe fever appears to precede the secondary inflammAtion,
but tliii U prob«bly bccnus« the first ehanges in thu wuuad, wliieh
limy be only slij^lit, linve eiu'aped our observnlioo. At all eretiLs. on
every actxasio« of fevt-T lliiil we delect, we slioiild at ouee »eek for the
new point o( inflamma.tioQ, wliicli miiy be Cbc cause. I mi liar from
ftsscrtiiijT tliat it is neevsesry to tiK>«siire tlw tein]i«niture in all oust«
of wouuds; undnulitcdly any cxpericneed iHir;peon, accustomed to
examine puttetita, wuuld know tlic condition of )iis ]>alic»t wttbout
tncttsuring t)ie temperature, just as an experienced [tractttioDer mmy
diagnose pneumonia nitboiit auHciiltatian aiid perciuwion ; but no one
who understands the Bij^iificanoe of Ixxlily temperature doubts that
tta measurement may somelin>os )w a very itn|vn-tAnt aid to diagnoeis
«nd prognosis. It is n-ith it as with vwry otber aid to ubservatioa ;
It Is not dilHeult to detect a dull penmssion-Miimd in tbc tbonuc wbere
it aboiJd not exist ; but the art and science of determioinf; llie a'lg-
nilic(uic(^ of tlii« dull pereussinn-snund in any given ea»e muat Iw
learned ; so, too, wilK meuMirenient nf temperature : for [u»tance, we
must Icara wbotbcr n low tcmpemUire in any fi^ivcn cue be of good
or bad omen. 1 sludl enter into more detail oii ttiis subject tu the
cliuie.
Expcricnoc teaches that secondary fever is often more mtoose
than primary trnumntie fever. While it i« most rare for the latt«r to
iK^n with u eliill (k slight ehilline!>!t after great loss of blood and
severe eoneussion is init usually ncnumpnni«^ by high temperature),
it is not at all so for a secondary fever to eommcnce tritli sorere "cLiiL"
We shall at oooe study ibis peculiar plienomennn more uttentivclir.
Formerly the rhill was always regarded aa e«»entially ilcpendeiit on
blood-poisoning; if we now regard fe^-cr genemlly as due to inloxi-
catioQ, wc must seek some s|Hwia) cituse for tlip oliilL OLservatinn
shows that llie chill, which is alwiiya fullowcd by fever and sweating,
ia alwuy« BCeoraptinicd by rapid elevation of temperature. If wu llier-
nioinetri<^nlIy examine the temperature of the btood of a patient with
chill, wc find it high and rapidly increaMug, nhtle the »kin feels cool;
the blood is driven from the cutaneous i-cssels to tbc intcroal organA.
As already remarked, TmnlM' cnm>iders thl^ ns Iho cnusc of the stt-
normal febrile elevaliim of teiniM^rattire. We shall not diücusiK this at
present ; at all event», tlicrc is so great a dilTernnee lietween tlie air
attd tbo bodily temperature that the patient feels ohUled, If wc un-
cover a patient willi fever, who lies wnippa^d up in Itcd and doe« not
feel chilly, ho at on«> begin» to fthiii*r. Man has a sort of coicicious
feeling fur l)ic stale of e<)uilibrium in which his bodily tcinporature
I
I
TREATHESr OP COSTPSED ffOUNDS.
IffS
to the Biirrountlüig air; if Uie latter he ru|M(lly vrann«d, be at
a<x fccU wiimier, if it be rapidly coulin], be nt once feci» cool, chilly.
trivial fftct iMtU us to another ol>sorv-nttoii. Tbie »cositireuess
■ vanntb and wjlti, Ibis t'ouM-iuus fuuliug of vhuagc of tcmpcTBturc,
varies witli the iDdividual ; it may also be increased or blunted hy Uie
mode of life ; some pvr&ons ore alvrays warm, otbera ever tou cold,
while for others the tt^mperature of the air is comparatively a matter
of imIifTL-rcftrc. The iier\'Oii8 system has inucli to do tritli thi». Ac-
ute stutlii» of ^hiube and J'vc/itnanit liuve in fact sbotrn that the
}iu exdt«biUly of aa itidividual ha« a gna.i efiect as to whetber,
la rapid eleratiDii of temperature of tb« bloud, tlic change tvitl be mucb
äveä or not ; hence tliat in toipid persons, iti cosMitose «mdi-
tlons^ chills do not so roadily occur with forer, as they do in irritable
pcnoiMi altvfi^ly debilitated by Ion(^ illnes«. I can only coulinn ibis
{rom my own obttorration, Ahlimigh I huvc a (^HieTal idea that,
where ihtTi; ia suflicient irritability, mpid eIt'\T»tion of temperature
and chill t-hiefly occur wIil-ii a quiintity of pyrogvtwiu» material enters
the blood at once, still I natrnot deny that the quality of the material
Ü alao impurluat. We know notbiug of tJiia qunlitr clKnniually, but
we tnay conclude tiiat it ii:i3 mrietirB, iM^cauae both the fevor-evnip-
toms and llieir duration often vary greatly, and th^t this doi-s oot
solely depend on the prculiarilic» of the patient. Acconiing to my
ob6errAtion&, in man reobHorption of pus and recent products of in-
flamtnation is more apt to induce chilU than Ut absoquion of putrid
ittcr, which is i>crliii[>s more poisonous and duugiTous. I ik> »ot
to voary you with too many of thcftC considcnittons, and so
rotum to the aubjwt hi the section oii gcoenl accidental trau-
I and inflaminat<iry diaeuses, which yuu may regard as a continu-
ation of this atudy of fever. I will only remark hero that Ixitb the
eepttc and purulent primary and Eecoiidary indamnialions, with llieir
actxjmfMinrin^ fever, may also occur from inciüc«! wouikIs, especially
after eilensJTe opcmti^'ii.-' (a» iimpulation» and reseetioos). We hare
considered this condition along with contus«! wound)«, because it
ooRiplicatcs them much more fnKiiiently than it <loes ordiuary incised
wounds.
Xow wo paM In tbe tntttmtnt of contUMd wounds.
many c&scs contused wounds nxjuire no more Ireiitment than
wound» ; tlw coitUitioDS for hcftlinjc exist ia both. Ucuce, in
■ contused wound it is only necessary to anticipate any accident«, or
■t all events lo nia»t«'r tlieni w that they may nf>t bccntDC dnngccoiUL
In both n-:sprc(ji we may do soincthiag. Fonuerly it was always sup-
posed that the air with its oxygen and its ferments particularly farored
ISO COKTCSED AS» UCERATED WOÜKDS OF THE SOFT PARTS.
the deoomjHwtition of dtuic), organic bodies, Iicnce of contused parts ;
to prrrrat llib, the wound was esclwlud from the air, and, to prcrcntt
warmth KCtinj;; as An aid to dccorapoxition, the wounded part was kept
cooL We altain both ubjiicts by placing the injiimd part in n renel
of cold watrr, whose tcnipcratiirt; is nlwa^'s krpt coo! bj 'k^. Thin
Ireattneut is culled "iiumersion" or "coultiiued cold-water batli/' 1
first saw this iised with oxceUent effent by my eorÜMt tt'aclicr in
surgcn-, Prof. Baum, in Gmtingcn. Thi.t mode of irt-utmiMit m only
r«ally pntcticul in thv extniniittea; in the IcguK ht^^h «s the knee, and
in the arm to a little above the elbow. We pla(V suitably-constructed
arm and foot reesels filled with cold water in the pntient*» bed, and
have the wounded extremity kept in it dny and night. The {jntJent's
position should bo such (hat he lies easily, and that the cxtromitic«
may never press too hard on the edge of the vefwcl. lliU is all very
ainiple; yon will often see thin iL)){writtii,s in my diuic. Id the most
common injurica of the hand, a bitxin with eold wulcr is sufficient in
private pravtice. In partim which iiinnut be kejit in water in this sim-
ple way, wc try to exclude the air by applying moist linen compresaes,
which readily »dapt tbemaelve« to the injured part; over these we;
apply a niliber bag (nr a bladder) filled with ice, whieh is to be TO-
plnce«! as it melts. It i» Mill ninn> cfIie8ciou.i to wrap tip a limb well
and pack it in a vessel with ice, A Uiird method of applying mid
water is the so-cnlled irrifialton. Fur this we nxjnire sjiedal appara-
tuses. 'Die injured extrvniily Is luid in a tin troitgli, supplied with an
eacape-tube. Above the extremity we place an appuratiia from which
a continued stream of cold water drops from a moderate height on
the wound. Ijistly, vre may simply cover the wound from tiino io
time with ootiipresses dipped in ice-water,
f have «eon all these modes of treatment in practice. Here is tny
opinion of thein : none of tliein act certainly «8 pro]>hyIaclJc«. In
contused wounds of the hands atid feet the watci^bnth is best; for,
under this Ircninicnt, extensive suppumtion is mrcst. To attain llw
saniG fiivonihle results by the ice-trewtment, we must cover not only
the woimd but the parts around with the ice-bladders ; pack the parts
in ice.
Ill applying eold-eomprpRsea, we shadl only really obtain the effect
of cold if we change the compresses every five minntes, for ihey
warm vcr^' ({uickly, and the ii.-tiinl treaimeut with oold-contprcsBCS
actually amotini« to nothing more than keeping the parlji moist;
hf'nee, this is, strictly speaking, no peculiar mode of trenlment ; uevei^
thelesSiUS 1 have already remarked, most small contused wounds heal
under it spontaneously, without our placing them under unnatural
floiiditions bj- the use of cold. Irrigation is not a bod plan of treat-
TREATMENT OF tOSTUSSD WOirSDS.
157
nirnt, but it is Iroulilpsoinv, nnd it is ofh-n difiicult to nvuid netting
lUe bed ; ttic condition of tlic wound su1»cqucotly (Iocs not differ
from thttt in the mon.* simple trpatniLtit bv iimnersioD or ice, so l)i.il I
liavr not felt nblig:i^ to rrsorl to irrif^tion. In France, ibis method
ia practised and liighly esteemed br eouic surgeons.
Apart frotii Uip prevnntion n( ii<<<<idf>iitii, for which all rein(>dieft are
as laeletv licre us ri>ncs(ation i» in pneumonia, nc tiarc »till in tbc
abore mode» dC treatment important uicnim for combalinK' Ibc usuiU
IcMMÜ aocidentA I linrc still a few spcrisl remarks to make about llie
mter^wtfa. As we here leave out of consid(>nitian injuries of the
boaca and joint«, I knon* of no con Imindi«.-» lion to it in oontuscd
wotmds of the bund, ftwcurm, foot, nnd lepf. In most races of these
tnjuncti the l^e^ing is so »light, and cvases bo sooii spoutaneouslj,
llwt tbc patient can place the «trcinitj under water very soon if cot
immediately after the iujurv, without the occurrence of bsmorrfaage;
but thr> blood clinginj^ to the part »■hould first be wanhed off, the water
il«*If Ijc perfectly pure and iranspan-nt, and, if it becomes cloiwled bj
the M.'cretion of the wount), it should be kept dear br frequent re-
newal». Even when the wound t«. two op three days old, the water-
bath may »till be employed with udvunla)^' ; later, it is of little use.
If the patient« lie comfortably in bed witfa the tub, tiicy urc more
cootentfvl nnd free from pain under this trealmetit than under any
other. Till» lernperatKre of the water may vary greatly uithout mtaji
clmnfifin^ the condition of the wound ; only ice temperature, atid tlie
biffh teniperhture obtftincd by cataplasm», eaiwe n »omcwhat different
aj^ieaiance ; but from 24° to 90'' or 100° F, it doett not vary mucli in
looks. Perhaps fiiippuratioti comes on a tfttlf sooner at the higfaej*
temperature, but the diSercDcc ia not great. Ucdcc, wc may adapt
the temperature of tiie water to the feelings of the patient. At first
the patients generally prefer a lower temperature (W-ßS" F.), Inter
a rather hif^lier one (t}8''-05'' F.) ; but there are also patientä wlio,
even during tl>e Gnt day, complain nf ehitls if the temperature of tlie
water (alls below 68* F. Henoe we nee tliat it n rather indifferent
whether wc employ Kann or eoltl water batlw. In some {>er«ons, on
the third or fourlli iliiv, there nriite« n f-ttiie which wndcrs itiimeraton
unbearable, that is, swelling of tlte epidermis of tJie hands or feet,
and tbo accompanying tense, burning sensations, which iwmcwbat re-
semble the action of a blister. The thicker the epidennitr, the more
£aagreeab1e this accident. It maybe avoided by rubbing the injured
extretnity with oil, before placing it in the water, and ad<ling o hand-
ful of sail to the water; thia does no harm to the wound An im-
portant quextion i«, How long iihall continued immer&ioQ be employed ?
Kulcs for this can only be given after considenbte experience. I have
158 COSTIISB« AND LACEUaTEP W0C.ND3 OF TRK SOFT PARTa
found froiD «ij^lit to twelve dnyn fuiougli. After this vre may leave
the liro1> out or tliu uriLicr ut iiiglit, cuvelopjog it in a auAät clotb cor-
ered with uiUmI silk ; » fuw days bilcr wc ntay employ this dressing
during the day altu>, aud uMt ibe watt^r-lutli only muniing ami even*
in;, or oiornin^ alone, Icaiin^ tlic Umb la it Laif »u hour or au boor
to bathe and cleanse it. Finally, we leave off ܻp water entirely, sod
treat the jrrniiiilatiiig, cicatrizing wound after the simple rulesalreody
giveo. Thv uiiangar» in wounds undt-r tlii^ treatment are M>meivluit
different from tiiosc provioiisly dt-»cril>e<l. In the lirst plaec, all gOM
on muuh slower; ftofiivtimes, especially in the trentitieni with the
r-ohl-water bath, llie contusud n'oiind luului as (rveh for four or five
days uswhcn lirst received. Tlic enme thin^ i* noticed for some time
under the treatment with bliidder» of ice. Tlii» is not m aatODisliing
as it at first sceni^ for, as is well known, dcoompositioD of orgnnic
Bubst«nccs goes on tnorc slowly in water tlian in the air. Subeis
queiitly Die pus usually remains on tbe wound as a Uocaulent, half-
ooagiilaleil layer, and must be wiislied or syring»] off to obtain a rie*
of the 8ubja<.'ent grauululioiu, which art- infiiti-uted with M'nter, bikI
ofWu quite pale, lliis obw-n-ation i» very imporlniil, and jiroteeta tu
from illusions in regard to the «fficiiey of the w»ter-liath iu deeji sup-
ptu^tionsj V.« iniglit suppose that the pus iloitcd tnm Uva wound
directly into the wnlcr and was th^ro difl'used, so that it would simply
bo oewsi^ary to pliioe the suppuraliiij; |iart in water to hara it always
clean. Tftt tfoter-bath dm* not favor tf»s escape of putf it rai/tT
prevent« it, I*u« on Üio griiiuiiiitioii», or in cavities coagulate» at
once on cuiilael with water, and iisimlly remains un the wound; wasli-
iny or syrin^ii^ is iictt-asiirj' fur its removal. ÖwcllhiK of the gninu-
Intions entirely prcvcrls the cscajw of pus from deep ports- Hence
we see, where there is suppiirntion from n caiity, that the water-bath
in uf no tittc, but i» even injuriuuH, and tliut »ii cxlr4>iuity should at
once be removed from tlic water as soon ils deep projfresüiive iiiQaof
nmtjons extend out from the wound. Hy this wo dit not mean to ex-
clude a Iialf-bour's bath of tlie part. Sljuuld there be no progrt-suve
in IIa mniu lions, there would be no particular harm from leaving the
wound in the water for two^ three, or lour weeks, only the healing
would bt"! niui'h n^tartleiL In the >vator tiie pnrts remain greatly
»wollen ; the griuuilauoiis arc full of w»ter (nrtitidally ledeauttoue),
pale, An<l cicatrization and contmotion of tlte wotinil will not occur.
If you then remove tlie extremity from the watts-, llie wound soon
coatracta ; in n few days the granulutiuns look stronger, aad ilie pus
better; healing progrossctt.
Kow I must say souifftbing about the uuntinucd treatment by ioe.
Suppose you cover the contused wound fiiani the first «ntli a bladder
TaEATMEST OF CONTDEE» WOPSDS.
159
of *oe? Here, also, you will find th«t tko crusbed part« are very
dovlf detached, and that no smell arises from tli« wound, unlcstg lar]g;o
masses of tbsue become gangrenous; to ptereiit (he Utu-r, ir pmai-
b\c, 1 «ppljr ctwpie, or a thin coniprcas wet witli ctilvriiiv-n'atcr, next
to the wound, and bavo it froqucnlly rL'nwod, If vo now cuntinue
»he treatment four to »ii wffks, oil tlic nvocsKBiy cbatifTCS in tho
WDUQ'i will go on very slowljr and sluggishly ; the cicatrization and
conlraction of the wound ar@ also vf?ry slow under the influnncc of
the ice, attd hcneo this method in entin-ly out of place if we desire to
bASteo the pTOcees of healing. MoM »urgcons believe that we niuy
prarent scTpre inflammalionH by applyiiif^ Ulodders of Ice to the ro-
oent wounds ; lientie you will find ke applied at ouoe to inoet cases
of ctmtuaed wounils. Ocoasiouully this proTcs very ^nilt-ful to the
patient, by relieving his pnin, but it docs not seem to mc a prophj-
bciio aniiphlogist'f ; for centuries, mon have sought such a prophy-
lactic, ju»t as tliey have for one for inllaminatimi» of internal organs.
Jiy the applicatiou of ice to recent wounds, wc cuu cvithcr prevent
aaoio^erous infdlratiüci, nor eupp«iral.ivo indummntiotiii, nt least, this
is my opinion. As already stated, many believe in the prophylactic
action of tec, and iu% convinced that by tltis means only tlicy coii save
perauos badly injured. I liavo become salis&ed that the dangerous
Qompltcaiioiis to wounds oft^n octnir in spite of the ice, and xn not
uo&equently wanting whc*n ice is not uKcd, when from the nature of
the wound they might be cxpcctod. From what has bcon said, you
might almost supfmse that I consider ice an inefficient remedy tliat
may be dispensed with, still, you will sm it mach employed in my
«linic ; in my opinion, cold is one of the best »ntiplilojfistiM, especially
in inflammation of an external part where it can act directly. ITenee,
ice is proper where there is inflnminution, especiany if nccompanied
by great fluxion, with a tendency to suppuration of the wound. If
inflammation of tiie oelltilur tissup^ tho sheaths of tendons or muscle«,
or of a Dcighborinjr joint begin, you should apply ice to the inflamed
part, and thus avoid the excessive hypcncmio, and so the increase of
the inllamntalion. You lliiiik I am here oontradieting myself, vben I
say that ice is of no use in preventing the development of inflamma-
lion about a wound, but il iit of ii»i> in lessening tlic corameoeing inflam-
matioo and preventing its spread. I3(it let me explain this by an ox-
amplr, and you will readily see the difference. M'hen any one suScta
imm headache, he certaiitly would not Ihiiik of l>eiiig bled for ovcry
attack, to prevent inflammation of the brain; but, if tlie latter bo
really developing, venesection tnay bo a very efficacious remedy to
anest it« further development and spread. By the aid of ice, wo do
Bot always tuocced in arresting the Buppuratiou extending from the
13
160 COXTL'SED SÜD LACEOATED WOÜSDS OF THB SOFT PARTS.
vouod, but occasionally tlie cedcmatous skin gtcfvs rctkW, bcoom«
painful, and, when you press on it, a lliin, serous, or eometimes quite
oanBMlcDt piu uccuviniially flows slowlj'from fMiinc o( the anglcfl of tlie
WMiud. Under such circiimstaiices, tbe retaIno<l pua, eäpedallj If
biitllj Ktnolling hikI ic-tiorous, must bo set free, and allowed to fk>w
unobstmctedly ; for this purpose, diK-p iuclHions slioultl lie made iii tlie
soft pari», ami then kept open. Wfisri thU should be done, oud bow
it may best be done io iiulividiial casL'tf, jou nill have to iMirti in tliP
clinic For jirobing wich suppurating cavities, I prefer a sligbtly-cumxl
ailvcr catheter, which I pass Uirough the wound to the end of the
canal, th«n preu the end up ngainat the skin and horn make tbe tn-
cisioEi. For eu1aT;gitig th«se «o<wlled counler-opemHQf, jiisl a» in
other wcundis, jou usu a tuli:nib1y lunp^ probe-pointed knife, straigbl
or curved {Polti kniTc). As a rule, the oounter-openin;? ihould not
exceed an in<'h in length ; if necessary, ire may make st.>vi?Rd of this
length; in stich raoca tliem iß usually no use in dividing tbe soft parts
of the foresna or leg longitudinally, as was fonnerly taught. To prereot
these new ojwnin^ from closing agai» too soon, which, however, rarely
happens, you may intruJure sl'vctuI iitlk threads through ihi* pus cutuila,
tic the cuds together, and leave tliem for a time. In place of IbcM
setons of Bilk or linen threads, caoutchouc lubes, with DUuiProiis lateral
opeuings, hare recently been uned ; lliey hare received the name of
firaiiuUfo-tubte^ an rx]>res»ion taken from sgrictiltur«! teolmology ;
Bonictimps, «t len«t. tlios^'. ttihc» facilitate the e-icnpe of pus very well,
but tlieir principle is not ii<^w, nor can we acooinplisti eudi wuiidcrs
willi tlicnt as is claimed by Chaamiyiutc, llicir invcntoir, who has
written a book in two thick volumes about ihem. In making theae
oouiilerKt|».<n!tigK, ymi will not mifpwjuetitly strike ou dead sbreda of
tendon or fascia, wliicb should then be re moved.
TTje skilful use of the alKive remedies is an art of expericooc;
what you cannot accomplish with tbein in ELippuratioii, you will not
accomplish willi any thing eist;.
One of our colleagues of furinor days would shake his head doubt-
fully, if lie he»nl that wu had talkixl su long about tbe treatment of
contused wnunds and secondary HuppuTHlions, without having men*
tioiied calajiiaemi, " TemfHtra mtitatiturf^'' Fennerly catapLunu
belonged to suppurating «'ounds as undoubtedly as the lid to tlie box,
and now, three or four weeks may jiass in my ward» without oata-
plosins being once eniployc<I fur their original uses. The emplojr-
ment of moist wnrmtli, whether in the form of cataplasm« or of thick
doths dipped iu wann water, is useless in the treatment of coiituacd
woninds, and, in tJie Imstment of secondary suppurations, it is occa-
sionally injurious; under them the vouiuU beoome permaucntly n>
TREATMENT OF OOXTrSED WODNDS.
161
Itxed, llie Soft part« swell, and hauling is not advsnoed. Moreover,
cauplasma only truljr ^d lui muist vrannlli when ofleti r«iiewetl ; their
rvuewal ia tircsomi:', tUo poultice easily sours, or may be scoitIkxI, ami
finally, the whole mess cannot be mrciull^' wnicltoil in a hospital ; a
cataptiuai covered with \n» mny he reniored, now poultice added,
and it mur tltvn Ik plucvd oit auotlier patient. In somr biwipitaU at
least bftlf of tJie Burgiml pnticnt» wear poultiM^ ; hundred-Mreighta of
grit4 and 6axsi;cd, i>tc., for poultices, are used tnontbly in tb« surgißol
wards; tbey arc almoet b&aislicd from my wards; as occasion offers,
I »ball »bow you t)io ««see wht-r« tlicy may be used with adraatagc.
Hitherto I bnte not mentioned tliat tlie abmol'itf, rfjit of no iujun'd
part is always necessary ; it mity seem sin^ilar that I should mention
(t at all, you may Ihiuk this should be eonfiidor«d a matter of coiuw.
I lay particular sln>6S on it, l>e<.<BiKo injurious eubslanct*« am taken
from the wound into the blood ; hence c\xry muM-ular movement, atkd
evety consiHiuenl congestion of the wound, in sliort, erety thing that
drires the blood and lymph more strooffly into the vicinity of the
woond, may eventuully provi^ injurious. Of btte, I rarely M-e contused
wounds do so well as oom[Mund fractures of the cxtrcmiticis where
plafit«r drf«dngs are at once applipd; henoe wc Imi-e a strong hint
to compel absolute rest of an extremity with a large contused «round
without frw-lure, by nppU'ing a frnfatrnted plaatcr-spint, Tlir ca-H's
where 1 bar« done lliis diJ romarkably well ; even after amputAtious
of the hand nail foot, where the patient waa very restlesg, I have «p*
plied the plnstcpspint with excellent result, and think that this mode
of trcatnioul, whiih wc shaU describe more fully under compound
fneturrfl, mar l>e more pxtensively used than hitherto.
Nor is n.n elevated position of the injured port to lie oeglecte<l wl>ere
itcan be tiied. Yon iiiuy ntiidily prove on yourselves that gravity liua
something to do with the movement of the blooci ; if you let your arm
bung perfectly relaxed for five minutes you will feel n hexviii««s in tlw
bnod, and the veins on the bai-k of the bond will look Hwollcn ; if, on
the oootmn-, you elevate the h»nd for a tlm«', it will booomo whiter
■nd Bmaller. While debiliuied persons »re lying iu bed, in the mom»
(ng, for instance, llieir faces look fuller than when they hare bamo
tbe head erect for the day. Becenlly, Vofkntann has strongly rccom*
metwled rerticnl suspension of tbe arm as a powerful ontiplilugistte
in intlammatkMis of the bund: r(iiisr<[<tciitly, I ha^i' employed this
method, antl in cases of cutaneous inflammations have found it very
.efficaeious ; it appears to do less good in deep inflanimatioas, as of the
wrist
Hereafter, the wat«i^b*tli, ice-trefttmenl, and cataplasms, will prob-
ably give place to the open treatment of wounds, from which I luivc
IftJ COKTÜSED AND LJICEKATE» WOUNDS OP THE EOIT VAXTB.
Bceti rvrj good resulU in contused as well as in indsed wouikIs (p. S9).
I did CKPt sajr this at the coinmencemciit of the secliiw, benus« I do
not cXMUudcr mjr cxperieucti of tliia mod« of U'tintmcnt auEEciciiLljr ex-
tensive for me to ffivc a final jud^ient, '['lie drouded «occss of »ir
to the surfiic« of thu wound, t'vc-ii tli« air of Indly-reatilatL'd ho6pitalS|
is not, in my opinion, so injurious ns tlrcs&in^ aud sponges of doubt-
ful cl«auliD«eö ; the idea that &ir is injimons to suppurating wounds
rents cliiofly on the oliservation that the entrance of air to iibsoeM
cuvities with rigid walls, and iiitn eeious b*c3, iisunliy induces BUp*
puratio» ; apart frorn the ^t thai, in many of these coses, it is not
provod that it I» intk'vd tlic t-nt nitii.-«' of uir whidi excites the inflam-
iiialion, irn must also attribute niutrh of the blame to the ikct thnt in
the pu9-M«8 the air is warmed and iiiipreguat«K] with watery \'apor
Ironi the pus; this eneloMMl air now bi^oonies a true luilohiiig-plaoe for
iboM minut« or^iiisnis which cause decomposilion, and wliich ore
always more or less presmt in the atmosphere. Every obserring
housekeeper knows that meat or j;«me hanging in the open air spoils
Ear less readly thaji when shut up in a cupboard, eren when the air
in the lalter is kept eool hy ice. Free air does no hann to ttie wound,
impriHincd air ia ver)- daugcraus, 1 have already lucntioned (p. 8{))|
that a wound treated openly J'fQtn fhe »tart has no bjid siiiell, unless
iarge shreds n{ tissue on it become gangrenous ; in aocordartee with
Ulis also, BieH tlo tiut deposit tlirir t^fig» in open wounds, wliUc they
aro apt to creep into div^sieings to do so ; I muat say these obsctra-
liona surprised nie very ngreeiibly, Itecjiuse I feared tliat flies would
n:ndcr the upcu treatmcat of wounds impossible in summer.
In the treatment of secondary inf1an^Tii»lion, roost careful prophy-
laxis is to be recommended; aroidunce of cangestiou of the wound,
catcjiiug cold, all niechaitii:»! and chemical irritatjons, and cfipeaaQy
infection. HercafWr, when s]K:ukJng of ucctilcntal traumatic disetteefl
in geiiend, we shall state wluil may bo dune in llie latter respect bf
ventilation and proper use of the room in the huspilnl. For avoiding
local infection of tlie wouud by dreseinga or instruments, wo would
give tlw foUowinj; advice. Be exceedingly careful in the dressings,
cleansing Üie wound, choice of compresses, charpie and wadding; al-
ways see to tlie most perfect pleiiDliucss of the mattresse», straw beds,
ooTeringB, oiled nuvdin, pnrchnient'pfipor, and in short of every tiling
about the patient. I'he bk-eding of the wound on dressing should be
BToidcd hy carefully syringing it with /^march't wuiiiid-douche, of
which there should ho two or three in every ward; wo sbouhl never
apply dry compresses, ehnrpic, nr wadding, to the woimd, but should
previously wet all these nrticles in solution of chloride of lime or other
antiseptic, und later, when the wound hcgioa to cicatme, with lead-
TBBATMEST OF COXTDSEO WOUNOa
KM
> , and for remoTing the piis ire slioultl oerer use spoiigM, nor
we use thcin in opcrntiiif^, but du it nil bj a^vrinfftii); or by
injung off with wadding wet with wut^-r or ctdorinfvwater ; if we
eannol «rgid the use of sponges, Üivj s)}ould be new ooes and disinfect
Üicni at cooe with h^-perman^tuitc of potash or carbolic add. Or-
gudc b<-inj[s npvor develop in chlorine-walcr (aqua chlori, with oqaal
parts of valor), eolutinn of chloride nf lime (chloride of liini?, two
drachins, water one pint), nor do lliey in lead-water, in e^^lution of
' of alumina, of permanganntc of potjuh, or of carbolic acid ;
'. have found the latter substances very useful iis anttse])tics, without
'ing able to give the preference toanyone of them. The organiBini
adudiif^ decompoäilion arc mostlir destroyed by these remedies ; beooa
', employ those n-asbes a great deal, but aokoowledge that the same
Icct may be obtaii^l fmni nlooltollc wn.<Oies and aome others. You
aust pay special attention to llic iiislrumciila with which you touch
the wound, nieb n8 pro!>e^ forceps, kni\'es, acisMirs; crery thing Hhunld
be wiped before being used, or, if it 1« at all suspicious, it should be
quickly rubbed with cleaning powder. In ordw to carefully obscrre
all tbeae preeautiona, you must be perfectly satisfied of their neoM-
ity.
IT* however, seconilanr iiiliammationa attack the wound, they should
treated as alrewly advised ; retoine^l pus should bo removed, foreigü
lies extracted, ete., then the Round trvated with ice, perhaps, Ü1I
. IB brought in order again, and the putJcnt free from fever.
In nob caaes slutll we prescribe any tiling for our patients beaidea
oling drinks and uiedicinee, reguktJng their diet, ete. ? 11»c febria
iitt4^-ng tiotunfrequcRlly accompannng surh suppurations readers the
itient dull, peevish, and oft«in aleeple». IVo remedies arc proper
i>re— quinine and opium ; quinine as a tonie and febrifuge, opium as
• narrotir, especially in the eveiiiiiij, to »«."Ciire s night's rest. With
such luilicnts I usually punsue the following method : As long a» they
are Uttle if at all feverish, I give nothing 5 if they grow feverish toward
I'ening, in the anemoon I give two doses nf quinine (five grsins
ch) in soliitiou or jwwder, and in the evening before bedtime from
Kti^;hth to half a gmin of muriate of morphia, or a grain of opium.
>n as the fovcr ceases, I *Iop these medicinErs; you must espe-
dally avoid liberality with oiMimt, when it is not required, fur it is con-
Xow a few words about Ueerated wounds. In general, these are
I dangerous than contused wounds, because they are more exjxieed,
'tnd we have no need to fear that the injury is deeper timn wo con
t«e ; wc pciceive how the akin, muscles, nerves, and vessels arc torn ;
1«4 CONTUSED AND LACEIUTED WOCNDS OF THE SOIT PASTS.
beflUng by finit iiit«u1 ion niny bo tried for and succeeds occasioiiaUjr,
•Ithotig^li suppuration generally occura. But staj, mpturca are nut
alvruya ex]XjseJ; tbcroaro a\6omibful<in<ou$ rupttir&t of muscle«, ten-
dons, or even of bones, without iIiltl* linviiig beeuauy ountusjou. A
pereoii wiHlies to leap a «litcli, and makes a start, but fails in his at-
tempt; be falb, imd fi-uis ii svvurc paiu tu one leg, auU linii» oa it. On
examination, just above tbo bocl (iIk? tnb<>TiK(itn.t oalcnnpi), vre fitul a
do|Mf ^.sion in wbicb the thumb may he latil ; chc niul ions of tlie foot
arc iDipcrfLftjt-spoäiiUv oslt'iision. What has bapprni^d? The tt^ntlu
Aohilli» lias bcca torn from llie calcaneus bjr tho great muscular ao-
tion. The sauiP thiii|; occunt \ritli tho tendon of the c|UHdrii?eps
feini^ri», which is attiichM to ihe patella, villi the pnielU il^L-lf, which
may be torn in two, wilh tho li^mcntum patellrv, with llic Inc^pit
bmcfaii, wliioli niiij bi* torn from the olvcranoci, and griifrally uttrriosa
piece of the latter along with it. Here yoii hare a few examples of
euc'Ii aubcutaaeoua rupturca of leudoiis; I have 8ccn aubcutanvous
nipKirc of the reotus abclomini», of the vastus <>xteniiis cruris, and
otbcr muscles. These »imple sulxrutiuieous ruptures of mu»t:le8 nrc
Dot serious injuries ; tbcj are rt-ailily rcL-Of^izeil by tliv dittturlmncv of
functifin, by the dppivssion, wliich may be seen and still better folt,
wbii^h at once occurs but suhseijm'iitly is miiaked by thei'ffused blond.
Tbc treatment is simple ; real of the purl, lilnriii^r it so that llie rup-
timxl ends may bo brought in contact by relaxation of the muscle,
cold conipressos, lead-w!»ler lolioitB for suvenil days ; aflvri'i^hlorl*n
day» tlie patient can geiieniUy rise without pain; at first there b a
00imective-tiS9iu3 intormediato substance, whi<^ soon cDodonsea so
much, by KhorU'iiiuiryndatnjplir, tlmt a firm tendinous eieatris fonna;
tlic eonnte is just the suine as in suhcittnneouR division of tendons, of
vrhich we slmll speak in the cliapter on defonnitics.
Fuiu'tiocia] disturbanrea of any onitidcrahlo amount rarelv re-
main; occasionally there Is some wuiltDestt of thi; extremity aud loss
of dehcal«; iiiovemeuls, eP|>etinlly in the band.
For such sul)ci)tnneons rupture of muscles and (endoDS to be
caused by contuiucin, llio cnishiog force would hare to be veiy great;
such A omtuaion would probably run a had course ; extensive i^uppu-
ntions and nocroscs of tendons might be crpcctod. Here, again, vou
KG how varied may be the eour^e of injuries apparently the aame,
according to the iin*de of their origin. In injuries by machinery
there is often such a -wonderlul combination of crushing, twisting, aiul
lacerating, that even with great ex[)tTivn{-e it is very ilitüeult to pvo
■ny uccuruto prognosis of tiieir course, ITic favorable ro)in*e of case^
where small or even large portions of a limb (as the hand) arc t«)m
oB*, is espcoially wortliy of mention. I have seen two cases whore
1«« COSTUSED AND LACERATED WOUNDS OF THE SOFT PARTS.
froin tlie roof of tlic liotise against vfiich tbc scafiblil rested, there
hun<r A loo|> ; llic Killing mao t^rasped tUis, but oü\y succeeded in get-
ting the midiilo firif^er of the ri^ht band tiimugli the loop; he hung b
motnunt uni.1 thiMi fell to tbc grounil. Fortiinatt;!^', tlie lieiglit was not
^ciLtiiLiid ht; wits not injuri-d, but tbc middle dagcroi tbu ri^^lit baacl
was guno ; it vras torn uut ut tlic juiiit bc>t\v(H-ti tliu first )>lialiinx aacl
tb« taetacarpal boue, and it still hung in the loop. Tbc two tendons
of tbc äcxors and that of tht: cxtcnunr remained attached to tbo fin-
ger- they bad boon toni off just at the insertion of the muwles; the
man dried bis ßnger with the tendons, and subMH|uenUy carried it in
hia pmsc »a a nicnient» of the oircumstauce. I stw a Biiiiiliur caue iji
the clinic at Ztlrich (Kig. 3S). Cnrc resulted without mueh inßamtna-
tion of llie forearm, itntl actually no tiviitnient wa» reqtiirwl. In
Zurich I saw two cases whc^re tliu hand was torn out; in one case
there w«s enough sidn remaining to leave the healing to it«elf, in this
other case an ampututiun of the furtmrm »"as necossniy. Butb eases
tcnninated farorubly. In war it is not rery rare for amis and legs to
be torn from their sockets by large cannon-balls. I have aUo eeeo a
case where a boy fourteen years old bad Üie right nmi with Uie xnpiila
and clavicle so torn from ihe thorax, by a wheel of machinery, that it
woa only atta<:bcd at the almuldcr by a strip of skin two inches wide
(Fig. 39). The axiltarj- artc-ry did not bk-od a drop; both ends were
closed by htrsion (Fig. 3*). The unfortiin»!« fellow died soon after
tlio injuiy. Tearing out of entire extreinities ift usually quickly ialai.
CHAPTER V.
SIMPLE FRACTURES OF BONES.
LECTURE XIV.
CiMM, Differ«!)! VwlctiM of Frattnra.— 8;mpUiniii| Diagooab. — CoitnM «od Extern*!
SjrmpWn».— AiMtoinj of n«aUog, FnrmatioD nf Callu».— Sour«« of Ükc InStuunia'
My Ommih Kew FonuMion.— UUtolo^,
Gbxtlxue^t: HittKTto we linvc been cxdusircly occupied witli
injuries of the soft ports ; it ia time to ooasi<lcr tli« bones. Vou trill
tuvt that til« pro«e!>sra tlint Nature excites for tbe restoration of the
parU are esflentislly the sitnie that ^ou alriMidy know ; but the circom-
stanccA urc more coiiiplicalrd, ntid can o\\\y b« fully understood wliea
joo arc perfectly acquoiatcd with the mode of healing in th« toft
parts. Every pf?TBon know« that bones may be broken, and ag»in be
finnly united; tItU can only be done by bnny tissue, as yoM will at
once see; bence it follovrs that new bony subatanc« must bo fomtcd;
ihc cicatrix in bone i» ni^ually lx>ne ; a very important fact, for, if tliia
were not the case, if tlic broken ends mily gren- togirlber by cotineo-
tivc tissue, as divided muecles do, the lonff bone« particularly would
not be aoited fiimly enough to 8up]H<rt itie IkmIj, and after tbc aiin-
plest fncturee many men would be cripples for Ufc Still, belure fal-
lowing tlie prooesa of tbe healing of bones to its more minute details,
a study that has always been pursued with great xeni by surgoons,
I must tell you 80inethin|f about tbe ori^n and eymptoms of simple
fnctun»; 1 tay '^simple or subcutaneous fmctiircs" in contindistüio>
tioQ to those aceompanicd by wounds of the soft part«.
Man may cren came into the world with broken bones: the bones
of the ff.'etu« may be broken, while in llic iiteni'», by abnonnal con-
Iractiooa uf that organ, or by blows or kicks on the pregrintit abdomen,
•ad such iutrn-uterin« fractures geucnilybeal with eoruuflerable dislo-
cation ; as we ahall see in other instances, the cm medietUrlK natvnt
1«S
81MPLB FR-lCTÜBES 0? BOXES.
ia a bcttrr physinUn than surgoon. Of course, bmchirce of the booes
may occur at any agp, but tliey are most freciueut between Uie ages
of twentylJve aud sixty year«, for the following reasons: Tlii» bones
of chililn^i arc still pliable, and liCDce do not break eo ««ily ; if b
phiUl fjilU, it <ioo« not full bfnvily. Old p(?o[)lo linvr, aa » pomtnotily
n'tnarkccl, brittle, friablu boni-s ; or, »naloiiiioally ex|ire«MMl, in uld ugH
the mediiHary cavity grows larger, the cortical aubirfaucc thinner; but
old persons arc less in dAng«r of fractures of tlto bones, because their
lack of stn^iifrilt prevents their doing hard and dunfrerous worli. It is
iIuriDg- tilt! iigc whpn men »re innsl cxiicsoii to hard work that injuries
generally und fntcturcs CHpccinlly an; moat liable U> occur. I'he less
frequency of frad am» among u*ontc>n 18 diio to the i-ariety of tbcir
nccupatioii. It ia also due etitirely lo extemiil rin'uiii^tunees that llic
long bone» of the extromitics, c^pecinlly of the right side, break more
frc([uently than those of the trunk. It ia evident llmt dioeisod boaes,
vbidi are already tveak, break more easily tlian healthy oni-s; hence
ocrtsin disL-asfs uf tlw boiicit greatly predispose lo fracturefl, especijilly
the so-c.-lIIciI FJiiglish disease, "riekots," vi)ieh is duo lo deficient do-
posit of liiiic^Bul'^ in the bones, and only occnira iu clitldren; sliso
BOfl«iung of the bones or "osteomalacia," which depcoda nn nb-
nomml dilatation of the medullary ca\-ity, and thinninjgf of the cor-
tical subslan«*, and which is, to a great extent, neoonipamed Yty
B " fragilitas oaüum," and exen by total softness and flexibility of ihc
bones.
Aa special causes of fractures, we have the two folloving ; 1. He
action of external forces, the most frequent cause; this action maj
T«ry in tlie following ways : the force — for instance, a Wow or kick — '
meeta the bones dinetty, so that it is crushed or broken ; or the bone,
especiallr a If^ng bone, is \ic\\t more than ita el«sticity pcmiits, and
brcuka like n stick that is beut too nmcli; licrij the fore« acts indi-
rtctlt/ on the point of fracture. In the roeohanijtm of the latter rariety,
instead of the Binglu hollow bone, you may consider a vrltote v% Iremily
or the entire spinal column as a stick, flexible to a certain extent, and
on thia siip|>Dsitiou found your idea of the indirect action of the force.
Let us have a couple of examples to explain this : 1( a. hcary body fidU
on a fureann at rest, the liones «re broken by direct force ; if a pencn
falls on the bhouIJcr, and the clavicle is broken oblitptcly tlirougli
middle, this is the result of indirect force. In both cn^cs tliero is usikI
ally contusion of tlic sofl part« ; but in the latter cose it is monj or
less removed from the point of fractim) ; in the former at that pointf
which evidently is to be regarded as less favoruble.
2. Muscular action may, though rarely, be the cause of fracture.
As I iili-eady indicated, when s)>oakiiig of tli« subcutAueoua rupLum of
TAXIETIES OF SOIPLB mxCTVBSS.
109
inuKi««» tlic pntella, the o]ecnuQO(i,Bnd part of tlic caknnciu aUo, nrnj
be toni oir by iitiucuUr uctioii, lluit Ik, obliiiiielj* fractured.
Tito way Id which the boD<.-ji hivuk uiuIlt these viirici] npplicattoDa
of force T»rios, but eomc typos hare been fonnod that you should
know-, Finit, we cHsttn^sh complete and incomplctä ÜBctures.
JnoompleU fracturea arc again sutxlivided iiito Jfoffureji, L c, dctta,
cntcla ; lliey are roost Sequent in the flat honea, but occur also in the
loi)^ bonott, especially as longiliitlinat fissures aerompanying other
fracIurL-^; the clefL may gape or appear »imply us a crscJt hi glass,
J>\fraction, or beading is a partial fracture, which, as a rule, only
occurs in very clastic, suft hoiii's, ami expeciulty iii ruchitiu children;
joa may best imitate this fracture by beading n quill till its cuncuvc
»do brviiks in. Iq childrcu, such ioCractioos of the clarlclc are not
rare. What wp mean by »piintermg is evident ; the most Irequent
fsauses are macliine^ utter«, »abrostrokes, etc Iji»tly, tlie boQe may
be perfomtvd without entire aolutiou of ooiitiuuity, as by a puncturt»!
wound through (he scapula, or a clean »hot through the head of the
humerus. The latter variety of injury is callwd ^per/orMeä fracture.
CoBipirl', fractunt arc subdivided into tratuetfee^ oili^ue^ tonffi-
liufinaf, ilcntatf, 9imple^ or mi^iplc fractures of tlie samo bone, iwi»<
tHiHtUed; all of these expressions eiplain tlicmselves. Lastly, we
roust mention that [K-isuns as old as twenty years nmy also have a
•duttOQ of coDtiouity iu the epiphysis cortilag««, olthoi^h thia is rare,
and the lung boues break muni reudily at some other ]Kniit.
Frequently ic is cosy to rccognlo: that a bone is breiten, and a
DC>n-pro£es«iunal person may maku the diagnosis with certoiaty; tn
atber cases the dingnusis may be very difficult, and oocosionaliy coo
coly be a proluihle one
Let us lake up the symptoms one after anotlicr. First, occubtom
^urself to examine every injured part accuratc-ly, and compare it
with healthy parts ; thia is particnlorly important iu the extremities.
Xou may not unfn^iuently know what Uto injury' is by simple ob-
serration of the injured extremity. You «sk the patient how it hap-
]>ennl, having him uudrvssed meantime, or, if this be painful, have his
dotbes cut off, that yoa may oocuratnly examine the injured pari, Tho
■XBOlier aiid severity of the injury, the weight of any body that hu
üdlen OD the part, may Indicate about what you have to expect. If
you find the extremity cmokcd, the tliigfa bent oulnatxl, for iustancc,
and swollen, if suggilUtions appear under the skin, if the patic&t con-
not move the extremity without great ]i*in, you may with ocrtiiinty
decide on a fractun.' ; here you oevd uo further examination to decide
on the simple fact of a fracture, it ia not necessary to put the patlcot
to any pain on this aoivunt ; you havo only to exaniiae with tho
170
SlUPLB FRACnmES OF BOSWS.
Lsnds to 6nd faon- and where the fnirture mmi ; this is Itss neoeosaiy,
on nccoimt of determining the treatnipnt, than to be able to decide
vhfithcr »r«! how roooi'ei-y will result. In llii» e«»o you hnve mad«
the diagnosis at a glancL', and In surgical pntcti^w it. will orten bo ca£^
for you to nxogobx rciy quickljr the true state of afTains, when yon
tire aocuatotucd Lo use ymiv vyva thouglitftillyt Bud w)i(>a you bare ac-
quired a oerlaiii bnbit in judpng of normal forma of the body. Never-
tfaelesa, you sbould koow perfectly bow ynu arrived at this aoddea
diagnoflis. Tlie first point was the niotlc of tlic iDJui7, (lien the do
formity; the latter is caused by two or more pieces of bone (Cng-
tnents) having been displaced. This diiilopation of the firagmenta is
duo partly to the injury itself (ihey are driven in the direction tUat
tlicy maiiilnin, from the bending of ih« bone), partly to the muscular
action which no longL'r affects ihc entire bone, but only a part ; the
musdes are excited to coiitniclion, partly by the paiu from the injury,
partly by the pointed euds of the bone ; fyr lustaiicc, the u|>pcr po^
tiou of a frattureti thigh-bone is elovatt-d by the flexors, tbo lower po^
tion is dmwn up near or bi^hind the upper fnigmcnl by other muscles,
nud tliuä thi; thigh is ahoi-teiieU and deformed. Tlic tvillirt(f is caused
by the effusion ()f hVtod ( ivo «poak h^re f>f a fracture tliat Ita» just o<y
curred) ; tlie b!»wd comes chiefly from the medullary cavity of (he
bone, and also from the tc&scIs of ttic surrounding soft part« whidi
hare been crushed or torn by the ends of the bone ; it loolca bluiali
through the skin, if it works up to the skin, as it gradiuiKy dtjes. Tlie
pntieiit ran only movo the cstTomity with great pain ; the cauae of
this diiturbanfm of function is c%Tdent, we need waste no words on
it. If we paatnine each of the above symptonm separately, none of
thcni, either tlic ninde of injury, the dtfürmity, sirelting, enii:(ion of
blood, or functional disturbance, wU alone be evidence of» firaclurei
but the conibiiuititin is very decisive; and you will often have to
make such a diagitoaia in prncttce. But all these srmptonia may be
absent when ihi^rc is fmcturc. If there has been an injuiy,and noao
of the above g)-mploms are well dtveloped, or only one or otJier of then
dblinclly exista, manual examination mimt aid ua. MHiat wiU you
feel witli your bandsV Vou rIiouKI It^ini this thoiouglily at oui.-«. I
do often see practitioners feel alxtut Uie injured part for a long lime
with both IiMmln, raiiMing tbe patients uns[]eakah1e p&tn, and after all
finding out uulhing by Ihcir examination. By tbo toucb you may
perceive three things in fractures: 1. Abnormal m^ilü}/^ the tytHy
pMthogiionionic »igu of fracture ; 2. Yo«j may often detect tbe course
of the fracture, and often whether there are ranre than two fragnienta ;
3. By moving tbe fragments yon wilt often expericoce a rubbing and
oraeking of the fragments again«! each other, Ibe »o-oalled ** erqtita-
SnOTOHS OF SIMPLE FßACTüBBS.
in
r^n" — alrioÜj to crepitate means tocnwkle; this is a sound, and sUU
My, «o feel crepitation ; it is ito ub« to object to tbia • this ii an
iboso of ibc wonl, wtiich has so ^onc into practice, bowerer, tbat it
canoot be rooted out, and every one ksovrs wliat it means. An cdth
cstcil touclk usunlljr- fuels ut oucc all that can be dele<^tcd by tlio
touch; bcDcc it 'a uimeocssary to moke the patient suffer kiii^ under
this examination. CrcpilaLion may lie absent or very ladiatinct; of
ooorse, it only cidsts irhen tlie Irngments aw bo move«], and vrhea
they ore quite near eacli otiier; if tboy be conidderably displaced
UlctttUy or be dravii far apart by mtuculsr coatfactioo, or if there be
Uood between the fragment«, no crcpitutino can be felt, and it i$
often dUBciilt to detect when tb« booes lie deep. Hence, if we
«lel«ct no m'pitatiDTi, tluJi, in opjioaition to all the otJier symptoms,
does not ppoTc that there ia no Craclure. StUI, even where there U crqp-
itatioD, you may mistake its ortj^n ; yon may have a feeling' of fric-
tioQ under other cücumatancea ; fur iiistancL*, the compression of blood
ooagula or fibriooiia exudation« may girc a feeling of crepitation ;
this soft crepitation, which U analogous to pleuritic &ictioo, you
shoulil nut and it-ill not mistake for bony ercpitti;) after some experi-
eaoe iu cxumioation ; nbcn opportunity oQ'ere, I «hall hereafter call
your atlentiou to other soft frictiao-soundB which occur espedaily in
■he ohoukler-joint in children and old per«oits. For ex^wrieuoed but-
geoa», ID certain fractures severe pain at a fixed point is cRuuf^h fur a
■t diagnosis, especially as in contusions the pain on jBfrasping; tho
<ne is mostly diffuse, and rarely bo serere as in fracture. If we aro
examining: an extremity, it ia best to seize it with Ixith hands at tho
empected point, and attempt motion here ; this manipulation sliould
be firm, i>ut not rough, of course. I must add something about Uie
dislocation of tlie fragmeots; this may I'ary, but tJie di^tlooement«
may be divided ia t-arious elates, which froui time immemorial hare
had ccrtmin technical designaUoii», uhivlt are still need, and which
ooowqueutly must be explained. Simple lateral displacement is
caUod düiocalio ad latua ; if the fis^mcnta form ao angle like a half-
bnkeo stiek, it is called diMocatio ad axin. If a fnigmuut be rotated
more or lesa on it« axis, we call it diiJocatio ad periphtriam ; if the
laolteu eoda be sboreil past each otlier vertii.:ally, it is a dülocatio ad
longitudintm. The exprcaaions are ahort and diatioetire, and easily
nmembeied, espectally if you represent to yourselves the di8|dace-
nieote by diagrams.
"We now pas» to a descnptioo of the course of bcaling of a fnio-
tur& Vou will mrely have tlio opportunity of seeing what happens
when DO bondage is applied, as the patteni geoermlly sends early for
a Burgooo. But occosiomilly the laity undervalue the imporlance of
172
nVPLE FRACHTRES OF BONES.
tbo iojuxy ; scrcral du^ pass before the pujn and dutalion of Uie
affectioD st last cntisc tlic paticAt to apply to a sui^^eon. In such
casc-s, bc»i<l<ra the symptoms of frncturc already fpveu, yiiii find gnml
OBdema, and in some few coses iaflammator}' rodncsa of the skin about
the point of froctitro ; under sivii circumstances the exaniinntion may
be v«ry dii&cuU; cxxiuionally the swelling is to cunsiderable that iiu
exact diagnous aa to the course und TuriL-ty of the (racturi; >a out of
the «question. Hence tlic earlier we see n fracttiro the Ijctt^r, The
subMquent externa] obaugea at tliD point of fmoture may bout be
studied on bones that lio superficially, and whirh cannot be aur^
rounded willi a baiidnji^, «s on fracture of lUe cUviclc. After seven
to iiitiu dikVH, ttie inllanimntory «edematous swellin;^ of the Rkin has
subsided, the cxtravasated blood liaa nin through ita diaroloratiotis
and goes on to reabsoiption, and a firm, immovable, bard tumor lies
uroutid UiL* point of fnicture ; t)ii)> i» larger or smaller noeording- tu tfao
dü]ocatioQ of tlie fragments; it is, as it were, poured around tlie frsg-
ments, and in the course of eight days becomes as hold as irariiJa^ ;
tbia is «died t'OÄuA Pressure on it (the frsginent« can witli difficulty
be felt tbroiigli it) is painful, though less so than previously; aubs»
quctitly tlie eallua bccouiL^ ubnoliiUly ümi, ihn brxikcn ends are Qo
longer movable, the fraeturc may be regarded as be&led ; for the clav-
icle this requirps thrtw weeks, in smaller bones a short«r,nnd in larger
ones» nnich lon^rtiinp. But t)iis dors notond theejttenuddianf^;
the callus does not remain as thick as it was ; for moitlhs or years
U grows tJtinner, and, if there was no dislocation of tlie fra^nonts,
after a time do tnioc of the fracture will remain; if (here was a dis>
location that coidd not bo rcJuced by troutment, the cads of tbo bona
unite obliquely and after uljs<jf|)lion of the calli»« tbo bone rcmnh
aoobed.
To find out the diangos that take place in the deeper [arts, he
the fractured ends unite, we try experiments on animals. Wo make
OTtLfldal fractures on dogs or rabbit», apply a dressinf^, kill the ani«
mtdft at varinufl stages, and IIh*» examine the fravtiin.-; we may thus
obtain a perfect representation of tlie process. These cxporimcnls
have Iteen made ianuineruble times. Th« ri'i>ults have always been
essentially the same; but, if we spcnk of rabbits alone, there are
certain Tariations wliicli, as proved by numerous experimeDt«, depend
on tb« amount of dislucaliou and of cxtravasation of blood. Henee^
before showing you a series of such preparations, I must give vuu the
leeultof these invceligatinti?, and exemplify tbum by n fcwdiogmms;
then you will hereafter readily understand the slight modificationa.
We ithnll first conrinc ouTSelvea to whotwc can see with the miked
eye and a Icna. If you oxamioc a rabbit'e leg three or four da^-s aAer
roiiMAKOS or cALLtra
173
tl»c Encturu, and, vrbilc it is firtnty bctil in a vice, saw the bone \ongi-
tttdiuUj, joii find tlic following : the soft part« about tli« fracture aro
swollen anil *.-1a«tic; llie muscles and subcuttttieom cellular tissue look
taiiy ; the swollen soft part« form u spindlostiapcd, not very tilled
tumor about tbo ecoI of ftacturc About the broken emiä vre find
aonc daric extre%-asated blood, and ttie in(>dulliu^ carity at tlic same
poiot is MiRicwlmt infiltrnted wiib l>Ioo<]. The nmount of this escaped
blood Tarier, Ix-iii^ souiotiiiK.-» very slight, iiguin cousidcnkblv. At tbo
point of frectMiv llie ]>criosti>iitn may tie readily reco^izod, and ia in-
tinutifljr ooiinectcd with the otLt-r swollen soft parts (which are tbo
aoet of plastic iufiltTution). Occa&ionaUy it is someirliat detached
from the bono at the point of fracture. The whole thing looks about
u follows (Fig. 40) :
Pk.41.
rM.icL
Ii««iBl<»tlW ••cllon of a l>«ctm« of«
nbkll'a luiM. ftrar riari old' o, «s-
UraMlcd UwkI ; A, >wnlli-n «ofl patl«
nwiMl Ml>ti ; t, potteiicain.
Dlurnua or« lunirlinillual »enliHtora
fllÜMDHbr^ld rnclnmof ■ ions bona ;
4. kunal mIIiw ; t. Innw. c. oour
tanr of «»dilution of Ulf KUttnkl
cdnnt A ae« poriwloom. T^ (tt-
moniloai uT Ih« eallDik la prapoMlon
to Ibe Millr« tedC or ilalocalto« «f
ilM fTumimla. ara repmcntad m flu
loo tr'**'- !>"< ■I'l» (ulUiMMikepM-
JtoUnirj (uxlu.iUuiUactf llMna&
If WO now examine a fracture in a rabbit »ft«r ten or t wflvc days,
I find that the cxtni\'a6atioa has cither entirely dituippcarcd, or that
a Hligiit amount remnins. I will not misu llto qucsliun as to
whether it has lieen entirely rcalutorbcd, or bos parity or^iiizcxl to
odlua. The spintUe-sIiaped swcUtng- of the &oft part« ho« mostly the
BppeanDce and constniencc of cartilapf, and has also the same micro*
■optical diaracteristics ; in the mcduUary catily also we find youjig
1?4
SDIFLG FltACrntES OP BOKEä
cartiluge fonnatioos iti Um vinnitj of Üie Cracture. Tlie lirokcn bone
sticks in this «irtilnge ns if the two fragments had been dipped in
Eea]ing-wiix aud stuck tugvtiier ; the periosteum is still tolerably di^
tinct in the cartiliiginotts mass, but it is «wollt-n, nnd its conloura aie
indistinct. Although there »re traces of o^sifieation crcn now, they
do not bpoomc very decided or evident to the naked cje for sorae dajB
(perhaps the fourteenth to the twentieth dxjr after the fracture).
Then we sec the following- (Fifj. 41) ;
In the vicinity uf the fracture theru is ymitig soft boiic ; ]. Tii tho
medullary cavity (a). 3. Iniaiediatcly on the cortical liver (i), and
eame diälunco up and down bonealli the jierioatciini, wlticli haa disap-
peared in the whole sptndle-shapcd callus tumor. 3. In tbe periphexj
of llie cullunt, whieh is still mostly rartilaglnoiu (e). The pejiosteum
which prcriotuly luv witliiu (he niiius b&s novr disappeared; la its
place a thickcnod layer of tissue has formed on the outside of the
cnllus, wliioh repreBont« the periosteum (</ ). Tli« youn^ honc^ub-
stani« LS ooft, white, and in it vre may sec a kind of fitnicturc ; for
Bomll parallel pieces of bone, corresponding: to tlie transrerse asia of
the bone, may he distinctly «ecn, espeoJally on examination with a
lens. The cartilflj^ous callus funned from ihesiiiTOimdingsoft psrts,
into wliieh the pcrioEtcum also has been (wruy trancfornicd, now
fomu on enclosed whole, and ossifies entirely, partly from n-ithout (e),
[tartly from within (&), till finally the ends of the bone stick in bony,
afi they previously did in the cartilaginous cullus. This houy ealliis,
which consists entirely of «pnngy bone-suhstunoe, is called by -/>!(-
put/tren '^provisional ralliu,''* As it is completed, Ihu bono is
usually Gmi euouj^h to be sf^in cufHible of function ; but the callus
does not remain id its present condition any more than a recent eieu-
trix of the soft paits does. A series of changes occiim in it in the
course of montlis or years, for up to this point yoti may still comjiani
the union to that by sealing-wax, wliich is not a true organic union.
So far the firm cortical substancte is only united by loose youngs bcme-
flulwlaoce; the medullary cavity is plugged nitii bone; the healing
is Dot yet solid; I^aturo does far more. We shall now study the
subsequent changes; they are confined to the spongy subataoco
of die callus. At a certain time this ceases to increase, and then
changes, by rc»b3ur|)Uon of tlio bciuy substance that bus formed ta
the medullary cavity (F^g. 12), and ty the dissppcaranoc of a great
part of th« external callus^ Meuatime, fomiatton of new bone has
commenced between the fractured cortical laycra, eo that thLi baa
become solid by the time the external and iaterual callus disap-
pears. This oonniCctiiig bony Bubstance between the fragmcnti grad-
ually inoreaacs in density, to such an extent tliat it becomes as hard as
KTNIUN W FEACTl'R^
IW
the umf mil>Mir|>tion and ixmilenurion
take liaise in the mcdulUrjr canal and the
Ih« boi»e in Ui« normal cortical «iihstanoc. In case there lus been
little or DO displacement of the fragmenia, tlie bone ia thus «a fully
nvtored tiiat vie can no loii^fcr detcnntno y^^ ^
tbc püiot of froctfire, cither on the living
person or tbt' niinloiiiioa.1 |ifT-p«nitioiL
The above churigrs occur in u lon{[
bone of a rabbit, where there luu been
tittle displacement, ill about twenty-six
or iwentT-eight weeks, but in the long
bones of man laat mucti longer, ao far «a
tre can judge from preparations that we-
Bcoidenlally Iwve the opfiorlunity of ex-
nmiDiog.
The entire proccMi, »to cxnellentlj? «in-
tiired by Nature, ia eiiseutially the sanio
ms wliat we otieerre in the normal dcTct-
onmciit of the loiw bones; for lltere, loo, LonsiioJiuni «ciioo »f * fMMUMd
• ^ ... hansrruiiikrmiiWl,mn'jr twtwty-
Iijur «colt«. PrestsMlT« roM-
■i>ri<il<.a at tfa« «•lUM. B«*4art*
■lot) ■>( ibc nadnllanr eavUj,
. , , , r % % I ntninl •!«* ; ■ft*r (7«rtt
cortiml lajcn of the long bones, as we
bare jiuit ftudie<l in formation nf eallus. Kxeopt the regeneration
of nerves, no Eui'h cumpleiu restoration of a (leslmy«^ part takes
phee in any other part of tbc human body as vre have seen occurs
in the bonea,
I must Rtill ndd a few remarks almut the healing of flat and spongy
boQCA. In the case of tlie lirf>t, which we sec moAt frequently in the
bealing of fiaiuivs of tlie (.T^uiiol bones, the development of provi-
flioofil callu« i» very sli^l, and occa>innii1Iy apj>eiLrs to be entirely
wanting. In the acapnia, where dtslotnlioii of »mall, or balf or
wholly detaehed ftagmenls ig more ajtt to occur, cstcnial callus ktrma
more readily, althotigfa even here it never beeuun>H verj' thick. On the
tnikia of spongy bon«-s, too, in whieh, ns a rule, there is also hut little
cUsIooaUoh, there is hAs ilevnlnpuieiit of extenial callus tlian in Uio
long bones; while, on the otlier hand, the cavities of tlie spongy snlv
suncv io the immediate vicinity of tlie fracture are filled with lx«y
aubetauce, ul which part, at least, Bubsequcntly disappenrs
Aa may ivadily b<> imagint-^l, the (^tiiditioni* will be somewh&t
mora oomplieated when the en^la of the bone are nnieh disloeated, or
when fragments arc entirely broken off nod displaced. Io such caaea
there is audi a rich development of callus, partly from Ihe entire sor-
6we of the dülocated fragmenta and from the meilnllary cavity, and
partly in the soft parts between the fragnveiits, ^at for some distnnne
all the Cnigmeat« are embcddv^ in a boov nuusa, and organicalty glued
13
IM
SIMPLE nUCTÜRES OF BONKS.
together. Tb« luTfCct the circle of irritatioa from th« ditlooftted fra|^
meats, the mon exttuisivo tlie fonmitive rcnotiod;].
Ill nuiii we most frcquttiUy haro the opportunity of soeing callu»
Ibrmiitioa Jo greatly Uislocated (ractures of tbe clavicle, where it i»
vevy cviAeat tliat the extent of the new fomuitiaD of booy «ubstanoS'
is direotljr proportional to the lunount of dislocatlotL Vou m&jr read»
ily UDdRTBCand hotv, in this way, with cztcnsiFe SomiatioQ of aoo-
plaatio bon«-«ubetAnoe, there mny be perfect firmoeea, eren with great
defonnity nt the point of fracture. Still, one would hardly believe,
without satisfying liiitisclf on llic point, from pn^tatatiooB, iliat with
time, cTca in such cose». Nature has the power of rettoiing, not only
the outward shape nf the bone (except the cun'uture and rotation),
but alw the medullary- cavity, by rrabsorption and onidensation.
FW. u.
Vn. U.
PMeliti««rth#tlMaaf> rabbit, ollli
(:n»i dlfllDoulnn, with exMiBlTa
omutloii of Ulla*, mfi«r tl i»j*.
K&lnrai »Ue, %ltrr Sbiück,
(üHrffi Ftactum. lui.i., p.tHt.)
Old aatt«d obltgii« tncnm of« Unmaa iJbU :
Iba end* of tbo fMtfiBMnu Imtw h**« ,
POUDdEd off tnr itMOnMloa, Ifa* «zMnd .
ulln* r«tb*orW : foraitioa «r (h* »••
dollaiT mtIit luconplvM SIm diailn-
Numbers of points, nodules, inequalities nod roughneMM of all sort«,
that ore formed on the young callitfl in nKient o.ises,'»o dianpiiear in
tbe ootine of months and years, that in ibcir jdoce there is only loft
some dcnsoi coiiipuot, cortical substance.
FOBHATIOK OF NETT BONE.
177
It «rill novr be intcrcstinn: to invcetigate the tmc (n%in of Uie
nevrly-formcd bony substaiico [ i» it produced bjr the bone iuclf, bj
the periMt^uin, by the Burmunding soft parts, or is the »trarasated
blood tnuiaformed intn bone, as was bcUe%~ed by old obHcrreni?
Hiul Ibnnation of cartilag« always pre«ed« tliat of bOB«, or i» tbia
oBiieoMeary? Thi^s« questions have raceirml various answera, till
qidt« recenUy. 1^^ tJie periosteum, especially, great power of prc^
dudag boac hoa at one time been ascribed, nt anotbcr denictl. lo
what jbllows, I will l>n«tly givo you the reetdta of my itureotigatioDS
on this aubjnct.
Tbe new formation that results from the fracture occure io tli«
medulla and Haversian canals of the bon«, in the periosteum, and in-
(lltmtec) in (he adjareiit mtucJca and tendon»; pnsKibly the extravu*
sated blood may alao liai'e something, but very little, to do with the
fonuatioa of the oalltts; a large oxtnuruMtioD is disturbing here, as in
healing of wound« of tbe soft pari«, for part of it must be organized,
while the mnaindcr is absorbed. The inÖammatory new formation
here, also, at first consists of smntl roimd cells, which iocrease greftltv
in number, and infiltrate the tiASues mentioned, and then almost tnlce
their phux. Before following the fate of tliig oeJl-fonnatiou further, I
muat bricfiy consider it« ooune ia the Haveraian oanaU. I'bc oell-ia-
filtratioa in the eonnoctlre tissue of tbe medullary cavity offers
nothing peculiar, except that lite fat-oells of the medulla disappear
in the tnaaa as the wandering cells take possession of the territory.
Suppose the fbUowing figure (Fig- 45) to represent the surface, or the
fractured nurfacc, of a bone on which, as j-ou know, the BaTendan
oanala open ; in tlicee canals lie blood-rcsaela, surmundod by fwome
ccmneotive tissue.
2f this bony sur&ce be in the vicinity of a fracture, numenius
Fw.«
raJtfc^
^^''*^^^.
'-M^.
-^J
-f^ ^*»i-.
Otamniinrakiniirliiiillni! imiIob ihmnrh Uw witkalBi*«l*ae«or»loi«b«»«. «^M'*««]
^i, IbivnU» uiul'. >llli blood-Toai^ «nd ouumtl«« UmQ«; I. ptrtottonaL lUgnla«!
AlriiaatMn.
ttB
StUPLE FRACrt'EE UF BONES.
oella finit come between the cotinedtire tissue in the Haveniiia (»dbIii ;
sliüiild til!» r(^ll-iiifi1tnil.!on tie ver^* rnpiil, il wnutd entirelj' nnmpreu
the blood -vcsficls, and cuusc ibu deatli of Üi« buue, a pnxx»a whitli
wo hIikII lientafter Ipsm, But, if the oell-iriereaso In ihmts miwls goes
on »lowly, their walU are ^duall/ ahsorb«!, as it would appear, by
the inSammator}' new formation itself; the canals aiiedilatcil, the oelU
fill them, nod at the ume lime the blood-reMels inoreue by fonniog
loops.
From the obserruitons of Cohnhcim^ we must suppose that in
inflammation of botic, nUo, the yoiinf^ ocIla in the H«rfrr«ian canals
are not newly formed, but ar« whilt- blood-oells escaped from the VBS-
aela. Thin has no cfToct on the «ubscqucnt course.
Now, let U9 turn to the ohamgce of forin Uiat we obacrre in tbe
ffitseous tissue Aa the connective ti!>ßu« of itie oMieoudi <!anala U oon-
(iniiouK, both wtUi the perloRteum and medulla, t)i« cell-i»6tlntion
into the bnnr, pnrioetoum, and medulla, is aUo continuous. The cause
of the «trophy of bone along; the walU of the Haremian catul»,
wliii'h takes place in thU, as in moot other new formations in tbe bone,
i» difKrult to «xptuiii; lh<; disappearance of the connective tissue and
miucular eubstanc«, aa well as of other soft structures, when tbe in»
ÜKiniiialDry new forintitiori owiirs in them, is less ntninge; but it is
truly ivinutkahle that hard bony aubstanw; should thu» \k di&solved.
This process lui^ht be represented by the foUon-ing diagram {Fig. 46):
-^tjiJ^ ..^W^*"
Diagmrn«! Iiitlkminal>jr7 a«ir ronnKllon la Ui« lUranlaa «aatl*. a.aoMlMe: B H, ll«ni||ia
caniili, dIJatcd. (lllnA wllhcnilaaru] nev reaKlBi e. pprtualoiuD. MipilSrl Itlff iTMTinHri.
Vou sec tliut tlie dilatation of the nmeous nnals is not regular,
btit of imoTwi widths ; the l>onc looks as if gnawed out ; this ia not
nwesMtarily »o, llic nliophy of the bone may be more regular ; aeeon)-
ing to my idea, these irrcgiilariLiea result from the oollcction of cells
In groups, or from looping of tho tcsscI», which proas against the
FORMATION or CAU.CR
17«
"booe uid cause iu atrophy. Virc/tote aud otbeni believe that tbese
;protubcniiic«s corrcspuod to tlic Dubieat tcrritor/ of certain booo-
«ells, which in thia process aid in reabsorption of tbe boiie. 1 think I
have refuted tliis, by showing that even dead portions of bone and
irory are also affected by the ioilsmmatory new fbrmatioa ; we shall
speak mnte of this w-hen treating of pseudartUrosis. At pi««ent it ta
luit known tiow tlie Iiinc-«alla aro disaolrcd id this prmiusti ; I think
pnibably the new fonnation in the bone develops lactic acid, vrhich
cliaog;ca the carbonate and phosphate o£ lime into soluble lactate of
lime, and thattliia Ls taken up and removed by the vessela; but this
ü only hypothe-sts. It would ulao be po»a!b1e for the organic imsh of
the bouc, the fio-callcd osseous cBrtilagv, to be first dissolved by the
iuflamtnatory ocoplasia, and then there would be a breaking-down of
the dialky aubstaore, MrhoRi* molecules woulil be Bubsetjueatlv re-
moved, even if undiitsolved. Although I have conversed with many
cbemifiU and physiologists on this point, none of them Itave given me
a simple explaimlion of this proeeas, nor oould they indicate any mode
of experi men ting tlial might aid in solving the question.
Ill tbe above diagnma, if we suppose the fractured suHocc where
there is no periosteum, in place of the »urface of the bone, you will
UoderalaDd how tliu uew fonoatiuii (the youug callus) grows from it
out of tbe Hav<;r»iitii o;inalA as above described, similar neoplasia
from th« other fragment me«;ta and unites with it, aa in healing of
the soft parta. It ig evident that the bone through which the ioilani-
matory neoplasia thus grows must beoome porous, from tbe rcaluorg>-
tioD that takes place on the walls of the cooal ; if you maoeratc a
bone ID this sLagc, till the yuiing neuplasta decompose«, the dry bune
will appear rough, porous, tH'swcd, white young bone-substanoe is
deposited on it and in its medullary cavity. In tliia whole explaua-
tion wc have not mentioned the bone-cella or stellate bone-oorpua-
des; I am convincei] that they hare as little to do witli tlieae pro-
ccMes as the Exed uonneotive-tisstie cells, and that tbe boue-&ub-
■tatioe, like the soft porta, is dissolved by a certain amount of inflam*
matioo, and replaced by new.
So far we only know the neoplasia in the state whore it consista
eawntially of cells and vessels, as the soft parts do under the same
circumstances; if there was retrogression to a coimectivicytiaBue ciea-
trix here aa there ia there, we alinuld have no solid hone formod, hut a
oonoectivfrtisaue union, fit«ud<tnttro«is (from ^tvi^y false ; npdpw^/^,
Jcdnt), afidaejoint; we shall hereafter describe Üiese exceptional eases.
Under normal oircmnstances llie neoplasia now osaifies, as you already
know. Tbi« oirificatioii may cither occur directly or after the inflainma-
lory neojdasia has been transformod to cartilage. You know that both
180
aiMFLE FRACTURE Of BOKES.
of these modes are seeu in ournwl growth of the bone ; direct ossl&cft*
lion of jMung cell-fonnatiotif for instance, in the periosteum of tlic
growinjc bone, or fonnaticm of cartilage with subsequent •»xificatiou,
M ut fint ii) tlie entire skeleton and in gruwtli of ibc bones leugth-
wiaa Cullu5 fruin fractures raries grtüutly in this respect in men and
wiiintls. la rabbits the oallus is alwaj-s changed to cartilage befor«
ossification, as it abo is in cldldren. In oUl dogs the callus usually
ossifies directly, ns in the humau adult ; wc on: far from knowing Uie
causes of thceu diiTcninccs, Tu obtain a hiatulugiuaU rbpfDCcataLioii
of these procossea, lot us return to our forraer diagruin (Fig, 46) ; now
inia^ne that the ct-lls, lying in thu «pace« cauiwd bjr rcabeoqttion in
the Harcrsian canaU and »urlac« of tbo bono, soon ossify and first fill
these spaocs (Fig. 47), then collect on lb« surface and in the medulla,
Fl«. -IT.
P^:
■-(^•■
t' >o-.-
;«><
■^\
^-K,i?VVa .4b^
BUtfiM er bmIBmUwi of iBfluuniBlon' doodIwU on Um •arfftc« ol ItoiMM Md la lb« Batrcik
«teenwla. OtlMiplsuLlcpiirimUiii udotlitb. MaosUtd MO dboaUn.
•ad thus fonn the external and internal callus. Periostitis and
oatitis, wliifh lead cli it-fly or exclusively to the formatioa of oew
bone, wc call oatcoplasUc \ in the present case the callus is tlio re«idt
of this.
As pn^viously rcmarkud, the pvrioRloinn is tiec^d up in tlie ncv^»
sia and ia ossifying oallu«, in its place, extenvully around the callus, ^
thick conneotive-tissue layer deTvlups, front which new periosteum
b fonncd. I will show you a few more preparations in cxplaoatioD
rORlUTION OF CAiUfUB.
Tin a.
IBl
r^k
Tkiallju(kaTMU)-«M(n«Mn. LüosluuliiMlMOIlia-«, «Ulaii ft, frjog. lUniaedM
aian«un.
Fm-Hl
*>/
[of tbe prnoeu in the periosteum. Yon see {¥"ig. 4S) tlie peculiar
rooune of Uie veooctts almoeC at riglit angles to ttie booe, which eutcr
tlic bone tbraugli the youn^ calltia
The oaaification ot tho callus bn^D«,
iiumtloUkc, around tbeae resseU, and
llie little colutiiim wliicli first u|i|>eur
in thf!«xl«riiiili!aitus are Utu» foriticd
{aee reiiwrka on Fig. 41).
You have a guod representatkm o{
the formation of «external (periosteal)
and inlenml («nduKtval) callus iu tlie
fdllowiog (ini-oiiiplct<')traiiar(^rec acc-
tioo of th« til>ia of u doj(, from tb«
immediate vioiaity of an eij^btnlay-
(lid fracture, in whtdi }'o<i niuat ulw
otwerve th« v^sscla of tbe oortit-nl sub-
fltanee, which am considerably diUit4^
M oompwed witJi normal {Fig. 49).
LmiUjr, obavrvv tbv following prcpa-
latioo. It ie »ii fi^lii-<]iiv-o1(l,alivudy
odüfiod, extvniul cnllusoD tlitf Burfsce
" ' 111-*«-**) rrw). times (Fig. 50).
ne Ttdnlij' or «n eli
tmt*. a. iBMrnal o«ll
*£i°^!rtEfJS!L°' *■ *°'* *•■■*■ If ^c »ow ricw tiro pmecsa as a
whole, we scf> that the cell iiiÜltfo-
ttoa in the bone itself, us well as in all the surrounding parts, aida
i'fai the (nrmatiun of ndlua, and that bence tlie periosteum pla^-s no ex*
I'dusit-c ueU^huitic nUf. 'IliU mi^it have beeit coiirluili:i) a priori*,
' beosuae, if Oto pf'HoAteum aioiio forraed the eaternal nallua, ai wat
formerlr supposeid, the partkxM of llie bone frett of |Mrio«teuiQ, na
tbnar place« whcie tendons aco attiich«d to the banc, could (ona »o
bcUlus; thift i» directly pontradioted by obssmtion, In normal growth,
IBS
SIHPLB r«ACTUB£ OF BONES.
also, the periosteum doe» not by any roc«n« play tb« importAiit p«rt
ii»crib«(I t() it ia ihe ibmuitioii of bonv; for we may just u coiTe«t1y
reganl Üii: luycr of younff evils lyioK od thr fturfac« of the bone, nod
<!xtcm1ing iiito tb« Hnvcraia» cuiiats, a« bcioogriag to tbe Imii«, u» to
Tcter it tu the periosteutn.
^^^ ^Äö.«^
> -
.";• '.
:i<2-
.»*:,
•^'
p_ jiij»
?-?r^T^
■-•J" ^'' 1 .T - ^.
ij^-^^ ^^_» '*
lOai rMm ibe Tidnltr of m alrttdar-oU baotam oT tbc tibia of ■ doc. Iumtlhidk
lOo, tuAfiiiAM u-Vi-ii, iv>rtl<allar*rof lb« Ifblt, wtth •'impwhiii ■lIliM Havprai»
iDNltl fr. Una jcaii;; iwcpuui cnbalsoc« MtlLcli lie !■ llreidv trm\y »lUt^nl ID dtobiifiB.
04«tb1n2
Th<* jMuisM»i«u«<Wn« i'Kllll T(ij-pbraui,lb«csvll1piiikn>flllnl »Uli yiMinjt Mm*ctlv«
llf>a* •Bd T**^U; aiaa, nim um'-duuI nnxiilu Hlmnoiju In luiijclluilliial aad baa»
I'pniixK'lloii; bti|n**n Ui*m *iv itrouii*or celU, whldialfc rTintuBEIr »■irj'.aeid tbui Um
LECTURE XV.
TlTilfTniHit or SImpU I'ractaraa.^Mucltoin. — Tlma for appljinit lb« DreMlng,
Ob«lM.— Plnsi'T «r rati» bud Stoniti DrEiiinjp, Splinu, Permaiicnt Siunaton.—
Bttainlne thn l.ltnb In PoiilUnn.'-lndtcBtioni for ivmoi'iDatbnDneaaiiigK.
Wk shall p«M Bt oil»' U> tW tre»tm<^iii of riitiiplc nr sulicutaneoiu
fntclurcs, eepecially fractures» of the rx I remitios, for tiipse «re by far tli«
more fn^quenl, and they jjarticulurly rei|uirt; treatment by t)r«sun}r)i,
wtiile tiiose of the head or tmuk arc to be treated less by drcsaiag;»
TREATMENT üV FRACTfEES.
188
,& bjr appropriat« povitioii, in ü luugbt in the lectures od »pnoial
and in th« surgic«! clink.
Hw indk'Htioas wv li»vt^ to ixifmidffr are, simplr to remove any
diskicstioiis and to keep tfac fractunxl eztxemitj' in the correct an»*
(omical poeition till the fracture is healed.
FSrst, the fragmeDts am to be replaced; Romctimes this may
be unnece-tsan-, an ivheii there is no di«.1ocHtioii, fur ttiKtanoe, in Bome
fractures of the ulna, Shula, etc. In other casea it is very dilRcult, and
Cauinot »lwa^-8 be done periectly. He obctadca to tLe reposition may
fcf in the position of the fragmentx thi^mselves ; one Jragroent may be
wcdiccd into another, or a amaJl fragment lies between llie chJeToncis
so tliat the Utter cannot be brought together accurmtely ; fractures
}4 the lower articular extremity of the humenis are Tery obstinate in
thu respect, for small frsgnteots may be ho disloi-aicd that neither
flexion nor extension of the «Ibow-joint con be pcrfonncd perfectly;
benee its functions rentain pemtanuutly inijiainHl. Muscular con-
irvccion forms a second obstacle to t1ie reposition of the fragmnnta;
the patient inroluntarily contract« the muscles of tbe broken limb,
thus nibs the Augments together or presses ihem into the soft parts,
causiogf severe pain ; this muscular eontraetion is ooraHionally almost
tetanic, so thai, even by great force, it is hardly possible to overvomc
th« opposition. Indeed, formerly tJiese difficulties uero, to soidc ex-
tent, Insurmountable; and, although attempts were now and then
Bisdc to attain the object by dividing tendoniB and muscles, it was
often only possible to attain an imperfect reposition. All these diffi-
culties were at once removed by the introduction of rhloroform as an
uHESthettc. Sovr, in all cases irhere wo do not r«^dily nuoceeil in
reposition, we nnieathetixe tfac patient with chloroform, till his mns-
des are perfet:tly relaxed, and we ran tlien nsunlly place llie fn^
mentti in position without difficulty. Sdint; surgeons gu nu far a» to
use chloroform in almost nil cases of frscttirc, partly for the examina-
tion^ partly for the application of the dressing. This is imnecessar}*,
and niay even pn»vc very unpleaAant, for some persons, capcdally those
in tbe baUt of drinking, at a certain stage of tbe anaesthesia are
■ficeted with spasniodin oonlmrtioiis of the extremities, so that, in
Spite of being oirefnlly lield by strong assistant«, thry rob the frso-
turcd cuds against each other with fesrful force, »ad w« must be ray
eareful that a sharp fragment does not pteroe tlie skin. This should
Dot frighten you from using dilonifonn in frsctures, witeti it is neces-
sary, but simply imro you against being too free with iL The meth-
od of reposition is usually »s follows : Tbo fiaetured part is grasped
by two strong asnstants st the joints sbove and below llie point of
fracture, and regular, quiet (ruction employed, while tbo surgeon
184
SIVf LB FKACTÜBK OF BOKR&
holds the cxlreinity at tlie point of Irooturc, and, bj gentle pressure,
atl<mpte to force the fra^ftnont« into pofiition. All eudd«a, impul-
Mvc, furoed tniotiou is uxeleKs, and should be aToided, üere vou
buv-c to tioUoe two tecbnkal expressinns ; we term the Iraction ou
tlic loTTcr pari of the cxtrt-niitj, «efwwJoi», tiiat oo tlni up{)Cr {«ri,
couitter-vitmuio». In fnicture«, thc80 arc boUi made Ij^ Uie Lmiids,
nrliilt* in dislooaiioTut w« miut ocautionally rt»Ofi (o diS«ivut mecfaao»
ioal appliances. Bj tbc above method accurate rcpo&itioa will only
be iinpoflsible when, from esoessive swelling or from ptKuliarly ini-
bvorable diakH^ution of the fragtncntü^ we are unable to correctly
recojtnizc tli« variety of the di^plnueioeiit.
From our present ideu, which «re ba«ed ort a larg« number of
observations, the sooner reposition Is nitwte after tb« occurreooe of
the fracture, iho better ; wc then at ouoe apply the bandage. THia
was not always the belief, but formerly the adjustment of the Crmo-
turc and the application nf tliH dn^ssin^ were delayed till ttie ili<uip{>onr-
anoe of the swWling, wliidi idratiAt always occuni if a dn-^ng i» iKit
at ouoc appliud. It was feared tltut under the prewuro of Uie drew
ing ilic extremity mij^ht mortify, iind the fomiutioii of cnllu» would
be hindered; witli cerlain cautions iu tlie applicatiun of the drea^
ia^, the former may very readily be avoided, and there ie
truth in the latter belief. Ri^rdioff the choice of the drejtaiog
8urj;von» have «if late reac^ied an alraoot unaoiroout Ofuuion. ft nuitf
(k mjarded at a nUe, tfuU a solid^ßrm drettiny stuiidd he applied at
nxrly (14 /HitstHe in aü cote* of aimpU tubeutattfcujt j^aeturt» of tAi
tMremitic» ; this may be changed altogutJisr two or threie timm, but
ill many cneai dous not need renewal. 'Hita mudc of dressing is
called lh« immotwiWc or ./fajerf, in contradistinction to the mov<tbU
drttsinySy wliit^-b must be mitewod every couple of daya, and arc
only proviatonul dressing.
There ore severdi varieties of fimi dressings, of which the mo»t
Rerviocflble are the |)Iri8ler of Parii«, Ktareli, and li<]uid glass. I shall
first describe tite pliutvr dressing, and show tta appltcstiott, aa it is
the OQO most Ircquontly used, and answers all rcquircmenta in a way
that can scarcely be improved.
PtaUer of Paris Bandaye. — After adjustment of the fragment«,
the broken limb ia extt^nded and counter-extended by two assiatants,
then one or more layers of wndding applied over the point of fracture,
an<l ove-T parla where the iddii lie» directly ov«!r the iKuie, u« oviv the
crest of tlie tibia, tlie oundyLes, mid muUeoli« Now it ts b»tt tn en-
velop till« limb with a new üne (Innnol rr>Ilcr^banduge, bo as to make
rt^pilor pressure on It, and cover all jiarts that an* to l>o HUfrouoiliid
by tbc pUistet^bandagc. In hospital and poor piactico^ wbere wooaif
TREATMENT OF PIUCTrüRBS.
165
not alwajs li&re flannel, we may use soft ooUo» or gnaxe buidnge«.
Now come« the application of tlie plasier>bujt]age« prepuvd for Üie
purpoto; tLu pluater-baiida^ ibat 1 berc laurv is cut Irom a VLvy tliui
fpitu«-Ukc stuff; it isprepnrcd by Bprinkliiig' finoly-povrdcrcd plaster
(tootlellitig plazttft) over tliu uurolliMl btindagv and then roUing it In
firivat« praclicc a number of these bandana of rarious aix«» niajr be
prepucd befurchaud und kept in a weU-c'loied tin box. Ucre in the
bwpilal, vrlieru the»c plii»tei^l>u»d»^'8 an- niticli lued, lUvy nie prC'
pared two or three times u. neck. Tliis boudu^ jou place in a basin
of cold water and let it soak through, then apply it like hny roller-
bandage to the extremity prepared as above described. Three or at
tooot four tliicJuieMtes of tliia plaster-banda^ suffice to give the dresa-
iiig the re<|uit(itti äminvas. lu about t«n miuutes good plaater b^
comes atilT eoouf^h for u» to lay the extremity loos« on the bed^ in
half an liour or an hour, th» dressing bet'otne» oa hard as stoo4f and
quite dry ; the time required for hArdcnitig dcpcada partly on the
quality of tli« pUster, partly on how much you liuve nioisteited tho
bandog- After many comparisons with other modes of applying the
plastor-bandugc, I have found this tlie most proctira) ; but I must
ncotioa somv modiÜcaUuna of the vray of lutiidling the platitur und of
the manual of the bauda^. For tnstaneo, wo may nib the pliistor
into the common musllD r>r flannel bandages, which makes the dress-
ing Mmewliot heavier »lul tirnier; lint thi» i» noL neoes&ury and the
looae gnuze is very much cheaper tliaii muslin •I>andnge. If the band-
age doe* not appear »ulGciently firm, we may apply a layer of plast«i>
paste over the droemoK ; this plnstcr-paate is to bo made with walor,
attdi spread on ih« b«nil.ifr(> very (|iiickly with the hand or a spoon ; it
should not be pr<>|uu«d till we wish to use it, as it stiffens very quick-
ly. The p1aeter-<lres&ing iis made with roller-binidagea waa first iii-
bwhiced by a Dutch flurg<.!on, M<ah*ft*>% ,* this method was (ir«t pub-
lished in 1S32 ; but it Itas only be(x>i»e well known unce 1890 ; it has
been spread tlin^xigli Gurnmny cliiefly by the llerliu nchool. A difler-
ent mode of applyiuj; the pUatcr-dressiuf; is by diScrcut strips of
handago ; Pirogvff firal hit un this mutliod frunn lack of baiida)(Gs
in th*? army ; all kinds of mnlcrial were cut into the sha[)e of s|i]!nta,
then drawn through thin plaatofpasle and laid on the broken limb,
ibeo the whole was ooet«d with plaster-paste and a fine capsule was
thus made. Sul)««i]uetitly the »ame siirg<eon inaile a special niethed
of this ; he out old coarse oailt.'tutli into certain patterns for e4K;li limb,
and applied it in thealx>vc manner. Lastly, tbe soKSalled many-lniled
baiidugu of Sculut was used in tlie sam« way as » pla8t<tr>bandnge.
The foimdatioa of the bandage has also been modified in various
ways ; it has even been used without wadding or any undor-bandage;
IS«
SIMPLE FBACTÜBK OF BONES.
the whole limb being aim]^j' covered with oil so that tlie pUstei»
bondage, being applied dirfctly, mij^ht not adhere lo tbe skin by the
fine bain. Others have emplnyed thick laj-cni of «addiitjf without
any iiiRlcr-bandsgc. Lnntlv, tliiti wotxlen «plints or strip« of tin lia.ve
been Imply used in it, as we slmtl ItercafUir oeu ; this may Iinrv certain
advaotAgcs in fenestrated bniida^^e«,
I have inteatiooally roprcaenled all these nrndificationB of tbe
plaster-bandage as only exrrptionally useful, all of them having cer-
tain objection» as cdtipureil with the uctliud firat described. A more
CATcful critleism of tlje«e modifiraiüons here would lead lis tt« fir.
For persons unskillwl !n llie matter, the removal of Üie pIksteM
bonduf^ is quite difBeuIl, but yuii may see that any of my nuraee
do it witb astotkisli inp <|iiickiie«»'. It h simply done as follows! witli
a sharp, strong garden-knifi; wc diride tbe plaster>bandage, not pei^
pendioalarty biit rather obliquely, as far as the undeHMndage, Uieo
remove the battdage entire, tike a shell ; we may also employ the
plastei^cisBors proposed by •Sx^ma»otr*X:i <:ir Uicwc of Brvna. Vte
use this capsule in suuie otimr cjusrs as a provisional drcsBiDg.
Statv^-ßamiagt^. — Before plaster^odagcs were known, w« bod
in tbe starctt-bandsge an execllcnt material for tlie immovable dreasiiig.
The »tan^li -bandage wns perferled and introduced chiefly by U>e Rel^<
on surgeon Seutm (t 18S3) ; it is only during the last twelve years
that it baa given pUw to the platrterKlresaing, but it in still used oc-
casionally. Th» application of the wadding and umler^lmQdagn is
same as in the iilafiUr-drrssing, but tlieii we apply spliiit«, cut
ooderately thick pasteboard and softened in water, to the limb, and 1
tentbernon with bandageH thoroughly soHked in «tArdi-poste; wei
apply woollen »plints till tho dret^in^ hii.->hnnk-ned, which at the or
nary temperature require about twonty-four hotirs. Compared to
phister-dressing this lias the disudvuutagc of liardening much moi«^
slowly ; wo may improve this somewhat if we use ffutfa-pfreAa aplinta
instead of pasteboard, tliesc mar be softened iu bot water, and
adapted to the extremity. Gulta-pereha bonds, BiM>h as are aited in
ftctories, are rery useftil as splint& Tt cnnoot be denied that tbe
Imtroductioa of gutta-percba into surgery- i» U> be ref^irdcd as a groai
advantage ; but it is too eostly to bo used in pnietiee for every »ttnplQ
fracture, althüugh tltick «plints of this nint«-rial harden even quicker
than plaster. Tbe drensing with roller-bandages prepared wttii plan-
ter b M cheap «ud firm that it will certainly not be displaced again
by slarcb •bandages, now tliat it bus been introduced into pracliee.
Instead of plaster, solutions of dextrine, pure white of egg, or
simpi« mixture of flour nod water, were formerly employed [ they
have all gone out of u»c, but it is well for you to know tbe useAdneu
TREATMKNT OF FBACTUBEa
181
of tbese subAtRnc««, vrhiRb aro ia erety bouse, and vbich we majr
well employ as provisional dreaaitigs.
Iiiyuiii-gUi*» DrtnthiQU. — Inslend of »tuvii, vir m&j en\\A,<ij tbe
liquid glaKs of llic shops (silicate of putaith). On upplying the drew
ing^, we paint this on the rnta»Iu)-b«ßd&go8 with % larpc Imwh, after
haring luadn a subsirätum of wadding as above dcsLTilx-d. The Uquid
^lam dries quidter than starch, but not so soon as piaster, nor does it
beootne aa baid as the Utter; this dressing doe« for fractures with no
leaden^ to displsoement; ifwewi^h tofixdiftlooatedfragrnßntsofboDe
bjrtbc liquid-güas dresün^, weuiu»t-str<.-Tif^hen !l by applying spllot«,
I doubt not the time will sooq come whca every country pfaysiciBa
win always k«»p a few p! aster-splints ready pi<epanKl; in spite of
tlteto, proviaionai drtsainga rcMiiain useful. These consist ot liantt
ages, compresses, and nplint«, of varinu» maceriala. Vou may make
■pliots of tiiin boards, shingles, cigar-boxes, pnsteboonl, tin, leather,
finnly-pbited »traw, tbe bark uf trt«s etc., and, for bandages, must
ofttm content yourselves with old ni;;s, iniutlin, torn iutu »ti-i[r3 and
»owed together; hence, in the pr«cti«ii roiirse» on b[indn;jing, it is
necessary for you to I«ini lo ni«k« us« of ilii! most varied mttterials.
It is DoC our intention here to intrtxlucc to you every thing tbat
lasy be used in the way of dressing, but I must still speak brteßy of
I a few thing«. A» may l>e r«iidi)y »oen, tbe object of Üie ttpliota is to
make the bone immoviiblu by supporting it tirmly on various sides;
thb may be attained by external, intcnial, anterior, and posterior,
I narrow wooden splints; we may, however, employ hollow splints,
^■D-called gutters. Hollow splints are only good when made of piia-
^Me material, a» leather, thin slicet-iron, wire-gauw?, etc ; an nhmiluteJy
Stiff, hollow splint would only do for certain persmis. Besides these
I mechanical shIs, tliei« is another nietliod of keeping broken ttiTibs i»
I postian, nsmply, pcrmanctU eaüferwion. Thb is particularly iiKJicatcd
ia cases whet« there is great teodeney to shortening, to diMocMiit (ul
I ionffUudinem. Atlempta bn^-e be^n made to attain this extension by
j attacbing weighta by various nie^'baaical rontrivancs, by coniinucd
traction made by weights liung to the injured limb, by the double-
inclined plane, where the weigtit of the leg is used as the exteiidin);
weight. Since, during the pajit two year^ I hsvt; tiuespectedly seen
such cxocUent effect from pcnniincnt extension with weight» in pain-
ful contractions at tlie hip and knee joints, I am compelled to believe
that this method may also (nrcntually prove very aeniceable for the
gradual adjtistment o£ dislocated fimgroent« of bone. Among the
UTsngenients of this nature with which I am acquainted, V. I>iim-
nicAef'» «©«died raihnad apparatus beat fulfils the object of perma-
nent oxlension, but it is too costly and complicated to come into
168
SIMPLE FRACTTRB OF BONEa
extenSLPC use in privale proolicc ; it is, doubtless, tbc intention of tbe
iarcDtor to employ it cliiefly in CÄses where the dislocntion is difficult
to oi'ercome. [Dr. Gurdon Biii.4c'8 apjuratus for fractured thigh i»
about as cfficncious aD<J murli niinpler] The double-inclined plane,
repreeeated by a thiok roller-cushion ttppltod under tbe faollow of the
knee, may oooasionally be empluyvd as a suitable fixaUoQ appanUtu
in fracture of the neck of the femur in old pcreons.
We niu»l alill tnealion »ome auxiliary appliances which -we K*tc
to employ to koep ibt' broken limb in ßood position after it haa been
dresaed; for tbc upper cxtrcmitr, in most crsc», » simple, property-
applied cloili, a mit^a, or «linff, in -which the arm is laid, »ufficea.
Patients with fractured arm or forearm may be permitted lo go about
with a plaKlen-bandage and a aling durinj; the entire treatment, witli-
out int«rferiiEg wiüi the favorable healing.
For keeping broken lower extremities in poaition, there are «
number of mcchimical aids, of which the following are (he most
serviceable : sand-hags, narrow «icka filled with aand, about the ]cnj:t}i
of the leg ; these »re placed both sides of the ftrm dressing, so that
the limb may not move from side to side; for the same purpose we
may use long, three-sided pieoes of wood, cut prismatically, which arc
laid together, so as to form a gutter. For some case« a sack, loosely
filled with chaff or oats, is sufficient ■ wc make a hollow in it length-
wise, and the 1^ b to be placed in this. If we desire firmer support«,
we vac JVadwe^oxe«, narrow, long, wooden boxes, open at tbc upper
end, so that the leg may he placed ta them; and the side« an*
made to turn down, ao that the extremity may be carefVilly inspected,
without moving it; the deration of these fhioture -boxes may be
suited to the conrctiiencc of the patient. Lastly, wc must mendoa
the $King, which is usually made witli a gallows, or strong bow,
that is brought over the foot of the bed, and to trhich the limb ta
su^ended in any sort of a (rftoturo4x>x, or hollow splint [or 1^,
Nathan Smith's nnterinr splint], so that it may swing about; in
TestJeea patients especially, this has oertain advantages. AM these
appaiatuees, which, although more rarely employed than formerly^
are still occasionally useful, you must Icam to apply; you will have
oppoTluiiity for this in tbe surgical dinic Of late we rarely apply
these ap]>aratuscs in the lower eictrcmity, as my former assistant.
Dr. jRi*, who has brought the application and elegance of the
plaaloh>batidage to in extraordinary state of perfection, a]>plie8 a
wcllpuddcd wooiien »plint, three or four inches wide, to the under
side of the leg, making it reach somewhat below the heel and aa
high aa the knee, or, in fractures of the thigh, as high as the middle
of the thigh. The Umb lies firmly on thi^ board, if the mattress be not
TREATNBNT OF FRACTUBttL
1«9
too uneroD ; if we wisli to uttnin »Lill grvntvr firmuees, we may lay a
board the widlli of Ihr bed ov«r the Iowlt lliiixl of the malifcs«, and on
thift place the limb, v^-itli its p]astcr^rv»6iiig and supporiu^ spliaL In
till* DitiDProus double Emctutvs of both lotrer extremitit'ji that came to
tilt? ZUrirli hospital, thin »uppoilintr apparatus did exix-lleiit »(.'rvicc
Tbe old tona of plaatßr-iiioulds Una btt-ii rt^retitlv stronglr advo-
OBted again by Ur. JI, MaUrr; vp iiavc tried it again, but it bean no
^^omparison wirh the pluKter-bandit^
^H Saäin tried to iiicrciittc the adrantafrcB of &rm drcsings by giving
■ids that might vnahle pnticiil» with fmvtured lon-or limbs to go
about to some exteoU For instance, a patient with a broken leg
may have a broad Icatlicr »tiap pasaing over tbe ahoulder, and buckled
jiut above the kn»c, so that the foot will not touch the Aoor, and then
let htm go iHi crutolips. Ilut I adnsn you not to carry these experi-
nent« with your pitlieiits too far; at all tivt-nts, I only allow my
patient« to make such attempt« three weeks after the occurrence of
the fracture, otfacrwü^ asdcma readily occurs in the brukon limb, and
■ome patient« ore »n cluntüy in the use of enitches, that they are apt
^^o fim, and, ulihuugli Lhi» may only cause alight oooctisaioa of the
^Hptoby it ix still injurious.
^B Laatly, we have to iürcush how long tbe dressing should be left
^^B» atid ibc causca that mi^ht induce ua to remove it before the cure
t» oomplete. The decision as to whether a dressing is too tightly
^—applied in entirely a matter of expcneuce ; tbe following symptomH
^Kiual giiiite the sui^eon : If there he swelling of the lower part of
the iimb, a» of the to«» or fingi*rs, which are uiually left cjcpoaed, if
these part« become bluish re<l, cold, or even «engele*«, the dn-ssing
•bould be remotrd at one«. If the patient comphiius of sei'ere pain
under tbe drcasing, It is well to remove it, even if we can ece nothing
to enusc it. In judging of tbe exhibitions of pain, we should know
the patients; some always complain, others are very indolcul, and
•bow tbeb- feelings but little; however, it is bcttcj- to reapply Üic
bandage several times uselessly than ooec to neglect it» removal at
the riffht time. I ciiiiiiot too strongly urge you always to visit, witb-
iu twenty-four hours at must, every patient to whom you apjily a lixcd
draoomg ; then your patient will certainly not come to grief, as un-
■■bi^innt^lv too often happens, from the carclcfsoeM ami laziness of
^His surgeon. A seriea of cases has been published wlien% iiftcr the
apjJicKtton of a Erm dieasing, the »fleeted limb mortified, attd re-
quired amputation ; tmra these cases it was decided tJiat firm drees-
inga were always improper, while the fault was chiefly due to the
Borgcoo. Just think bow little trouble we have iu trcaltiig fracturcfl
r, oompared to former time«, when the splinta had to be renewed
190
SniPLG FRACriTRR OF BOXES.
every three or four da/n ; nov you D«a] only apply a {Iressiiig uoce.
But you must not lliiiik you luivo ^nt rid of aU truubic in tlio appli-
Cfttion oS drcMing«. The application of tbe firai drvasing requirr<8
just u muoli practice, dexterity, and tare, aa did dresaiiig with
splinta. If you aic first called to a frncturc wlien it ia two or three
dxv» old, when there ia «Ircndy consid^rahlo intlanunatnry swelling,
you may even tJien apply the fin« divwtiiig, liut must apply it more
l»josely, and with plenty of n-adding. This drcwiufr will be loo Ioosl',
wid sliuuld be reuewed in ten or twelve days, when the ewclling hu
left tlic soil [iftrls. It will chiefly depend on the ltx«eDcss of the
bamdage, and ihc giv&tvt ut les« tendency to diAlncation, wbrn and
boTT oflcn the drcening sbotdd be ruiuuved during fha treatment.
Swelling, if not accom paiucd by ooiisJdcrablc conluKion, tx no oontra-
indieation to a carefully-ipj.ilied firm bandage; nor du large or lunall
resiotea, full of clear or slightly-bloody scrum, present any great ob-
jection ; aueb vesicles result not unfrequently from contused fractures
with extenKire rupture of t}ie deep veinn, nince, from obstruetioo to
tlie flow of venous blood, the seruu readily oacapes from tlie cu]nlla-
rie«, and elevate« the hard layer of the epidermis into a ve«iclei we
puncture these vesioles with a needle, gently preu out th« fluid, aud
apply some wadding, and they soon dry up. It is the same with
slight superficial exooriatioQa of the skin ; we are only rarely obligfd
to remove the drcüsiii^ »iid apply another, when new vesicles fonn^
as we may know by the pitin.
The length of timL- tbiit a &rm dic&sing must remala on for tlie
difienrac fracture» you wlli lenm pnrtly in Ihe dirue, partly from spe-
oial 8UTg(?ry ; I »imply iiictitiou here, as ihe limits, that a finger may
require a fortnight, a thigb sisty daya, or more, for healing. If you
apply the ]>I aster-dressing immediately after the fraeture, dislocatioii
baling bm>n completely removed, the provisional callus will always
be leas, and hence firinuess re&ult lac«r, ihan where iberc is some dia-
location and the dressing is applied Inter; but this has no efleet on
t]ie fonuutioii of definitive oaUus, und the actual umoa of the frao-
lured ends of the bona
CHAPTER VI
OTEUr FRACTURES ÄXß SUPPURATIOX OF BOKR
nee Wt««eii ^ubonuaeoui anil Op«n Fraoture> in rtgnrd to ProKnoaU.— Tsri-
attM of CaMA.— iDilkatioiu for Piimarj Amputation.— aeoondarj AmpuUtioji. —
Omne «r Um Con.— tiuppuratioo of Bemc— H«orMii of tba Bnda at KragmMita.
Wi shall now pass to oompliL'ated or opeQ &ucture&
■When we speak simply ol (Complicated ftacturet, wo usually
lean only those accompanied hy wounds of the f>kin. Strictly «peak-
ing, this is not exnct, because thore are oilier cumplioa lions, some oJ
them much niort- impurlant tlititi wuinid» of i\w sk!ti. If tlie aWull be
&Bclured, and pari of the bnuti-aulwtaiicu crualicd, or Houie rihs
broken «nd the lunf; wotindcd, i\\f»^ ftrc «Uo <»n)plic«t«cL (rncturea,
even thouj^b lliir skin ttbouliJ rt-maiii uniujurML But, t\i\<x in these case«
tb« ecrnipliaitidiiii thnuisclvcs rtc uhick important for the organism
than the fracture is, wc usually tonn such cases contusion of the brain,
or injury of the lung, with fracture of th« skull or rib». But we shall
not here enter on the subject of injuries of internal organs bj frap
roents of bone, because very complicaled states of disease are OOCfr
Skonatly ioduef>d in this way, whose analysis you would not now tui-
derstand. For the pros^nt let us limit ourarlves to &actur«% of the
extremities, accompanied by wounds of the skin, which we shall call
open fractures, and which will give us trouble enough iu their course
tzcalmenl.
In speaking of the eoum« of simple oontusiona without wounds,
contused womidu, I hjtvc alrciuly shown you liow rr'ndily r«ab-
I of estrovasuttrd bloüd und the bcnliug of »iiitused parts go
on, as long as th« procc«« i» aubculaucoits, hut how much the coodi-
tk>uft change if the skin also be destroyed. Hie chief dao^rs in such
OBsee are, as you mny remember, doeonipcaition in tho wound, exten-
sive ocK'Tosis of crushed or de&d parts, progressive suppuration, and
accompanying protracted, exhausting fever, while we hare scarcely
U
\92
OPEN FRACTURES AKD 8ÜPPDRAT10H OF BONE
mentioned the severe general diaeases, erysipclus, pulrid-blood poieoo'
ing, pyiemia, telfliiii^iiiul 'ieliriiirn treiiUMis. Thu diffonnuxt butvreen
«onluaiona mid cutitiiscil wuuiids is eveu more strongly marked ia
simple aiid compound Iracturce, u regatds ooutbc and prognosis.
Wliili- ill muuy uasos we can ecan-ely caU a person with simple frao-
tun; wck (wc have not »pokcn of fever there, for it rareljf occur»), aud
uodor the preairtit oonvruient traatiment such an injur)' is milter aa
iDoonvetiienee llian a miaforlune, a compound frunture of a large htme
of au extremiljr-, or wimetimen even vt a fuijfcr, may induce soverr,
and to» fn-(]ucntly futnl, diaetun*. liai, not to alurm you (oo much, I
■will ftt once add that tlierc nro many griidos of dnnfivr even in opeii
fracttirtnt, and, moreover, that thitir Lnrntment baa been mucli improved
of lute.
It is Yi^jy diflicuU And important, but not aln'ajs po«eible, to mak«
a correot pm^dsis about an open fracture at once. The life or d<4tüi
of the iiatirut may occaHioiiidly Imn^ on t)i« choice of the trcatint'iit
the first few day», ao that we irnisl st udy Üüa subject more aix-uratt'ly,
The nyrnplDnis nf nn oputn fracture arc* of course eraieniially thv aame
as uf I lie »ulienutneoiis, cxt-ept that diHcoloration froiii cxtnraaatcd
blood is oftcQ waating*, because at least part of tlie blood eacapo«
tliruug-li tiio wound. The frnrtiin>d eiidfl not infrcqueully piojcet fnmi
the wound, or lie e»jio»e<] in it, so that a frlatice may suffice for the
diagaoeia of an open fracture. Uut this is not cuou^b. Wc mustdo
our best to ascertnin how the fiacturi! iras caused, wltether by direct
or indirect force, and liow Rreat the force; if it was aoxuupauied by
erubhiiig iiud twiiilmg; whether arteries and nerves have been torn;
if the patient lust niudt bluud, and what is his coadilion at presenL
Tbvre are cases whefc we can saj, at the first glance, liealing is im-
possible ; amputation must )>e reported to. When a locuinotiv« bus
nm orer tiuT kne-e of an unfnrtwiaU* railroofl bnnd, when u luind or
forearm Ims been caught in the wheeLi or rollers of machiitery, wben
a prenwture explosiou iu blasting stone ]iaa eru&bed or torn off a limb,
or h imdred-neights have oompletelj mashed a foot or leg, it i» not
difllnilt for the auigcon to deride atonnenn primary amputation, »nd
usually in nuch cases the stale of the limb 1« such tltu.t the patients
also, though with a sad heart, quickly consent to the opcralion. Tb«SQ
are not, the difficult citsesL And in other cases it may be Just as casjr
to foretell, with ooiisiderable certaiuty, the probability of a fnToinblo
eure. F«ir iiHlaiu>e, if fraeture of the Jog from indirect foree lias fol-
lowed loo great beiidtng cjf tlie bone, tlie broken pointed eud of the
crest of the tibia may pimcture and force through the skin ; io such
a case there la no ontuMim, Init »imply n tear tbr>}iip;h tbo akin,
MHien a pointed bodjr strikes forcibly against a small portion of a
PROGNOSIS IS OPEN »KACrTUREä
US
limb, and injuK'S bono und «kiik, the whole exircmitj niay be greatly
slukai ; bat the ext«nit of the injuiy ü not fitcHt, and most of sucb
cases tenntaatc fütvrably under euituhlo treatment, Tlie queeliou-
aUe cases lie between tbese two extram««. In cases where there
is Homo oontusioti, but only a sH^t amount evidrni, and tlie ftkin in
oaljr injured at u shiaII spot, it will be very difÜcult to ilccide wltetber
heaUnff should be ntleinpted or amputation be reAorted to, and tbo
[MViiliantv of tlie indirklusl caw alone cao eetllt^ tlie {{iil-sUoh. Of
late the teiidtmcy ia iucruasiiig ntthirr lo try to jirvscrvc the limb la
the«« doubtful rasea than to amputato one tliat might postdbly have
beun ssvixl. Thiif principk- is certainly justi6ed on liuinati? grounds;
but it CKDRut bo denied that ihU confiervatiTc burgcry may be pno-
used at the onat ol life, and that we cannot with impunity vary too
vtmch frnm the principlea of tlie (Adei aiirgcoiis, who generally jire-
kncd ampuuiion iii Uicse tloubtful oases. Besides mode of origin
of the injury, and t)i« anioimt of aflcotnponying contusion, the iinpoc
tancc i» any given lawc ile|ieiidi uii whether we liavu to dead with
deep ntiuods, with fruoturcd bones lying fiu: donni amon^ tJic muscloa,
or wttli bones lyin^ near tbe skin, as the daogcr of euppuratioD de-
peofla groatJy on the deptli and exteut of the bone-injun,-. Thus, an
open fracture at tlic anterior part of the leg i» of mon^ favottible
pro^osis than n ainiilnr injury of the arm or fureann. Open frocturca
of ilie thigli are the mu«t unfiivornble; tii(U>ed, »ome surgeoua alwayt)
amputate for such injuries. Large n«rve-tninka art- rarely torn in
bactuRs, and, wben tbcy arc, it docs not seom to have much eObct on
Out cure ; and experiments on animals, aa well as obserrstions on
mail, sbow that bones may unite normally in pandyied limbs. Injury
of large venous trnnka, as of the feniomi vein, t«uscä iiietimrrlutge,
whiofa may be readily checked by a oompressing-bandage, it is tme^
but may prove dangeroiia iclien the blood offiued between tlie niusckw
and ander the akin begins to decompose. Rupture of the arteriu]
trunk of a limb oeoa«iontdly leads at oooc bo eonsidcrablo arterial
hgpiDOJrhages ; but this is nut a necessary scquoooo ; for, a» previously
ihown, a tbiwiibus quickly forms in the crushed artery, so that we do
DoL always have extensive Laeuiorrh»^. Dul, if, frotu the nature of
the luemorrhftge, we recognize tlie rupture of an artery, aceonling to
principles already Uid down, we shi:>u1d either attempt to Ugate tlie
artery- at the wound, or else »t tbe i>uint of election. It is true, tbu
pny<p«8 or healing will be dehkyed liy thi«, but, except in cue of tho
thigh, it is still poasible ; so that I do not t-unsidcr the rupture of a
kige artery, in a cose of open fncturc of a limb, us an al»oIuto indt-
Mtloa for amputation, unless, as ia often the case, the other circum*
rtanoes of tbe injury are such as to reader union impoeaible. Lastly,
IM
OPBK FRACTTBI» AXD STPPüRATIOS OF BONE.
in the ^luestion as to whether we shall try for onion, or proceed to
are]>ut«tJon, vfl must uonsiiler how usoful tho limb can be if union
result« ajid nil unfHrorablc clianci^a liavo tccn ovcroomi-. In codpli-
oated fracluros of the foot and lowpr part of the leg thia question
may be particularly important, and it has frcqumtly be<eii neoessBiy
b) amputat« a foot beoause of tlio change of Uyna and position result-
iag afl«r union of an open, comminuted fmctiir«, which rendered it
uaelefls for walking. Ilie same thinfif h to bc) conaiilered when, in a
ease of moderately cxtiriisivc gangrone of llic foot, we wish t« decide
If it should bc amputated or Dob The dead portion of the foot may
be di'taclicd in «uch uri inoonvctiitrnt eliupc tlmt l)ii> reniniiiing stump
is neither useful for walking nor for the »dupt^ition of au artiGcinl
hmb. In such caacs wc should amputate, for all our methods of am-
putating are designed for the future application of arlifivial limbsi
Sinioe the nature of the aubjnct hun led ua directly la tbe tndic
ttoDS for aoiputation in injunes, I aball at once proceed to tbe sub-
ject of ßoeondary amputatiortM. In the question as to whether a
oomplicateid frxcture should be «mpuUitecl or not, you niigtit readily
eatisff yourself with the idea that it might bc done at any future
time if tlic fear« of an unfavorable course should be mtlisci^l. On this
point attentive ubBervstiuii shows that there are two periods for this
seooadary ninpiilution. The Hrst danger thr^atena the patient frrjni
an acute decomposition about tbe wound and the consequent putrid
intoRication of the blood. Tho question iis to this danger is settlL-d
during the first foiu" daj-s; if it arises, and you then amputate {this
must be done fiir above the point of putrefuotion), tt ia just at the most
unfavorable periwl for the opeistion, fop you will very rarely succeed
in saving your patient. Somewhat more favorable, Imt still un&vor>
able U9 compared with primary amputations {tlK^i- made witliiu the
first forty-eight hnurs), are the results of amputation* inaflc {nun the
eighth to the fourteenth day ; they are partieularly unfnvoniblo if the
symptoms of ocute purulent infection, pyibmiu, arc distinctly present.
If the patient bus eumrcd two or three weeks, and profuse exhaust-
ing suppuration or other local indication for amputalion arise, the
result« are again mlatively fsvorable. Wlien some surgeoos bare
asserted that secondary amputations give better results than primary,
they have nlmost-exclusively considered these Inter secondiiry amptt-
totioii». But, if we bear In mind how many [jntients with open fruo
turcs die during the first three weeks, that ia, bow few of them live till
the hvombte time for Recondary umpututions, it seems to me we oau
have DO doubt about the dc<;idc<l advantages of primary amputationii.
Up to the present time I have rarely found indications for lat« second-
ary amputatioiu.
DNIO.V OP OPEN PBACTURIS.
19S
An open fnicttire may unite in various vrajrs. The «kin-wouad, aa
WcUaa the deeper pnrta^oocaaicMially heals by first mtention; Uiisbthe
mo«l ftivorable case. Under modern tivatmeot thia ooeura more fre-
quBuüy than formerly, although, from th<> nature of the <!ase, tlte n^
qoircmcnts for tliis result an? not often presenL Far more frequently
(and this i§ also faTorable) lh« wound only luppurat«« superficially,
and not between and aroiind the ends of tbc boii«, but union of the
bone takes place aa in simple subcutaiKX>us fracture. The cuscs where
Ute wound only affects ihc ekln, and docs not coiuniuuicatc with tbfl
fracture, should not bo counted among oomplioat«d fracture ; but the
limit« arc difficult to trare.
The process of cure must of course differ gr«aUy from tlto above,
if the Bkin-wound be large, the aoft parts j^reatly contused, so that
fiagmenta are detached from them ; tf Uie suppuration cxlcuds deep
betweeo the musvlea and around th« bone, and even into ita medullary
cavi^; if the fmgnwiit* are bathed in pu«; if hiUf-loosu pitwes (if
bone lie abotit, and longitudinal fissures ext^^ud iutu tbc buiie. Th«
activity of tbc »oJl parls will remain csseutially tbc same as in subcu-
Caneoua fractures, except that io this case the inSammalory new fuima-
tioo does not directly become callus, but, after detachment of the
crushed, nccmscd shreds of tissue, grunulatione and pus arc fonned,
the former of which arc (raii»formed to ossifying callus. The form of
the callus will not be mucb dianged, except thai, where lite opeo
BuppumliDg wound exists for a long litnc, there will be a gap in the
callufr-ring till it is closed by ibe after-growth of deep ossifying granu-
latiooa. Hence the process will terminate for more slowly tbao bi
subcutaneous fracture, just as healiag by suppuration takes longer
than bealing by tiist iuteatioo.
Now, what bcoomes of the cndit of tlte fragments which, partly or
entirely denuded of periosteum, lie tu the wound? What becomes
oC pieces detached from the booe,and ooly loosely attached to the soft
partst As in the soft p&rt^, eo here one of two lliirigH ni:iy happen,
aocaüdiag as the ends of the l)one are living or dead. lu the first and
□Wat frequent case, granulation» grow directly from tbc surface of tbc
bone. In the latter, as in the soft jiarts, phistjo activity in the bone
oocun on the border« of the living; interstittal granulations and pus
Earn) ; the bone melts away ; ttit* dead end of the bo|te, tlie MgutHrum,
GUIs oft Th« extent to which tlti« pcoccM of detachment goea natu-
tolly dcpoitds on the extent to which the bone is dead, or, expresited
noore phyciologirally, on the extent to which the circulation has ceased
fiom «lo|}pigc of til« veMcIa. This extent may vary grciitly : tt may
ponibly extend only to tbc miperficial layer of the injured bone : and,
änce tbe whole proe«ss is oalletl ntcnuity tliis superßdal dotncluneul
IW
OPEK FRACTUÄBS AUD SDPPTTRaTIOX OF BONE.
of s plaie of bone i» tvnnecl riMrtMfs miperßciails, \r\nla tttat of the
whole fractured «nd of tlic bone may be wiilffti necroaü totali* ; but
the latter tertn is more usual for indicating tlint the entire dispLj-w
of a long honr, or a.t Inaitl iIm^ greutcr part of it, ia detached, aad tlie
opposite of tili» is necrcfi* partialU. The opposite of the nbov«-
mentioned net-posis siiperfioinJU, wliioli is also termed ei^'oSintion^ is
properly' necrosis eeittralis, that is, dutaühtneiit of ao inner portion of
bone Necrosis aupcrficialis and necrosis of the broken ends uid
pATtlv-detached frs^ients of the bone arc so oftcu combined witli sup-
puratinj^ fractures, of which we hare to treat here, thut mc must treat
of lb«in in tliis pUoe. It will »t tirst seem strange to yoa that vascu-
lar granulations sbf)uld »pring from tlio hai<d, smooth oortioal subatanoe
of a loii^ boni'. From what has alrL-H'ly bc<'u said, it will seem po^
»ibie that, uodcr the influence of this pluatic process, the hard osacous
tissue should be go dissolved that there may be a spontancoua solti-
linn of continuity tiptwoen the dead and healtliy bone. We shall now
Btudj' more exactly these processes of fonnuliun of gnuitiUtkms and
of tnppuiatioa in bone.
You will romeniber, from the full description of iiauinatic suppu-
ration of the soft parts, that in traumatic inflammation the process
cüiieflj depends on free suppuration ami e^iteiisive formation of new
Te$s«ls, AS well as on direct oell-iTifiltrHtion from the blood, while tbo,
intcTcellular stibstunee assumes a gelatinous or fluid coiiststei;
Both of those proccMcs can only take place to a slight cstcnt in bone,"
espeeiiilly in the firm cortical substanoe of a long bone, because tJie
tirm osseous substance prevents muob dilatation of the copiilaties
which arc enclosi^d in the Haversian t^nals. I may at onee call yoi
Srltention to the fuct tlmt, from tbit« slight distcnsibility of tbe vc
in the naseous eanals, portions of bone may inure readily die thu
would be the case with llie soft parts, because, in case of cuagulatio
of blood, even in the smaller vessels, the nutrition can bo only im[
foetly kc]it up by eollateral circulation. Moreover, the cotiiiectiwe '
tissue and the vessels in the HitverBian canals may lie enlirely de-
stroyed by suppuration, so tliat necrosis at the ends of tlie Eru^^uieota
will lie inevitable. Should a vnseular granulation-iiiuue develop 041
the surface of the bone or in its compact sulwtanuo, this can only 1
as previously ileflcrih<-J, after the osseous snbstunee (liine-snit^s as woQ
M organic matter) ho.* disappeared ot the point where the new tissue
Is to mppeur; lienee liiere must bo solution and atrophy of the lione-
tlssoe, just ns thiTc urL- of the soft part« under similar circiimstonc
{sec Fig. 36). The whole difference appt-are chiefly in the diflbreno
of time, for ihe development of granulations on and in tlie hone tab
much longer than in the soft parts. I have already stated that
BEVEI^PJIKMT OP OSSEOUS OHAN'OLaTIONS.
m
nunc pfoceas irquimi miidi longer In the Lendoiiet nriil £(t»ct«.>, vrhidi
hive few vobmU, than iu the connective Luutuci muscli», uiiJ nkio ; in
the boiM> it reiguires evi>n more tim« thnn in thi' loruloiis. Tim i^ou-
stituttiitiul pow<^r i>r the iiidividiiul, sutl tlic- consuquout stxralled
nt&Utjr of the timuus, uv also to bv tukca into coustdcratioo.
LECTURE XVI.
— pure
tlopmeitt of OisioQui Qrnnulationii.— tlUtfltoip'.— DctachtiiFnl et tkn 8«^nMtniro.—
Hittdoc}'- — O'lTou' New Farmstiun around tho Ditoebnd Scqtieiitniin.— CallUJ In
B<l|ipuruiii(Fmclutii>.— ^Ufi|>iimti«c PvriaiiUii und Unloomjaliti*. — GancnJ Con-
diliOD.-'Fpvcr.— TnmUDoM : ITijicitntlci), Clnnod, Split Dmainfiu— ABtlphloflMla
R«MMdioa. — Iniincniaii.— Bale» nbonl B«ne-KplinIor*.— Aftar-TraataiaoL
Whes n domuled portio» of tmnc begins 1o throw out ^^raniil»-
tioDS oil its suriacv (vrliicli in cotnpIi<;aieii fractures vre cao only scir
«hen the eods of thv fntf^nont« »re exjioKcd by a Urgp skiu-n-ouod,
on the tnlerior surfiicr of the \vg, for in»liincL>),'\*'c rccoffiiiic this with
the atkcd cjc h^ tho foUoMiii^ cban}r<--s; For the fint rijrbt Of ten
tlays sflpr bviD)^ d<^Dudi>(l of ])(.'rimtPiini, tlip bono inoiitly pI'(^setTe8 ita
r J}ure vellowuli color, whirh, ev<>n during (he last day of the nbove
riod, ctuitiKCH towiinl bright niW'-color. If we the« v^amine the
Kttr&fle of the bone with a li'n», we may notiee numbers of rery fine
jtii poiutx niul stria.*, whirli n feu- days later 1>eoonie visihle to llie
1(M] eye also; these rapidly increaae in tixe, grow in loDf^th nod
1th, till they unite und thi*n present n perfeft f^nnulntinjir surfiiee
vhieh [nsses imtnet.tintely into thi* gnuulHttoii» of (he surrounding
parta, and eiihsrqucnlly [nrtiripntea to the cicotrizntion, so that
a eicotrix adheres firmly to the bone.
If we follow this process in itit finer histological detuls, which
be chiefly done esperiinentÄlly, liy aid of injected bones de-
rived "f llieir Itttte, we have the foUomnj; result : If the cärcutatioo
tD (be bnne in maintained near to the ituriace, there is a rich infi]tr&-
^^on of «-ll» iiil" the coimcciivi* tissue accompanying tlie ve-sselo in
^■le iJareraiu) cdtiuli«; this tissue gron-s, with the vascular loops dc-
^Beloping t«>wani the sur&ee, out of the Imne at the points where tin?
^^Bapeniun cntiahi «pen extemallr. T\k developmeni of this younj;
fpanulatifiD-niasA laterally re&tilts at the expense of re(ib»orbed bouc,
If we raarersite one of these bones with snjxTficial (rrwnuIjllionR, it«
will appear gnawed and rough ; in llie living bone. gnmulatJun
fdla the nuuieroi» small holes, whicli all oommiinieate with the
iversinn earailt^ The nii&oe of the bone dues nut, however, nunain
108
OPES FRACTÜRK AND SUPPCTUTIOfl Of BOKE.
in tiiifl stnte, biit, iirhile the ^{sseous gnnulations on the miHkce ood-
dcnsc to oonncetire tiKsuf> and oicatriii«, in the deeper parta they
ossify quiti> rapidly, so that ut Uie tvrniiniitioi) of ih« pitK-(«sof bcul-
ing the »iirfarc of the iojiireU banc doc« aot show a dpfidency. but
Appears denaef from deposit of new bone. You see that here too tbe
ciiY'umst&nrcs are exactly the Hnme as in iiuboutaneoUK development of
the influnimiitory neiLiplu-siii. If you look at Pig-, 4fi, Hnd supposo the
pcrriostcum removed (rum tlic surface of lite bone, the new fomiatioD
(in tliii- ciiKi' H8 graiiulatioiiR) will grow fungous-like out of Itip Hii\*pr^
^an csnaU.
Vou will uRderstand tluB better if we now follow tnore carefully
the prooeeB of detacbraent of necrosed portions of bone. Let us re-
turn to what we !»^e tvilh th<> naked e^e, and letu« mppntw we hn%'e
liefore ua n porlioii of tlm purietnl huiie denuded of »uft piirts; tlim,
if no (fmiuiliitions, flu aliove described, grow from the hone, we chBÜ
have the following symptonnc Whilo lli« surrounding soft parte aud
the portion of bone still covered with prriostemn hare already pro-
duced numerous granulations and secrete pus, the dead portion of
bone reroaiiiu pure wMte or beeumeü gray or even blaekiidi. It re-
mains some weeks, soiti«- times two inonlli» or nioiv; most prulifemnt
granulation» grow around it; eiculnzation bus nlrendy beg^n to Lbc
periphery of the wound, and we cannot decide how the case will t«r-
minute, for in the aixth week the surface of the bone may look just as
it did tlie day after injury. Rome day we feel tlie Ikihc aud liiut it
mornWo ; nfter a few attempts one blade of the forceps may be intro
ducei) under it Hnd we lift off a thin plate of hone, under which we
find luxuriant ^n^nulatioiis; the under sutfa(*e of thifl ptnte is very
rough, as if eaten awny. Now hcnüng goes on rapidly, It is oftco
long before tlie Hcatrix betiJines permanent aiid »olid enough to re-
sist all injuries, such ns pn-ssurc and frit tion, but healing often tertni-
nates favorably. This is the process that we term ntfroti* tufftrf-
eiaii» or exfiiliation of bone. We are nlrewly ac(|uain1ed willi this
process in the .soft jiart.-*; during tlie first week large .«lireds of tissue
£iill Jrorn tlie contused w^nmd, since on the border of the hculUiy tis-
sue then.' i« nn interstitial di^iTlopmenC of granulation, by which the
tissue i» detached ; t!ie prucOKS i« the 5anic here. In a bone deprived
of it« lime wc may readily examine theüc processes uiatamicully. The
inflammotory neoplasia, or gnnnilutirm tissue, dcrelope on the mar-
gin of the healthy banc in the Uarenüan canals. Tho aooompnnyiug
figure (Fiff. ßl) niay represent to you the details of this procet».
If yon hnve fully underst^iod wliat has been said, it only requircB
a slight «treteh of imagination to sec how the same pn»i-«*s of detach-
ment of a fmgnieiit may extend through tlie entire thickDete of bone;
DKTÄCHMENT OF THE SEgOESTBÜK
IBS
'W£
'4
'I
Uisl 18, bow (and here vre oome back to complicated fmctuivs) a vari-
able lc-n0h of tlic fractured end of a bone una; be eiitiirly detached,
when it is iDcapabl«- of livinff.
Wben tlie bone in ciur>»tiun is
Uüok, Ulis process requin.'s sev
eral mooths; but at la»t vc
may find cron lar^- pi^v«« of
bontr movable tn the wound, and
rvan^vc iitcin a« wc would a su*
perficial bony pUu^.
As rc^ids Hplinters nntirely T L<l !
detiK-bed froni tUe bone, atid ouly
ntlnolied to tliR aoTi partfi, their
future fate, as regards liWnf^ or
Dot, depends on how fur their
eirrulation i« pivsorved, If tbcy
are nut rjipablc t>f livtug, tbey
at last become entirely detach-
ed by suppuration of the sofi
parts attached to tlxMit, and of- rj|]
ten, OB forcipn bodie*, keep up
initatioQ and suppuration of the
wound. If they are capable of
living, they produce ^ntiiuln-
tioDs on the (roc surface; thc'»<> itu1>ite<tucritly o«sify and unite with the
other callus, fonning nroutul the fractured etids,
To represent the rclatiun of thi; romiatJoD of callus to thU process
of detachment of the necrosed ends of the fractured bone, I present
the fnlloM-iiig figure (Fig. S2).
The fragtoents of tlie broken bone arc noi accurately sdjtLrtcd,
bat displaced somcvrhat latcmlly ; the ends of the (ngmente have
both become nwrosed, and nearly detaehed bv interstitial protifeTatioa
of graoulaUonf on Uio borders of tJie living bono. Thi- uholo wound
tt lined with granuUtiond, which secrete pus that escapes ai cL la
both &sgmenU, an inner callus (bb) has formed, which, howevi>r, from
Mlppuratiot) of the fractured surface«^ luis not yet been soldered U>>
getbcr. Um outer callus (ce) is irregular, and interrupted at J, be-
OBose the pus escapes hciv from tlie 6fsL ^Nlte» the grsnulnlioos
grow BO stroDgly as to fill the entire carily, and subacquenüy oest^,
healing is completed, and the final result is just tlic same as in tho
healing of subculaneous fraetureK. Porthistotake ptaee thenecroaed
porliooa of bone must be removed, for experience shows they cannot
bcal up ID the osseous dcatrix. This elimination of the sequ^tcated
DlBcmni of dotsduDeai of a necraM4 portion of
tiuur. Hae«"*' *"!- f^ DBOroMri uorllun at
Wdc ; b. llTtii( boo« : t, D«v rormatton In Ifar
Uavenun aeftb. bj wlilcli Uw bone U il«-
Uch»6. Cotnp«!« rig. M.
300
ores FBiCTtmES AKD SOPPmATTOS OF BOXE.
fra^mcnU takes plane vitliur bjr reubsurption or by ortificiiil reinoT»!
outwardljr ; the fonopr i» tlie more frequent in smiill, ih« latter in
iMTgc scqucslm ; but. union nill not n^sult ua loug &» the sequestrum
remaiaB between tlie g-ranulatJons of the frogmeQts. Siooc tho open*
ing at d uay be tnucb oontract«d by Ute deTolopmvDt of oxtenul
na-a.
d
iH^CniBl of lYaclnr« «t a I<)D£ bono n-lth
«HMiitl nooiKi. lorcltodinKi iMtiun.
Silnnl*lEe. «(.bcini; ////, lOli partii
of IbB limb; a a a a. Docmtd endt uT
btHi» ThK ilitrklr-iiliuS«! wK t«|>r»-
BMiM iliR risnaiBlioDi, nhrrh iliir irfl
Um <raan<r thai iiprai ouliraKliy. oni)
IHi«1«pli«: t&, uitcmal tiillua In Ih«
tmitlatocatBd endi at bona; cr c itur-
Dttlallnii.
JLnpaMdM
callus, ttip opfTative rpmovnl of the necrosed ends i» often very diffi-
cult, W« find, by ('xuTiiination with the prohn, whcllier wjcb iwifiinf
tra in tho dt-cpiT parts really cxiHtr^l, and if thpy arc dctocbed. If
you suppose the sequestrum, a n (Fig. S'-i), removed from the wound,
tbcre is no übslftr^Ii> to the filling of the tgrnund with grannlBtitxia and
to ihoJr BuhBequcni. oesiÜcation. Snrli Brf[uestro in pomplirated frac-
ture» are frequently the cntisc, not only of new exaeerbatifin« of the
acute Bupptinitive inllamniHtioT], but also of subacute and chronir peri-
ostitis, nitb protracted firm nedcma of the ezüy^mity and aiinoyinp
eezewÄtous emptiors on the »kin, as well as of long-continued boue
fbitulie and ulcerations of the ends of the frajpnent. The action o)
tliia sequestrum oomlnno» tlic ilntililr «fleet of a foreign body nni]
that of local or gcaerat puruknt infecUun.
SrTPlTHATiVE PCniOSTITIS.
201
We may speak here nf rondiliruw is they exist in the bone aAer
ampiitAtion. Imtigiue. Fig. 52 (livi<le<l tniiaverscly at the point of
frw-tim* and the lower boir rcranrcd, then the conclitiun trill be juBt
the. Nu»e lu >rt«r ampuLiaion. Gmiiulntiuns cither grow direotJj
bom tlic wouiidetl eurfaoe, or a portiuii (the Niwüd HurTarc) is nocrosed
to R peotor or lew eit«nt (Fig. ^3), I^t this be as it may, iu Uio
iiK^luUnry cavit}-, as well at) on llie ouUido of the bone, « neoplasia
(a hair callus) is formed; thia subK-qucntly ossißcs; if you examine an
vtiputAtioQ etump ecT«mI months old, you will Gnd the medullary
spaee in the stump of the boni* closed by osseous deposits, as \Tell as
rxtcrnal thickcnio^of the bone Wc may here remark tliat the name
callus is used ainiuet esclusively for the bony new f(;riiiatioii in üao*
tureo, while the young bony formaliüns on the outside ora-nrring in
Tarious ways arc called "osloophytea" (from äffreov, tionc, and ^v/w,
temor) ; callus and osteophytes are not then very diSercut, but both
■re designations for youn;; oRseoua foimatiuis.
In considoring the process of suppuration, we bavo left ont of eon-
ridoration two of th(^ (^nstltuont« of bono, namely, the periosteum and
medulla. In oh^'rving the development of callus, we saw that tlic
periosteon also had something to do with the formAtion uf new bone.
Bat, iE^ in open aupp\tratiii^ fractures, the »uppuralive iaQammalioo
spreads greatly as a r^wult of extensive eontu^ion, • large amount of
periosteum may neerosi; or suppurate, and in such eases wc find
nidc-eprcad mtpptrrativ« periottitU ; the greater port of a tong boEW,
as the tibia, may be batlied in pus. The bone thus losing its coiineo-
tioB with the soft parts, its supply of blood is withdrawn, and fixim
thiacause ihnrc may bo extensive nei^rosts of the bone as a result of
suppurative perioetiti& But these loeal dangere are slight in ooto-
parison to the dangers to the organism at large from tliese deep SU]>
purations ; we «hall lierenfler treat fully of these.
In the snim* way the medulla either of a long or spongy bone may
partieipale t» the suppuniüon. From what has already beefi »aid, you
know that, iu the course of the normal union of fracture, new bono-
ticsue form? in the modiilUry eavlty, and elow» it for xninc time. In
open, aiippiu^ling fraetures there is also ocrasionsUy suppuration of
the medulla, that miiy extend more or leaa. Such a auppurativR Os-
teomyelitis is quit« as dangerous, both for the life of lite bono nnd for
the entire urpiiiism, m» suppurative jx^riostitis. From various causes,
too, it may asssume a putrid character; tlie larger reins of the bnue,
that come from the medulla, may participate in the suppur&tion, and
20S
OFEN FRACTURES AKD SCPPÜRATION OP BONE.
this diecASC if the mon» dostniotivc hccAiiM of its 6cöp sttuation ; tt is
ofteu firat recognized at tlit! autupsy. PunilvDt usleotnj-eUttB alooe
may also lead to paiiiul aa<l cvcu to total necrosis of & booe, llie more
GO wlien oorabinud with suppurative pcriosUtie.
Although it was necessary to make you inquainted wiUt all the
Above local cotnplicatJonfl of ojMsn frarturwi, 1 inay »ay for your rtilicf
that they nrcly occur so extensively ts «bore described ; nciltier total
Dcvnisi» of both end* of tlic fraclure, nor exl«ii»ivL' puniluiit perios-
titis nnj osteomyelitis ure fn^juoul rvoutt« of th<»c fmctuiv« ; but, for>
tunalcly, hcaiinff of the deeper port« ofUa takes place very tiutfAj,
and suppuralioii only costiuues Pit«.'mally.
^^*bclhcr B traumatic inflamniation leidiog to suppuntioo shall
extend beyond the borders of the irrilutioa (of Üie iujury}ilependsf lu
in simple oontused wounds, on the grade of the lo<-a] infectioit by
mortifying tifUue In the wound, and later on all the circunutanoes
thiit wc have Ivamed aa diruut or indirect causes of wcoodary in-
flatnmittion of wotitid*. The ffwatcr the shattering of the hone (espe-
cially in guiishot-vrounds), the greater iire all mediate aud ioimediate
results of the injury.
Now a few word» about the genemU'onditioo of the patient, espe-
cially itnto/ej>er, \yhile in subcutaneous ftucturesitis to be regarded
us a rarity for a patient to have fever, the reverse is true in open frmo-
turc. If ever the fever evidently depentls on the extent and intensity of
the loesl prtMress, it docs so here. As wo li»ve ulreiuty inontioiiod, io coo-
twied wounds, ever}' extension of the inflammation is accompanied by
au ini.Teasc of fever, and, gcnctwUy 8|>cakiii^, this is the mote decided
the di_>(.'per the siip]>tiralioii. Iti a.oeidetital osteamyclitis and pertoa-
titis the evening temperature of the body not unfrequcntly rises above
one hundred and four degrees Fabrenheit ; rapid «lovatiou of tem-
perature Tvilh cliills is, uiitorliiniitety, a frequent symptom ; septicfemia
and pyemia, trismus, and delirium potatorum, urc cspectully apt to
aocompany suppuratiiif^ fractures, so that 1 oau only repeat here,
what 1 said at the beginning of the ehiipter, that any open fraeture
may be or may l)e<onic a »even? and dimgerou» injury. Heuce, the
greatest cireunujietttioii and cure are ncccasaTy, I can tell you, Erotn
my own cxperieuee, that the most successful operation never gave me
such pleasure as the sucesssful union of a severe complicated fracture.
Lot us now pass to the tre(ttm<nt of open ßra^urM. Aflrt the
advantages of firm dressings had liecome apparent, it was natural to
try them in modilied rt)rms in open fractures ; indeed, some time nnoe,
8tutin^i\ic inventor of the Ht»rch~bniid.a)^% usmI tlie so-callod ,^%ne»-
traUd iandaffif i. c., in tJic Brm «tarcii-lisndAgc )ie maile an opeoitig
oorre^KiDdiag to llie wonnd in the suit parts, so us tu teuve tho latter
TRKATMKST OF OPEN ITlACTWRra.
2oa
Opfln to ol»ervntif>n during trentmeiit. lli« primitive forms of Ikes»
feocstratfd efauvb and plaster bandages iilso, wbicb arc dow often used,
bad great objoctions, ttiKt may now be coiitii<lcrod as overcome. Tbe
chief ol)j«>ction tu lhi> f(.>nes(niti.>d baudag« was tbat tht! imder-bund-
age and tlie wadding were readily aatuiated witb pus, wHirb decom-
posed and b«vaiue olfcusive. Ejttenaive eiipericnce bus »bow» mt;
tbat tbeae objeetiona may be overcora«; it is oiily i»w««sary to mnk«
tlie o|)tMiing» largo enough, to rouml cifT iJi« edgv» witb »lri|>s of
tuuaJiu attacbed by plust<:r, to mak« tlic dru-sstiig ßrm by lucana of
R{^a positIoii-«pUnta, by intfoduciog strips of wood, etc, and to catch
the «»cnftioD ^ni the wound in baxiiia placed beneutli. If this dn^s»-
in^ remain 6rm and clean, the trouble of its lirat application in
well repaid, not only by Ibe brilliant suocess of this mode of treat-
ment, but also by the great saring of time in the subsequent core of
tho wound. For some time I eniployeil plasler^bandiigea in open
fraetures in this way : at first I applied them eloAod, just an in simple
fracturea, and soon slit tijem up IcnffUiwise, opened Üieni, and dressed
tbe wound every day or two as required, without moving the Erag-
m«nt«, and continued this till tbo wound was healed, then applied a
new I'kiM-d bandago. Tliis inplhod k good fur soiuu cases, snd shows
some good results. "Wk cssctitiul thing in thuse dressings is that,
after deeiding not to amputate, vveu Üie moat coniplieated fncturca
should be placed in the plast^rKlressiiig immediately after the injury,
just a.1 in the ni.se nf simple fracture, <iiily wilh the differtMict^! that
tlte wound «huuld Srat be corered with eharpie or eompri^sses previ-
ously dipped in lend-wat«r or solution of chloride of lime, and that
quantllie« of wadding (two frnger-brvadtlia thick) aliould be laid on
the limb before tJic dressing is applied, so that, even if there should
be swelling, tlio limb may nut be strangulated by the dressing.
Tho difTicully of applying any firm dreaüng is increased by the
presence of a large wound or of several wounds at the »ame time.
Should tlHTrc bo extonnire and doep suppuration in stich caseK,H> that
numerous counter-openinga must be nude, and tli« nuiiiticr of the
wottnds thus inercased, it will be impoaaihl« to keep tlie name dreaa-
tug long, and we may then be obliged temporarily to retiun to splint«
and fraeture-hoxea, wliich muat he completely renewed every day.
Moreover, as you may gatlier fn>ni wlial has betni Miid. these severe
CMes often stand on the borders of amputation, i, e., their union is
ray problematical. The more practioe one lias in the application of
the plaslcr-dnvsing, tlie more rarely will bnd aecidcnta happen.
Sine« I bare applied the drcsaing in tlto above maimer to complicated
fractures, 1 see diffuse septic infiammatioiis and seeoiidary suppura*
tiona much more mrcly. I am oonritKcd that the ticalmcnt of open
ao4
OPEN ITIACTÜRES AKD SUPPCHATION OF BONK.
Iracturcs b^- plastcr-dn-ssiogs is the best; I»ut thia mcUicMl must be
studt-cd, wc mu&t Dot suppose we kuou- it a priori.
Should u. surgeon of tbe old rcIiooI see our present treatment of
fractures, simjile ox well b-s conijilicat^d, he woidd consider it not vn\y
imttiituul Iitit f(j<il hardy, for funnerly IJHClurcs, like all other injuries,
were irouled finti l>y Aiitiphloj^stti-.t, «very thing elae Iteitig secoiidiiry,
Heiu^e it vr%3 cüostdered necesMry to apply Jeech«« to the iiinb in the
vicinity of Ihc fracture, to kiicp ou cold cumprt'ssL*» or bliiddent of ice,
Aad to purge the palieut freely. Subscquotitly, when suppuratiou
from the open fracture began, lliey usually resorted to calapluüiits,
whieh were continued till healing wn» nlmotit cximplcted. Beside»
this, splints were upplled and ciiaiiged tibout every two or three dayis
aeeordiag a» the wound yra» dri/t^^ed tnore or leM fre«]uently <iii ac-
count or the Buppuratiu». Litrr^y whs uih* uf tli« first to s|K.-iik
ogainftt this frocjucnt change of dressings in wounds, oqiccially in open
fmcAure« ; if wo may tniat his notes, he carried this idea to «u uiijus-
Li6abk' extent, for he did not always remove tbe dressings eveu when
quantities of nrnggol« liail developed under them. Of late, the gen-
eral opinion is that, in the trc&tment of open »s well as of simple frnc-
tures, the arciinito fixniinn of llic frngmentii ix the first requitenient for
fiivoniltle union, und thnl nutliinK is more apt to excite ititlaininatiuu
iLTouud (lie vroiiuU than inoycnicnt of the frugiiicnts. Uviice a. Brm
dressing Is Uie most im[K)rtant and eflicaeioits iititi phlogistic that we
can use. We hero «.-[«jit n previous remark, that cold und abstjuo
tion of blood have co prciphylaetic and jin tip/hlogiatic action, as was for-
merly supposL'd. If, on aec<iunt of eotnmeiiciiig progr(!^vo indanuna-
tion omund the wound, I consider it neeessaiy to apply ice, 1 remove
a piece frtun the plaster-dret^iag, eorreeponding to the point where
the iee-bladder is to be applied. In case of supj>uration about the
wound, opening» are to be made for the escape of pus. The geneiiil
principles as to tbe choice of the point for llie opening; i» to make the
counter-opening where fluctimtion is mo»t dixtiQ«t,aad where the «oft
pans nri': tliin»e,%l, wlieru the |iuh will escnpe most readily nithuut
prcsevrc from the finger. If wc have to cut openings in iLc baudagv,
ttiia may l>c done most cusily two or three hours after it« application.
After making openings in the piaster-bandagu corresponding to the
wound, without disturbing the limb, we separates the wadding, remove
the cLaq>ie, auil bind the opetiiug carefully ; then with a spatula we
intmduce, wadding under tbe edges of the opening to prevent tho
secTL'tion from the wound getting under the dressing. Pot more
than a xffftr I Itave been U^aving tiirsa tcotind» open abo, and hate
beert astoniehid at fA« »xtecua of thh method of tnatmtitt. la the
treatment of oomplicnted fractures with plaster^eaängs, very car^
TBEATMSHT Of OPEN FBACTDRES.
205
mnniptiUtion and the knc>wl«d^ of a lat^o Dumber of deteils
liEtfh cmii only be iicquirwl kI iIi« bedsKl» of th« putiaDt, are ueoea>
tbo giA of itivciititi^ mtKlificaUons of mriuiis fonns of dxcsBinp
< tweetauy. Thit tIy^stnlC^l of open fractiirv^s is often v«rjr dUB-
ruU; crvrj on« «tiipIuTs in practice ttie method h« has learned; it
makes Itttic difTcmiiDC whcUicr we timploy plaster, stiucli, or liquid-
^iacs dreesin^; the ra&cnlLal tlüit^ is for tho fr«j|^>ents to He quiet
«ad finn, nnd not to be moved hy the dresainf^, then the patient will
reooTBT well and mtbnut paio, Tlie favorable expericiim of iinnier-
aion in coutused wounds of the band and foot has induced some suf-
^enns to treat ct>mpl)cat(>d frneturefl, of lh<! leg and forearm at least,
in the raiuo why. In ibn Berlin Aiirgir.tl clinitT tliey bare tried koep-
itig tlie fraclured limb dmssed with :i fenestrated plastei-bandaff«, in
» pemuinent wati>i^biith ; for this purpiuie the planter rnuM be made
water-tifrht with cement, etolutiuii of shollac, liquid gha», coUodium, or
lometliinfr of that Aort. The rosult» of thi» treatment itiv celcbnitcd.
But, should any »tuppitnitivi* iiitliimntatidii «>Ci^ur nlKiiit the woiuid, ia
which tJtv wat«r-bath i» hijunuus, this method would oppear to mo
I«* «iiitnble than any Other,
lu (he iivatincnl »f open fnietiin'H with splints, we ^'nenilly uso
iVThtj'iamw ivuoilcn foUiiIs; 'm the lower rxtrüuuty these urcpio*
dcd with > suitublv foot^ticcc.
Am we eommeiiced (i|>e:ikiiig of tlie treatmeut uf compticstiod Irao*
v» by ilcscrihiu); tlie dn*»ii)i^, I must uthi a few words about the
St cxan>inalioD. The dia^o^i« of complicated fracture» is made
Uial of simpht frnclures. Passing' tbe fingers into the wouad is
iy imncw'ssary and iiijurioua ; we ahould only draw out splhitcrs
' boae when wc think wc feel or sec thorn entirely loose; the less
exiitniiio the wound t)ie better. We h-ave all adheiX'nt splinters
ibonc; sawin;f off poUit*--d ends of fia^meiits (primary resection of
■ fragmcots) I conddor unnecessary and gcoerally injurious ; I ha^a
■ty flouo it whcu, eri-n under chlun)form, they projeoled sn tliat it
impossible to replace imtl keep them in position. The reposition
of tlie fragments should be accurateit/ made before tbc application of
dressing ; eubeequeiit iKmiUng and intetion shouki bc> decidedly
>id(^], and, if it »houlil lie tiecesaary on »ecüunt of great dii^localion,
liould be poatponed till healing; uf the wound. In tlie aiimu >ray
riy trnotion on half-detaehed t^linlero of botw is cnlirvly inaj^pro-
and useless ; a piece of dead bone ndherenl to tlie periosteum
'Other soft parts u p^idually detached apootuneously, and may then
I reraovml. AVe Uiuuhl not examine till qiiito lat*^), when the wound
is 6atulou3, to sec if fru^neuta situated deeply arc neerosed, and
should then do it very earcfutly and with very clcaa instrumeuts. If
SOS OFEK FRAOTÜRES AND SÜPPDRAHON OF BONE.
there be extenBive necrosis of one or both fractured enda, their ex-
traction may be very difficult ; we then resort to the same operations
aa for necrosis from any cause ; we E^all speak of this when treating
of diseases of the bones, but this should not be done till the process
has become chronic.
The union of complicated fractures always requires longer than in
simple fractures ; indeed, in protracted suppurations it may take double
the time. We have to decide this by manual examination, and not
allow the patient to attempt walking till the fracture is perfectly con-
solidated. The disappearance of the callus, its condensation, its atro-
phy externally and its reabsorption till the medullary cavity is re-
stored, go on just as in simple subcutaneous fractures. The treat-
ment of complicated fractures is one of the most difficult things in
surgery ; we never cease learning on this point.
n S\mm MEDICAL LIBRARY
APPENDIX TO CHAPTERS V. AND VI
LECTURE XVII.
1. BoUnleil Fonutkni of 0»llui sad Davetopmmt of P*oad«rtkr<MU.— Ciui*M oiUn
■nknowD.— Loeil CaowM.— Cotauiaiioiuu rBn«M. — Atutomicul Cundltion*. —
Trtalawnt: intonul, «pcnttiv«; Critimtn cf Muüinj«. t. Obli>iuolv-anllad
Tfietnr««; Ecbrüaküig. Bloudy Ojientiorw.— Abnonnal Dovelopmnit «f CtSiUa
1.— HETABDED DEVEIOPSCENT OF CAXLC8 ASD FOHMATIOS OP A SO-
CALLED FALSE JOI^-T— A SO-CALLED PSECDABTHKOStS.
U.1DEB some drcutnstances. which we do not almtjn sufGcicotly
uoderatanil, a fractur« i» nr>t cniisolidated nitrr thi> liipne of the usual
tim«; itiilr-i-^1, it m»y not coiDMiltdate «t nil, hut the »c«tof fmirture
tnty Txrmaiii paiulvas and movable, lA'hicb of course impurs the funo-
tioo of the limb, cveti lo the )K>iiit of ciitiiv uhcU-smi«««. A short
lime since, n strung fkrnit-r-buy, with simple sulicutunc^ouB Iracture of
tlie k-g vitbout diftloc&tion, eotcntl the hospital; as usual, a [daalei^
bandage was appliod and roiiewud in fouAeen days. Six \r€«k3 after
the fivcture the clrwssbig waa remored altogether, in the expectation
that uoion b»(l taken place ; but the point of fraotuxo waa etill pci^
fcctly movable, nor could au/ callus be felt, I here tried the sim-
jäeat remedy in such coses, I niircotiwd the patient, and then rulibed
the Tni^nwiiti) etroDgly togetlier till cn-pitatioo could hu distinctly
perceivtNi; Uten I applied another plastcr-drcsunf^, and on removing
thi« in four weeks found tbe (lucture tolerably lirm. I placed the pa*
Ucnt in a fraclurc-bos, and, nithout placing any bandage on the leg«
bad its anterior surface painted dailjr with strong tincture of iodine.
After litis had been continued u furloight, the fnicture was jwrfectly
firtn ; the patient now stood with the aid of crutches, and in a «hurt
time was dismissed cured. I know of two other e««es from the prac-
tice of colleagues, where simple fractures in very bwdthy young pei^
sons di<l not consolidate, but fonncil pscudnrthroscs, Such occurs
lenoe» ar« to be regarded as very rare ; ttsaaUy there is sotnepccuUsr
IS
208
APPENDIX TO CHAPTEBS V. AND VI.
cause, eucli aa dlai-juc oF tliv Ix>ne, tlwl induces f«läC juiuL. Tbere &xe
oertaiii fracture« of tbc liumnn «kcloto« which from varot» eausw
very rurvly uiiitL* by bony culhis; »mong Üivse, »re inlTHCopsuW tm^
faircH of tbc ncrk af ihe fcnnir, neck of the humcnis, und £raclurc3 of
tbe olecranou aod patcUn. Wlica fractured transTcr&cly tlie two latter
bones sepanttc so far that tlif o<u;4.>uus substance funiied on tbe two
ends cannot meet, so that only n ligaim^'iitoua union mn take filacc be-
tween these twe ]inrl8 of bone, "niien fractured williin the CHpauJe
tiiB be4id of tlio fejiiur has, it is true, a sup]>ly of lilood tbrougih a
Bmall artery uhieh enters it through tbc ligatiienLutn tereü, but ibU
source of nutrition is very sliglit, «.(■nsequctitly the produclioti gfboiic
from the eniall frngiiienls in xlighl. In fnietunp of (he IkmuI of tlie
humerus wiütiu the capsule, in the rare case of part of the bead be-
ing enLinily dctaebcd from tbc real of the bouc, thi« portiou of boDO
will receive no supply of blotKl, and will act n» n foivipi body ; ita
anion can scarcely be expectod. In the »hove exiimplcM, wc regard
DOR-uniou ao nucb as tbc rule that wc do not usually call them caaca
of pjwudurthrosis. But I wish lo show you that there may be purely
local caused that predispose to pseudartlirosis ; amonjr these espe-
cially belongs coiiiple^.e loss of large piece» of l)onw, afier the ri?aio\'aI
of which, in open fractures, there may he ao larf^ n defect that it will
not be again filled by new boiie-tiiwue. Protnieted «u]ipiiratiou with
ulcerative destructioii, and estensive detaehincnt of lie rods of the
(raiment«, may also lead lo pseudarlhrosis. Moreover, tbe trcalnietit
is oceufitoiiBlly blamed ; too loose a dressinf^, or nnne nt ail, and Uxi
early motion, arc ocxasionally accused. On the uiJMrr hiiml, it lias
been aasertod that too continued »pplicution of cold, tliu simultiuteuua
tigntion of large arteries, and, laittly, too tij^ht a dreisinfr, may inte^
fcro Willi proper development of bony CHlla«. All ibia ulone does not
necessarily lead to psL'u<liirtliroNt<t, bnit niny art lis a eecoud cause whoa
the gcncrid cnnditiun» of nut.ntioii in tbe orgiinism predifipusc to iL
On thcpenurul predispoBJlionaandbone diseases, (be following may
be nientiuued as disposing to pseiidarthrosis: bad nutrilion, debility
from rcpL-utcd losses of blfxKl, ppecifie diseases of Ibc IJood, such as
neorbutis, or caiiei>rous eacliexto. Of the diseases of the bones, it ia
diiefly oatcomalaeia, atrophy of the eorticiil sulistance, with enlarge-
meat of the medullary cavity, in which, a» already mentioned, in e«rtatn
»tft{^ there in not oidy deeided fm^j^litHSossium, but in which also the
ohanocs for reunion are slighi. I have stated all this, bee«us«' il is gea-
orally aceeptod, al(hou{;b, on sharp critical exaniinatioii, tiotne of tlic
abOTO-meiitioJiod predisposinn; causes for pseiidartlimsia nrc of %-cry
different value, while the significanee of othent i* entirely dnubtful.
In the same wav it ia a common belief that fractures arc not cooaoli-
FSEI-DABTHROSIS.
200
ilated in pregnant feraalm. Tliis is not true in all ras« ; I Iwve iny»
self seen Dumcrous fractures unite in pregnant womvn, cnitj once
budeniilf^ of tlic coUu« yns d4>laycd a fcvr weeks in a fracture of the
Iow(T ?ni1 of the nidiuB, wliich wa» ivcognizvtl late, as might also
occur in women ocit prcgnntit, or iu men.
Tlie abnoniiil^- of Üio liealing process in cnse of ])scudarilirosi$ is
Dot flu« to the non-formatioQ of callus, bitt to the foilurc of osstfic«*
tioD tn the oew forniatinn. Tlie ttubelAiice connec-ting lli» fnigmeats
beccwaes a more or \esa rifptl cviiceirtive tit>3iic, by wliicli the (.■iiüs of
tbo booc ■«• bcW more or less closely tc^ethcr. If tho fragments lie
so cIcKc tliut iIhtv eome in oonUtct on motion of tlie limb, s cavity
witb Eoiooth vralls, Sllcd vrith scro-murous fluid, forms betvecn tlicm
in the uniting tissue; and, on the ^acturcd ends, cartilage lifts been
round, so that there wna, in fact, n, sort of ncn* joint. This docfinot,
bowcvcT, nerur very ofion, hut in most cases we liave simply a firm
cuoncctiug mas«, which »into dir^-ctly into the fngmeuts like u
trodon. "^'hen siieh n pttouditrtlinjsis is in it siiinl) bone, such as the
cJaride^ or one of tlio bones of the forearm, llie ilijiturbaiicc of func-
ibn ia tdvurs bearublc ; but, if it be located in the arm, thigh, or
leg', of eoune tlicro mu^t be considerable imjiairment of function.
In Bome cases it is posi^ible, by f^iiilable stippnrling apparatus, to give
tbc limb the Qcceesaxy liminees ; in otlier cases ivc oanuot do this at
nD, rv only incompletely, fto that for a long time attempts hare been
made to cure ibis AiseMe hy operation, that is, by inducing ossifica-
tion. IJefore pulsing to tlie iiiethuds tLsed for this pur]>Dse, wc must
mention the attempts made to prevent false joint, and to cure it, vrben
oooe establislieJ, by internal remedies. Preparationa of lime are
chiefly used for this purpose. Pfiosphatc of lime was given internally
iu the B'hape of powder; lime-water was given in milk, but without
much hrnefit. Of tlie lime given in this way, little is ahsoT)>p4l, and,
of thiü euperlluous lime taken into the blood, much was excreted
tfarouirh the kidoeys, bo that the psctidarthrosis had little good from
it. We may expect more from generrJ regulation of diet, and pre-
scrilnug articles of (ixxl tliat contain lime. R«Mdence iu pure country
nir, and mtlk-diet, arc to b« recommended ; but you must not expect
too mueli from these r<?rnfi3ie», espeeidlly in a fiilly-fonned false Joint
that Ims ciisted for years. The local remedies all nim at inducing
inflammation in the ends of tbo bone and parts around, because ox-
perienee slioira that most inflummatioas in the bone, especially sul^
cutauooM ttsumnlio ones, induce formation of hone in their immedi-
ate vicinity. Tlic rcme<Ues employed vary Tery greatly. We have
already mentioned two of them, n/Mtn^ the Jiraffm«nU together, and
paiating with tincture of iodine. Here also wouH belong the appU-
310
AITESDrX TO CHAPTERS V. AND VL
citJoii of Hitter» anA n! tlie Aof iron to tlie [«rt of tbo limb com-
Dpooflio^ to tiiti fractiiro, Hy the folluvriug rviiiedtua vre act more an
tW inhTniciiinto lignincritoiis lissiio: long, tliiii acupUHCture-ntfilUt
are passed into tlic ligumi^utuus baud, kikI left Uicro for a few days ta
excito irntatinn ; vre may connect tbc ends of two of these accdlea
with the poles of a galvuniu batti-rj, »nd ]>a8s an ploctrical cun^nt »s
an irrilaiit. 11m proceeding is called eU<lro-j>uncture f it is little
used. We jnay alao pass a thin, small tape, or several tJircads of
sUk (a so-called aetan ar \ strong ligature), through the lijjramMitou«
tissue, mid leave it tliere till tlicre is free suppuration arouod it, TTie
followiiig uperntiuua iittuck the botie more directly; iLc^ ore (juile
nuini>rou$. Kor instnucc, a nairovr but etronfr koif« i« passed as deep
a« the fracture, aiid th« ligamentous tissue is shared first fhini the
cad of one fragmcut, then from the other, without pnlarginjf the »kin-
wound. This is called the ai^utontou» bloody /nvhtmn^ of tbc
fra^^ents. Or we may make an iucisiou down to lite bnue, dJseect
out the two fragments, j>erfomte them rloee to tlie frnrtured cttd, »nd
paas a au(Dct«ntIjr thii:k lead wire througii tlic iK-rftiratiuos, twist tlie
end« togf>tlicr, so n« to approximate the frngiiiouts, or else, after
making ao incision, we xaay saw oIT a thin piece from eneli fiii^nieiiti
Bud tmt tho resulting wound like nn open rmclurc ; attd to this
operation, miction of the fragment«, we may add titc upplii-ution of
a Ȋitre of t/u bone. The following operation originatci* with Ditf-
feniaeh : Corresponding to the ends of the fragments he makes two
small inciüoDs down to the bonis then he perforates the ends of tbc
1x>nc close to it« bordcn, and willi a hanunor drive« ivory ptg», of
auitablu thickness, into tho perforations. Tlie eonsequenoe is, a for-
mation around thcAo foreign bodies of new booc, which, when ex-
tensive onou^^h, a« it may always be mode in the course of time by
repeating the operation, causes firm union. I will here mention Uiat,
when cxtrai^ted in a few weeks, tliese ivor)' peg» look njiigh and
corroded at the points where they were in contact with the bone,
while tlie perforation in which lliey lay is mostly filled with gnuiula-
tions ; oecasioualiy (he pegs are Dot retnoved ; the opeuinga llmxigfa
which they were introtluoed heal. This prove« absolutely that deaä
boue, umoEig wIülOi ivory is to he elussed, majf be tlittolved and rtab-
torbed by the grvmng oatoti* ffranulations. Wc ahaU bcrcafter hare
frequent occasion to rettim to this much-coatcsled (|ueslioi), which is
very important in some bone-diseosce ; we have already spoken of
the theoretical causes of this rcabsorption (p. 17S). S. V. Zanfferf
btck has modified this operalion of l>teffenba<K by using melnl
screw» iostCttd of ivory pegs; iinmetlintely after tho operation lie
fastens these screws to an appamtwi, which kec|)s tJie fhigmettta tm-
OeLiqUELT-UKITED FRACTTREa
211
moTsble. After nil tticse operation», a suitalile dressing roust be
applied to keep the fra^iK'iilä fimi.
Til« modm of opcroLion iti pseiidnrtliroMS, of whii^li I have only
mentiooed the princ'ipal oiics, »re, ntt you tee, quite numerous; and, if
the resist« of treatment corresponded to the iiumbcr of remedies, tbis
^rould belong to the most etirable c\ass of duceases. But in medieine
^ou m»j genendly take it that, with the incr^ase in number of reme-
diee for a disease, their valiac decrease& Ewy and rertain as some
forms of pMud&rthoaia uc to eure, others arc just us difficult ; nor are
all the different metbodn nuitctl to the same case. In the firat fthice,
the operatious vii,ry grcstlj as to danger, being nniHi more (hiugvrous
in limbs with thick soft parts, e^pociaU^ in the thigh, than in others;
«ad, as may be n.'a(Ii!y *iipprnied, the non-bloo«iy o]>i>ratii>ns nre le«9
«Ungcroaif than the bloudy; those mude with a amnll wound Icea so
'than thoM with Ui^f, As rcgnrd» efficacy and certainty, I eomtder
'the introduetion of a bone auture and re-ztdioti as tbosu whidi, eren
an the worst eases, give proportionat<'ly the quickest rcaultn, but
-which still have all the elements of danger of a (rscturo oomplicated
"by a wound. The treatment with irory pegs is less dangerous, ex-
cept in ttie thigh, where every liilsc joint ta dangemua, and I tliink it
"wotdd oocompliah the object in most canea, if the operation were
lepeated often enough. I have Been gfwxl results from this tntat-
xicnt, and from Von Lanyenhec]^» screw ajiparatus, as welt as &ota
ibo bone euturr.
Id pseudarthros» of the thigh the question may aeriouidy be
asked, if we should not prefer amputation at the point of the i»\m
joint (which is of fnvorahlo pmgiiosi») to any other dangerous or
doubtful operation. Iliis question only the peeuliarilieA of the in-
dividual case can decidi». In «ome rases the safe aid of a suitable
apllnl apparatus, mudc by a skilful Jnstnmient-mnker, is prefeiafalc to
any operation.
S.-OBUat^EI,y.i:NITED FHACTUEEB.
Altboagb, with the progress made in the treatment of bncturcs, it
is now raro for union to occur in so oblique a direction as to render
the Mmb entirely usele«, still, cases from time to time arise where,
in spite of the greatest raie of the surgeon, in fractureit with npeo
wounds, dislocation cannot ho aroidcd, or else, from carclcjuncss or
great restlessness of the patient and loceie ap]^ical!nn of the dres»>
ing», a considerable obliqiiity tn the {KMition of the fracture remains.
In many case« this is so »light timt the patients do not core to get
rid of the defunuily; Improvement of the position would only be
dodrcd in cas4^ where, from coasidcniblc obliquity or sborteniug oC a
212
APPEKDIX TO CHAPTEItS V. ASD VI.
foot or leg, the movRmenta arc ileeidmdlj- impaired. There are vari-
ona mt'Uiis by wliirli w»^ iii:i_v greatly improve or entirely gvt rid of
these deformities. If, duriii;; thv pruvcsä of uuiau, wc notice that Uio
fragmi-iitK »re nol exactly onnpted, ve may undertake the adjasttnent
at itny time in almple Bubcutaiii-oin fnirtiire«. If, in an i>]M;n Cmdurr,
obliquity of the fragmnnls has takon plucc under tbu- liret drfSiaiit^, I
strongly UTgo you not to try to rectify it bcfon» iIil* «-ouud hu healed ;
yoti irotild thus break up the deE>per granulstions, and tlie severest
inflainntiilioa might iif^iii bu excited. Iii fractuie» that hare long
suppurated, tlic coIUis long rcmftii)8 «nft, »> thkt yi^u nuty always tnb-
soquently flL-complish a grudual im]>rovciucut iu po&ilion by properly
padding ihn splinta (intt in one plaoc, then in snotlicr, or perhaps I9-
coutiimed e^t«ut>]Oii vrilb weights, If the fracture be fidly concoli-
dated in tin o))Iir|U4! pfjsition, wo hare the following rt-tnedies lor its
iinpruvetnciit :
1. Coxivctioii by bonding the cultui*^ by it^fraction ; Uv this pm^
pose we aniPEthetizc the patient, and with the hnndmittcmpt to l>cnd
the limb at the point of fraoture; if we siiccewl in sodoiii«;, we apply
a firin drePAitig with the limb in the impmred position. This method,
BO free from danger, can only be successful wMlc the csllus is stJll soft
enough I0 be bent ; henee it can only be done hooii after tbe fractUTR.
ä. Complete breaking up of the cnailied callus. Tliis aim taay
eonietiineä be done by the hands alone, but frequently other mecban-
icnl means will have to be resorted tu For this purjKMO various ap-
paniluaes have hceo conntructed, mich as lever and screw machines of
oonuderaMc power ; one of the most terrible bears the naroo of ** dya-
inoTphoatODpnlinklaste&'' All these apparatuses should only be used
witli the greatest care, so a» not to cauitc too much bruiüing and oon<
ftequent necrosis of the akin at the point where the machine is applied
on which the limb n>»ts. For the not unfrergui^nt obUipiely'unitod
fracliirejj of the thigh, the^forctd atteitslon of A. Wagnis (by the
appnntliis of Schneider and Mentis which wc ulao employ f<ir reduo-
itig old dislocation«:] has been reMtrtc<t to «rilli siioees«, Tlie follow-
ing illustration will fully eiphiin the meehiLnieal effect of this exten*
won ; If you have a bent rod, and let a strong man tatic bold of caeh
end and draw, the rod will break at the point whore it ia beot most.
If a new fmctnre of the thigh has been caused by indirect force at tbe
bent part, »nd the fnifrments l»e adjutiteil in a dti-aight position, you
apply II plaster-dressing at once while the limb It still held in the mo-
chine. As far as our present experienoo goes, this method appooM to
be entirely free from danger.
3. The bloody operations on the bone, of ^vhich thero are two iu
use, arc more dangerous ; the lirat of these is the subeutatMfua CMf«-
«PBIUTIONS 90B FSBDDABTnßOf^lä
otwftif of B. V, ZangenbMk. "Dna consist« in nmkiiig' a snuill iucis-
ioQ (lüU'Q to the bone at thf bt^iit purt, iutrwluning a iiiodiuin-siKc«!
gimlet tbrouf^h ttiU o]M>niiig and jx-rforating llie buiic, witliuut., lio\r-
ever, pivrviii^ the soft pnrta on the opposite side; then draw out the
peWoralnr, ami piuM n f^iiiiill, fin» saw through the pcrruralkni, and sair
the Ixiuc tniDxrcntcIy, lirst to one side, then fo tlic other, till vou can
break the n*«t of the bone with your himcl ; now ll>c bouc ia to be
»liaightenvd and tho injury trvntol as a coinplicatod frncturcL This
cqictBticm has oiily bc«i done on tlid leg, but, so fur na I know, alxraya
with ^rood ivsutL It may alao 1)C done by not nudiing th« adjust-
neut lit) supjnualiun begins, and thu L'allus has thus been softened
and portly nfahsorbcd.
4. Lastly, wc tnay employ tho method of JRhta Sarton, whidi
oonsiata in ritpofting the l>ou(> by n Inigc iDrision tliroiigh the skin at
tlie point of cun-ature, and sawing nut a wedgC'sliapt.-d piece in auch
» wny that the broad port of the wjldgc sbull corrrjtpond to tlie cod*
vanity, the point to the coftc*vity of the almornial ourvatiire of the
boiHL This method also shows gootl results.
On the wlitilf, the tKHi-bloody arc to bo prrfeircd lo tlie bloody
inelbods, if tliey do not cause too much contusion ; but the latter aro
lest dangexous than brcnking up fmcturns with strongly-cüotusing
appanttBesL
If tho deformity, especially of a foot, Ixs »O great, in different
directions, that none of the nbuve methods ofl'er mticii prospect of cure,
we Buy have to resort ti^i amputation in some cases.
In »vne few eaaes tin; callus is abuomially thick bikI cxt«iiBire,
juat as happens in riintrice« of llie skin and nerve*. Do not he. too
Iiaaty about operaliitg in such case», for slow subaeqiimt leabaoqitioo
nsoally takes place in every callus, Tlic rcno^Til of ^ucb callus masses
eould only be cfTected n-ith chisel or saw, and I should bo unwilling
to deckla OD such on operatioo.
CHAPTER Vn.
imURIES OF THE JOINTS.
C':>nuiiil4n. — DUtortlo«!. — Openinf of tho Joint, and Anita Tnunutie Artionlu InflaiB-
tnatlon. — VuieKj of CoaiM, and Botnlt».— TroatoiMii. — AbkIoibI«*) Cbft^ocM.
Hirnsitro weliave HtuJicJ injunca of (dimple iinsue-cleinenta ; now
wc mu»t ocoupy <iuiv«!rcs witli more complicated apparatwtet.
As ifl wt^U küüivti, til« JoiiiU are conijioiieil of t»-o euds of bonM
ooviTcd with cartilage; ofu »«c fiviiiii'utly contotiÜD}; nuiny appen-
dages, pockote, and bulgings ; the synointil membrane, wbicli is cLosecd
among the- sr-rous merabratteK ; and of the fibrous capsule of tb« juitit
vritli its »trengilioiiing ligaments. Under Homc circumstaaccsi, all
tbotc parttt participate in the disf ascs of Uie joint, so tliat at tbo sami»
time wp may htiv« discuso of a Hcrouii inciiihrane, of u fibrous capsule,
as well as of cartilage and boue. The participatioii ofllirsc diflereat
part« Tories csccodiii>{ly in Intensity und extent ; but 1 muy atate at
onoQlliat tlic synoviul mcinliniTiu plays the mo«t important part, uid
that the pcculiurity of joiut^liscoscs is chiefly duu tu iho cluacd oni)
inogular furm o£ the syuurial eac
Elrst, a fow words about cniHhing and eojititiion cfthejoint. If
one receives a licnry blow against the joint, it may swell moderately ;
but in most cases, after a few days of rest and applications of lead-
water or simple cold watt^r, the swelliof^ and pain subside, and the
funotionjt of tlie joint are restored. In other c-ases, slight ]»ain and
Btiffneas remain; a diroiiic inflummution develops, which may lead to
serious disease, of which we cannot at present spenk more fully. If
we have n chiuice to examine a niotlemtely-coiitused jnint, the (latient
having died perhaps of u serious injury* rec-eireil at tlie mkdl- time, we
fihall find extnvasntioos of blood in the synovial membrane, and even
blood iu the cavity of the joint itself; in the.8e eontusluits without
fracture the tiffuaions of blood arc randy so extensive that the joint Is
tensely filled witli blood; but tins may ocetir, This con<lition is
tsUleA hmnarthron (from ni^'n, blood, and o^p»)', joint). If a joint
that has swollen greatly just after an injury remains painful for some
OPSNCtGS OF TUE JOINTS.
2tS
timc^ nini feels hot, n sorDfrivlia.t more actire Botiphlogistic UeatmeDt
is Indicatod. This mnsuita to the appUcatloo of leeches, regular eii-
Tclopmcnt of the joint in wet bandages, causing Rio<lersLe i^ompre»-
eion, and in appljinf^ an jci^bhulder to th« joint. Ab a rule, inSAin-
nutiud of this grade niiiT bo rpn<lity relieved, although ehronio dis-
eases and a certain irritabiUly of the joint timt Itas l>eoi) iiijuru-d not
un&«<iuent|ir Miovr. It is very important to detcnnine whether the
crushing of the joiul be acconipiuiifd hy fmcluro or figure of th« end
of the bone, iii wliich case, it would be nctejuwrT to apply a plaster-
dK.sxinf;, and ^vc n ^ortlcd prognosis us to tlio future usefulness of
ihc joint ; of lat«>, in suvorv eoiilusions of the joint, even when there
«raa no fracture, I hare applied the plaster-drrsang and abstained
ttom all aatiphlogistics ; the results were very favorable.
A iarm of injury peculiar to joints is diätartion (lit(vrally, twist-
ing). Tbi« is an injury that occurs especially often in llio foot, and
which is oooniouly called " tuniiuj^ tlie root.** Such a distortioD,
which is possihl« in almost any joint, conRiittit eAsentislly in a tensioD,
too great stretching aod even parlial nipture, of tlie capsular liga-
ments, with eseapa of «ome blood into the joint and Eurrounding Üs-
[soe. The injury may be very painful »tthc time^anditsconscqusaoea
are do! unfrequeutly tcdiou», eaixxHally if th« treatment be not
lightly conducted. Usually ahstmriion of hlnntl and cold are resorted
to in tbeae eases also, hot with only temporary benefit. It Lt much
more important to keep the joint perfoclly motionless after such in-
juries, so thai, if any of the ligaments be niptured, they may beat and
acquire their prerioiia firmnesji. llie simplest way of nttiitmng tilifl
ot)jc<rt is by applying h ftmt dressing, such as the plastcr-tniikhgo,
with which we nuiy permit the patient to go about, if it gives 1dm no
pain. After ten, twelve, or fourteen days, oecarding to the serecity
of the injury, we may remove the dressing, but renew it at onoe if the
po.Lient has pain on walking. It may sometimes be noccssary to wcor
this dressing three or four %TCoks. Tliia appears a long time for audi
an injury; but I can ussure you thal.,wi(hDutthoapplication of a film
dreswing, the consecjuenres of these spntins often continue for months,
at the same timi> the danger of subsequent chronic inflammation of
I the joint u incn»Bed. Hence you must not promise too dpeedy a cure,
•ud inu«t always« treat thcfie, often apparently insignificant iiijuries,
conscicotiouslr and carefullr.
OPEÜTKOS OF TUE JOIXIS, AXD XC.VTR TKAUICATTC ASnCIILAK
Tn now passing to wounds of liie johit^ we make an immens«
spring as regards the importance of the injury. While a contusion
910
INJURIES OF THE JOIST«.
And sprain of thr joint arc scamrlj' noticod hy many pattent«, cbe open-
ing of a sjnovinl sue, tritb cscApe of M'novta, cvca if (be wound Im
not lar^, always lias a serioti» 4>lftf<<t on lli« fuiictjon of thv joint, Mid
la not iinfrcqucutl}' dangerous to life. Here, ngniu, vre liavo the dißer-
cuco between subcutonvoits trnuniatic infUimniutions and tlioac wbich
O))«.'!! outM'unlly, of wbioli wo spoko when on lli« subject of cott-
tusions, mid which vcc also suw in suticutaacnus awl open Iraclam.
Morcovor, in the joints, w« liaro closed irrrr^latly-iiliagtcd cues, io
vlitdi the pUB, once fortned, ictnains, and, besides intlaiiunntion of the
»tinuA membrnitea, may result in v(^y tedious procesec», but in its
uculo älatv «rfu-ii lilts a Imd elTi-ct on t\w g«DCi*\ facalth of tliv pati(.'iit,
1 think Ihc quidcpst way to d(>iti?rib« tlie procrss iviU be U> give
you a f»w example«. We are liLie Bpesl(iii;T ordy of simple piincturvd,
incisL'd, or cut wounds, without complicntiona frum sprniiiti or ftv>
turcs, and cbooso as our example the knee-joint; at the Kiimc time w«
muat remark that injuries of this joint arc regarded as the most ecf
vctc A nan ootnea to you, who, in cutting wood, has received a
wound half an inch long, near the p»tella, and which has b1<^ but
little. 1'hiü may have happened some hours bpfore, or even the jire-
vious (lay. The patient pays little attention to the vrouiiit, ami only
Bsks your advice; al}out a proper drcssinfr. You inspect lite wound.
Cud that fmm its piBitiou it correBponds lo the iaiuo-juini, aiwl nrmtnd
it you may perhaps see some scmus, thin, mucous, rh'ar fluid, which
escape» iu grcattT quautiticä when tlie joiul ta moved. Tins will call
jroiir nttcntiou particularly to the injury; you examine the {Mtticnt,
and hnirn fnim him th:it, iinniediati'ly after the lujury» there was do!
niitch bleiiUrig, hut a fluid like wliile of cf^ vAapei). In such ouics
you may Ix; certain that the joint has been opened, otberwisc the
Bynoria could not hare oecapHd. In smalt joints tlu! esciipe of
synovia is no slight as to be scarcely noticeahle, hencr, in injuries of
the Bogcr-joint, and even of the ankle, elbow, aixl wribt, il nisy for •
time be doubtful whether the wound has penetrate«! (lie joint or not.
Wlien a penetrating wound of the joint id oertain, tlte following rules
shoid<l nt OI1I.-C he pursiKHl : 'I1iu patient should keep quiet in bed,
the woiiiul slioiild 1k> uniied n» quickly as posaihic, lo prevent the es-
cape iif mtm* »ynovia, which would iiiterfero witii healing of the
wound by tirst intention; hence we closv tlio skin-wound, if it has a
tendency to fjapc. This may best be done by suture« nccuratdy ap]ilied •
in »uuic »mail wound», carefully -a] tpli<r<l adhesive plnstcr, or ichtbyt>
oolift-plaater, painted with oollotliou, may suffice Now the joint ta to
be kept al«k)lutely quiet ; Ihia can only be done by firmly banda^og
the limb, from below. With wet bandagcaL In the case brfora u5,
the whole leg should bo kept seouicly and Unnly extended on a hoi-
OPEKIXGS OF THE JOIJJTS-
«17
iw spUat, or IxHwiwa two sacs of sand. If^ besides this, you f^re
3c intcnul rctuedr, ainJi as a mild purgative, I tliitik eiioiigli bu
dune fur tbe time, lu moat text-books uii Burj^-ry, it is true, you
rill und Uin ndvioe to put oa a number of leeclics, niiil to keep a
Usdilerof ti% corulanilr apjiliutl, to previrnt too tiiucli iiiflamination.
But I can BBsuic you Uiitl l(x-ul ubstravlion uf blood suid a^ld do not
«TOB bero liavc tbU propliylactJv, nntipblugüittc oction, aod that it is
time caough tu n>«ort tu ice iu a biter stsgY>, altliougli I will not blame
any one Tor using ico from the firet in inflammation of tlic joint. Tbe
■bore dfcsiiing I have of lute ropLiced hy tho plnstc^^resainj^ ; I apply
it as for a fracture of the knetvjoint, from tbe fixit to above the mid-
dle of tbe tbigh, with a pceition-splint^ tlien out an opening' coi-re-
gpooding to the anterior surface of the knoe and the wound ; the result«
of this lrentraent> as compared to the old regiiliu- antipbloj^i»;tlc treats
menl, are very brilliaiiU Let un rehim to our patiuut. Vouwill Und
that, oa tlie third or fourtli day, be wUl complain somen-bat of huming
pain in the joint, and he slightly fererish ; on applying your baiKJ,
tho joint feels warmer than tbe healthy one. AVhcn you have re-
moved the sutures, on tbe fifth or »ixtli day, iu the following two days
tbe ooiirso may be in one of two very difienmt directions. Let os
fitat talcc the iaTorablc chsc, wliic-h is fretiuent under early tJt^aliiieiit
tritli firai dreasings ; the wound will bcnl entirely by lirat iuteution,
the sliglit swelling ond pain in the joint will diininijib during tlio fol-
lowing days, and finally dijuppcar oulirely. If you nimorc tlm dress-
ing to from Jour to six weekis the joint will be again Rioi*Bble; tlio
WDovory ia eom|deta
But in other cases, especially vliere the patient comes uni3er
treatment late, thinga turn out worae. Towanl tlie end of the fitat
week there are not only grt>at »welling and heat in the jmnt, but there
is (edena of tbe leg; tb« ]uttient bus seeere pain on lK>i«g toui-bod,
aa welt as oii every att^impt at motion; toward evening be has high
fever, be loses his ap]>clito, and bcjfitw to omaciato. At this time the
wound may \ms closed, or a seru-mucous and subsequimtly purulent
fluid escape« frwrn it. But even if this be not the case, the above symp-
toms, especially the »welling of tbo joint, with distinct lluoluation, the
pain, increased Icinpemture, «edema of tbe leg, the increase of fever,
piwit to an acute, int^nne inflanimalion of tbe jcunL If iu such cnses
the limb be not fisttl, it gmduiUly aasumes a Hexed |)osiUo«, which i»
the knee-joint may iiior*>x»)e to ail neute angle. It in not efusy to give
tbe reason for tliis flexed position of influnie<I jointtt; it seem» to me
most probable that it arises, in a reflex manner, by a transfer of the
itation of the sensible nerves of the iiilluTned »yiiovia to tlie motor
of the flexor musclea. Another explanation is, tltat crery
218
LVJCRI£S OF THE JOINTS.
joint may contnin mor« fluid [a tlie flexed than in the extended posi-
tion, which boK hefm proveit Exporimciitally by Sonnet, who imually
brought t]ic joint» in the railarcr lo a flexed pastion, by injecting fluid
into tbcm. But these experiment« do not seem to me to pror« any
thing «bout the nbnvi>.nientJQnfxl fiexed posilion, for these aUo occur
in articular iiifluiiiiiiutit^iiis where there !» no fluid io tlie joint; od the
otlicr hand, they arc often absent irhcrc there is a grottt deoJ of fluid.
Observatiati ehoirs that fMute pala/i4 s^'novili» mo«l disposes to
ftcxioD of the joint
If the «boT« symptoms have presented thcinsolre», »ntiphlopÄlic
lemeüieü assume Uieir historic vxluc, but we tnu»t uol forgut that at
tlic 8»nie time the potntion of the joint should not be neglected, so
that if ftb»ulut« etiffncss of th« joint should occur, thia may rcsitlt in
the position reUitively most £tTorable for its usefulness, that is, in tbo
knee-joint fully extended, in the foot and e.\how at a right angte, etc
If atl<;[ilion lo thid point was neglected at the commencement of the
treatment, you »hciuld repair the error by Bniestlietizlng tlie patient,
so ihiit you may, withotit diffictJty, give Ih« limb the proper posiiiun.
Among the antiphlogistic remedies, I attach must importance to pla-
dng one or moro ice-kladdcrs on the inflamed joint, aud [mhiting it
with conccntratfld tincture of iodiii«, which sliould he used till a oon-
sidtrable extent of epidermis is elevated into a resicle.
If the fluid IQ the joint increases veiy rapidly, and the tension
becomes tnsu})portabIe, and if there is no freu esen])o fur the pus
through the wound, so that there is danger of ulceration of the cap-
sule from wilhiu, aud of ihc pus flowing from the joint into the cet-
luhir tissue, wn may eareftUIy draw off the pus with a trocar, of
course guarding against the entrance: of air Into the jcünt. Tlds tap-
ping of the joint, which of late has been ii]iccially recommcndcd by
K. ViiUemann, I formerly uaed \rith good rcnults, and by it 04ired, u
I believe, four sucecssh-e caaes of scn're, acute, traumatic iuflamma*
tioa of the hnee-joini, with perfect restoration of mobility. Since I
have applied the pluster-bandage in i-imjile penetrating wounds of
the joint also, I have not resorted to tapping. If the patient is kept
awake at night by pain, he should tmve a dnso of nwr|ihino in tho
evening, and antiphlogistie diet and oooling drinhs during the dar>
By -this treatment we may succeed in cutting short the acutetiess of
tho diaca.<>e, rvra in this stage; hut even then the function of the
joint may not be fully restored, although this is possible in eos« th«
auppumtinn of the synovial nieml>rane remains cliir-fly KuperflciaJ
(catarrhal). Frequently, however, tliu disease parses from an acute
to a chronin course, the suppuration attacks tho tissue moro de^y,
tbcD after recoircry there rcuaius more or less stiShess.
TR-IÜMATIC ARTICULiR INFLaUHATION'.
SI9
But, uofortuiiatcly, the itiflammnlion in nnä around the jniDt occa-
ily extend« uticontrollablr. And, fmally^ tlie ooty lUiDg to be
dooe is Ut enlarge the wound, to make onw openinfri in \iinous
phoes ; vc then have complete suppuration and dc9lniction of tbe
rpiOTial sac. All tbc comnmiiicatiuf^ sytiorial ucs do not partici-
p»l« eqnslly in tlie Buppuntioa ; on tapping, you nuy at one part of
tbe Joiot cT&cuAte seniia, at anotlier, pus ; tlii» in prolmblr because
tbe swollen synovial mcmbnuie cloaci>, like ft valve, tbc openiogs of
commuiiicatiou, whioli are oftvu norrow bctwet'ii the oavity of the
joint and the adjacent sacs. In bad cases the suppuration L'xtend«
to tbe aoR. part« of the thigh and leg, the patient is thus exhausted
move aod more aa )i« also is by oev-ere fever and diiUs, his cheeks sink,
and ice beaitate about our treatmenL Itecovery is possible, even in
this stage ; tbc acute suj^urmtious gtadually mMiae, and the disease
become« chronic, and nftcr sevcnd montjis may terminate in eompletc
stifflMW of th<* joint. In many oases ire strive iii vain to keep up
tbe strength of th,e patient wilb tonics and strengthening remedies,'
but be dies of exbauation as a result of new suppurations which
etreo occur at points having no connection with the wound This
onfortuDste Icnnination we am only prcvt^nt by nmputaion; this
ledy which ts oo depbnible, but which in these cases freqiiently
tsaros life. The difficulty here lies in the choice of the proper time for
[operating. Obeer^atioos at the bedside, which you will make in tJie
I'c^ic, must teach you how much you may trust tbc strcti^b of your
it in individual casea, so that you may determine when the hict
it (oc tbe o|>eratiou bus cnme. In hospital, you will always
see many such oiisea <Lie of purulent infection (pysmia), with or
witbout ani]>utation.
Since, iu describing tniuuiutic articular inllammation, we held to
^tbe prusentalion of a specini cusc, and let the Irentnicnt follow thv
■ymptoms, we must add a few rcmnrka alxtut the pathological aaav
ouiy, OH it luts been accurutely studieil on the cadaver, oti amputated
limbs, and by aid of cjprrimcnta. The diseusc allects chielly, and at
first exclusively, the synovial membrane. If this has not been sceit*
rately observed, as I knnw from my own cxperienct-, we are apt to
consider it too thin »nd delicate. Uut, by examining a knee-joint,
fou may mdily satisfy yourselves (liat at most points it is tbicker
and more Biiceiilent than iha pteiira and peritonaeum, and is separated
&om the fibrous articular mjittule by a loo»^ subscnius cellular tissue,
wbich sometimes contains much fat, so that yi^u may detach Ihc eyno-
vial sac of a knee joint from tlic cartilage as an independent mem-
bniDC. As is well known, it consists of connective tissue, has on its
■ur&oe pavement epithelium, and contains u considerable capillary net-
220
ISJtrniE3 OP THE JOINTS.
work ucar its surlticc. Wc hnv« tbo inrcstignttons of Ma<t<r, «bout tlie
lj*in])])atic voHScls of Üie sjmoviiil tncinliniii(> ; iic<ronIing Lo Uicm tbis
tiienibnini? itself contains no Iv'tnptuitic», vrliUc the subajruovinl tissue
U suiti lo l>R very ricli in tli^ni. lliii^ result is surprisin^f hikI Iicdco
requires repetition with aJl Ute aids of modem anatomii.-al nrt. Sinue
tbn HriiDrint sues are seroit» membrnnps, it I» inc»l probal^R that they
contain lymiilintJc vrascls, &»»h as Imro lieun ik-scrilwd !ii Ute i>erilo-
iwpiim and other serous mcmln-Ancs, hy Von lUckiin^hauMiny foriiiiof;
supurGcial nets covered with epitlifliiim, and partly opAttlng^ on tlie
Biiriacc of tlic membrane. The «urfure of the synovial mcmhraoe, es-
pecially at the sides of the j«int, eliows a number of tufted processes ;
these hiivpwoll'forinetl and ofu-n complicnt«] capillary nets. Sytit^
ytal membnmes »hare vr ith other flerou» ineinbranen the peculiarity of
leTrctiuj; a oousiclcniblc quantity of eeruui ou beinj; irrilnteU. AC
the same timt' the vvHsela become dlUteil and iK-filti to gn>w lociuooa
toward the surface, the mcitihratic Itncs its lustre and smouilincss, auil
firat grows cloudy ycllowisli-rctl, and later more red aad rclrcty on
the surface. la most cases of »cute innaTiimation a mora or less
tlilL'V fihroiw deiMisil fonns on this surfare, a son-allpd pscMdo-mmi-
bmnc, like that in inHammaÜun of the pleura and prrilonieum. Mi-
croscopic«! examination of the synovial membrane iti this «tnte »lioirs
that its entire ti»nie is ffreatly infiltrated with plastie mat tcr, and that
on the »nrface the collection of cells is so coiisidcrahic tliat tiic tissue
bcrc consists almost cxcliisirely of enml), round cells, of which the
more supcriteial have the charaeteri^itirii of puit^ells ; in tlie imine«^-
atc vicinity of the greatty-dilatcd vessels we find the oollt-vtioii of
waDtlcrinE; cells piirticulurly i^rt^at, which is probably because in ncnto
synovitis nunienxis white blmid-cell« wunder through tbn walls of iho
vessels into the tissue, and culleet in the ■»■idmty of the vessels; in
Itiifl process red blood-corpuscles seem also ta escape fmm Uir \'essela
in preat quantities. The pseudo-membranes are rompoaed entirely ot
small, roinid cells, held together by coagulated fihrine.of whose origin
from fibroseinms mid fibrino-plnsiicsniislaneo we lm\-ealrLwly Bpnken
(pt CT). The connective tissue of the membrane ha« partly lost its
striiited elwracler, and hiw a gelatinous mitcnu« coiiii-itenry, so that it
greatly resembles the intcrcellulnr substance of fTTamilation-tissnc ;
IB the fluid in tlie joint, which is constantly becoming more cloudy aod
puruloid, there are at first a few pus-corpuscles, which constantly in-
crease ill number till Die llui«! has all the chnracteri.stii'a of png. Still
later tlie surface of tbe 83*aovial membrane in so vascular lliat even lo
the naked eyo it looks like n *<]ionf;y, ^lij^htly-noilular granulation-
surface, on which pus is constantly forming-, as on an onliuary graou*
latlng surface. The condition Into which tho synovial membrane
8ÜPPDIUTI0SS OF JOLNTSL
921
poasea, m Iho 6rst sUgee, moat resemliles ucutc i-aUrrfa uf tbutaucous
tnombmne«. Aa long as thnrc haa been only supcrKcial euppuraüon
. witJidiit (lUiittegmlion or lis^ite (wiliioiit ulccnitioii), tbe toGiabrane
»■y rt-turn to Uie iiunniil sUite ; ImiI, if the irritation be sul^oicnt not
otil^ for tltc formAtion of pecudo-mcDibraiio (wlticli uiAy also be ogaia
disiategratod), but to anmc stippiuutioa of t)m BV-Duvi:tl lufiinliraiic it-
aeiS, the oaly result will be fonDatiou of cirjitrix. Tn dirM-ribin^ ■
typical case of suppurotio« of Iho knee-joint, we havo uln-A'ly fibuvro
ibat Ibe pus perforates from the loicc-joint iiita th<} Butkcui»ii43otig ivl-
lular tissue; ttiis undoubtedly occur», but pertarlicuW sulK-utuncuus
■uppiintttoii», after pcnelnitiiig wouud» of joint«, also occur ocva-
sionslly without dciieuiliug tin porforntiun«. of pus; ire see tlicm
botli in ncutc tiiid i-krouio itu])]Minti[Kis of joints^ without bcniig abln
to detort u dirtx:t commuuiiiitioa iritb iho cavity of tbo joint. Fmin
my enperimoBls on tliw pblogistiu «clion of pus, I tliiiik this iiiuat be
due to llio rraWorption of quickly-fonncd poi.sonoiDi pui) by t)>e Ivm*
itic Vfvsols of Lho syiiorin! iiiembniiu^, »nil itA coittinction to the
Eieular crllutar tiwtuc ; at t!ti> siim«^ titii<; Ibc iici^bborin<; lyni-
»bulii- cbxids «re alway8 swolU^u. When iri-ulirp}^ uf JYiuphiLngitis,
sc »ball bare tu ix'tuni iu ibii» subject. 'l*lii.^ i-arliUifCr docs not |)nr-
tidp&te in ibe injlammatioa for Bomc time; its surface becomes
cloudy, am], when the proecss is very acute, it begins to cUuintegmta
■ to fine mol^cub-s, or even to become nccjosed in birge fragnieiit«^ and
^hp be delacbcO fKiiii tbc bone by tbe occurrence uf inflnnunatiou and
^Kuppuratiou betwet^n ennilaj^ and bone ^subchoorlml ostitis), Al-
^Btiim^b (be cartilnge with Its celb is not wboUy iiinctivc id these
^RinHaniinatiDitK— for. from various ob^m'utiotiJs wc can ecnrcely avoid
Hrlielicring that Ibetnrtiligo-cells miiyAlKo prcnliicopus — still, I consider
this state of tlic cartilage is essentially a passive softening, n sort of
tnacoatioii such ao occurs under tike circiiniiitanccs in tlie conic» when
tbere ia severe blenuorrhiKi of ibo cunjuuctiva. J»doed, ther« ore
scarcely two parls of the buniHu body sn analogous Lu their relations
as the oonjuuctivu in Ua relations to the oomen, nnd tbt; synovial
mnbnuu) in iu relations to the cartilage. Wo shall frequently ba^-c
occasioa to leUirn to ttiis point, uwl sliall Iivrv ceaso ibe ooniudor»*
tions, which we i*haill resume more partinilarly hereafter. If the ncuto
pcvcess bCDomes dironic, und a stiff joint result», au anch^loai* (Crom
hyKvXff^ twnt), it nlwai*» oocurd in the same way in all suppurative
inflammaliuiis of the joiula We shall investigate this more exactly
Vlieo treating of chronic articular inilanunations.
222
1N'JVR1£S OF TUE iOlXT&
LECTURE XVIII.
Biaapl« Ptslcwtlooa; Tnuntik, Coagn^U), PMliolc«laal LnxMlcoi, Siäilozalloiw.—
Etiolcie7-~I^>'BcultlM ia B«dact>on, TnalutMit; Bcdnotioa, Afler-TrmWwpl.^
SnUtiul Liuaiitnw.— Old Lus&tioiu, TrcMaicnt.— C«uii>Ucaied Luutloae.— Coo-
SIMI'l-B UISLUCATIONS.
By a dislocation [luxalio), ve undcrsland tliat conditioa of a
joint in wliich I lie two articular ends are enlireljr, or fix- tlie most part,
thrown out of iJirJr mutual rclattnnp, llict uriicular rapsiJc being gea-
enlly partly niptiirwl at llie same time ; at loast, this is almost alvraja
tbe rase in traumatic luxations, i. e-, in those tliat have oocurrod in a
bcnUliy joint as a result of tbe applic&Uon uf furce. Ueaidcs Ihi-se, we
distinguish confjtnital, and upotUattew« or jHttJtolo^ual luxations.
The Litter result from gradual ulLvntive d(.*8tn]dtoa of the articular
extremities and ligntncntA, since (here is no loDfrcr the jmninil oppo-
sition to niuaoilar contraction ; wc Eball speak of tliis bcrcaftor, aa it
O-ssentialij' bolonprs amon;; the results of certain diseases of the joints,
At the end of this section we shall say smnetliing alxnit oan^nital
luxations. At present wc »ball apcuk vn\y of traumatic dislocativos.
\\'e oeeafüonnlly hoar also of auhluxationa ; by this oxprvssioa we ,
imply lliaL the iirtii>ulnr Riirf»ees have not separated entirely, so that
the luxation is iiiCDiiiplete. By cwnplicaied luxations we meaD thos«
aocompanie<L by fractures of bones, wounds of the atcbi, or rupturea of
large veKftt^l», or nerves, or all nf tbe^c. Voii must alao obaerve that
it ia niMtdiiiar)- to de»gnatc the lower part of the limb la tbe part
Iuxat«d ; its for instance at the shoulder^joint, not to npcak of a lux-
ated seapulu, but of dislocation of the btimenis; at the kiiev-joint, Dot
of luxation of the femur, but uf the tibiii, etc,
Dislocations ^nemlly arc Tare injuries ; in some joints thoy arc Bo
rare that the whole number of cases known is scanvlybalf a doxen.
It ia said that fractures are cigbt times os frequent as dtslocations ; it
ecems to me that cvea this is too larg^c a proportion for dislocations.
Tbc dislribulinu of luxations amoufr the diffi^reiit jninta variea very
greatly; let me show you this by some figures: According to Mat'
gai^n«'* slalitttics, among 4B9 dislocations tbero were 8 of liw trankt
6Ä of tlie lower and Jt9 of tbe upper «xtreinity, and atiiong tho lat-
ter there wen^ 321 of the shoulder, Hi-tire you see tfaut tbe abouMer
ia a very favontv joint for disluaUtons, wbiuh ts readily explained liy
its ponstntetion and free uiobUity. Dislocations are more frequent
among men than women, for the same rcasoDS that we have already
fibown fractures to be more frequent in men.
DlSLOCATtON'SL
SS3
As hidiicing CAQses for dislocations, vc hare external spplicatioas
of force and muscular actiou ; tbc lutti-r arc rare, but omm have lieea
o1m«fto<1 wlierc dislocations were caused, iu cpiloptioA, for instance, hy
muBCular ooti tractions. As in £racLurps, tliu VAtcrual uuusc« i^ divided
iolo direct and twIir^cL For instance, if one gets a luxatioa bjr
fiJUog OD the shoulder, it is due to direct fore«; the same luxation
might ooi'ur indirectly by a person with outstretched ann falling; on
the band and elbow. V^bcther a dislncatioD or a fracture will result,
d^OHls chieflr on the poution of tlte jotut and the nature of (be
onve; but much also depcrMi« on whotbor %\w. bone« or the articular
I^imenta give way the more readily ; for inslHiice, by titc same manwu*
Tie on different dead bodies wo may »Hnctimea cause fracture, sonko-
ttme« dislocation. As in fracture«, there are numerous symptoms of
luxattan, of whioh some may lie very i)oti(*eable, and are the more so
the sooner we see the caac, and ti>e lens tbc displacement of the ai^
ticulor cods is hidden bj ioflammatory sveUing of the superjaoent
•oft parts. Tlie altered form of Ilic joint i« one of the roost important
and strikint; »j'mptomtii, but wbit^h only lends quickly »ud ucrtuinly to
ft diagoons when the eye ba« been aecustomed to readily reco^i»
diffefenees from the Donnal funn. Correct measurement wi lb the eye,
aocotatc knowledge of the normal fomi, in abort, aomc taste for sculp-
■tun sad sculptural uiuitomy, so-called artistic aiialomy, are here veiy
toefiiL If there ia very slight change of form, even the most prao-
tWd will nut be able to dispense with a roinparison with ttte opposite
mde, mmI benoc 1 earnestly urge you, if you would avoid error, always
to expo«e the upper or lower half of the body, as the ea«e may be,
and to compare the two tide«. Vou may brat follow with the eye
the direction of the apparently displamd bone, and if this linn does
not strike the articular cavi^ accurately, there will most probably be
a dislocatioD, if there be not a fractun*, do.«« below the articulaiing
bead of the bone, wbirh must lie del«rmii>ed by uuintiul eittmiiuilion.
The lengthening or shortening of a limb, its poaitioo to the tzunic,
the distance of certain pmuiineiil points of ilio skeleton from each
other, often aid ua iu mukLng at least a probable dijif^usis very
qinckly. Another symptom perceptible to the sight is cccli)'nK>eis of
the soft parts, or suggitlstJon. This is run^ly distinct at first, liecause
the blood, escaping from the toin capsule only gradually, perhaps itot
for several days, rises near the akin and becomes visible ; iu some
eases the efiuaion of blood is so inoooaidemble that it is not pe-ronivcd.
The tymptoois given by the patient are, pain and inability to moxc the
limb normally. The poia is never so great as in fractures, and only
appean on attempting to move the limK In some cases, [»tients
with luzatious may penomi some moUomi with the limb, but only in
SS4
IXJÜRIIS OP THE JOIXTS.
cerUin directions, and to n rery limited r-xtcnt. SInnual cxuninaUoa
miut fiitally settle t)ic qiiesltou in inost roses ; it must bIiow that tjie
artioiil&r cnvity iit ompty, nnil tlint the hpnd of the bone is at come
otiiür p<ünt, uL one stJe, ubtnc or Mmv. If thu soil j>arts bo c»iiwd>
erably swoUeo, ibis cxanmuition msy be quite difficult, and the aid
of aofestliesia is often necessary for a correct diAgooeif^ cspc<,"i«Ily if
the exhibitions of pain and the motiooB of the patient inlerfen?. On
moving tlie extremity, which we find npringy or slightly moi'Bblc,
i\xcrc is occwicnally u feeling of friction, an tudistinct, eoft crepitation.
This tnay result [inrtly from rubbing of the bond ßf the bonn on torn
cspsuliir ligHineitts and tendons, partly fmin the compre«»io» of Gnn
blood-cuu^iln. Iiluncc, in such x-ariut jcs of crcpitfittoii, wc i^oald not
at i>»i% eont^ludc on a fraciurv, btit be urged to inon* careful oxnmirui-
tion. Fractures of certain parts of the articular ends, with di&loc?a>
tioR, are most readily mislakrn for luxation». And formerly the rooclo
of expression on this point was not exacts for diBpIaceni«nts abooC
the joint, combined witli fractures, and oniiNed entirely by Lliem, irere
also termed luxations. At present we di^Uneiiish these fractom
«ithin the joint, with dit>location«, more ahorply from luxations
proper.
Should you be in doubt as to whether the cnsc is nnc of dislocatcid
articular fntctuic or of luxation, you may easily dedde the quest ioa
by nn nttempt at n^diirlii>n. If cudi a digloration i* readily nvlurod
by modemto traction, but at once returns wlen you leare off tie
traction, it is a case of fracture ; for a certain art is necessary to the
rcdnction of a dislocation, and, when once reduced, it does not readily
recur, although there are exceptionn to this rule.
A contusion and »pniiti of the joint may uLio he tnistokni for lux*
ation, but this error may he avoided by careful cxaminaliM). Old
traumatic luxations may sometimes be mistaken fordislorations caused
by contraction. Lastly, in parnl^-zed linihs, where tlicre is at the
same time relaxation of the articiJar capsule, the joint may be »o rery
movable that in eertain positioiM it will took as if dislocated. In
tHeae eases, also, the historj' of the c»»e. and cnrefnl Ux^l examination
will lead uct to a correut conclitsioii.
Hegnttling the «tntfl of the injured parts immediately after the in-
jury, in casv» where therr lias been u chance to examine them, it has
liccn found that the cjipsulo of the joint and the synovial locmbtane
ape toni. The capsular opening is of Tariabic siüe ; occasionally it is
a slit like a buttoaOiole, sometimes it is triangular, with more or less
ragged edges; ruptures of muscle« aiiij tendinis immediately around
Üie joint hove also been obserred. llie coutu&ion of the parts Tvies
greatly, as docs also the elTusion of blood. The head of the bono does
REDUCTION' OF DISIACATtOXS.
ss«
not always remaia at Hie point whore it escapes from the niptnwd
capsulf, btit in many ruses it is tii«:Iier, lower, or to one side, as tbe
nUHcles ai1ach«d to it conlmct nml dtepUcc tt'. It is imjxu-tJiDt to
know ttiat wo must frequent))' bring the luxsted head of Üie bone into
a diSercnl position before wc caa carrjr it back tbrougli th« opeuing
in the capsiil« into the arti»ill)ir cavity.
Ocr&sioiially, by Bom<! ac>oi()ental muwular actinn, the dislocation
is spootanoously rcduocJ. In the Hlioulder, especially, tltui has been
observed several times. But »uch Bpontancous reductions arc very
rare, bcMnusc tliere are usually certain mechanicAl oWlruotious to the
reduction, which must lie overcome by skilfid tnaniptilution. These
btoderancoa eouaist partly in conlractioQ of tlic rausclcfl, by wliich the
head o( the bone may be eitii^lit Iwtwcc-ii two contracted muscles ;
anotlwr lar more frt^^^ueiit obstacle is a small capsular opening, or its
oocloston hy the cntraDoe of tlio soft part«, Ijostly, certAtn (ensiona
of the capsular or Btrengthcning ligaments may hinder the reposition
of recent traumatic luxations.
In treating a luxation it miiHt lirat be »Wilfully reduced, aud then
means be employed for reeioring tlic function of llic injured limb.
We »hall hpne only »peak of the reduction of recent dislocations, by
whicli we ineun tboe« that are at most eight days old. I1ie most
furorablc time for reducing a dislocation is immediately after the in-
jury ; then wo have the It'sst swelling of the soft parts, and littJe or
DO displacement of the luxated bead of the bone ; the patient is still
mentally aud physically relaxed from the accident, so tliat the repoai-
lion is not unfrequenlly very easy • later, we shall often have to fkcilt-
tate the operatioa by resorting to anjcstbetica to remore the oi>pu^tiua
of the muaolos. Beganliug the proper manoeuvrce for the reduction,
we can say but Lttlß in general tc-rms, for this of course depends en-
tirely on the mecliunism of the different joints. Formi-rly, iL was a
grnerol Ttde, for the reduction of disloculions, that the Itmb sliould be
brought into tlie position in vhieh it xrns at the moment of the dislo-
cation, so timt by traction the head of the bone might be rqilaoed as
it had escaped. Tliis rule is only important in a few cases ; at present,
in the diifereut dislocations we aro moro apt to resort to very different
motionR, such as flexion, hyper^xtension, abductioa, adduction, eJeva-
tkm, etc Usually, the surgeon directs the assistants to nuike tlie«e
motiona, and himself pu»bes the head of the bone into place "when it
1ms been brouglit before the articular cavity.
Finqueotly Ih« surgeon alon« can aooomplish the reduction. I
haro often thus reduced a dislocation of the tbjgb over whidi various
colleagues, aided by muscular laborers, had workctl in i,-ain for hours.
In these oases, erery thing depends on correct anatomical knowledge.
5*20
IKJrRIBS OP THE JOINTS.
and you may readily understand thai in i certain fiirectioii you may
not unftequently slip tlic liead of tlic boot! into plncv -willi vtrj- littlu
foroe, 'while in Another position itmlgrhtbcontiR-ly impossiblo. "NVTmjo
the hwid of Ü10 buuo enters the irtieular t-avity, it occasionally causis
a ptnccptiblc soap ; but this does uot nlvrays occur ; wo arc oolj per-
fectly a8»ui«d of successful reposition by the restoration of nonnal
tnobiUty.
If wc (1q not succeed alone, or with a few nssi&tnuts, we bavo
T&rious aids, by applying long stiugs to the litnb, ond having 8CT«imJ
nssistants draw in ono dir»?ot!on. Tiiis traction, whidi of course must
he opposed by a couut<?r-cxten»ion of Uie body, must he regular, otA
by sturts. If wc do not succeed, cvcii in thU way, we call in the aid
of laachtnory to increase tho power. For this pur^tosc I'nrioufl iiuitru-
nenta were formerly employed, such hs iIm; lever, Bcretr, Imldt-r», cCc
Now tho multiplying pulleys, or }ichiteidnr-Men<Pa extension-appara-
tus, is almost cxdusiwly used. The multiplying pulleys, tm instnh
mcut lliat you aln-ndy know from your studies in physics, for inrn.ta»-
ing pmTcr, and which is greatly resorted to in mechanics, are used aa
follows : One cod of ilie rope is fsstcued to a strong hook in tho wall,
while the other is applied to tho limb hy strap« and bucklea. Count^f-
cxlcn.'iion is made oo the body of the patient, so that it sliaU doL
be muvcd by the cxtr.nsion. An assistant draws on tlic pulleys,
whose power of course increases with the number of rollers employed.
Schncider-Mtnera apparatus oonsästs of a strong gallows, to the ioncr
aide of ono post of widish is attached a morable windlaas, which may
be turned by a handle and held by a toothed wheel - OT«r this ivind-
la«s nttis a strap which i» nltacbed by a hook to a baodago applie«!
■round the luxated extrcniitr. In luxation of the lower extmntty Uio
patient lies on a table placed lengthwise between tlic posts of the gal-
lows, or for reduction of an arm he may bo sonled ou a chair placed
the same wny ; tlie oouuter^xtvnslun is mode by straps by which the
patient is fastened to the other post of the g-allows. Both of these
apparatus«« have certain advanluges, but botli nro troublesome to a[^
ply- In your practice j-ou will have Utile to do witli tlicro, as they
are almost exclusively employed iu old dislocations whose treatment
is more rerely undertaken in private pmctice than in hof^itala and
surgical clinica.
At present, when we uiidert«kt! this forcible rcthiction, it is always
under the influence of aniPsUietics. To produce complete relaxation
tliis anxsthcsin must be %'ery profound, and, as the cheet is ofteo oav>
ered with straps and girdlt» for countcr^stension, the nnicstbotlc
must be very cjirefully cmployeil to aroid dangerous results. But
there are also other dangers which were known to the older BUfgeona,
aCDt'CTION OF SIfLOCATIONa
2»r
wbo did not ute chlorofona These are na follows: If Uie pnttcnt is
uiet] too long with tbeEe powerTul remedies, lie may suddonly colkpee
aaü dicj inoreorer, llic limb m%j become ffaiigrcnous from tlic press-
ur« of the straps, or tlicri; ma^j be subcutaneous rupture of large ncrvea
and vessels, and cooscquciit psnil^-sis, tmutnatio aneurism, extensive
Buppumttou, «od other dangerous Ioca.1 Kviilenui. Tlie n>jiu1t» of
prcaeuTC from tbe appliances miiy best \m uvuidcd hy npplviuga moist
roller-bandage from below upivard, and fiuttenitig the rtraps o\*er tlii*.
Since a regular presaure i» ibim iiiiido ovi-r llie eutirv linib, th« prv8»
ur« of tim apptiauc«! c1u«c above tbu jdnt docs not prove so iujurioua.
The time during whirh ve mtiy oontinuo these forcible attempt« at
rejilitcement »Luuid be ut most half ao hour; if we do not suoceed in
tliia time, wc mar be pretty certain of not doin^ so at alL If we
wiah to try further in euch cases, wo should resort to some other
melbod. Until recently, we hnd no measure of tlie force tliat oould
be used without danger, ar.d had to content oureeUtrs with eslimuting
if. It s««m9 scarcely poHible, by the abore tncima, to tear out an
%rm or a leg ; but not long since this did occur in Paris, and in a ease
where only manual extension n-as eni]>loycd ! GcncTallr, the straps
tuir sooner, or tiic buckles beud. Subcutaneous ruptures of the uer\'ea
and vessels would scarcely be caused in a healthy ann by regular tiao-
tion on the whole extremity ; but they may ieur, when adherent to
deep cicainccA, and arc so atrophied ns to buve lost llieir Dormnl ebs-
tieitr. If, under eueh circumstances, the conditions coidd always ha
accurately appreciated beforehand, wu sliould frt<c[uently eutirely al^
atuia Irom attcnipts at rcducüon ; for, in such cases, rupture of a Den's
or vessel tnsy follow attempts at reposition with the band, and w«
cannot refer the accident to the mnchinciy. An instnimeDt has hei^n
invented, by whose aid the force employed in extenaiou may be mcua-
ured. Thi;« inatrumenl should be inserted in the cxtcmion-apparohii!,
and shows tlie force employed in weight, ns is eustomary in physics.
Aoconling to JVati/aiffne, nc shouUt not ga above two hundreil kilo-
gramtDcs with this dynamometer ; but such directions arc of course
only appro I in I II live.
If the teduction has been accomplished, Ute main ]ioint Itas cer-
tainly been gniucd, but sonic lime is «till required for fiJl return ol
the function of the limb. The wound in the capsule utiist lical, for
which purpose perfect rest of the joint for a longer or shorter time is
requisite. After reposition liiere is always moderate infbunmation of
|1m9 synovial membrane, with a slight cflTusion of fluid into the joint,
and tbft latter remains for a time painful, stiff, and unwieldy. If ro-
dnctiun hascloeely followed the iujury, the joint must finit be kept pci^
32S
Ei JURIES OF TUE JOISTS,
fectljquiet ; it is surruuiidml with mcisl bundagcs, and cold ccmpressee
are applied ; the swcUing is rarel/ so great as to demand other anti*
pliW^ibtic rctuedies. In tlicBtioulder-joint after ten to fourteen days we
b^frin passive rnotion and coiiliDue it till active movements €^n be
mad« iiiid llie «mi is fully useful ; fri?qucQtly,it isnianymonllts Itefore
moTCmeiit« arc qiutv five, and elevnting the arm Jit the Inst niotioii to
TCtum. In otiior joint» tlint Imve les* mobility, active movemont«
may be pfmiiltt-d iiiucli »(hjiht; lliua tlit'y are rextorvdespeciBllycarij
in the elbow and hip-joints, and in llic latter joints wc may permit
attempts at motiou the earlier, bocausc there luxations do uot eo
»»dily recur.
If iLclive motions lie permitted too aoon nfier reduction of a dS»
loeation, especially In those joints where dislocation readily recurs^ as
in the sIiouKIcr and lower jntv, mid if the luxatiun recur« o«eo or ser-
erol times before the capsulox upenin^ has healed, occasionally llie
capsule docs not heal completely, or there is 6o mudi distensibility of
the capsular cicatrix that the patient only has to make a careless
motion io luxate the part «gain. Then wc hare tl;e stale called
hahituat haation, a rery annoying. slate, es{>ecia]|y in the lower jaw.
1 knew a womftn wlio had a disloralion of the jaw and did not take
earc of hcncif lung' enouglt »flerward, so that it soou returned and
had to be Tedunei) a^n ; the capsule nas so much stretrlicd ttiat, if,
in eating, she took too Inrgo a morsel of food between the back leetli,
•lie at once luxated the jaw ; she accustomed henelf 1o the manceavie
of slipping it i]ito place, so that she cotild do it with tlie greatest
focility. Sacli an habitual luxation of the shoulder may oceur in llie
same way. I liavo seen a yuunf^ man, who, when gesticulating n<v
teiitly, had carefully to avoid raising his arm c(uirkly, as he almost
always dislocated it by this motion; such a state is very aimoyiuj^,
and is difficult to cure ; recovery would only be jwasible by long
rest of the joint, but patients rarely have int^lination or patieni'e ftir
this trcaliiiciit. It ia well fur such patients to wear a bondage that
will prevent lin.{Rg nr throwing Imek the. »rm too much; if tltc luxa-
lion lie nvwded for a few years, it will not recur so readily.
If a »imple disIu<»tiori bu nut rucof^iizc-d and reduced, or if^ for
Tarious reasons, we cannot reduce it, a certain amount of mobility is
oerertlieless restored, which may lie considerably increased 1^ regu»
btr use. Fmiu the relntion of tlie Jiead of tlie bone to adjacent bony
proousca, and fix>m displacement of muscles, it may be readily undci^
Blood thai, for purely incchuiitcnl reasons, certain motions will t>c im-
possible, while others may approximate the nonaal mobility. But,
if tlie moTcments bo not mctliodteally restored, the limb romains st iS*,
ILo muscles become atrophied, and the limb is of little use. llie
CUAKGKfl IN OLD LVXATI0K8.
SS9
vutomical rlixngos iu Üie joint «iid [Mirt« ATOUDtl are &3 foUows : the
cxtniraaatcci blood is rcabsarbcd ; tlic capsule fvlds together and
atrophies ; i)ns hvad of tlio Ihhiu rvm» aguiiint some bone in tho yirin-
itr of the articulating cavit/ ; for instance, in luxation of the humerus
iovanl against the ribs under the pcctoralis major, the soft parts
about the dislocated head become iotiltrnted with pUstio tjnnpb and
tnnB&rm to dcatrlcial ootinactive tiasue, which partly osslfieSi so
that a sort of Iionir articitlar ca^nj again fiinus, while the licnd i«
■urroundod by n newly-formed oonnectire-tb^ue capMiIe. In the
carülnge of the head uf the bone, the following changes visible lo the
nmkcd eye ocvur: the cnrtthifre hu<.*omes rough, fibrous^ aud grows
adbcrcat to the purl« on which it He«, by a cicatri«i(ü, firm conaootJTO
tissue. In tlm cuiiree of time this adhesion becomiw very Gnu, espi^
ciaUy if not disturbed by movements. ITic metamorphosis of curtilage
to cooaeotiro tissue, followed tnicrosoopically, takes place as follows :
the oattilage-tiKSue divides directly inttj fine tilameiits, so that the
timie acquire» first thtr appcaranec of fibrous cartilage, then of ordi-
nnry cicatricial connective tissue, which unites with the parts around
and receires veiuelit &om tJiem. Tin? surrounding nitiseles, as far as
tboy are not torn, Io«c a large part of their filamenta, partly from
OM>lccular disiiit<-cr*tion, partly from fatty metamorphoait) of the con-
tnetile substaoce; sulwtMiuently, new muauulor filamonU form in
Uteae muscular cicatrices.
Tliis is wliat WR call au old luxation, and it is in sucb coses espe-
cially that the abore methods of forcible r^ucliun arw employed.
The qveitliun, how long a luxation must havn existed before its rvpo*
Bition Ü to be coiiKidervd impossible, cannot Itc nnHwcrcd »incc tlie
intnoductioTi of chloroform, and is to be <lilft>reiitly answered for ibe
Tttrim» joints. TI1114, itiüloratioasof the shoulder maybe reduced after
existing for yciu?, while those of tliu hip-juint two or thnw nioiitlia
old are reduced with difficulty. The chief obstacle lie« in the firm
adhesions of the head of the hoiiv in its new poaition, and En the loss
of oontractility of the muscles, and their Jcgoacratioa to coiineoliTe
tissue. Another question i«, whether, when «ucli old dislocations arc
mliicvd, we attain the desired etFect on the function, especially tn tbe
shoulder. Imagine that the small articulating cavity ia filled by tbe
atrophied capsule, and that tlie hciid of the bone has lost its cartUag«,
then, uven if we euct;eed in bringing the head to its normal position,
restontiua uf function may atill be impoeeible, and I can assure you,
from my own expencnce, that the final result of a rery tireanra« and
laag afier^trciilineiit In audi oases docs not always ivpay the patience
and pcrsrvemncc of the patient and mirgeon. In such case«, tbe result
will KSfcely be loore favorable than if tb« patient trJt», by methodieal
S30
ISJUIUKS OF THK JOtST^
«xereisr, to make his limb aa uacful as possible m ita new positiaa,
nrhich it taay Imve uccujiied for inonlbd cr yesn. We tnaj EscUiUte
this oxercise \iy bcrmkiiif^ tip tlu> n(lbf>sio«s about the hewl of the bane,
hj rotatiug it fmvibly while tlKt pniieitt is aiucsthctixed. If, as occa*
siooalljr happens ia aboulder^ifflijciitiuns, thv hvail of tlic bone in its
abnormal posilion so prassesoii Ute braohiiil plcxi» as to cause pnnljf
BÜ of the arm, if rpJuctiou be impossiblv, it maj be adiisable lo make
an inciiuoD down to tbe bcud of tlic bono lo dissect it out and snvr it
off, i. e., lo make a n?^!ar rvs^ctiun of tbe bead of thi^ htitniTus. I
bare aern a case vhcre, in ctiniplctc paralyais of the arm after a lux»-
Itoi) of tlie Uuincnis downward and inward, decided improvemnni of
the fxinction of the arm weu attained by the above opemtion, although
there was not c»mplete Tvcovery of the paralysis.
COHl'LICATED DISLOCATIOXS.
A dislociktion tnny be ooinplioat<><l in vnrioiui ways; most fre-
quently with partial or entire fntcture of the head of the bme, whicdi
is difEcult to cxiTBy nnd in which rcpoaitioa is often only partly su^
ccssful ; in treatment, attention must always be paid to the fmcture ;
i. o., a drcBsiug mn^it be worn till the fnu-ture bus united. At the
snroc time it in advitwhle to renew the dressing frequenlty, say rvx^
week, and to apply it in a diffvrcnl position each time, so that tbo
joint iiuy not becnine KtifF. NV-vt>rthvlc«s, we Mooot alwitvs aiiucen]
in attaining' perfect »lobitily, so that I «.'an -only advise you in your
pCBctico always to i^ivc n duubtful prognosis in Euch cases.
Anotlier compIiL-atton is a txiincidunt wound of the joint. For
instatice, tiie broad arliinilar siirfuec of the lower epiphysis of tbo
bumcrus or of the radius mar bo driven out of tlie joint with sue
foroe u to tour tliroug'h tho soft parts and akin, nnd lie exposed.
Of course the diagnosis ia eaay in suvh cases ; reposition is aceom-'
plishcd acoording to tbo above rules, but we tttJll have a wound of the
joint ; und we arc liable to all the rhaneei spoken of under wounds
of joint«, so that for tJie prognosüt, Hie varieties of tlie poeable n-Aulta
and tho Ueatmcnt, I refoT you to what litis already been said (p. 218).
Of cour&o, it is worse when there i* an open fmrturc through'' *hc joint \
licrc we can neither e):pe<t mpid clusiiii- of the wiHind nor restoration
of tlic. function of the joint, and we run all tho dangpts that thntaten
complicated open froetures nnd wound« of joints. The decision aa to
what niiMt be done in snrii ciiHOs is eji!>r, when tlicre ia at the same
time ooosidexaltlc cniahing or tvarin); of tlic soA pnrls; under sueb
(üeunlstanops, primary nmputntion must bo done. If the injury of
COKOBKITIL LFXATIOXSl
231
tlio soft parts be not great, vie tn«y »oinetiincs lio|>c for a ctire bj
Bupfnimtion, with a mib«e<|[ueiit stiff joint ; l)u^ as experience bIiows,
Uua is ain-nys a daugcxous experiment. Acoonün^ to tlin priix-iple«
of modpm sitTgery, in sucb ca«c« we aroid ataputatioa by ÜJäSc-ctii^
out and uwtng ofT thu fnictiired nrlicukr ends of tlie bones so an to
make a fiimplc wouud. ThU is the regular iolai nsf-dion of a joint,
an operation conoeming which Tcry extcasive obsetvaliotts have be«ii
made duriog the last twenty reuni, aiiit of which niotlera times is
Justly proud ; by its tncAris many limbs liavu bet-» preserved, which,
according to the old rules of surgciy, should uobesittttiugly have been
amputated.
Id regard to their danger, these resectiona rary greatly uccoitiing
to tbo joint on which they are luadi;, so that it is difficult to make aoy
gtaierxl remarks about them. But, in a subsequent section (iu the
treatment of chronic fungous dt»ea««s o( the joints), we sliall study
ttiis veiy tuiportunt point uiore carefully ; what has bcea said w'Ul gi«*«
you a general idea of a rescetioo of the joint.
COKQEMTAL LLXaTIOSS.
Congenital luxations iure rare, and we must distinguish thrm from
ttKMiiifttea iuttr purtum aeijuisi'tay i. e., thus« that hnrc resulted «t
Urth from manceu^Tes in extracting the child, and which are merely
stmplo traumatic luxations which may be reduced and cured. Al-
though congenital luxations hare been oliGorved in most of tbo jwuts
of tl>e extremities, they are partteularly frequent in the thigh, aud not
unfrequcntly orctir on boib sitics at tlic same lime, The head of the
bone stands somewhat above and behind the acetabulum, l>ut in many
eases it can readily be repUeeil. As a rtil4>, tli« disea&e is first noticed
when the child begins to walk. The nKmt noticeable 8yni|itoni is a
peculiar wabbling gait, whi<'h in cawio^l Ky the head of the hone
standing behind the Hcctahuluin to tJmt tiw pelvis inclines forward,
a»d also becaose in walking tbc head of the tliij^h movea up and down ;
tfaero is never any pain. To examine the child more accurately, you
may uudothe it entirely and watch its gait ; then lay it on the back,
attd compare tbo length and poattjon of the extrvmitics. If the luxa-
tins be ODe-sided, the luxated limb will be shorter than the other, aod
the foot turned innard ; if you fix the peh-is, you may often reilucs
the dislocation by simple traction dnn'nward. The anatomicnt exami-
nation of such joint« iiaa led to the following results ; not only i-« the
head of the bone out of tlw snekel, but the socket is irregularly
fiarmed. — too shallow j later in life, in adults, it is greatly comprcaeed
md filled with (at ; vbcn the ligaincntutn teres exists, it » ikboomMy
long ; tlie head of the bono is not properly dorolopcd ; io some caeca
it is not half as large as nortnal; iho articular cartilage is usually
oompletcljr formed, the capsule rery largr anci relaxed.
Under such circumetanecs, ^'ou may iiiKleraland that it is exoeutl-
ingly difKeult, in most cases impotuuhle, to effect a eure. If tiie head
be only partially dereloped, the npfwr border uf tlie aoctabulum ab-
sent, and the cnpsuli; enormously diatcnUod, hour sliall wc n-storc the
normid condition» ? A» to tlie cauees uf Oiitt mnirurinatioii, the most
varied h\'pothcses liavc been udvanccd ; iJic opportunity bu never
«ocurrcd of studying it in the ctuhni'o. There is an arrest of devf^op-
ment from some eau&e. It ia assumed that those disturbance« followed
previous palliolngicnl prQOcasc<t in the f(Rtus, and the raoftt probable
hypothesis is thai, in vcrj- early cinVtrjoiial life, the joint was filled
with an abnormal quantity of fluid, and so dint^ndcd as to induce rup-
ture or at leaat great dilatation of the C]i|)6iile. Au«er tliinks tliat
abnonnal intra-uterinc positions may fipvc ris<; to these luxations.
Cure of this state has been attempted in those cases where direct
examination has slionti tlic existence of a tulerahly-developed hcaiL
In auch caacs the luxation has been reduced, and attempts made to
preeerre the normal position of the thi{;h by aid of dressings or band*
ages — the child being kept quiet for a year or more Tito result of
this treatment, which requires great pntlence on the part of the sur-
geon nitil parents of the child, ia shown by ejiporicni?« to Iw only
partially satisfactory, a« after this treatment there has only been an
improvement of the gait, but rarely a perffx^t cure ; and, when you read
in orthopedic pamplilela of the frequent euro of congeuilal luanlioos,
jtya may be sure tlmt in most eases tlierc hare been enors of diag^
Dosk, or thcru in iiilenlionn) deception.
Congenital luxations of the iliigh arc ocvor dangerous (o life, but,
since they are accompanied by a change in the centre of gravity of
the bndy, in the eounte of time they hare an effect on tlie position
and cur\-»tiu« uf the rcrlcl>r;kl column ; Ihts, and a limping, wabbling-
gait, ore the only inconveniences they cuuae. lliero can only be n
iK^e of BtMiceasfiil (j«atment in very early youth ; but, as tlie surgeon
cannot promise a auccessful result in less than one to three years, few
pattcnta arc put under trcutmcnU
CHArXER VIIL
Q UNSHOTWO UXDS.
LECTURE SIX.
Uiitoti«»! JCcawilui.— Injuiiot (Vvm LorsoUlMllM.— TarlouFMnu of Bullot-Wvn&ii.
— TmitffinfUiian and Circ i>f ihu Vnimilcil tn tho FIilJ. — Trcaimtnt. — CoDiplb^
ud QmükA^FnclureB.
Ix VKt many injuries ocour tlt&t arc t<t he C-1aH0<l o-tnonj; ftim|)le
htctsed, cut, puiK^ttirod, niid ooiiUisod wounds; gunsliot-womids thera-
selvfs must be cloasL'tl vritJi coalu»rd wounds ; but tlicj hare some
pecvliantics that cntiÜc them to separate coosidcration, ia doing
wbii^h tre must hriefijr come in coataot witb tlio domain of military
surgery. Since fire-arnis were first used in warfare {133ft), giintilioi-
vounda have rcccJrcd spocül ntletition from surgical writer», so that
tbc literature on tins subject bu beoomo very exten^vo ; of Istc^ in-
dwd, mililaiy Bui^fcry has been made almost a sepaTste branch, which
itidiidf^ the care of soldier» in pcAce and war^ and tbc RiKrcial hygienic
md dJetetia rulos vhich arc en iinporiant in btunu^ks, in Etationarr
sod Grid hospitnlx, also tlie clotliitij^ and food. Although tlie Itnmanü,
aa vas mentioned in ibu iutrodadion, bad surgeons appointed by tbe
Btate with th« army, in (he middle a^s it vias. more common for creiy
leader of a troop to harf a private doctor, who, with one or rioto
assistantfi, very imperfectly took care of the soldiers after a battle,
and then usually wcul on with the army, leaving tbc wounded to tbe
care of Dompasfiianate peo|iIe, without the oommandcr or the army
taldog tlie responsibility. It wa» not till standing armies were formed
that surgeons vere detailed to certaiu battolious and compauicH, and
certain («till very imperfect) rules and reffuhitiou* were made for the
care of the wounded. Tlie jvjsitiuiu of military surgeon was, in Uiom
day«, very ignoble, and siich as wc do not hear of now ; for, even in
the lime of Frederick the Great, tbe amy surgeon wns puldiely Hogged
if be permitted one of the long grenadiers to die. At that time, when
834
GÜXSaOT-WOCNDS.
tlie troops miircbud lo luoct die eneray mt b para<I«4tep, Üie raove-
menl« of thß snii^ were very tcdioos and slow ; tbc Ur^ armies bad
iromenae trains ; for tnstuioc, in tlw» Tliirty Te»rB' War, the lancers car-
ried nlotig tlioir wiif-x aiid eliildrcu in iniiuiiienilile iragona ; Im^oco, iu
UiL- medical nrningeiiieiiUi [lertnitiiiig lo the tmin, tfacre mvu» no ne-
cessity for greater facililic» of niotioQ, llic tactic« started hy Vnd-
erick tbc Great required (^renter ntobility of the lic»v-y tmin«, whicb,
hovevcr, wafl only prmdii-ully nirric-d out in tlic Frcndb nrrny under
^«poleoo. As long ns n hhuII province rcmiaincd the scut of var
during a wliolü campaign, a few liirj^ bD»>]üUi!ii in neijTlilioriDf; cities
migbl HufEce ; tmt, wlicn amiie» moved about mpidly and liad a G|^it
now bcrc now lLcr«% it became UL-cuMary to furnish more morablo,'
»o-callvd field liospitiLlii, )iot far from tbo field of l«ttlo, and vrbidi
could be readily moved from plara to pW'e. These unbulaucrs, or
flying hospitals, are the idea of one of the greatest of stu^^coas, Xor-
r«y, of whom wo have already spoken. As I shall shortly t<ll yon
what is done nilh the wounded from the time they are injured till
ttiey enter the general lioepitsl, I will here diftmiss this subject, and
only mention some of tiie many excellent works on military surgery.
Es])ceially intcn-stiiig, not only iiiedic«lly but liiittoHcully, nro tb«'
somewhat lengthy " Memoirs of LurrL-y," iu which I cspcetully recom-
mend to you the Egj'ptiuu aud ßuaaiau canipai^is. These memoirs
contain nil Napoleon's mmpnigns. Another excellent work we hare
in English literuture. Jo/u* Mcnneit's "Priuciples of MilitHry Sur-
gery;" and in Oenuiut, besides many other excellent work«, wc hare
"The Maxims of MiUtary Surgery," by Stromeytr^ whieh is compoaed
chiefly of experienc-es in the Scblcawig-Hol&teiu "War ; und^ lastly,
" Priuciplea of General Military Surgon.", from lieniintHrviux-s in tbc
Crimea and CaucaBua, nnii in tlio Hospital,'' by I>r. Ptrcgoff,
Wouiidtt eaiised by large missiles, sudi as esiinon-balls, jfrenades,
bombs, phmpnci, ete., are partly of sueh n nature that they kill at otice^.i
in other case« tcnr off whole cxtreniitie», or so shatter lliciit that
putatiou is the only remedy. The exl«^'usivu tearing aud orushinjf
caused by these shot do not differ from other large crushed wounds
caused by mscliinery, which unfortunately now so often ooour ia
civil praeljco.
Muskct-balls used in modem wariara differ in some respects:
while the sn>«U copper bullets with which the Cirassaiuux iltoot are
searecly Urgcr tlian our so-called buekshot, large, hollow, leaden bul-
leLs were iimhI in tlio late Italian War; tliese a'cre much larger tluin
the old-fushioned ones, aud were portieuWly dangerous, because tlicy
(cadily broke upon aLrikiiifr a Ixnie or tense leudon. Besides Üicw,
the solid round and conical l>ullut are used, but their effects do not
i
TAniOCS rOIUIS of BltiET-WOnNDä
330
L
differ much. Tbc Pmaüso lonf^ bullet, irliicli is bdd ia tlio cartridge
of llto necdlc-^n, is > solid )mllot »f tbo form miid six« of an ocom.
Tou tnuat not think tbnt ihv proJLTtik*, aa fouad iit tliR wnimd, lina Ü>e
wate ebape as wbcn put in the gua ; but it is rbangnl iii funn a» it
eoiDM out of ihe rifli*s of the ^xm, and is also flattened in tho wound,
K> that we ofben find it a sliapclosa moss of lead, wliirh aramely »howi
the ronn of the projectile. We sboll now brieflj cooftidcr Üic \-ariou»
injiiriM thai m*j be caused bj n bullßt ; in d^in^ wtijoh, we shell
Dsturall/ coufine oiir»eI\'ex to the chief fonru.
In oac set of <»»es the bullet nmlces uo n-ouud, but simply a con-
tu$t»i% of Ihe floft part«, accompamod hv gfrcAt eug^llatio» niwl ocoar
■touallj' hy Bubcutaneou» fracture. Aecoidiiig to reecut autborities,
aimple wibcutanoous fmctarcs are not vcrf uncoiniDnn in war. llieae
iojurios »re caused by spent bullet«, i. e., such as oomc from a long di*-
lance and hare not fotce enouj^ to penetrate the iddn ; fiucb a bullet,
strildag' over the lirer, may push the skin before it and nwko a deprea-
nooitt or a lupture of th« liver, nod tlieu fall back witboat producing an
external wound. Like injuries are caused by bullets strikir^ tbo skin
at a very oblique angle. Firm boiüe«, such aa watcbes, pockct-books,
coins, leather sLrapH on the uoifonn, etc., may also arraat the btdlut.
Theae oootitged wounds, which, espeeially when affboting llie alxiomen
« tborax, may. prore very dangerou», hare always excited il»e atten*
tion of snrgeona and soldier»; formerly they were always rererml to
the «xalle«! " wind of the holi," and it was thoujjht Üiat thry were
eatued by tbo bullet passing very I'lose to the body. Tlie ideji thai
Injaries could l>e caused in this way wbs bo Grmly estobtisfaod, that
even renr well-iiifi>riiied persons worried themselves in tt^-ing to ex-
j^aia theoretically Imw they resulted from Uie wind of the ball. One
said that the air in front of and near the bullet was so nompressed
that the injury wna due to this pressure; anollicr tbouglit thnt, from
the frirtion in Ibe barrel of tbe jfun, the bcdlet wa« elmr^l with
electricity, and could in nomc unknown tnamier cause eontiisiun and
burning' at a certain distance. If the jranclusioa that the whole idea
of the wind of balls wns a fable had been arrivetl at sooner, these
&u)tasttc theories would not bare arisen. Contusions from spent and
oblique bullet« arc to he Ifcatod like other contusions.
In tbe secomd case, the bullet does not enter the soft parts deeply,
hot carries awny part of the skin from the surface of the body, le>aring
a gutter or furrow. Tliis variety of gunshot-wouud is one of the
■lightest, tud/^««, as may happen in the hnsd, the bone ia grneed by
tlie bullet, and portions of lead ntniiln in tbe »kiill.
The third case is where the bulkt enters the skin without escap-
ing »gain ; the bullet enters and generally remains in the soft parts;
290
ODSsnoT-wotrsDS.
it makes a tubular wound. Various otltcx foreign Ixxlies may lie c«i-
ried into thcsi: wound», Micb as portions of uniform, clutli, Icxther,
buttAoa, etc, \ a. bono may aim be xplintercd, nntl I ho S]>liiiter8 drivaa
into tlie wound and t«ir It. After perforating ihc skin atNl »o(t
pnrts, lUe bullet might rcbouiid from a booc anO full out of the same
opening, Ko that ynu would nut find it in tliu tvouitd, in apito of tbtire
being oiJy one opening. The vrtnuid that the bullet makes o» eDtertng
llie body is usually round, oorrespoodlog to tbe ^ape of tlie ball ; tU
edges are contused, oocsBionolIy bluicb-black, and eoucwbat tDrert<4.
These eba.racttMl'ities hold in the majority of caees, but are not sl>-
Bolutc.
TliR fourlti and last caee is where the buUet enters at one point aod
escapee ut nnother. If tlic course of the wound is enliipJy tlirougfa
the soft purts, and tht! bulli't bus carried in no foreign body, the point
of exit is usually smaller than tlio entrance, and is more like a tear.
If the bullet hua struck a bone and driven bone-splinters or otbtrr for-
eign body befoie it, tlte point of exit ia oocaäonally much larger than
the cntmuou; liiere may also be two or mote points of exit from
bursting of the bullet into several pieces or from scTeral BpUntcre of
bone, Lastly, splinter« of bone may mnke opening« of exit like tlioae
fttim a buUiTt, while tin; latter, or part of it, remains in the wound.
Too luucli value Las bee» attached to tbc distinction fit tlic openings
of entrance nod exit ; this is only important in forensic cases, where
it mny be desirable to know from which side tlio bullet came, as this
may give a clew to tbc autlior of the injury. The course of the bullet
through the deep parts ia occasionally very peculiar ; its course is some-
times deviated by bnnns or tense tcndnns and fasciH^, so tbat wc
should be greatly miatakea in eupposin^ tliat the union of the point«
of entmnee and exit by a straight Ün« nlways represented thn coarse
nf the bullet. In this respect, the encircling of the skull and thot^x
is most peculiar ; for instance, a buUct strikes tbc sternum obliqudj,
but without sufficient force to perforate this bone; the bulliM may
tun along a rib under the »kin to the side of the thorax, or even to
Üie spinal column, beforo escaping again ; £rom the position of tbe
points of entry and exit, we might suppose tbc bullet had passed
directly tlirougli the chest, and bo greatly astonished when audi
patients come, M'itbout any difficulty of breathing, to bare their wound
dreac«d.
Tbe complication of gunahot-woiiiid« witli bunts by powder, such
OS results from shooting at close qtmrtcnt, rurcly occitrs in war. It is
□ot rare In cases of accidents from careless handling or bursting of
fire-arms, or from blasting, and may cause the greatest variety of
bum. Tlic burnt particles of powder often enter the skin and lical
TftAXEPORTATlOS AN» OABE OP THR W0(7N"DED.
8»y
tberc, giving it & bluisli-blavk sppcaraooc for the reat of life. More
of ihift ill Uie clinptcr uii biinis.
In i^unsliut iiijiirk-s, there is said to he srarpel/ nrty pain ; the rapiili^
of tbo injuij U euch timt the patieni oiilj- toets n blow oa thu side
from which the buUet cotnea, and doe« not for »omc time perceive the
bleeding wound and actu&l lutiii. Tliere nre numerous examples
when combatants have received a shot, Mpecially in tlic \ip|x;r ex-
twunitr, without knowinff it till lold by somo one, or liaving tlt«ir
atteutiun attrAf^tt^d \>y Hie fluw of blood. •
la ^nshot, as iu contused wounds, the bleeding is usually Ifsa
than in inriKed nnil ptmcttircd wounds ; but it would be a great mis-
take to Mi])]iosi* that urteriea whieh have been shot through do not
bleed. On ibc contrary, maojr soldiers nei'er leave the batile-fidd,
having ^ed from rapid hfeniorrhnge froni large arteries. When one
has seen a fully-dirided carotid, Kiihchivinn, or femoral artery bleed,
he irill know that in a very fthort time the loss of blood will be so
grett tbnt the tmlj- hope of safety li<.-3 in iinmcdiale aid; so that a
htemorrhage of two uiimiteV duraliun from one of these arteries is
certainly fnlal. But nrteii«^^, even iis large us the radial, often bleed
but Uttlc. TliQ first surgeons who gave us dcscripLions of gvnshot-
vouiids called atteution to tliis point.
Before passing to the treatment of guniihol^woundf^ I would
briefly picture to you the IraiisportaUon of and Ürst aid ojfered to the
wounded in battle. For the fin^t aid there are umially exiablishol
certain temporary places for dree^ing the wounded, in some sheltered
pUoc cloflO behind the line of battle, usually Jn rear of the battcrtcs ;
these are designiitcd by white flftg«. The wounded nre first brought
to this Kp^it. eitlier by soldiers or by a tniined iirabulniice corps. Of
ooutse, ihose noundfxl slightly or in the upper estromitJes walk to the
spot. The ambulance corps has proved «o efficient in late war« that
it will certainly be more trusted to in future. It is »imposed of
nurses trained to bring the wounded from the field, niid, when nece»-
Baty, to give them temporary aid, as in arresting UeedJug from arte-
ries nod wounds, etc. They have been trained to carry a patient
bettreea two of tlmn, either without other support, or on an impro-
nted Utter. For Ibis latter purpose they usually cury a lane« and a
piece of eJotb longer and broader than the body. The lances ore
pawrd throogh hems along the »ides of the cloth, and a harrow is
tbus nwdc ; bayoDCt« or swords may be used «e pro\-isional splints for
snpportii^ a limb that has been bsdlyshut. Tlie wounded nre thus
hrougbt to the dmssing-plaec, and tlie first dressings arc applied ;
thee« retnain on till tlie patient reaches the nearest field-hospital. At
the same time biemorrhage must be seeurely arrested, and injured
limb« BO Brntng«d tint transpnrtatton may tlo do liuta ; buIleU, for*
tägn bodieK, nncl looae spliatera of bone nrv Uie eiirface, slioultl be
removed, if it can be dooe quickly and readily. liml» tbat have
been entirely cruslMcl by lu]^ sbot sliouUl be al oac« »mpuUlcd, if ■
dreseÜDjR^ caoiiob bv to u)>)>Ucil a» t« reuiic-r tnii»[K>rLatioa pouiblc.
Tlie chief object of tlits drcseing-plnoe u to nmdcr llic wounded
transporlsblfi ; beaoe it is not pruper to du iitaiiy or toilious operations
there. From llie great pressure of thn confttantJy-iiicrcaüin;): throug
from (he ftx)iit,only thetaoitt important cases caa be «ttentlvil to lierR,
and Pifogoff i» right, though it «Htois cniel, when he says the sut^
geutu should nut uxliaust their strength on the mortally wuundoiJ aatl
the dying. UuL, if possiblc, crury putient, nhca carriod to tlw
fie)<l-ho«pitaI, should ruooive a sliort irritt^n aocount of vhat was
found at the fint examinatioD ; a card, containing a ievt word», thrust
into on« of hia pockcta is onough. "nie chief point is to toll whether
tile boll has been extracted, wbether a wound of the breast or abdo-
men is perforating, etc., which will save time to the surgeon at the
bospitul «tid pain to tlie pdlient. Part of tlie lunbuliuKi; corps has
the further duty of ploctng the wounded properly in wagons for fur-
t lier truiLsjiurtätiun, under lUrL-eUon of tliB surgMiu. For this porposo
there are .special ambuhinivs, construct<^d most raiiously, wlikfa take
some ]wticnta lying down, others sitting up. There are rarely enough
of these, ami it is ofti>n necessary to use common wagons, om'cred
with hay, straw, etc. Tlicse wngoiis ooovey the uoumled to the next
fiebl'hoapital, which ia v.-'tabliahetl in a nuighbunug dty or towD ;
for it the largosL attninabic rooms sliouJd bo taketL Scbool-hotiftes,
cburchcK, (a baniM, may be seized, although the latter are the be^
In these places bcda arc prcpnrtxl with straw, a few uiattresaeo, and
bedclotheis. Surgeons und utmufi await anxiously the amml of the
first load of patients, having been already notified of ike ■.xunmenee-
ment of tlie battle by the tiiunder of the artillery. Here begina the
accurate examination of patients, who were only tcm|>orarilv dressed
on t)ie field, and here operatitig g"e» on most actively. Amputations,
rcscrliona, extractions of bullets, etc., are done by wholesale, and the
aurgeou who has been auxious fur liia first o|)i-ntlion dd a living
]wtient niny operate till he stops from exbaiistion. This continues
till far into the night; the figlit laats till late iu the evening, and it is
near morning bcforu the IttaL loads of wounded conic in. A\1Üi bad
lights, oo a temporary opcrating^table, and often with unskilful Qursas
for aasistenta, the surgeon must at onoo exanunc every patient, down
to the last, and Ihen operate and tln-jts his wounds. In the field-boe-
jHtals the wounded have a period of rest, and, if possible, those who
have been operated on or are seriously hurt should not be moml to
4
4
•
CARE OF TUB WOCNDED.
339
ftootber hospital till benltby suppuration begins and licaling' lias at
least coaimc^oetl. Thta c-aniiot xlwaya be don«. Occasional)}' the
p1a«6 where tlic ficM-hospiltil hiia been cstaliliahefl must bo vacated.
If one belongs to ibc vaiuiui&br^d party, »ml tlie ciieinj' tAkea Hi« place
where the field-bospitolvraa established, the Kurf^conH are usually taken
prisoners with tbcir wuuudtHl; for, crvn when tho cQeiuy is most
buinane, after a great battir there is often sncb a demand for surgeons
tliat tbose of the enemy cannot take ttc proper care of wounded
pri^oiiers. A few yeoni sinei>, in G(>iu>va, a encivcntlnn of European
pav^n clrtcrmined that surgccms and sflnitary suppliui nhould be con-
ndere<l neutral. Although there arc some practical difficulties io
carrying out this principle, it has done gn^ut good in the wars of late
yeant, and is eapable of still further development. At all evenlfl, the
]'d«a of considering n wouiKletl cnoiny »s an euemy no loitgtr, but as
a patient. Is to be prized n* a bonutiful «videnoe of wh-ancing hu«
manilr.
WbcD the wounded have nil been brought under cover, bedded,
and tho accessary operations doue, and the diet, cte., has been at-
tMidetl to, arrangi^meuts should be mudt* for their proper dispositjon.
Pcrmaneut collection of many wounded men in one place is injurious,
attd, when the seat of war is a poor country, with few railroad con-
nections, the carv of th<! wounded is [itirtit'ulurly diflieult. Hciiee,
they should be sent off as soon as possible, Tliis may be done, even
with the soi'erely wounded, when thnro is a railroad handy ; when the
trtneportation is lean convenient, the more slightly wounded at least
can be removed. Tliis ny^tem of scattrring, which of late has been
conducted with excellent result-», requires great circumspection »nd
trouble from the superior mcdieal and militaiy authorities, but it hu
proved advantageous. If houses (barracks), or, in summer, tent«, eao
be erected for tho-se reniaining^the severely wounded — that will bo
best. If this be not pmctieablc, l])ey may be distributed in private
house«; it has proved uimdvtMiblc to leave the wounded in schooU
boDses uu] churches.
The war in N'orth America, as well as that between Austria and
Pmsno. in 18G6, showed timt thcro were still improvemeiil» to bo
made in military sanitary amingf>ments. A factor lias been added
tll«t never before cam« as an aid, namely, extensive assistance from
»ociotift*, Sister« of Charity, ciril surgeons, and many oth^ persoos
who, cither i>ersoiinIly or by money and stores, aided in the care of
the wounded. ^VheIl this private aid is properly organized, under
proper management of the military officcM, it may be very useful.
OoDoeming the treatment of gunshot-wuundj, views ha*e greatly
changed from time to time, ooconling to the ixnat of view from whidi
U
240
cüysHOT-worxDS.
Ü1C7 n-ere rega^d(^d. The oldest aurgcon» wboae opinions we bare,
oonsidered them ob poisoned, nnd thought, cxmsequenlly, Ümt they
nhoiihl l)e Irpate«! >i'itli the liot iron or boiling' (mL Tbc first to op-
[KKSti this \'Kvr «uiX'Cisfiill/ nus AmbrCK I'are, n-hom jou already
know to hnv« introdiiccil tlii.* lij^iiture for nrtcrics. Ho nOiitcs that in
tJic cAiujuii^ iti PicdiQüEit (153ß) hc- run short of oU for burning th«
wounds, nttd be expected the dcatli of all the patients who could not
he tmitpd ncxxinliug to \h^ rules of the time. But tliia did not bitjv
pen ; on the contrarr, they diil betltT lh»n the cliosen few on whom
be uaed Uie remains of bis rul. Thus 11 luelcy nccid«iit tolmtbly soon
freed medicine of thia siiprrntition. Ijiter it «■n« %'ery «v^rectlv ob-
eened ibul the great diftkully in healing giitishot-wounds was due to
the nurrownvst» of the cannl, and attenipts were made to obviate tliia
by plug^ng tbo wotind with chnrpie or ^;ontifln-root. But ecnsible
eurgoons soon saw that this still more impeded the escape of pos
from the deeper part.«i. and the eoirrct view commeneed to make
HOme bcadnar, that a j^uuahot-wound was « tubular contused wxiltnd.
Tliey Mnij^ht to fmprore this in n peculiar way, by Uyinfif down the
rule that every »ui>eri)nnl punsliot'wouud »hoiild be laid open, the
opening of a cnnaJ lending into the deeper parta was to be cularged
by one or mom inc'isions; rarious methods were proposed for chui-
gini^ the contused wotntd into * einnpl« incined wound by tbeM fn>
ciftioiiB, while, in fni't, the only thing Lhtit was done wo» to add no
incised wound to the rtiii« hot- wound. The «wp wsa »omcwiiat dif-
ferent when the rule wns given to cut out ttte wliole coursir of the
cans], and elose tlie resulting nmal by mitures und DoinpresscK, 80 aa
to ohtnin heaiitig hv fiwt iiitentinii ; this proeewling rnntiot often be
applied, and obtiiineil little rcputiilioii. Of l»te, Kince lb« trvntmeot
of all wounds is so mueb simpÜfied, tJte same thing has happened to
gunsbot-wounds wliicli are treated on the same gener«! pTinoi|>le8 as
contused wounds, in tliese, as in other wounds, tJie first thing is to
arrtst iiuy iirlcnal biemorrlukge. Tliis is to be donti awortUng to tlie
lulca already given, the bleeding artery being tied either in the
wound itself, or the eorrcfiKindiiig arterinl trunk being ligntcd in its
continuity; to aceoniplish the former, it is generally n<L-ci-KS&ry to
enlarge the opening of entrance or exit, othc^^Tisc ve sbould not find
the bleeding artery. If there be no liiemtirrbage, we should rxamine
the wound, e«peeiiitly any blind canal, for foreign Ixidics, particularly
for the build. "YWn may \w. «lone most certainly with the finger;
should it not be long enough, or fihould the «nal be too narrow, wo
Rinv iwst use a silver female catheter, with wbicli we may feel more
rertiiinly and »afely than with a probe ; if wc fed the bullet, wo try
to remove it the shortest way, that is, either draw it out at the ptnnt
TRKATMEyr OF OCNSnOT-WOUNDai
S41
of entraitoc, or, if it lie» in a blind cannl, dose under the skin, we
miikc an iactstoii tliiouKh the aldn and extract it tbnm^h titis, thereby
dttnging the t)lin<l cnnnl into a <«inp1ötc one. The extraction of
bullets tliruugfa tli<; opening of entrnno« may bv mudc hy aid of spooa
or forcepa-shapcd instnuncntn. Bullet-forceps with long, tbin blades
are often difficult to use, l.>eenusc tti^y cannot be suffiHentlv opened
ID Ü» narrow csnal to seize the bullet, hence many militaiy surgeons
prefer the spoon-shaped inntmment. Sucli a bitllct (vcoop has lately
been ffugi^ted by M. v. Lanfftnbe^JSy and soems very practical ; in it
the spooQ IB mtnrable so ns to pass bebind tim bullet, and pusli it
fbrirard. Still better, it serms to me, i« a revently-iii vented AiiienC4iu
foroepa, whose peculiarity is that they can be opened even in a luii^
row canal, and they seize very »erurely. If the bullet be lodgwl in a
bone, wo may bore n loos' gimlet into it, and try to cstniel it in that
way. If we do not succeed in removing: the bullet or other foreign
body by the opening- of entrance, we proeeed to enlnr;^ it to gain
moro nxim ao as to apply the instruments better. The experience
that bullet« may often remain in the body mtbout injury should warn
na agUDst any violent operation that aims only at their exlraclion.
Benoe, hieinorrliagt; and dilfirull extraction of foreif^i boilie« are the
chicF indications for primury dilatation of f^nahot-wouuds. I^tcr
other indinitions may arise to noecssitato it ; but, in the ppinshot-
vountt, such enlargement is not neceraaTy for a cure. Tliia takes
plaoa by the throwing off of a small ring-shaped eschar, and the do-
taehment of gangrenuiw slircds from tlic track of tlie wound, till
Iiealtby granulation and suppuration begin, and the canal gradually
closee from within outward. In most casea the opening of exit
tfcatrizes before the entrance. Certain obstaetea may stand in the
way qC thU nomuil course ; there may lie deep progrcaaire inflamina-
tiona, Tvadering neocssary new incisions and the einijloyment of ice,
as in other deep oontused wotind».
The first dre«»iiig of a f^iiishot-wouiid in the field is usually a
moist oompress, oovcred with a bit of oiled munlin or parchmmt-
p4per, held in place by a bandage or doth. Frequently nothing
fiirtEicr is recjuirod thnn simply keeping the wound moist and covered
with charpie, lotions of lead-water, chlorine-water, etc. As yet tJiere
are no full observations of the treatment of gunshot-wotmda without
dreasinga. They occasionally, though mrely, hejil by first intttilion ;
aa ft rule, tbey suppurate for a longer or »horter periwl, <.>ue of the
eliief causes of deep infianuoatioD is the presence of foreign bodie»,
■aeh a» bits of clothinj?, leatlier, ete. The presence of tlie bidtet, or
a portion of it, Li fnr lesa dnngcTx>us, for tbo cicatriciiü tissue may
grow uousd and entirely encapsulate tlie lead, white the wound
342
otrKsaoT-worxDS.
do«ei orer it; the patient kecpe tbe bullet la lun. But tbcse bullota
do not älwa^'S reiQa.m in the same spot ; they partljr «ink, from tbcb
weight, partly are <äJ&plaeeU, by muscular action, so that after ye*a
ihcy arc found at ditFeiY>nt (^^nerally lower) points: for instance, a
bullet may enter tlic thigh, aiiij subsequently, aA«r 1>ciiig alinoAt for-
gotten, may be felt initlcr th<; skin of tlie calf or beet, and uiay tbeuco
be rciulily cxtiacted. I bare t«kl yon the same tlihif^ nbont n<;e<II«.
But nuit-inelnllic bcMÜes si?em never able i« Teniain thus n-itbout
injury iu tho huinnii body, and hciice should always be cxtiartcd
wlion discorercd in b wound.
In guuHliot'K'Ounc!» Üie fever federally depRods on their size and
extent, us wAl as un the nocidentul suppumtiou. Tn the excellently-
directed hospital of tlic Bavariiin chief »tfilf-itur^on J?«*, which 1
visited at Tauberbischofsbeiin (IStiS), tliu therinotiicter was used für
detenniniitg the amount of fcrer ; the results as to fever gcnenlly
oorreapood with those in otlicr injuries.
The spcm! niles to be obserred in perforating wtHinds of tlie
akull, thorax, und abdomcm, arc given in »pecial surgery ; let us hero
make a few r^^marks on the fnictuTeii rc9ultiii<; frum ffiui&hot'ivoiiRde.
W« have already stated that simple subcutaneous fracture« occur from
spent or oblicjuely-falling bulluLt ; hut^ in most cases, tbe fractures are
accompanied hy wound» of the soft parts. The soft, spongy bones
and the epipb)'fiea may be «imply perforated by bullets without any
splintering'. Tlii^ injury is euniparstivfly bvorable; if tlio adjacent
joint be not o|)tmed, the bullet may remain in the bone, and, if it
cannot bo extracted, may licni there; the track of the wound in the
bone suppurates, fills with gninulfltions, which at leaat ]»rtly CMUfy,
BO that the firmness of the bonn is not impaired. If the bullet strikes
the diaphysis of a long boue, it genenUly splinters it. In these eases
tlie splinter» of bone, which are I'xise or but siiglitly attached to the
suH parts, should be n-tnun-d, and the injury tiit^n treated aa a com-
plicated fhictun;; the fonriblc removal of Grmty-nltaohed ptorrs of
bcoie c«nnot be too much contemned. Gunshot-fractunea do not dißcr
from others of this class, unless by the sharpness of the fracture«.
HUB has induced some surgeons to saw olT the Bharp ends, or, aa it la
teebnieally termed, to make a resection of the bone in iU continuity.
It was hoped tliat Üie wound would thus tx^ simplified, and its rouree
rendered more favorable; at the same time attempts were mode to
■void B pseudartlirosi« by detaching tlie periof^tcum from the fi«^
ments of bone, and preserving it in ihp wound. Experience has
i^iown pretty decidnlly that tlii» proceilure is not generally sucooa»
ful, although some favomblc and peculiarly successful cases seem to
&rorit
GtWSnOT FRACTURES.
94S
K tbe iojur^r lias cat»ei] a comiilicstcd fracture in n joiul, nc cau-
Dt bope for mucb frcim an expecUitit trL-utmimt, orrording to present
rieooc, vbicb is bucd oo sUUstics; the <)uosti«n ratltor seems 1o
be, whether primary reeoctlou or amputation is preferabk* ; this can
oalr be dscidcd by tbc^ peculiarities of each case.
Lutly, we must mention that sccoutlar^' hseiuorrhages »re par-
ticuliri^ EnK]iH?nt in guiisliot as in otJier contused wouuda.
1 consider tbe treatnii*nit of g7iiislint-fracturcs, by fenestrated plna-
tcr-bandages, as the only proper uielij<.xl (exci^pttiij^ pcrlutpt) those in tlie
uppeT part of the nnn or thigh) ; thi? only tiling ugninst It is, lli&t
Burgeons who liavc not already trented open fnirtiires with plaster^
dreeaiDgs, and arc not adept» in the ii[ipliaitioo, should not maim their
fint ex{K^rimeTits on gtiDshot-fractureHjbuttthouldunly applydreseings
with which they are familisr.
Secondary siippumlivo inllnnimalions occur in ^nshot-wounds
even more frequently than in other contused irounds; the same
OkOtea that we Itave already learned fnr these ilanj^rous accident«,
nofortuQstely often act in guushot-wouuds also.
W« must satLtfy ounteJvefl with these few rcmarlcs <>n tlie subject
of gimtdiot-nuinids, glad »h t tthouUI b« tocontinue the subjeet. Those
trlio feel speciiil interest in tiic subject, I n'fer to the works already
mentioned, and to a littlo book of my own, "Historical Studies on
tbe ConsidPTation nnd IVcatroent of Gunshot' Wounds," in which you
will Sod tbe old literature brought togctbei.
CHAPTER IX.
BURKS AK J> FItOST-BITES.
LECTURE XX.
1, Bonu : Qrade, Bitant, TrNtmonL— Sniutroke.— {Hroki of Llglitsliig.— 3. Fn«-
UtM: anäb— Otoini Ptemliiff, TnunBoiiU~CliilblBliu.
Tns «jmptoms due to burns sod rroet-bitci ore (|uitc RimUar, but
aiosufficiemlydistiiK-ttobc regarded seporaUMy ; m'c sboJt first trvnt of
BÜRS8.
Those are cousod by the flaiuM, when, for iustanc«, the oloüi*« buro,
but inorr frcqueiitly by hot fluids, as when duldrvn piill vt-wd» of bot
water, coffee, eoup, etc., off a taUc on to tbcrasclvt-s. And, unfcn^
tuaatcly,iu factories, burns from bot nietalK, itucb as mullon lend, troo,
etc., arc Dot rare, and lu cvcry-day life BÜ^litcr bums fratn mmtohcs,
sealing-wax, etc., often occur, as you bavc all doubtless seen. Bcsid«3
the ahoTc, concentrated acids and oauHtio alkalies not unfn?quently
OLUAu burns of viirious dcgrera, analogous to lliosc from hot bo<lics.
In burn» tlie intensity and extent of the injury ai« to be regarded ;
we shall h»roaf tor study tho liiL(«r. The intetmty of thn hum d«-
pends ess«atially on Ihö grade uf the hent and tbe duruliuii of its
action ; according to the rcault of this uction, bums bare been divided
iuto throe grade«. Tlieüv paes into one unothtT, but from tbe aoucotn-
panying symptoms may be dist iuguishcil without difBcu] ty ; the only ob-
ject of this is to render explanation cosier. M'c oRsuine three gradea;
Fif^t degret (hj^pcnemia) : The »kin is much reddened, vt-ry juiüiful,
xiid »lightly swollen. These symptoms arc duo to dilalaticm c/t ibo
capillaries, and alight csudation of scrum in the tissue of the cutis.
Tlierc is a mild grade of inflanimation, in which there is an increiife
of cells in tbo rute Muliirghii nlou«, which is followed, in ninoy cases
at least, by detadimout of the epidermis, llcdncss luid pain occasilm-
DSeRBES OF ßtmS'S.
849
ly UaI b few houre, in oUier cases scvcml {lays. But it is uot moeB-
and
aU
tical, to make several grade* on this account.
Second dtgro» (formation of ve»icW) : Beüdes tbe »ympLoiitti of
tlic first decree, veeioles sriM: on the autface of the skin ; before burst'
ing these contnin B<-nim, clear or mixc^ n-itb n little bl(xyl These
vesioke ftxm immediately', or in a few hours after the reception of the
bum, atui may raiy greatly in size Anatomically we lind lltaL in
most of lbe«e eases tfao boray layer isdetaobed from (lie mucous layer
of tbe pjüdermig, bo that tlip fluid rapidly escaping fium the capUla-
riea lies betn-eeu these two layers, just as results fruui llic action of a
blister, llic vcsidvs rupture or arc punctured; from the rcmaioiug
rote Malpigbii a now liomy layer of tliv epiderniis formH quiirkly, and
in nx or cijtht diiys the skia \» the same us before. It nmy also hap-
pen that after rentoral of ihc Tesicle the denuded portion of skin is
excessively painful, and for sereml dnys, or even a foitni^t, there taty
be superficial snjijuiration ; the pus finally dries to a seal), under whidi
the new cpidcnrii» funDs. Vou iiiiiy induce this statu also urtificüilly,
by leaving a blister for a long lime on one spot. Here also it is ud-
neeesaaiy to make new grades of th«so rariatious, for they only de-
pend on a little grcntcr or less destructioa of the rete Matpigliii,
while the greater or less pnio corresponds to the amount of dcuuda-
, of the nen'cs in the pajjilhe of the skin.
TTurJ deffrtc (foimuliou of eacbajs) : By tlits tenn we may dcsig-
^ute all those cases where there is formstiou of eschars, L c, where
portions of the skin, and even of the deeper soft parts, are destroyed
by the btira. Of course, the rarieties may be very great, as in one
case there may be only hiiniing and cliurriTig of the epidermis »ud
papUUe, in another death of » portion of tlic cutis, in a third charring
of the fckin orof an entire limb. In all cases where the pnpiUary layer,
with llie rcte Midpigbii, is destroyed, llierc wiU be more or less sup-
puntJon, hy which the niortitied portion will be detached, which of
ooune will lenvc a gruDuiniing wound, (hat will follow the ordinaiy
ooune in healing. If only the epiderini» and the surface of the pa-
psUaa be chaned, there is wdy s%ht suppuration, wilii mpid repUoe-
ment of the epidermiu layer from the remains of the retc Malpigfaü,
From what has been said, you may miderslaud bow from four to
aercn or more ilegrees might be formed ; but^ to make tbe subject con^
prebcnsible, tlie three degrees of re<inefs, vesicles, and eschars, are
caoogb. In exten^ve burns we often find these different degrees
combined, and, when tbe injured part is oOTered with clutrrcd ciüdci^
mis and dirt, it is often difficult to determine tbe dc^pe« at any point
If there be suppuration, it may he etttier superficial or deep; oocasioti-
ally it appears as if islands of young cioitricial lissuo fonaed in the
246
BOBSa AND FEOsr.BITEÄ
midst of k granulatinf; woimd, und tliis li&a fftvcD ii«c to the false idea
thiit tlic laltcT oouki cicatrize uut only Eruin tlic edges but tKua diBet-
L'ut puiiit5 in the midst of the wound. But such dcatricial tslsnds
never form whcm there is total ahociiee of tlic papilWry bodies of tlie
skin, but only from some remnants of tbp rpt« .\fnt|ü^liü, n» may hap-
pen in biirns and certain ulcemtioits to b« hereafter itieittiontrd.
Tfic pro^noBi» for the function of burnt ports may be inferred from
what has bc<>neni(l, Wc should, howcror, add that after «xtciisiro loss
of the skin, us occurs especially from burns of the neok and upper px-
trcmitics by hot liquidü, there in very consiilcrable cicatririal conirac-
ti«ffi, by which, for instance, the head tniiy be couiplutuly drn'n-ti to one
side of Um? neck, or anteriorly to the stoinuin, or the artii fired in a
flexed position by a clealrix in iIjc bciiJ of the elbow. In the course
of time Üm;8C dcatriccs become moie diütcnfiiklc and piinble, but rarely
to suoh an extent as entirely to remove the disturbance of finictioa
■nd the disfigurement, so that in many cases plastic operations are
aeoeeaary to improve these conditions. It was formerly Asiterted that
the cicalricp« after Imm« contrnnted more strongly than any other
cicatrices. But this is only aj^jarently so, fur scarcely any other in-
jury ever causes the loss of Buch Urge porliona of skin ; wc may
readily perceive that, when this does occur (as in plastic opemtioiks
and after extensive df#triieiion of the skin by ulijpnitinns), the ooo*
traction of the cicatrix is just ns ^reat.
Entirely apart from the diffcrt-nt dcfrreee of bums, Ibcir valtlU iB
of the proutcst im]>orttiiici% us rejjanig llieir danji^er to life. Itla gen-
erally said that, if two-thinls of tlie Hurfuec of the IxKly be bumrd
only in the first degree, death soon occurs, la a manner that has an
yet received no physiulog^ical explanation. Persons (bus injured fiül
into a state of cnllapat^, with small pulse, abnormally low temperature,
and dyspncca, and die in a few hour» or days. In othcc cases life
Inxtg somewhat longer; deatli occasionally results from severe diat^
rhu», with the fomintion of ulcers in the dnorlenum, near tl>e pyloms,
a complicniian which nho sometimes comes in »cptiaemia. The rapid
oceurTcncc of death from extensive bums hn* received rarfoiis cx-
planations : first, it wan asserted that simultaneous irritation of almost
all tlic peripheral nerve-terminations in the skin was too great on irii-
tant for the central nervous system, and hence cnnecd paralj-sis; ibe»
that the cutaneous perspiration was srresled, and death was to bo ex-
plained here, as in the case of animals, whoso whole body has bccTj
corcrcd with an sir-tiji^ht layer of oil-paint, caoutchouc, or pitch. In
the latter h\'pntli(>sis it is asaumcd that liie excreliun by the skin of
certain substances, especially of ammonia, is interfered with by the
impermeable coating (as by the burning of the skin), and tlint u fatal
TREATMENT OF BURKS,
S4r
btoo()*poisoaing is tbus* induced. Lastly, Üie sjmptoms might be Ute
molt of an intense phlogistic or septic (nbcre there is formation of
e*c)ian) intoxication. Should the burn not prove fnttU from its extent
■loDC, llio great loss of xkiii himI consequent suppuration inijr prorc
dBngcrouut, especially for I'liiklren und old person»; in the suine wiiy
tbe ampiitatioDS ncccesarj fi-otn eonipletc clmrrinf; of single extremi-
ties involve oertaJn dangers, \rliieh are the more serious as they affeet
persons alrrady jrrcatly di-prc^srd by ilio bum,
III the trcalmait of Inirus in ihe lirst and second de^jce«, more
depends on alleviating tbe pain tlian on any energetic treatment; for
we cannot hasten ihc retiim of the skin to its natural state, but mint
IcuTc the course of hcaliug entirely to Nature. If there arc anjvcsi-
dco, it is not advisnblo to remove tlie loosened epklermia, but to open
tbe vesicle by n coiiple of ueedle-puoctures, and carefully press out the
serum, to relieve the teii»e feeling. It froulcl be moat natural to cool
the burnt part, by applyinjf cold cotnprossea, or holding it in cold
irater. But this is not usuidiy very |K)jJular with patients, as tliecold
sboald be ootisiderablc and continued, to relieve tlic pain very much.
Hie oold-vratur compresses warm too quickly, and itnmersion in cold
water i.i only applicmhle to the extremities, hence cold ia coinpani-
tlvely little ttscd in burrts. Xume-rous remedies are wicd in bums,
wbom only effect is to perfectly cover the iuDiuued skin. Suicai^ig
tlie sttrface with oil and applying wadding is ii very common and pop-
ular treatment. Maihwi potatoes, starch, and collwlion, are also iimch
used as protective coverings for tl»e bunie<l skin. The two romier may
be regmMed as popular remedies ; lor extensive bums I cannot prtise
ooUodloD very much ; the cotlmlion eoi-ering ancles readily, and in tlie
Gimda the skin becomes sore and very sensitive, Some sur^xms tiae
peculiar salves and liniments instead of oil ; such as a liniment of
equal parts of lime-water and linaeed-oil, salve of equal parts of butter
and wax, lard, riml of bacon, et«. Another plan of treatment ia with
■ Bolutio« of nitrate of silver, ten (Trains to the ounce of wftterj this
is to be painted over tlie burnt part, and oom]»essos wet with tlio
same to be kept constantly apjilieil. At (imt the pain from the oau-
lerijsatton of tl«.' pnrti dcniMlcd of epidurmis is occasionally very great,
bet a thin blacktsh-br'jwn crust soon furnis, and the pain then oeosee
eotifdy. I particularly recommend to you tliis plan of treatment
when all three degrees of hums are combined.
In bums of the third degree, if there is only mortification of the
cutis (when this is not charred, but burned by bniliug watCT. it gen-
eraOy becomes perfectly white), tlie treatment is the (urnie as that
above given. Should it »uh»eque«tly be dcsiraWc to hasten the de-
tubnent of the esohnr, cataplasms may be employed to stimulate
248
BCBSS A>D FROST-BITES.
flupjKinition ; in most «woe, however, this vill be unDcccsKniy, and
the trt?utm<.-iit by nitnit«.' of »ilviT nu>)- be cuntinucd l!ll tbc i-üiliar is
oomplQtcIjr detached. If large gnuiulattiig Kurfun:» ruioaiu, (■«pucuUIjr
oo ptrts of the buHuco tbat itru niuvtid iniwli, ui>d wlivro Üic utrigh-
boring nkin is not verj* movablv, it may luke a long time, often dumiUU,
for them to lieal. Verj luxuriant gT^nulatioiia fonn, and their tcn-
dCDCj to gT»uulfl.te is always very sliglit. Of the remodics olrcwljr
given for promoting tlic Iitnling of sudi woundd, I porUculiuly reconn
incod to }*ou tfae coui]H^ssiuii of tli« vruiiiid by titrips of udht-sti^>
pliistor, wliicli arc of excellent s«rvitfo in some of thctc cstsoi. In Uic
ti^eatmeut of cicatricial CM>ntnictlouä resulting Jroio tbesv buma, com-
preasioa of the dcatridal banda bjr adhcsire plaster is cue of the most
iaiportaal remedies, and you ^Tould always do well to try this pcr-
nttcntly before n!Sorting to excision of the cicatrix, or to plastic
operations^
H, in a bum of the tbinl duf^rec, there has bueo charring of a
limb, it may often be advisable to nmpntate at once; not only because
the detacbinent of a largo part of the body is not free from danger^
but also because the atunips thus left ave unfit for the ajiplicaiiun of
an urtificiul limb.
If csllvd to a case wlieiv there ts n bum of llic greater part of the
body, you must give your vrltole attention to the gencTal condition nf
Uiu patient, nod try to prevent collapse, by the u&e of stiuitJaitte, such
OS wine, hot driiilci, hot bntliR, ether, ammonia, ete. Unfortoiuitely',
in Ino^t of tliese rases, our efforts to preserve life are in rain. HHra
pralBeti tlic treatment of extctiMve bum» by the continued wann bath,
which, under proper circuiustancca, may be kept up for weeks.
Persons with delicate skins, long exposed to the xun'j ray«^ may
havie alight degrees of bums of the face and nedc Tliis is often tA>
servml in peisons txavelling on tlie mountains. Wlien persons, e«pe-
cially woiiiL'ii, who do not usually pass the day iu the siui, travel for
several bright days in summer, without carefully protecting the f«c«
and neck, the skin becomes red, swollen, und very painful ; after three
or four days tlio skin dries to brown cnists, crocks, and peels oK In
otiier persons, with still more inilablc skins, vesicles fonn, which sub-
sec{uently dry up, without, however, leaving any cicatrkes (eexeiiia
solora). Besides pro])hyIaxi8 by veils, sun-sliades, etc., it is well to
cover the skin of such mountain tni^-ellers with cold croum or glyce-
rine ; the same remetlies may also be used in developed sunlniru \ if
the burnt parts l>c very iminful, we may apply cold oouiprvaiscs.
Hero wo must also speak of awHtlrakx, or inaoUUion. In our di-
FRORT.ßlTEg.
S49
atP, tltü disease oci:iirs almost exciuürelr in young soldiers, wbo
have to nutkc bti^ruing marclH?» in full uniform in very Iiot, bright
westfacr. Tliere aje severe lieadacbi», dizzincts, unconsciousness, and
sometimps dmth in a few Ikjuts. In tlii> Orlt-nt, (wpocially in Indin,
this disease b not rare nmo»;; the Kngltsli sutdivrs ; Bome cases are
quit« acute, CD(linj;r with t^lauic epoains ; others begin vith lon^ pro-
droriL&ts, and dra^ on with eyniptuuis of twvtro hüadaclic, burning
sldn, nmtinuccl fatigue aad Jrprcssion, palpilatiou of the heart,
iwitciiiug of the muscles, cte, ; even ivhen this slate ends in rccorery,
relapses are comiunn. I^ticnUi vith sunstroke nro to be trcalcd like
those vith congrstinn of ihe braJu. Cold affuuons and bladdrrs of
ice lu the head, ml in n cool chamber, purgatives, leeches behind the
e««, sinapisms to Uic nii]ie of the »eck, are llic proper remedies. Ac-
cording to the eipcrieuce of English surgeons, x-enesection is injuri-
ous.
We also have something to say about the effect of being struck
by lightning, Pr^ibably all of you have at some time scMi bousea or
trees that had bcca struck by lightning; vre usually* see n large rent,
a fisnire with charred edges. M^n and nninials may ulsu be struck
M as to lose lüiigte licnl», but ttiis in not nlivays the case ; ususUy
the ligfat&iog travels along tlic Ixidy, in at one place, out at another ;
the clothes are rent, or even torn off and east aside ; peculiar, branched,
zigzag hroffnish-rrd linrs arc found on the body ; these have been
reganled as rcpreaentatiuus of tin; nearest tree, or u bloüil coaguIate<l
in the vessels and shining thrfittgh; hot!i views are ioeurrecl ; wo do
not know why the lightning niiis this peculiar course on the skin. If
a penon be directly struck by lightning, he is usually killed on tho
*IK>U If tho lightuing i^lrike In his inimeilinifi vicinity, it induces
symptoms of cummutioa of the brain, paralysis of certain limbs or or-
garts of special scn»e, and occasional cxtiavaaationa and bums. The
latter beol like other bums, according to their degree and r.xtent
Paralysis from lightning i« not usually of bad prognosis; the nervoufl
^UH^muscolar activity may return afler a longer or shorter time.
^^ We may aivide frost-bites intn three grades analof^ous to tliose of
burns ; the first of the&c is characterized by rcdnes» of the sidn, tho
second by Itmnatioii of vc*.icle», the tliird by eschars. The firitl degree
of &ost-bitc is quite well known ; we might reganl the oo-callcd dead-
Dcaa of the fingers as its mildest fort« ; probably each of you lias some-
time had this in a cold hath, or iu winter^time. The finger becoonCB
7I108T-BITES.
raOSTDITB8.
331
nonDaL Generally do remedies aro used in Uiese aligbt cases, but,
very propeily, patients are wmrnml iij^ioBt warmiDg the p&n» too
mpiiUy; nibbing urith snow, tlirn gntJuiitly cleratiug ihn lempenL-
turc, it) jcconiiueiHled, Th« above sjiiiptomB arc thus c-xplaitied;
First, the capillarira arc strongly conLnivtvd by tlic cold, and an? then
paralyzed Fur a tiiiK>. J »hall not tiero discusa the tenability of this
hypothesis; this cxplaaatioa involves all the difficulties that we liave
■Iraaciy mM in tlic th(.-unt.-ä of iiitlntnmatioii.
Bednesa rollowing a froRt-hite may tiometiiiies remain jioniianeot,
i. li, tlip cHpillarics remain dilated. This is especially apt to occur
in fro6t-bit(?ä of the nose and ears, and i» usually incurable. Iii lli:r-
Jin, J treated a young man who had a dark-lilue nose, an a remit of
firast-biie, and wislied at all hazard» to be relieved nf the deromilt^'.
Be peraistCDlIy pursued tlie <liffert-iit mode* of treatment ; firat, bv bad
tbo nose painted with collodion, nfter which it looked as if varaishcd,
Rnd,sa long as the I'oating of collodion continut^J. it vra» sumewhat paler,
but the impfOToniciit was not permanent. Then llio nose was painted
iritb dilute nitric acid, which ^ve it a yollow tint. After dolaehnumt
of titc epi<lenais the evil again a|ij>eared improved for a time ; but it
»oon relumed tn its former atatc. Then we tried treatment with
tincture of iodine and nitrato of silver, which for a thne gave the nose
a btowniah-rrd, then a hrou'nüili-blaok color. The patient bore nil
thcae rhan^-a of color lieroiciil ly, but llie per\-er«e capillnrics continued
dilated, and the nose remained bluish red at the last, just as it had
been. I atill titought of trying oold, but feaivd tlie condition might
be made wor^, ami, after several montJia' treatment, had to tell the
liero tif ihia tragi-comicol lii&tory that I tould not cui« bim. The
treatment of chilblains and the consequent ulcers^ of whinh we shall
speak hnmeilialely, may Vie jii»t «s diflii^ult.
Froet-bitc, whcrv, besides redness of the skin, there is fomiatioii of
veslcJes, is more ivver« ; it is oAen acoompnaind by complete loss of
sensation of tite affected pari, and ibere is ahvays danger of mortific»*
tion. The formalioD of vesicles in frost-bitv is proguostically mucb
xrone than it is in bums. The scnrai containe<l in Uic vesicles is
imrely dear, but usually bloody. A limb completely fnjzun is said to
perfectly sUITuikI britlle, and small portions arc saiil to break off
glass, if carcicwiy handlwl. I have had no opportunity to verify
statements, but renwtnher lliat, when I was a student, a man was
was brought to the UntI ingt^n Huri^icul clinio with both feet frozen ;
during Iranaportatioo to tbc hospital, they had become spontaneously
detached at the ankle-joint, so tlint they liung only by a couple of
t«aidoQa. Double am]Mitation nf the leg above llic tnnlleoli had to be
Uow Ear a limb nuy be entirely Erozoo, so tliat the circulation
^»rely
Bepc-
2A2
BDRNS iyj> FltOST^ITEa
is entirely nrrcBtc*!, frequently' e«nnot b« detcmiinc<l for a ibcae
heooe we must not be tcx) tiuitty »Ixnjt Binputating. In ZUric]), I hatz:^^
tWT> caers where- ix>th frnt were dark bluLi Biid without (rclinp, andE— ^°
on Ix-iug punctured with a. needle only a drop of black blood c»-ape(l^
nevvrtheleM, tbe foot lived, and only a few toes were lost. In n ümd^E:^
0B3C, ill a very debtlitatcd {jultciil, wbcrc lioth feet a» high aa tiie ^^*
calf were dark blui: find cvvcrvd with ^-eaiclee^ tliC'y become entirely
gaup^'nous. If ther« be esteiisive pingreno of llie akin, bej'otitl ■
doubt, yvc should not delay ampulatinf^, for these patient« are very
subject to p^-teniio. A very sad case occurred in the Zurich hospital
A powerful young' man hud both hiuids utid both fet^t tnaeo, so.that
att became gangrenous ; tlic patient could not make up his miod to ihe
four amputations, nor could I brin^ niyaclf to persuade him to the
fearful opomtion. Ho died of pyiemia.
TIio ends uf tiie extreniilies, the point of the no8e, and t({ia uf tlie
cata, arc most liable to \jc froz«.-ii. Closely- fitl in;; clothes, which impede
the circulation, inorcase the prodifiposttion. Cold wind, and cx)1d aiy
oompanied by moisture. Induce frost-bite more readily than rery great
at ill, dry cold.
There is also a total fi-ceüiiig or stiSenioff^ of llie wliol« body, in
which tlie patient loses ennseiausness, and falls into a state of reiy
limited ritaltty. The radial pulse can hnrtlly be felt, IJie heart-beat is
searccly audible, the respiration almost inipcrceptiblv, aod the whole
body ia icy cold. This stale rnav piiss at once into death; then all
the fluids harden into ice. This general freezing ia especially apt to
occur when tlte in<lividual, overcome by fatigue and eold, lies down
while freezing; ho soou falls aeleep, and sometimes nci'cr wakcc
again. It 1ms never Ix-cn accurately determined how long a. patient
may remain in thb stiff condition, viHh very slight appearance of life,
and again recover; we find mention of the atiite having laitt<.«d six
da^rs. Whether this be true or not, we should eontiriue our ullcmpts
at leeuseitat ion oa long us a licarl-bent can bu detected.
Let u9 eommenee the trectmtnt of frcst-bite with thi« stale of
general stifinesa. We must hero avoid any sudden change to higher
temperature, but increase the nanath gradually. Such a patient
should be placed in a cool chamber, on a cold bed, and frictions nuul«
for several hnun. At the »irae lime, artificJal respirntion should bo
occasionally trii-d, if the breathing liecume» imperceptible. As slight
stimulants that may do good, 1 would mention encmataof cold water,
and holding ummonia to the mistrils. Very gntdttiilly, aa the patient
Iweoraes conscious, wc raise the surrounding tcmpemtun-, keep hira for
a time in a slightly-wamied room, and at Gret give only tepid drinks.
As the different parts of thi> body, one by one, regain vitality, there is.
TRCrtUEST OF yROST-DITE.
S03
lally fioinc pun la tbn limb«!, cs)»cctally if thr^* were warmed
Aoo rtipi<Uj ; in tlicse cases it is w«ll to envelop tbe painful pnrts in
«lotbs (lipped in cold water. The patient may reroain for lioiin; or
«^ja in a bcnumbr«!, wsnscIeM rcniditioii, whidi disajiiieiirt i^diially.
KX late, expcrimiMiU liniv I>o«n itiAdc ii^ r«Ai»oitAtinj; »lifTcixN:! aiii-
mnls, wbicli iippt.>nr tu titow that Hninuile arc iiiotv ccrtiiiiity eavtKl
-from iValh by rapid than by slow wnmiitip. I »bould not readily de-
cide, bnm tliese experiments on nnimnb, to depart from tbe rule«
atlreody wnpirically employed for Ircatntcnt of pprsons frozen stiff, and
irbich appi'ar to be coiTcct for Ineal fr(M<>biteA, but tlie qiie^Lioo is
-worth further experiineot. Such va»e» of g^neial freeziii)? rarely
«aoapc n-ithout low of aom« limbs, or parla of tliem, nrii, in r^'gari to
the treatment of iht-Sie frozen jxirt», T esu ;^ive yuti littk advice. Tlie
resides arc punctured and cracuatcd; tlic feet or bands may bo
wntpped in cold, wet cloths ; then we must wait to tee whether ond
bow extensively gangrene will oociir. If the bbiish-red color passes
into a dark cberry-red, tbe cbaiices of restcirntJon tu life arc alif[lit
Gaagreiie wiU occur in the fiircAt majority of such «ocet. By testing
the Bunsibility with a needle, and noting tlic escape of blood &om
these fine openings, wc test bow far the iimb has ceased to live ; but
thia only becomes certain when the lino of dcTnarcatton fonits; that
is, when the dead is abarply Ixiunded from the Jiving, and inilitmma-
lory redne« de\-elops on tbe border of the gangrenous parts. We
have alreadv spoken of tlic nmputation of sui'li limbs. Tbc* dt^acb-
ment of single toos or fingers we may leave to itself, b\it, where there
is gangrene of a lai^ part of a limb, amputation is decddedly pref*
crable.
I will bere retiini t» chilblains (pemiones), not because they may
particularly diingiTous, but because thcty are an exceedingly
tnoying disease, and are in t«oine c;t))*-«i ver3- difficult to cure, and fur
which, as good family doctors, you must have n scries of rcmeilics,
Chilblains are caused by paralysis of tbe eaiHllarics, witJi serous exu-
datioa in the ttasuo of the cutis; tl>ey are, as moat of you know,
bluish-re':! swellings on tl>c hand« and feet, which proi-e exccHi^*ely
annoying from their severe burning and itobing, and fmra the occa-
sional formalinn of ulcers, Tliey result from repeated slight frccsdng
of th« same spot, ond do not occur with equal frvqueney in all pcr^
sons; tJiey an» less annoying in very «okl weather than during the
cban^ fnim (»Id to warnt. At night, on guing to bed, when the
hands and feet become wann, tbe itching occasiottally becomes so
troublesome that the patient has to scratch tliem for hours. In gen-
eral, females arc more disposed than males, and young persons nxFre
954
BURN'S AND FROST-BITES.
Oian old, to chilbliuns. EmpIoynienU requiring frequent dinnge of
tcmpermtuTfi particularly prtxUspoM; to tlieic ; clerks and upoUiccttnes,
who Btsy for n time in a wnnn motu, llieii in u L-old cotlttr or vrsrc-
bouse, arc frequent Bubject«, But no suUun is exempt ; peopl« who
aln-nys wear gloves, 8Q(1 rarely go out ia winter, may bo attacked aa
well as tIio6Q who have never woni glovoa. Among fcTnales, chlorosis
■nd disturbaDces of meiistruation occasiumtUy seem to predixjioite U»\
them; gent-rally, frequent returns of Croet-bite appear to be coniiecteilj
with some ronstittitionnl anomaly.
As K^itbi trtralitieut, it in usually very difficult to combat the
causes due to constitution und occupation ; bencc we arc chiefly lim-
ited to local remcdica. In Italy, where the di&ca&c is very frequent,
if a cold winter ncours, frictions witii kdow and ice compreasec are
recommended. With us, these are less used, and do no good, or at
m06t only allt-mtc the itching for a time. Salvo of white precipitate
of mercury (one drachm to the ounce of lanl), friction« with freeh
lemon-juice, painting with nitric add diluted with cinnamott-water (one
drachm to four ounce»), solution of nitrate of ailver (ten grains to tlw
ounce), and tincture of canthorides, are rem«dica that you may resort ^
ta SomiitiniG« one answer«, soinetiines another ; hand or foot ball» ,
with muriatic add (about one und a half to two ouuoi-« to a foot-bat
use for ten uiluutes), uud ^vashiiig with infusion of mustard-seed, are^
also cclcbnted. If the chilblains open on the top, they may be{
dressed with oiulnient of ziiic or nitrate of silver (gr. j to 3 j fai). I i
have hcn^ given you only a »mail number of the r«mcdic» rcooin-
mended, tfao cBcut of most of whidi I have mysvlf proved, although
there are a number of otherv; at the commencement of your ivacdoe
you will find these enough for combating this common, trilling (haeaaCa
CHAPTER X.
ACUTE yOJV^TJiAUMATia IXFLAMMÄTTON OF THE
SOFT PARTS.
LECTURE XXI.
<}«Df ral Eiiolofj of Acute Indaminoticiis.— Amte InflnarDalloii : 1. Of Ui« Cuti*.
0, Btr>^MaiH Indanunklion ; i, Furandc; e, Cutnmcla (antlmi), riutula &!•-
Ugas. t. Of llwHacuiu Membrane«. 8. Of IbeCcUnlwIlnuo, Acut« Ab*c«WM.
4. Of Ik* lliudaa. t>. Of tbo 8arM» Hcmbnso*, SliMtlui <rr tli« Tondon*^ 4Dd
gnbcttlmoM MaooiM Burt«.
GK?mJ{UEK: So far vre have treated onl^ of iojuriee, now «e
shall pafts In the acute inflfttnroa lions which «re of nnn-lnuiniAtic
origio. Of ttieac cft«c», tbovc bcloDft to turj^ry that occur oa the
outer part of the botljr; uIm thos« which, occurring in internal organa,
«w still «roessibt« to aurgical treatinpDt, Although I must start with
the idea that you alrRady know t)io causo» of discas« in geocral, it
still %iicm& neoessatj to make tome prcliminary runiarks with special
refenmc« to tiie subject of irhirh we arc about to trnit.
The caiifles of acuU' uou-tr&uuiatic infbiiiinnliona may bu divided
into about the following categoric« i
1. li^xatid Mtchanicat or Cftemieal Irrit(aton,~-At the first
glance, thia Bcems to come uudcr tbc head of tisumB, but it makes
ooDsidera'bIc difTcrcDoe whether suc^ an irritation acta onco on a ti^ue
.or iriietbor it be frequently repeated, for, in the lutter case, each suo-
Cocding irritation alTecU a titsue alrmdy irritated. Ati example will
Ualce ihia clear to j-ou. Suppose a ]>vnH>n ia rubbed ooulinuoualy by
a pTOJoctin;; aborp nail in his boot or shoe ; at first there would Im» a
•light wonnd with circumst^ribed iaHammatioti, but a(tL-rtvunl the
htflamnution will spread and become more intense aa long as the irri-
tation lasts. L>et us take another example of chemical irritation : If
a petaoo not accustomed to bighly-wttsoaed food eats Spanish pepper,
IS
ACCTK XOSTRACHATIO INFLlIfMATIOX OF SOFT PARTSL
it woiili] induce temporary hyperanoin. and ewrlUng of the oral ODtl^^W
gBBtrio mucous mcinbraae; »bouJd one coiittaue tlie use oC ao send« .^v
siibstAHcc for ft leng;tb of tiine, he miglit exäte a levers guAtrilia. — jM
Except ill cases of ttie firat cxurn])!«*, Uic»c niptdly-rcpcated irriuilioiu ^BJ
arc not frequent io practice, but tliey bare a gieat deal io do wltli Ibe ^*'
oHgiu or cJiroiitc inflnmiruitio» ; whvii, of tltetrtsdvcs Insi^ilintnt, thef ~^
act on parts more or less woiik. AVc uitut agaio retiiru Io this ^
point. ^M
3. Catchintf CoM. — You aU know that hy cafcbing cold on» may ^^
aorjuire variou.s dinenAes, cspeclullr acute eatarrti and iiLflammatioos of
the juiiils or lunf^ ; but vie do not know what is the purticulnr injo-
riou» influence in cutclün^ cold, or vhat iminwliiit« chivng«ii il caus««
in the tissue«. The rapid cbiing« of temperature 1« blamed u ttie
chief cause of catching cold, but by this means we cannot eiperi*
mentally inJuce an iunauiuia.tion,or any Bimilar disCMO. One caldiM
cold from Iieiog hented, and then \»iag expoecd to a cold draught for
a leiiftrth of time ; by carefid obscrratinn he may say just when lie
caught cold, 'riie cold way have a purely local action ; for inslaoce,
one Rita for a Itnic nt ihe window, and the oold wind blows on the side
of his face ton-ard llic window ; after a few hours he ia attacked bj
paralysis of ibc facial »crrc Wc may here uesamc that molecular
ohangea hnre occurred in the nen-e-aubslanm.', by wliieli the condact-
it^ power of the nerve is lost, Aiiollier might get a conjunct iritis
from the suine cuwe. These arc purely local colils. Another caae b
more frequent, vJE., that oo catching cold that part is attacked whtdi
in the person alTected is moiit liable I» disease, the "/ortu mtnori*
miit^aiir." Some persons, after catching oohl in any way, hare
oeute catarHi of the nose (snuffles) ; otiiers have gnstrio eatarrii, other«
miisciibr pains, and «till others bare inflnmniati'ms of the joints.
Now, ns these parts are not aln-ays directly aßecte<1 by the injury (as
when one has nasal catarrh from jjvlting his feet wet), wc miait sup-
pose* that the whole body is implicated, but the iictiiKi of tlte injury is
only shown at the lacru minori« resfalenlitr, Whether lliis transfer
of auch injurious influences to a special part of the body is due to the
nerves, or to the blood and other tiuidsof the body, isaqueiilion which
cannot nt present be decided, and about which physicians ore divided
into the two ^re&t bodies of neuropaths and humoralist«. Raaaocis
may be adtlueed for both rien-a. I rather incline to the bomoral view,
and regnrd It a» possible that, for instanc«, cbomiral changes may
occur or be prevented in the skin while svreatinp', wbicb iiuy hare a
poisonous effect on tbe blouil, nnd may act as ao irritant now on tbls,
now on that ni^n. According to the old form of speech, tlieae In»
flnmmatiooa due to catching cold arc called "rheumatic" {irota fitvfui.
«lAWATro wrecnoT.
BB7
6ow) ; but ihia L-xpirssion is su much tniiuiscd, and Ii»s come Into Buch
disreptit«, thnt it ebouM not be employed too often,
3. Toxic and Sftasmatte Infection. — M'^e have ah^endy (page
153) stutcd that moist nnd dry, purulent and putrid, substanoea
brou^t in contact with a wound induce severe prof^ssiTC inäaianiB*
tiooB, if they enter the beüllhy tissue immediately «ftor tlio injury or,
mder certain previouftly-ineiilioiied drctunstonces, pass through the
(fcanulatioas of a wound into the tissue. It is true, the body is
tolerably protode«! on its eurfoi'i» by the c|ndennis, on the mucous
ooat« by thick epithelium, n^nst the entrance of such poiHonoii» and
tnflamaiatorr materials, but the protectkwi is not perfect, nierr uro
tnnny poisonous aubstnnreji whioh rnter the body throiig^h the pkin or
oiucous nieinbrane. Some uf theui we lenu poison, aufh as the secre-
tion from f^bndeiMilc'ciB in the borsc, or from thn enrbuQCuIous pu^
tules in eattle ; othen we only know Irom their elfcet«, from some
circumstanee« of their origin. There are invif^ible bodies which we
XKTxa ** miaainatio iwiaona," or briefly "miaem" {fitaofia, uncloannefis);
it i» »uppoAed that Uiexc minsms develop from decomposing orj^nic
IwtUes. Some ounsidcr them u gases, otbers as dust-like particles,
others as minut« or^nniams or their pjrms ; I think that in many
CMC» the hitter is the correct Tiew. The action of these poisons
'Varies, inasmuch sk some of them bare a direct phlogistic action ; in
ethers it is more indirect, Tliun some poisons, as pus, nadaveric
poidon, induce sererc inflommalion at the point where they enter the
^toAy^isifeetiotisalritrm) ,' othem excite no infkmimalinn nt thftt point,
"bat are imprrcejrtibly tukcn into the hlood, and, although circulating
'through all the organi», otdy hnre an inflammslory effect on one or a
few puts of the body. Tliese poisons are, (o a certain extent, only
injurious to certain organs ; they ha\*c a " specific " action. I shall
not here speak of the primary action of this poison in transforming
the bloud. We do not know tlH> cheinio»1ly active constituents of
most of theao jxrisons which act specifically on one organ or tissue ;
we caanot see tlietn circulate, nor can wo «lwa\-s see their eflects.
HcQoe, you may very juatiy ask me liow we can exprcs«» ourselves
witli so much certainty on the subject. We deride on tJie causes 1^
ohserving tlie morbid M-m|)tonii<, and, in so doin;^, support outscIvcs
mainly on their analogy to the effects of poisons intentionally intro-
duced into the body, esjiecially to those of oar most actire medicines,
tf wo take the group of narcotic», they all have a more or 1c»i be-
mimbliig effect, that it^ a paralyzing effect, on the psychical üinctions,
but they bare also the must (leritliiir specllie effe^ifs. Bellndcinn» nets
on the iris, dij^italis on the heart, opium oo the intestinal cnnal, etc,
Wc foc tho same thing in other tcmcdiea. By repeated doses of can*
258 ACCTE NOX-TIUUMATIO IKfLAMMATlON OT SOFT PACTS.
Uiaridefl wo ta&y excite inflamiuation of the kidoe^e, hy uiewuij ^^""^
fianiinnti^n of the oral mucous membrane and mIivoi^ gUn<U, (M— ^^V^j
wbctlier we iiitrcxluce them into the l>loo«l through llie stonincb, iCL.^ ~''^'
turn, or fiUiiL So klw> thoru ts uu t>iKitu«a Dumber of known ux^^^
unknown organic septic poisons, of vrbich mttny, if not all, have nli ^ ^'^
u 8pecifie pLlogogfiious acliou. I mtiitiou onlj one example : if yc^^^^C
inject pulriii fluid into the hlood uf n dug, in manv cascR, he^des ll«i^*"
direct bIoo<l intoxicHlion, he wiil have enteritis, picuritis, or pericat-^*'"'
ilitici. Must H-e not ben* suppose that the injected lluid contains ons^*^^
or mon; mnttors which hsvo a specific inllainmatnry effect on ill» *^J
intctftinid mucous membrane, on th« pleura otid pciicudJuui? If w.-^**l
know llif )K>int of vutranee of tho potHon, and hare eomo expericne»'^
of the poison itself, there will rarely be much doubt about ihe c»i]
and a<;lt()n, Hut how many cases there may bti* wliorc neitlier exists
J believe that infection is a much more frequent source of iciHar
tions, e-speeiall;^ in BUi;gery, than hau hitherto heen susjiected.
I would still make n few general remarks about the form» and
eowrae of noti-traumatie inflammations^ I have alreiuly tohl you that
tlic clioracteristio of tmumuti« iaflaminattoDS is, that they are linutcd
to tlio wounded jmrt ; if Ihey hocome progHWsive, it It genenHy
tlmiMigh mechanical or losie {septic) irritation. This woiüd imfiljr
tliui inflammations imluncd by niechaniral irritations and toxic acUuoa
have a tendency to progress, or at least to diffusenesa ; this is true of
tno»t iafliimiiuitions resulting from nitcbing cold, which all«ck eitlwT
u whale or^in or a large ei'dioii of one part of tlie hody, In tkb
regard, mucli depondü on the intCDsily ^i tho mocbnuical irritatMtt,
und, in toxic inflainmnlioiis, on the quulityand quantity t^ tho poison,
e'*i)erially on its more or leas intense fcnncutin(i^ action on the llnidR
[x;niicatiiig tlic tis&ues. As rcgaT<U inQammationa due to repeated
mcclumical irrilntion and catching cold, wc do not always have reason
to siip[X)sc lliat iheii'products are. more irritating than thrweof simple
traumatic iiinuinmation ; but if, duriii;; the latter, the affected part
be licpt abeoliitely «juiet, and tlie lymphatic vessels and tnt«r»tices
betwoen the tissue!« an- closed by the infiltration of the pnrld about
tbo wound, the oxtcusioa of the products of inflammation into tliQ
surrounding parts it) much iiiterfored with. But in repented mecbaii-
ii>sl irritntions the tissue is not kept at ntx, and eoDSCipitfiitly the
product« of inflaminittion extend unimpeded around the irritated part,
and excite new inflammation. In inflammation duo to catching «old,
according to my liumonl view, the vuiteria jxfcan» is poured to a
whole organ or tissue; hence, these inflammations are mostly diflusc
icrre lyn-ASTMATTOx OF Tire cms.
S89
from Ü3C coQuncnccmrnt. If, rrotn an cxtstiiig point of iaflatnmation,
ft phlogogeucnu uiutc-riitl entor lliö blood, »od tbeooe spcciliciitl^ ulR-ct
any otbor ftrg»n, wo mil this «ccondiiry inftammation ** nu'lastiitic."
Hut tlicac inctaslatio iiiflttmmatitios nin^* ixrcur tii nnotticr Biid miich
moro cridcut maomr, by utcou» of a blood-clot in the reins, ss tn
shall sliow in tbo section on thrombosis, embolism, nnd plilobitis.
Non-tntumaiic inflammiit ion» may trmiinatc in resolution, in firm
Org^anöatioD of tbo iiillamnintor)' product, in 8uppuratiofi, or ia uiortl-
ficatiocL But wo will now cease imatinj^ this «ubjoot in gen««!
tnmiMf and pan to the iidUmmatioiis of th« differeitt Ussura.
1. ACCTE LNFLAMMATION OF TOE CCTIS.
Tbc simple forms of a«^tr inflammation of the skin (spots, whenls,
pApulcs, tesiclt«, ptietulea), which are grouped under the oonimou
name of "acuta eKanthemata," belong to inlcrnal medieine. Only
d^pelatotts inflammntion, furunrle, and rarbuncle, are generally
Epokcn of as tme pripinry inftummations of ttic cutis. 1 will here
rmiind you lluU very frenuently tlie «kin i» Rccoiidarily nflccf««!, from
inflammation of tliu aubcutuiit-oua cellular tissue und musclea, or even
x>t tiie pcrioetcum or bones.
(a.) Grysipctatous inflanunatlon is looaled rbiefly in Uio papillary
layer and in the retc Tkralpighü. The local symptoms are great led-
sesa aud ocdentatou» swelling of the akin, paiu on being touched, and
nibacipieiit detariiment of epidermis • tbeee are ooeaaionally accotn-
penied by very high fever, out of proportion to the extent of (be local
affection. The disease lasts from one day to tbre« or four weelcSh
Any part of tlic skin or mueoos membmne» may b« attacked, but
idiopatfaio eri-sipelas is parttculnrly frequent in tlio bead und faee.
like tbo acute exantbeinala of the skin, aeeording to the rieva of
many psthologista, erysipelas of the head and Im* should also be re>-
gnnied aa a symptomatic cutaneous inllammntion ; that is, that tbo
local aAwUon was only one symptom of an oeutc general disease. In
that cate, aorgcry would have as little to do with erj-sipelas as with
•cartatina, measle«, ete. ; Vmi, a» it occur» espocinlly in wounded per«
•ooa, and partioularly often nrmutd woiiiids. vre must study it more
attentively. I consider crytipclaa traumattcum not as a aymploinatio
inflammation of the skin, but as a capiHaty lymphangitis of tbo skin,
which is always due to infeetion. We shall treat of this disease more
dosely amoBg the accidental Iraumatio diseases, and content ourselves
here with having called att^ntinn to its relationship.
(h.) Tlie fiiniiii-le or phlegmon is a peculiar form of inflammation
of the skin, usually of typical course. Some of you may know it
200 ACCTE KOX-TIUUUATIC ISFUUIUATION' OF EOFT TAItTS.
* fiom pcrsoQftl obetn^'ation. First, & nodule fti Ivgc as a pea or bo&a
fbrmR ill tlic Kkiti ; it is red and thiIilt »L'tmil iw. Suoii a small trhite
point fom].<i at il.f aprx, tlif! swelling spn'ads orciund tbis centre, and
usually attuiua about Uie sii« of a dollar ; soiuelimee tlie furuncle re-
mitiii.t qiiit^ KRiftll, about tlin size of a obcrTy; ttic* largt>r it bi, tbo
mon- pHiiifiil it Woüiiie», »nil it may render irntaltle |iersoiw quite
feverish. If vre let it nm its own counte, toward tliu fiflli day the
central, white point, becomes looeenoi! in the shape of a plu^, and pus
mixed with blood and detached shreds of tissue is evacuated ; three
or four Anya later tsuppunition ceaaes, the swrlUng and rxtdncss gradu-
ally disappear, and finally ouly u punctate, »carwiy visible oicatjix
remnius.
Wc rarely bare the opportunity of anatomically cxaminin]<; sui^
furuncles in tlicir first stage, as they are not a fatal disease ; but, &om
wliut ive »*e of tlio development and from tnctiiion, tha death of a
small portion of slcin (perhaps of a cutaneous gland) seems to be the
staTtiiig-)H>iiit anil ventre of an inflammation, during' which the blood
finally ftta^ates in the dilated capillaries; by infiltration with pl««tio
mailer, the tis^vue of the cutis partly turns to pus, partly becomes
^ngreiioua. The peculiarity in alt this is, t-Iiat sulIi u poiut i>f iii-
floniitiation shotikl, a» a general rule, show no tondeney to spread, but
should tlirougliciut icinain circumscribed, and tenniuate with the de-
tachment of the little plug above mentioned.
I'hcre is uo doubt that in many eases the cause of single furuncles
is purely local. Some parts -where the secretion of tJic ciitaneotis
glands is particularly strong, as tbp peiinieum, uxDIa, etc., arv esjje-
ciully prcdis|)oscd to funtUL-Ics ; they are also particularly comtnon
in persons who have very large aehaceous glands and so-called pim-
ples, maggot», <ir eoniedones. But there arc ulso undoubtedly consti-
tutional conditions, di:4uuaes of the blood, wJiieli dispone to the forma-
tion of numerous furuncles on various parts of the body. This morlnd
diathesis is called furune\ilotis j should it rontinne long, it may proro
. rcry exhausting; the patients grow thin, anil iin^ greatly pull^ldown
by pain and sleepless nights; children and weakly old persons may die
of the disease. It ia very popular to refer funmelc« to full-blooded-
neas and fatness ; it is believed that fatty food predisposes to them.
In my country (Poincrania) they say that persons who sufiiir muoh
from {nistulcs and ftiruueleä have "b«(t blood," I should vcrv mudi
doubt the truth of the supposition that fntty food especially disposes
tc furuncles, Vou will ofb^n find that miserable, atrophic children, and
emaciated, sickly people, arc frequently attacked by furuncle, ond,
nithongli the lack of rare of the skin has something to do with this,
it I9 tiot the sole cause On the other hand, it ia also true that well-
FITBIJNaj: AND CARBCXCLE.
361
iKnurish««! btitt^hcrs are often utlackcd by ftintncJcs ; but tins tnay be
otbcrwisie ex}iliiiiH?<l, for not unfrefjueiitly it iiix/ be fuuud that iu
UiciD tlic furuDclca uv due to {xjUoiiiuff by soiiiu mutual matter ; we
(boulJ at leftst flJn'K}'» esiuniiic fw thU i»iuc. Uut I tJiink it is going
too fkr to auutne thitt every ruruiiclt! a causv«! by infection, and is
always to be rrgiuxlcd as ooc sytuptout of a gcacmt supjniraliYC ilia-
lb«s)a — of H pyiemia.
Tlie Lrestmi'ut of individunl furundu is very simple. Altempts
bftre been auulc to cut sliort tbo proceaa, «nd prercot suppuralioQ, by
carJy oppliciitioiis of iofc Uut this «rely iiiiccetKiR, «iid i» a very tire-
Butnc trcatiDMit, nliicb is not often {»opiitar witli ibu pslJttit. I prefer
baslcoiiig suppunttioa by warm, tauüst coDiptrsdcs, und, if ibc furuncle
«Iocs not spread too mucb, to quietly await the detacbmcul of tbc
opntrftl plug, tbca to Bc\utvza out tlm furuncle, and do nothing more.
If tilt; foruitclc Ix- YVty large and painful, vre may mnkc one in<:i!«ion, or
two cTOBBiug eadt oi^ur, ibrougb tL« tumoi ; then tlie uatutal course
of tbc proci't» is fftForcd by the escape of blood, and the more rapid
auppuralion.
GcDcral funioculoeis is n diiBcult diecoM: to treat succcasfully, es-
pecially if wo know little of ila cau«c UHimlly wo givv quinine,
mineial acids, and iron, internally. Besides the«e, votm baths con-
tintial pereeveringly arc to bo rcconunnudcd. A perfectly -regulated
?t, e^pocioily nutritious meats with good wine, is also ad\'issble.
iodividuftl furuncles are to be treated as above advised.
(o.) Car&unde and carötuictäoua tt^mmation (antÄrax) aoalom-
ically rcecmMofl a group of sovcnd furuncles lying dose togctber.
The whole process is more eitei>sive and intens«, more incUoed to
progress, so that other parts may be affcckxl by tbu extension of the in-
flanunalioo. Many carbuncles, like most boils, are originally a purely
local tUsfflue. Tlieir chief seat is tlie bard skin of the bock, especially
in elderly persons. Tbeir ongin and first stage are the same as in
5iruDcltf. But soon a number of whit« poiats form near each otber,
and tl>c swirling, rednc»), luid pftin, in the pcripliery, inerease in
some cases so much llial Om carbuncle may »ttain the »ize of a soup>
disb; aod, while tbu detuclimcnt of the while plui^ of ekiu goes ou
in the 0Gntn>, ifac prwMS not imfroqucntly extends in the pcripbeiy.
The detachment of gaogrenuus slineds is much greater In carbuncle
than in funiDcle, After the loss of the plugs of cutis, the skin ap-
pears pecforated like a sierc, but subsequently not unfrcquently sup-
purates, so that after a carbuncle a large cicatrix is alway-s left. But,
area when moat ioteDse, the process is almost always limited to the
■kin and sulxmtaneous cellular tiädiie; it is most rare for fasdiB and
■imcIgs to he destroyed, so that, wlieii a largo carbuncle is in the
252 ACUTE XÖS-TTUÜMAnc I.VFLAMHATIO?! OP BOFT TABTS.
Ticioitj of aa nrtenr, the danger of dcstrucüoa of the arterial walls
Is more apparent tfaao real, as is shown by experienoc. After the cs-
teosive tbrOMin^<dr of the cellular tissue, and tlic float »rrcütof the
process in the peripber>-, heoJUij aad usually very liuuriant gmauU-
tioDS (le^-vlop I healing goes on in the usual mauner, nnd in accooi»
plUhed to a time corresponding to tlie size of the grsnulnlitig- surface.
You will have ulrcudy nuticed that Uic prooeBs ot foruiiiUon oi
funinckis and carbuoclc« diflen from tlie iiitlammatinna with which
^u are alrea^ aot^uaiiited, by the constant ami peculiar deatb
of portions of skin; ami I hurc mtiiitionml that tins gnii^rcnc of the
akin, at first very small, is the primary and local cause of fumnclea
and carbunclea Of course, this must be induced by an early, per-
haps primary, occlusion of small art(.>rif«, possibly of the vaäcular
nct-work around the sebaceous glands, witliout our kuuwiog on what
final cnusu thi» Inttor dcpt-iid».
The course of tlic ordiiiiiry carbuncle uu the back is tedious and
painful, although it rarely causes death. But ther« are cnst^, especially
when the carbuncle or a difuue oarbunculoiia inftemmatlan oocun in
the bee or bead, whioh are accompanied by high fever and septic or,
as was formerly said, " typhous*' eyniptouis, and which pro\-e danger-
ous and nro even frenerally fatal (•:ArbiincuIus maligna, pustula mali^
na). All Rirbuuolcs of the &ee ar» nut of ibis malignant eharact^T}
some run the usual courBe, and only Icarc a disfiguring cieatrix ; but,
OS it is dilScult and often impossible to tell how the coec will turn
out, I would adrise you alwayB to bo pory eareful about the progno-
BiH. Unfortunal^ly, I have had surh sad 4>tperienpe in these rarlnin-
cles of the ioce, that in any aflevtion of tltu kind I am very Bulicitous
about the life of the piitient. Let me briefly narrate a caxc or tvm.
In a young, strong, healthy man, on » jouniey to BltÜu, from some
unknown cause a [miiiful swelling bc^n iti tlic lower lip ; it increased
rapidly, and soon spread to {he whole lip, while the patient became
voiy feverish. The surgeon who was called applied cataplasms, and
apparently undcrralued the noiulition of the patient., as he did not see
him for two days. The tliird day the faoo was greatly swollen and
the patient had a severe rhiU, nnd was quite delirious when brought
to the clinic. I found the lip <lark bluisb<red with numerous white gsn*
gienous patches in the skin. Several incisions were made at nnoe, the
wounds were dressed with chlorinc-wster, cataplasms applied, and a
bladder of ice placed on the head, as meuinfplLs was beginning. As
aooQ as I saw the patient, I dix'Iared his cnnditcon hopeless ; lie ftOOQ
foil info s deep stupor, and died twenty-four hours later, four diji
after tlie commencement of the carliunele on the lower Up. Cofoi^
tunatcly, an autopsy vaa refused. I will moilion anotlicr case: A
C.1BBUXCLE, VXUaSAXT POSTULEfiL
963
cati
■bed.
■um
adcnt in Zürich rwrived a surordcut on the led side of llie heiuL
Ite wouml ht.iiletl witliuut any lemiirknUe »^-mptoniH; but it was u
long wlu'lo before it closed entirely. For »omc time there wna a
Enullf opun u'ounc], which wus so slight that tli? j>mitfnt jxiid no at>
tcoUtm to it. Violent stnUniii^ while fencing, und pcrhups Bubsc-
qtiently catchtni? iv)ltl, may I'avt been the causes of the follonrinp
catn5(mphf>. (Jno momirij^ the young man awaken«! with Ootisid-
ble pain in tlic cicatrix, and a general feeling of iUncna; a iqbjt
!n93s and inodciatc eweUing of (bv scalp rendered an attack of
mplc er%-8ipclss CHjiitifi probable. But the fever ini^n-asecl in an
imusual maniRT, without the redness aprcnding over the liciid. Tliu
patient bad a chill, and became delirious. When on the third dity he
was brought to the hospital, in the ririnity of tbu cieatiix 1 found a
nutnherof sin»I] white upots, which showed me at once that there
«as tmrhunciilous inlhimmatiou ; as the piilitrnt was entirely uncon-
•eJooa, and toe scrcnü rensoni there was probnbly inflnmmntion of the
meninges of the brain, T had little hop» of a cure ; I gave the ne-
cessary directions, hut the iii^it day tlie pntii^nt was dead. Tlic
autopsy showed variou» white gangrenous points in the t»fl:imcd scalp
irix ; onseelcinjr fiirtlier,the neif^hboring veins were found pluji^jed
tfa clot*, and along thfm tl« cellular twsuc waa swoUcn and con-
iCd points of pu». Antoriyriy I could follow this c<w<iiti<«i of the
ii» as &r as th« orbit, but did not try to follow it farther, not wish-
ig to injure the eye. After opening tbc skull, as soon as the hrtuQ
•a rcinoTcd, wc found iti the left anterior cranial ft^iSHi a moderately
»pot about aa large aj» a dollar; the disease affected both tlte
dura »nd pia mater, and even entered llie brain-auhstance. Tlicrc
waa no doubt that the inflammatiou starting from tbe nt-atrix on ll>e
head had travelled «long a vein into the celhilar tisaue of the dibit,
00 through the optic fontmcu and etf]>erior orbital ßssure into
m
In many coses of malignant carbuncle of the faec, on cnrcfiil ex«
tion 'we shall find siieh an extciisioD of thu inltammnlion to the
ial cavity, and «instrqucnt discnse of the hniia. But 1 must re-
mind you that the extent of this inHammation as found in ti>e cadaver
IB not at all in proportion to the severity of the eonstjtutional symp-
toms, so that the latter arc by no means fully exphtincd by the poat-
fsrtfm Bppearnnves. Indeed, there are cases, and just the mo«t
lielily fatal one«, where death occuni without our being able to Bnd
any disease En the brain. Here there is full room for hypothesis; in
Uie rapid, violent course and tbc quick change of onrbuneutous in-
flammation to gniigrene we suspect a rapjaly-oceiirring deeompositioti
of the blood, of which the carbuncle itself may be either the cause or
204 ACCTK XOS-TRACJUnC IK KLAMM ATIOS OF SOFT PJJtTS.
result. But, oa the deconipusltian of the blood must liuve its cause,
it lins l^ccii sufipoftcd that an ioecct which haa atightcd uii 5umc> car>,
rioii, or oti the nose of a horse with gtandcr», or a cow with carbuit- '
oie, etc, ligbtti soon a/ter an a man and infects liiiii ; you will here-
aAcT Icurn thai malignant carljiiiic-lea result particularly from carbuu-
culoiu ciiLLlc-, 1 know of no cases where tliii» has been uctuiill;
obs(.*rv'('cl, but I du nut coiu>iilcr it impossiblo in rertuin caae^ ; this
suppositiun is supported bv the fact that these carbuncles are most
irequent on ports of the body which arc usually exposed. At oil
events, the high fever and fiital blood-infection afe mostly results of
tliu lucul diiu.'ase; bc-uce, wv itiu$t siipposu that in tbeae carbunclcts^
under circumstuicus which we do not exactly understand, peculiarly
intense poieons arc fonncd, whoec renbsorption into tlie blood causes
death. But the eauses of maligii&ut csTbundc am in moNt ca«cs en-
tirely olwwure. In diabetes melUtiifi and urseniia carbunck" occurs,
just as bugAt id obeerved in the urine of pcraou» othurwiKe healthy,
who hnre fumnelos and carbunolea ^ Üiese are enigmatical facts. Pot-
tunntely, cHrbuiieles are not fret]U<>nt; even «iinjile henig^iant earbun-
clos are so rare tliat jn the cxteiiaivc aiu^icnl poUcliuifi of Berlin,
where every year five or six thousand patients presented thentselvc«,
I only saw a carbuncle once in two years or so. In Zurich also thojr
were mre. Tlie iliagnont» of onlinary carbuncle is not diiucult, cspe<]
ciully after you have seen one; difluse carbunculous inllumuiation cmnJ
only bo rocogtiizcil after a period of observation ; at £r&t it resembles
erysipeluK.
The treatment of carbuncle mult be very cncrf^ctie, if wc would
prevent Uie ndpancc of Uie disease. As in all inflaminaltons disposed
to gangrene, numerous iiicülous «liould be made early, to permit the
escape of thir decomposed, putrid tissues and fluid». Hence in every
carbuncle you make largo crucial incisions, dividing the whole tLick-
npss of the cutis, und long enough to divide the infected sktn ek>ar
through 1o t]ie healthy. If tliis does not aufQcc, you add a few other
incisions, c«p«UIIy ■where from the white points you recogni2C gan-
grene of ibo skill. The bk'cdiiig from these incisions is piupurliou-
stely slight, as the bluod is coagulated in most of the vessels of the
carbuncle. In the iacisioos you place charpiu wet with chlocioc-water,
and renew it everj- twu or three hours; over this wnrm L-atsplasme
may be regularly a]ipUed to hasten suppuration by the moist wanatb. ■
If the continued wannth be not well borne, as in carbuncle of iLe
tiCick, where it may induce cerebral congestion, the cataplasms may b«
omitted and tlie antiseptiv dresKiiigs continued alone, or even cold
may be resorted to. If the tissue l>epns to detach, you dniiy pick off
the liaU-loofte tags with the forcc^is, and so try to keep th« wound a«
ACtrrS IXRAHUATION'S OP TOE IftCOUS UEMnR.O'SS. 3efl
BB poB&ible. Strong granulations will soon appear bere and
sre ; finally, tha Insl gbredfl are detached and a honovcombed granu-
ting wirfat-e U It'ft; tbls >oon smooths off, and 6iibiiC<[uenÜ}- cica-
farixett in the u»ual uiaiiucr, M> tbat it only require» a little oocüAiona]
sttanilalion (rttm nitmt(> of fiilrcr, liko other j^runulatisg surface. In
nmUgnaat cnrltuiid« tlir local treatini^iil is Uie same tliatwe liave just
described. Fur thv rapidly-oci.'UTriiig cvrubial <lisciM» tlii; only Ibiii^
wfl <-an do is tonppljrico 1o the bond. Inlcnially n-e usunllj give
qttinme, arids, and other antiseptic ruiniMliws. But I must nckiiowl-
tdge tluU the result« of this trentmnQt arc tcpt BÜ^ht, for !□ tnj own
experiettoe I do not know a cua« where it has suceeedcd in aborting
death when Heptiaemia wax at all developcsd ; this is tlie more depress-
ing', becaim! tliese malignant t»rbtiin:U'ft geiierwllj iitUck vt>iiiig, »trong
indindntls. Ercu if tho course be f-ivonible an rugurds life, there will
be eonridessblo loss of »kin and great di»fi<Ti]reiiiont, e«pecialljr in car-
banouloas inflammatioa of the eyelids or lips, as tbey arc raustljr de-
strojred by gaogrcDC Early incision, oxcisioD, and burning out of
the carbuncle, also have little eSi'ct un t]ie further course of the dis-
eaae, as I liave proved to myself in a few malignant eases. But do
not be dotcTTod, by these liopclees views of troatmcnt, imm making
cavly inciaioas, for cases occur where earhuneles on Ihe faeo run the
tisiial course after onmnieneing wilh high fever. Frcnd] surgeons
liaTC attained aouie good results by early buniiug out the maligoant
»QStulc.
i. AOl'TB l.NFLAMMATIOSS OF THE MUCOrS MKMItß.VNE.*.
I '
^B While trounuitic iuQatnuiatioi] of the miiooud membnin» prcccota
Bsothiog' peculiar, " aeutc ealarrh " or *' acute catarrlial inflanimatioa "
of tbeae membranes is a peculiar fonn of disciise which is Anatoiakmlly
characteii2«d by great hypcrtcuüa, ä>dcmatou5 ftwcUiog tad Croc seen-
tioo of afluid at unit serous and fiulMec|Ucntlynkuot>-purulent, und ia most
frequently caused by catching' cold or by infection. "Bleunonboea"
is aa increase of catarrh to such a degree thut quantities of pure pus
■IQ secreted. Catarrh uud blciiiiorrlnLra niiiy bt^'come eturmic. Simple
olwerTBtioa of exposed mucous membmnes affected with catarrh
shows that it may be very severe sod long continued, without tlie
mhgtnnoo of the ounnbrane suffering much; the aur&ce of the mem-
Iraae is hypenemic and swollen, somewhat think anil puffy ; in rare
cases tLere ore 8u|>erilcial loss of epithelium and small defects of sub-
tlnioe (catarrhal ulccn), but it is only in very raro cases that these
csDse more extensive destruction. Tliis obeeiration la suj)ported by
poal'tnortem examination and histological investigation, llie 0| union
now is, that there is only a rapid throwing off of the epilltclia] cell«
sc« ACUTE KON-TRAriLinc IN'FLaMMATION OP SOFT PASTä
whk-li ftpprouch llic surfiioc aa pusK^elb, «nd tliat tbe connect) rotü-
suc InyiT nf the mucoiw membmiie tnUe« no part in Ibe process. Al-
though many utUinpts lutwi hvvn inxile to find »egregytioD of the
ccUs in tbc deeper cpitbcliu] lajen dT mucous mvoiliranca affected with
catarrh, Ihoy wc«? unRiicwssfol tili Rtmnk; B^iMy und RiM^eiteh,
disc-ovLTctl lurgt! motlipr-oells in the vpitliDÜal laj-eni uf tuob tnem-
bnuics.
Pis. B.
€>
BttlUinlUl bf«Tuf B ('(n^unctlm adeued with eaujib <sRcr J?fii4M«M). JUgAlftfd 400iUM»
«Bf».
Tt was most natural to frxpluin this olisen'ation bj assuming diat
Üie mnther-cpIU were fonncd by cndo^nioua si-^fgiition of tbc pro-
toplasiii, »1x1 siihsm^ncntlv turnt^d out tlicir broods (us po^oeTIa).
Since, in opposition to tili» vi«w, it wns rüppatwily eliowu that, if
this were Ütc t»Sf^ the inottirr-ct-lls sliuuM alivaya bo found on cat«^
thai mucous mentbrnno«, while thoy were found only at first and
then in small numbers, of lal«, llicv have been explained quite dit
fercntly. Äte«f?«Bffrand TW^-ww/nn first advancfid the idea that the
young cells do not form in the older ones, but tlint, iin<ler certain m»-
chanically favorable influences, the Utter may enter from wititout, but
liHTC notbiii|f to do with tlif; origin of tho catarrh. AlUioug^li this
view is very difficult to prove, nftor much consideration nod weiffliiag
of known facts, I consider it oh very pmliahle. Tliis Is not tbc plac«
to go into details on the mutter, but, since it has been provLHl by the
cinnabar method th&t the white blood-cells c»eapc from the TC«&els of
the iuQanietl mucous uietnlimiie, and not only wtrnder tietween the
cjüthclium, but are iiI»o fouml us ptis-cells in the catarrbiil secretion,
I should think catarrhal piM bad the enmc origin as other pus, vix.,
that it came directly from llie blrxxl. ßetiides catarrhal in flamm tttion,
mucous mcnibratea arc also subject to rroupmia and diphlltftitie in-
Simmations. Wlien, in iullamuiutlon of a mucous mcinbrune, the prod-
ucti of inflammation (oella and transudation) appearing on th« sur^
PULEGMOS'Ul'S IN'FLAUMATrON.
ae?
Ciico &xm fibriuo, uiid thus Ixxotnc a membrane cliiiging lo tbo siu-ruc«,
wbicb iiAcr n tunc dissolves into iniicom and pus, or is liflvd up by
pus whJcli is produced behind it from tli« muoous mvmbraoc, ire call
it a "croupous inilamnialioa;" the mucoua meiiibtuiiä And its epithe-
lium toeantinic n.'^main iiitAct^ tlie {mri« are perft.-ct]y restorciL Diplt-
theria is cxMctly »imilurtu tliu nbovv pnKCW, but the fibiinou» layer
is nul only attüdutl moiv firmly to Ihu tttfiue, but tlie aerum pe^-
ineatiiig tttc substuncu of tbu incmbrant: cougvlates; the circulatioo is
thoB impsirod so much tlutt cx^caaioaidly thi: affected part becuriies l>d-
litely gangreuous. In diphtbcriii, the diaintrgratirju nnd gtkn^^no
■rv prominent Bynipttnus ; tbey probably de]>eiid on very rapid devel-
opment ofgcnns of fiinp und iiifusoriu iu tbu dipliihcritic mcmbntno.
Wtctlior thcso fungoiis j^rm« ut\\ as nmny Buppose, tho causc of
(lipbtberia, at presfiit n>iiuiinx doubtful. The güHeral iiffGctioii, the
I fever, rosy be voy scTen? iii cxtcDSiTc croupous infUmniaiion {as in
tlie fine bronchi and alveoli of tlio lungs, croupous pneumonia), but in
diphtheria it is of a more septic (.'taract«r ; the hitter diseo.-^^ i» f»r
tbc most maligniiiit, Tlie mucous nißuihrano of Um ]>liiiryii]i und
tnwbctt ifl often exposed to both forms of tbc iU$OiJi»o. CuturrbiU con-
jUDcUvitis, which i« »o very common, may become diplithcritii^, but
nirely suffers &om rroiip. Tli« mucoua nietiibrane of tlii; intcstin&I
eaaid ta seldom tbc seat of thctje diseases, tbc Aomv is true of the mu-
cous membrane of tbu goiiituls, ulnoh ure so often »fleeted with oon-
tagioits blennorrhixa (clap, gonorrlicra).
ÄCUTB IKFLAMMATIOS- OF THE CELtFLAB TIBSCE.
tSFXA«MATtOK.
PHLEGMOSODS
r
■ This term is pleuiiastio, for ^ <pXtyitövt} means iuQamiiuitioti, but
Hpraotically it is so excbiRJvely applied to hitlammation of the cel-
Hlular liffiue tending to «uppiiratinn, that every surgeon knnw» what
Hit means; another name for tlw same disease is pfudo-erytipt-
V Im ; it ia juat as much us(>d, but seems lo me less diBtinoLire. Tbo
Bcausea of this Inäainination are in many cases very obscure ; a scveru
cold can rarely be pmvcd to bo Uic cause; frequently theec in-
IBammntions might result frotn infection, creu if the cuti« bo irnio-
JQRxl, hut this is only hypothesis ; we lisve already seen these pro-
greadvc acute inflannnationa as a complication in injuries, espceJally
IS & residt of local infection from mortifying fbreds itT tissue in con-
tusions and eontiLied womids. Spontaneous inllammation of the cel-
lular tissue is most frequent in the extremities, morn frequent above
than below the fosciic, especially prone to affect ihv tingers and hand ;
bi>rc it is called [mnaritiiim (corrupted from paionychLi, inllammation
around the nnil, from 5vti nail), and to distinguiiUi it from deeper
248 ACPTE XOS-TEAHMAnC INFLAHUATIOK OP SOFT PARlft
inllammsUon« «lao oocurriog- in the fingers nod hand, panaritium gah-
cutaneura. If llie inflaminatit^iii alTocrt tlio riciiiity of the nail, nr the
i)ail-be<l itsL'tr, it is tcrmi-d paDBritiiun sub ungue. Let lu flrat con-
sider tlic symjitoma of pbtc^tnon vi the forearm : It bcKtos *ith
palrL, KnHlirig, unci rcHlii^fis of thi> skiu, uiid usutDj' witli hif^li r<>ver;
iliG skill i>f the ann is somewhat ».-d cm a to us and wry ttrnsf. With
this oommciimReiil, wliii-h always sDitounccs an acute iaflammaticn)
of the arm, its swat mny vary greatly, and in llie first day or two ytm
ma^ be imable to decidt; whether it is a atse of inilniamation of the
ftubcutntieoiis cellular tissue, of perimutwuUr iiiflammalioQ below the
fiucifl, or «rcn »f pcrinatitU or notitis. Tlie (greater the (Edema, tha,
more rocutiilerablt! the paiti. the les-o the re(]iie»i{^ of Hkiit, and tlie lefts
iiiteiisc the fever, the more probably you hare to aulici|Mte a deep-
seated itiHmnreation whicH will terminntc in snppuration. If the io»
äsmm.tlioii attackfi only thL' 8ub(nitati(.-ous ci-llular li^ue, and goes oftl
to Buppiiratioii, as it docs in most cases (though resolution is seen),
this crinces itself in a few days by the skin boooming rod at sooifl
point, and distinct fluctuation oocurring. Then the pua either per-
fbttttea nponlnneously, or is let out by nn incision. If the inflanim»-
tion affect parts of the body where the »kin, iind especially the e|ü-'
(lennix, i» purtioularly thick, as in the InimlS' and fiwt, there U iit first
little perceptible redness, as it would be hidden by the thick layer of
cpidcnnifl, Paiu, nnd a {x^culinr tension and throbbing in the inSamcfl
part, aanount^Q the formation of pua under the skin.
tn some uf these cjisc» a portion of the skin becomes gangretKKln,
tlio circulation being disturbed by the tension of llie tiaaue, part of
tbo skin loses its vitality. The fasciie also are occaaioitnlly threat-
ened by these inllammationa; in such cases they come tJirougli the
openings of the cutis as large, vliite, consistent, thready taga. Thi«
is parti<ru1arly the case in inflam mat inns of the scnlp, which not tm-
fretjiientJy extend over the emire skull ; the wlwle galea aiM>»eiirotica
may thus be lost,
Ix^t ua now jrntt to the more miimte anatomicnl changes that taVft
place ia acute inflaiiunation of the eclluhu- tissue; we shall not hoe
rOioni to the dispute as to whether vessels, tissue«, or ncrrcfl, are lirat^
■ffii^ctod, but shall only^pesk of what wo can find on direct anatomical*
exaininutiun. A series of observations on the cadaver, inhere in rarious
coses wo sec inflammation iit different stages, gives us nufllnleut Inforv
mation on this subject, Tlic first things we find aretlistention of Hxt
capillaries and swelling of the tissue by somiLs oxudalion from the
vessels, and n rich, pla-stio infiltnition, varying with the stage, t e.,
the eonnentivc tissue is filled with quantitiea of young, round oelll.
Tliiif theo, is the anntomicAl condition of tlio ocllular tissue under the
I'UUEOHOSOUS ISIXAUWATIOS.
369
m
oedeoMtous, reddenedf painful skin; subst-qiipntlj the collection of
cells in Ui« itiB*med oonnoctire tiMiic and f«t becomes more promi-
DeoL Tbosa täasitec b«x>mL> iouhp, nnJ tlicn.* is sts^iutiun of blood
io tbo TCSBels »t Tarious points, f?pL-c-inlly in the capilliiri» nnd ruins ;
Bt sDcnc places the circulation cca«c8 cntiroly. Tbis aUgiiatioa of tbo
bk^id, wliiL-li at finsl catisos a dark-blue color, and then Mhitenesa from
tbc npid discoloration of llic n;il Itlootl-cclU, mny <rxL<^n<1 so far as to
<maet extensive gan^^ne of the linue,a result u-hicli we bvre ulre»dj
ineDtioaed. Uut in most cmsp& ih'm does not occur, but while tlie cells
{ncTease, tlw> (ibriltar iiiterrvllular BubKlancc disa|>|x-are, jmrtlv bj tlic
dokth of small btgs and parlick-8, pattl/ hy graduallj becoming gclat-
tDOUfi, and liiinlly cliangiiig tu fluid pus.
As the infUramatioQ progrcssos tbc entire in6sincd part is finally
tluutj>cd to pu^ tlwt is, to fluid tissue, conaisUag of cells with »omc
Eerous inl4?rceUubir fluid whicli ia mixol with slireds of dr^ad tisaoff.
It the pnxe« goea on in the aubcutancous oelhilar tissue-, extending
in all directions (most rapidly where the tissue is most ^'ascular and
richest in cells), the purulent destruction of tissue or sufipuntioa
«ill ext<>i>d to tbr cutis from within, perforate it at wane point, and
:irough ibis perforation th« ]>U6 will escajie outwardly; when this
occoTSf the proeeM often ceases to extend. Tlie tissue siurounding
the purulent collection ix tilled with cells and very vascular; nnalomi*
cbUj it doficly re-scmblca a Knuiulaling sur^cc (without any distinct
pvDulations) lining the whole canty. W^en tlic piu is all eractiatod,
the «alls come together and usually unite quickly. The plastic itifii-
tiatlon rontinuea for a time, causing the akin to remain ßmicr nnd
tDOre rigid limn usual. But, by disiiiU'jrration and r^absorption of tbc
infiltiatingenlls,and transfonnation of the connective-tissue substance,
this state also returns to the normal.
Vou will readily perceive that, anatomically, the process is much
tbe same whether it be diffuse or circumscribed ; ibe finer changes of
tissue in the two arc just tite soine. But in practice we distinguish
between purulent it^Uration and a**?«*. The first expressioii ex-
pLuDS itceif: by an abaoeu we tuually understand a circumscribed
ooUection of pus, excluding furllir-r progneae of the inilanimation ;
tlMM ibnnii^ rapidly, from acute iaHamatation, are called ncttt« or
hoi abaeette*, in contmditttinction to cold a&w««am, or tbose due to
shraoic inflammation. Tbc following figure (Fig. &6) iiuiy render tbe
fotawtion of abscess more clear to you.
I You here see how tlio young cells gnidimlly collect nt ilw points
«there the eonnoctivc-tissuo coqjusclcs lay, while intenncdiate »ub-
stSDM coostantly decreases, and bow in tbe middle of the drawing, ia
the eentre of the infiamed spot, tbe gtoups of cells unite and f(>nn a
ruLEuuoyous lvflaumation.
9Y1
infiaiDinatioo, the fat-oelb being compressed hy Iho new ocll-maesea,
ami iIm< fat beooming tluid ; subsequent!}', it is OGcasionally found ia
tlic stutpt; of oil-dro{)8 iiiised with Ük pus. In tliis pnT)uinttit>ii yau
may see the microticopic upp«aniiioe iii indamniutioQ of the cellular
membniiKr.
In examining such preparations we not unüvquciitlj fiiiJ filanumts
of coagulated fibrinc iutUiratcd iu the tissue ; possiblj it is fonucd ut
the commence niont uf the inllamnmtiuit, us previuiisty di-scHbt-d ; but
it ii also posüible tliat these liUmciits appertain only to the fulljr-
fiamwd pua — possibly they are produced by Uie alcohol.
I must call your attention to the lact that, until the process ia
arrested, we always huvt^ a prognuive aoflening of the ti»m»e, or flu]v
puntion, ill wliioh it dtETera from a developed gra.uutaliii]g surfaoe,
which only fontu pus on its aurfac«. All suppurative pareiicliymntous
inflammation» bax-e a destructive or deleteriuu« action on the ti^Hue.
As rcjcards the relation of the blood -vcsscln to llic new formation
of U>o young tissue an<l it« speedy digintcgrution, it lias already been
stated that they are at Gret dilated, and thim the blood stagnates in
tbetn ; if the circulalion be cnttrrly arrested in certain pi^rtJona of
time, in which case the coagiiUtion iti the veins ooL-osiooally extends
> eonsidemble distanoe, tha walls of the ve&sel» and tlie rh>i ituppi>>
Ltc, or fall into shreds, ua fur as the border where the circulation
i(ar1l|cU]lrlii>ct«d)c^i1t«>ntn>or4n kSt«** {hot IvtJ biv-n )n4a<:«it In tha KmKaeoT
adiDic. UivnutudlidlMaMen.
19
S7a ACÜTB SON-THAÜMATIC IKrtAVlIIATIOH OF SOFT PAETa
begins again. As we have already seen when studjiiijc th« detach j
ment of necroaed shredfl of tissue, Ta»cular Icops tuuat torax on
border of the living tisgue ; that i&, the whole inner suHooe of atrJl
absoeas, ia the amngeitients of its veaseU, ta artalogous to • graouU— ■** I
ting surijicu folded up tsuc-Iikc.
Ill rogard to Üio IjrniphKttc vessels, we may ooDdude ftom aiuJc
that hcK, as in tho Ticiuitjr of wounds, they are closed by tbe inQam-
znatory neoplasia ; special iuvceligatioiu ou this lubjvct wuuld
xeiy desirable. So goon and so loi>g as an alwcuis i» surrounded by
a Tigorous layi^r of tissue infUtratcd nitti jiliutic nutter, for trasons
already mentioned thcro will be no reabsorption of purulent or putrid
Buhstances from the cavity of tbe absceee. I can give you praetioal
evidence of this, if in the rlinic ^ou will smell pus from an abacest
near the rectum or In tliu mouth ; tliis pus has au exceedingly peoe»
trating, putrid odor, still is not reabsorbed by the walls of tlie Tcios,
or is 8U to only h vltj- sltght extent ; syiitpluiits of grnrTal strpsis very
mrcly oocur. But at the commcnct-mcnt of iuflaEnnrntion, and later,
vhen it is acromponiol by rapid destruction of tissue, as vrcH *a in
some progre&sive iaflammalions around contused woumlH, and in
phlegmonotia infiamtnatioa of ttic cellular tissue, etc., if the lympbtttto
vessels are not yet stopped by ccll-fomiatiot», organized indaomtatory
new formation docs not occur, or comce on late as the guigrenona
destruction is being bounded ; Uicd the dccompoaing tissue enters
the open lymplmtin and acta as a fcnneut in the blootl, causing CaYer,
Although inöummation of the «.-UulBr tissue (eeUulhis) may oeeur
at any part of the bcxly, it is most frequent in Uie hand, foiream,kne^
foot, and leg. It is often accompanied, and, when extending, preceded,
by lymphan^lis, uf which we shall spo-ak ainotig the aocidonto] tnMt-
matic diaeaspH.
Tlie intensity* and duraiion of the fever, acoomponjing tbcao in«
fiammntions, depend on the quantity and quality of the material re-
nbm>[l>ed. At fintt a quantity of these matters is thrown into tho
blood at once, hcuc« at tlic onset there b usually high fcrer, aoin&>
times eliill; as the inflammation progresses, tho fever continue*; it
ceases when further absorption of the infiammatury product is errest-
od by the above changes of tissue, when the process stops and tfae
abscess is fonncd. The fjuality of the iiLflummatory material formed
in cellular inOsmmation certainly varies groitly ; for inst&iiee, in sone
eases deep in tlio neck in old people there is auch latcose paiaomng
that tlie patients die without oUier sjmptonu. It is here the same
as in carbuncle — some cases cause little fever, others prrNliine fatal
septic fever. If apMeginon be due to a dangerous poison, such as that
of glanders, we do not wonder at tlie fatal termination ; but for tbe
Pni,BGM0S0U3 DiFLAKKATIOS.
S7S
itaneoua casp» it oHea seems rcr^ stma^ nrlir aonie sliould be mi
' oerere, wliile moet of tliem are rdntively mil J.
Tlie progiKMis of phlegmonoiis iiifl&miiiatiniift viirios immoaadj
ritli the location, extent, «ntl cmuki^. While thv dtBease, oocurcing aa
» mctaatoas in s frencnü plilogistio or «uppuratiro diathesis, or ia
^loders, giv«« little hopes of euro, wlnlc clcL>ply-fieat«d nlieeesees ia
tbe walls of the alHtoroen or in the pelvis are very slow in tbeir course
•ihI any prorc dan^fcrous from tlic lot;alitv, or, hy destnjction of la»-
ciff, t«niloD8, and skin, mxy impair the functions, moat äues of phle^
Dioa on the ünf^rK, hnnd, frircann, etc, are onljr moderate diaeaaea of
abort diimtion, nlthou^li v<.'r^' piiinfiil. The socfikt suppuratiou occurs
id tlie moro ci«:um»cribed th« inflnmmiition, the better the prognotis.
Aa i^ards the trtotment, at tliu <;(>inmt!iicL'mi>Dt uf the dUvaxs its
|ia to arrrst the dci'L-lopmcnt of the disease if possible, that is, to
the catrlio«! p>o$«ibli; rcabsorplion of the eeroue and plastic Id-
filtratkni. For this jiuqwee there are vHrioua remedies: first, the ex-
ternal use of mereurr; the inflamed part may he »mcjired with nier>
cutial ointment, the patient placed in bed, und Uie itiiluincd extremity
envcIo]Wd in warm, iiioi»t clot)» or litrgc catapliisins. Ice ako maj
be nnploj'ed at first, if tlie whole iiiKamed part can be eovereil with
cercisl bladders of ice Oraiprcsaloa by adhefiire plaster and band-
ages is also a very effectire remedy for aidinif absorption, but it is
little iMed in Uiftse inllamiittttionx, partly beeaiis« of the pain It cause«
Id sucb eases, partly bet-nu»» the renietly t» not free from danger, as
gnngreoc mny be easily induoed by o littic too much pressure. If the
process be not motiemted soon after the employment uf tlie ubove
remedies, but nil the sjinptoms increase, we must giro up the hope of
resolution, and resort to remedies to husten the suppuration which we
cannot avert ; the ehief of these is the appUeation of moist warmth,
espedally in the shape of rataplasms. Then, as soon as fluctuation is
detected at any point, we do not usually leave the |)erforaUon to Na-
ture, but diridc the skin to givo vent to the matter; if the suppamlion
extends under the skin, vre make several openings, at least I prefer
this to one very large incision, from tfao dbow to the luind for instance,
because in tbe latter the skin gapes wi«lely, and takes n long time to
beaL If the pus escapes naturally from the openings, great cleanliness
is the only thing nccrsMiry; this is greatly assisted fay local warm
iBtha.
While it is n very simple thing to open subcutaneous abscesses,
"oncolomy*" of deep abecessc» require« great attention to the anato-
^^Biy of tlie locabty: for instance, the dtagnnnis may be very difficult in
^Ht^ipitrations deep in the ru'ck, in the pelvis, in the alxlominal wall,
' etc., and can only be certainly made after a long period of obaerratioD ;
274 ACUTE SÖN-TRAÜHATIC WFLAHMAnOS OP SOFT PiBTfi.
still, pnrtij for tlie relief of Uie pntient, partly to avfüd * epooUDeout
opening iiito tli« alxloiTicn, purhnps il ma^ be desirable to eracuat«
the pua early. In such casmi we must nut piling il bistoiinr boldlj
in, but dis&cct up layer afUtr layer, till wc reach the Suctualing^ cxtvcr-
ing of the absccsa; then introduce a prubv carefullj-, uiid dilat« tlw
opening bj exti^niling- tlic hladoii of forceps introduced into it, so «5 to
avoid hnHnorrliii^ froia the deeper part.». Occasionally dcc>o^lp(^
wtJoo of th« ptis in an absocta cauaos so much gas as to give rise
tu a tympanitic pi?rcu8sio)i*sound ; after Uein^ openeil, these ]iutrlil
■bscesscs should he ajringod out and dreuud with chlorine- water.
4. ACUTE INFI,AM)IAT[OS OF THE MtrSCLFÄ.
Idiopathic acute intlaTninntion of muscTiIar substanoc is reW
tirely rate. It ooctus in the mugrleü of the tongue, in the paoaa,
pectoral, and gluteal muscles, and in thnsn of tlic ihigh and calf
of the leg; the usual termiuati;>n is in absocss, although resolution
lias Iwen obHervetL Metastatic muscular abscesses are very frequent
in ghiiiders. Regarding tli« »(lecial blatologtoal omuliUo«!», the io*
tCistitial counuctive tissue of the muscles, the perimyi>ium is here,
as iu traumatioviyoiulis, the chief scat of the puridcnt iufiUration;
from the very acutt; disease, the nuclei of the muscular Blanients
are destroyed, with the contractile auhatance and the sarcolemnia ;
only on the etunips of the mua^rular tiUments in l)ie capsule of
tlie abaceK» do we and the muscular nuclei (iniueuliu' eorpusclos)
in group« aiul adherent to the cicatrix; iu auch cases, oooording to O.
Weber, there is n cousiderable new formation of young muficl^^ellft.
The symptoms of an ahseess bi llio muscle are the same a» those of
any deep abeccsa; their periods of development and pcrfontioD rary
with their size and extent. In many cases there is contraction of the
musclea in w))o»e substance the absceu develo))«, as in psoitix. I shall
not discuss whether this in the physiulugtcal rcsidt of the inflammatory
irritation, or whetliur it is half voluntary, and luadc instinctively by
the patient, but am rather incltm-d tu the latter view, fur io small
and not very piiinful abaceascs and iu tTuumatic inflammations of tko
niudfiS, there is usually no contraction, but this occurs only iu largo ab-
scesses, whidi are compressed by strong £aacia>. Abscesses in muscles
sltould bo opcnoil as soon ils fluctuation is felt, and the diagnosis
f«rtain.
A very peculiar form of disease of the ma<cW, which, according to
my view, »lionld be clitMt-d among subcutaneous inflammstioas, has
been recently discovered and described by Zenker; it oocurs ohicUy In
typhoid fever, in tlic adductor muscles of the thigh ; in it the contrao-
INFLAUUATIOH OP TOR SHKATHR OF TKNDONS.
278
tile kabstancc in tbc saroolcmma crumbles and is graduaDy absotbcdf
wliilo new miiseiiliir (tlaments fonn to replace the old. Tiiiu, in most
cue», the pnrts arc fully n-stornl; in other caaea permanent atrophy
of the muEclc rcmaias, llicrc is do acxnirate knonled^ as tovbether
this disease may load to suppuration, although abeceeses ot the ab-
donunal mwiclrs have be<!n ob«urrved alter typhus.
«. ACTTTE INFLAMMATION OF THE SHEATHS OK TENDONS AN» SUD-
CUTANEUl'S UCCOL'S Bl'ES^ iSKKUl'S UEUJtIUNES).
^^8 IB w^ (cnowD, the tsheaths of tendons form abut nica, whioh
oae some of the tendons of the bands and feet. Tbej may be-
e aoulcly inftamiMl from contusion, and in some few «Utes also
•pontaneotudy. Like all acutely-inflamed serous memtmtues, these
sacs at (ifAt exude a quantity of fibtinous scrum; recent Gbrinoua
pseudo-membrnnfs composi»d of wandering cclU may again disaolTC,
but they may nUo indince t«niporAr|r or permanmit ndbesioiw of the
shcatb to the tendon; Itutly, there t& not unfrequcntly suppun^
tioD of the membrane, and at this time the tcrdoo may become
TiPoroscd. Pain on mution and slight sn'ollinrf are thr> tirst ÜgOM
^^of sueli inflnnimatioQ ; ocoasionally there is friction-sound, n grating
^■b ibe sboftth of the tendon, which m«j be perceived bj the liaod,
^Rr, still better, by tlie ear. Thl) noiae is due to the »urfaoes of
^Pfae tendoQ and of iia sheath having become rough from deposits of
fihrinc and rubbing agnin»t each other, when tbc tendons are moved;
this fonn of subeutancous inäammalion is most common on the back
of tlte liand, and almost always terminates in resolution. The rery
acute iuftammations of the sheittliH of the tendons, arising from tin-
known causes and going on to suppuration, arc rare ; they begin like
an acute phlegmon ; the subcuLatieous cellular tissue quickly partici-
pates in the inflammation ; the limb hwcIIs gmitir, und the arljacent
finger or wrist-joint may be drawn into the inflammation. F>ikc the
synovial membrane of the joints, that of tJie tendinous sheatlis occa-
sionally SGctns to furnish products that intensely afieci the surroitad-
ing parts. If, under suitable treatment, the disease docs not go oo to
sufipuration, or, if this be only partial, resolution slowly oecun ; the
limb remains stilT a long while; tlie adhesions between the tendon
and its thcath do not break down till after months of use. If there b«
«itentive suppuration of the sheaths of the tendoa (wbicli, in the hand,
fcas been tenned " panaritium tendiiiosum^), the tendons usually be-
come ncerosed, and uAer a time may be drawn out of the abecess
openings as white threads and shreds ; the membrane then dcgeoer-
itca to spongy granulations. If the process be now arrest«!, one or
noro fingers will be stiff, and remain so for Ufc. If the joints be nlao
2T6 ACDTfi KOKTRAÜIUTIÜ LSFLAIUIATION OF SOFT PABTS.
«ttackcci in the fingets, there may be recovery with knohylosis ; but, if
Iho wrixt or Knicle-joint be aOected, its existence will be fn^atly endao>
gored. Id unite suppunitire inflinnnifitioii uf i\ic tviidiiiDus tthcatlu^
the /ciw is occaaionftUy slight ni first, but in severe ca»c8 the diseoi
may begin with a chill. Tliu furibi^r tbo iuflammation atiil suppuration
exlcnd, the leas the proocss tends to formation uf an abaccss, the more
coutiuued the fever becomes, aod it aseumca a distioctly rewittent
form ; at Ui« name time the patients an»? rapidly pull»! dowTi ; in n few
weeks th« strongest men emaciate to akciotons. The prngriosiB is
bad wbcn the fvrer niits oa wiUi iutermitleut attacks aud diiila.
Tho trtatment of »ubcutaneou«, crepitating iiitlnininatioiu of tlie
shoaths of the tvnduiia coiiftista in keeiting the part quiet on a Bpliut,
SDd painting it with tincture of iodine ; if this dors not afford epccdy
relief, a blister may be applied; under this treatment I have always
seen this fnnn of indammation disappear \a a lew days. If the aymp*
toms are sevBre from tlie fintt, qitietof the part h the first rv-i^uisite;
this should be aeoonded by mcrounal oiatin«ntnud bladdcia of ice.
This trcatmont should be penistently pursued ; in the«e cases I de-
adedlj prefer it to cataplasms and local wann baths, which are rery
ooaunoa. If nbM'eara form, ind^ione and plenty of oounteropeniags
ebould be made ; in these casea drainagifvtiibes are very useful, because
the granulations projecting from tlie openings often obstniet tlie
escape of the pus. If the suppuration will not stop, if the spongy
Bwclling of the limb continues, if crepitation appears in th« joint be-
tween Üic bont-s of tlie wri»t (showing that tlie <'artilBginou8 ooreriogs
hare suppurated), and if tliu patient oontioues to sink, there is little
liopc of a termination in anohyloaia of the band, but tbc danger to
life ia so great tliat amputation of the forearm should be made ; the
jmtient may thus escape with his life, and will soon recover hia
atrt'ogth.
Acute inflammations of the »ubeutaneoti» mucoHt bitrtce are less
dangerous ; the buiva pnppatL'Uaris and auconiia are moat frequently
aficcled cither from injury or spontaneously ; they are connected
neither with the joint nor with the ebeaths of the tendons ; they be-
come painful, fill with fibrinous serum, the skin reddens, and the cel-
lular ti.<wue ill the vicinity participates in the inflammation; buC 8ui>-
puration rarely occurs if the patient is treated early. The reinedica
are mercuiial ointment or tincture of iodine, keejMUg tlie limb quiet,
and compressing tli<j swollen buisa by applying wet bandageiL
Puncture is unnecessary, anil may be in jurioua, from being followed by
•uppuntioa and a tedioua suppurating h&tula.
CHAPTER Xi.
WTE IXFLAl^mATIOTiS OF TITE BONES, PETi}
OSTEUM, ÄXD JOINTS.
LECTURE XXII.
'AMiaiy.— JltBta PcriMtitU and Oncorarditi* of Uie Lonff Boom: SjTsptama, T«ir-
MlnatHina in )t<M>tuli«ii, Suppiir«tk.n, Kk^toiLi, Piwpmwi», TrvaLmont.— AeoU
Ostitii IB E[>an^ Uauo*. — Aoato InSaiDinAli«na of th« Joint«. — }l]pdr«p« Acutu ;
Bfiaf tocD*, TroatiBMkt.— Amito Suppanliro InSuntDttioiiB or JoiiiU: ä/mpt«na>,
Coarse. Trvatnent, Anatongr. — Acute Articular Khcuinftliam.— Aitkritia. — MaU*-
titio laiuuoi4tias* of JoiuU (Qoaoirhu«!, I'jcmic, l^uorpcnl).
TnR perioittoum nnd th« bones are pM'stiolof^caltj so intimat«lj
leomiect«! that disease of on« gorienllj KfTeote the otiier; altlifMigli,
'In spite of this, 7c art.-, for practical reasons, oblijj^ to oonsidcr acuto
sod dironic inftamniation of tlio pprioetcum and of bone scpuniMj,
BtJll we »liall often have to refer to their connection. I must here make
a few prcHmiiuuy anatomical remarks, as thrj* arc important for the
comprebension of th« following process : ^Vhen speaking briefly of
the periosK'ura, we uKuallj' mean, simply, the white, glistening, thiQ
niemhraae, poor in veAsel^, whicli irnmcdtabelj surmtintln tli« bonp. I
TOtut here remark that this representa onir a part of the periosteum
tliat is patholo^oally of little relative iniportanoe. Upon this juit-
(lescribed inner la^-er of the ])eriosfcum lies, nt points where no ten-
dons or ligament« are in»ert«d, a. layer of loose cellular tiiuue, which
U also to be oondilcrod as periostctun, and in which principally lie tlio
Teasels that enter the bone. This outer Injtr of pcritfcteum is tho
noct Crequeat «eat of primary inflammatioi», eitJicr acut« or chronic;
the tooBO oclliilur tissue uf whioli tliis layer consists is very rich in
cells and vessels, hence more inclined to inflanunation than ia the ten-
dinous portion, poor in cells and vessels, which lies imntediatcly on
the bone: As to nutrient vessels, especially in the long bones, the
epiphyses have their own supply, which, sa long as the epiphyseal oar>
a7S -ACUTE nfFLA.MM\TtOSS OF TOE BO*fES. PER10STBÜM. ETC.
tilagM contiaue, do not communicate with tbc vcfiecls of the dinpbj
vhieh iuvvc tbeir own nutrient art<>riea. This distribution of the
seb ex[>Iiiiii8 wli/ diseast!» nf tlie diaphj'üfs in ^oung pcr^nnii rarelj
puMt to the cpipbj'SL-s and tbc nrvcr^t'. Genetically tlic urliculitr cnf
Bule is n continual ion of the porioNteum, nnd a certain connection
often observed between jirticniUr and [wriosteal dineise», the di8/?af
of one rradily passinj; to the othL-r. In tbc course of tlic fullowiq^r
obsecmtioiis we oball haTe occasion to recur to tbese ftnstomic&l ooiH
ditions.
Firet, let iu speak of acute ptrioatitia nod otitomydUia, of trhidi
you bare «Ircadv beard something in the rematlcs on suppunatk»
of bon« ill the ohnpter on open frnotures (p. 201). T!üs disease
is nob very frequent; it occurs chiefly in young- person«, and in its
i^rpical forms nlmoat exclusively in the lung bones. Tlie femur Ü.
most frequently atlackisl, next tho liliiii,niore rurcly the hiititcnis ntitfl
boDcs of thf. forearm. I Imre &i:en the- disense occur primarily crj
secondarily in the vicinity of acutclr-inSumed joints^« ftftcr eatchiof
cold, and afbu- sevfire concussions and ootitusiuiis of tlie bones. It la
poMiibl« tliat the extmvaitalion into the medulla from ciMshing nr coa*i
tuüon of a bone mny be reabsorbed, without the ofcunvnce of »ny
Symptom but a continued pain ns the ro»idt nf tJie injury* but sueb
injuries may oceadonally induce elironie ufTcctions of various Bort&
In many case» we cannot discover wlictlicr oiiiy the periosteum or
Ü1C medulla of the bone ia affected ; the distinction is usiLiIly only ren-
dered certJiin by tlie sub^equcitt course and by the tenniaation. Ite
Symptoms oreasfollows: The disease begins with high fever, not uo-
frwjiiently with a chill ; there is K-vcrc pain in the »fleeted hmh, which
«wells at firnt without redness. The severe pain prcvenis motion of
tbo limb; every touch or the slightest jarring is veiy painful; the
skin is tcnec, usually ardeniutotis, und occasionally the distended nib-
cutaneous veins shüw thruu^li, a sign that the flow of blond to the
docpcr ports is obstructed. The iiitlumnialion may affect the whole
or only part of a bone. But these symptoms sinipty indicate tlto ex-
isttince of an intense deep1y.seat4.>d acute intiaiunmtton. But as idio-
pathic inflammation of x'he perimusculnr and peritendinous oeltulnr«
tissue is very unfretiueJil, and, rarely begins with so mud) pain, wo
•boll not err in mo.<it eases if, with the atxive Symptoms, we diagnosti*
cat« acute periostil is, perhaps ar>:ompanie<l by osteomyelitis. If, wlitW
there are great pain und fever, or coiiipleto inubtlity to move the lirab
on account of pain, swelling doe« not occur for several dayn,, vpa may
suspect that the primary sest of llie inflammation is the medullaiy
cavity of the bone, and that at ßrst the periosteum participates but
little. In this stage tlte diseased part is in about the following ooO'
ACUTE PERTOSTTTTS.
3?0
dition: Tlie vessel» of tlic moiiiilU awl |y.>riosU!tiiu an» gruaÜj diUt«d
and distended with bloucl; perhaf» tlicrc may be slaitis of blood «t
different potnln. Tbc mcilullo, insteail of ita luuaL brifrlit-yellow
cdIüt, U (lark blue, and pi-rmvaUHl with extnivK^ntioii« ; the perio«'
tcutn is jrrcatly loHltrato], und on inicroacoi>i«il ezmniiuitiiiii of it yoa
find Qumbera of joung c«lU, u jou also do in tbc medulla ; that ia,
there i« plasiin infiltmlion. In thiK triage, » complete return (o the
nonnad state is possible, mid, if pruper treatment ia begun eartj, Ibis
is not eo lan.*, particularly in the mom aubaeut« cases. Ttic ferer
falls, the sweUing decreases, and the pain eeasea ; a fortnij^ht after the
eomtnenoeoiont of Iho disease the palient ma/ be ruvovere<). Even
wbcD tbe proccM is somew-hst further advanced, it may stop ; then a
part of the new formation on the surface of the bone oe»i£e»,aQd tbus,
fur a time at least, there is thickening of the affcx;ted bone, wliieh may
again be absorbed in tha course of months.
In most ciises the coureu of periostitis is not so Invonibic, but the
pttie««s goc8 on, and tertninates in snppurutiun, tbv symptom» being
as follows : Hie skin of t]ie swollen, tense, and painful limb is at first
Teddiah, then brownish red; the oedema estemJa furtlicrr and fiiriher;
■the neighboring joints become painful, and swell ; the fc^'er rcamins
at the same point; the ohitls are not infrefiuently repeated. Hie
jwtieiit ia much exhausted, as he eat« little, and nt ni^ht is kept
»vrako by tbe pain. Toward the twelfth or fourteenth day of the dis-
ease, rarely earlier, but ofteu later, wo may clessriy distiuguisb fluctu-
ation, and may then greatly alleviate the suflcrings of the pAtient by
letting out the pus thruuj^li one or more openings, if the ^iii oi-er the
nbcocss is «uffiniciitly thinned ; for the opcniog of deep, stitF-wallcd
nbscCRKfS which do not collapse may prorc dangerous from decompo*
Bltion of bluod and pus in the insufficiently-encapsulated abscess.
The spontaopmis perforation, esjiecially the suppuration of the fascias,
occastoaaUy takes a good while, and, moreorer, the openings thus
fortnoJ are usually too small ; they must subsequently be enlarged.
If you introduce tlie finger through one of thwe artißcial openings,
you come direelly on the brnie, and in many oases und it denuded of
periosteum. Ilic extent to wliioh this deiiudation oocurs depirntia on
the extent of Iho pcriogUtis. It may e»ten<l the whole length of the
diaphysis, and in these n'onit catu.*« the symptoms are the most scverv.
Probably, however, only a half or a third of the periosteum is dis-
eaeod, nor is the entire circunifei-ence of the bono necessarily affi^cted,
but perliapa only the anterior, htteral, or posterior portion is so. The
pcriostili» ta particularly apt to stop at the points of ori^n or inacr-
tioD of strong muscles. In those cases of slight extent all the symp-
1 ^ill be miltler.
880 ACUTE INFLAWMATlOXa OF THI BOXES, PEIU08TEÜJI, ETC.
Even in tfais stage the disease m&y take one of two different direc-
tions : poAsibtj', after the evacuation of tbc pna, ihn eofl partd mojr
quJokly become uUierent to tlie bone, tA tliv nulls of an acute absceas
do to eacii oilier. I have seen lliis a few times in periostitis of th«
femiir in clüldrt'ii two or tlirvv vl-uts ohi. After tlic o|ivuing, a slight
quantity oi pua coaliaucd to diacbaifrc for only a aliort time Tha^
opmings soon closed eoitirely, the tumor receded, and perfect reco^
took place. But, aneordin^ to my experience, sucli a leiminatiotQ ouly
ocoun in aniall r1itlrln;n. Jtltan freqtirntlYt aa a result of tlie »uppif
ration of tlie periosteum, the bone is mostly robbed of it« nutrient
vesaeU, aud partly or wholly die», leaving the condition tcmu'd
oeeionx, or (^anirnrrMJ u( tbe bone. The extent of this necroeis will
MMntiidly depend on the extent of the periostitis. The partially or
entirely destroyed dtupliysis uf the lung bonca nnist be detacfaed as a
forci^ifn body, as we hare seen to be the case in gangrene of the aott
partaand trauniatio necrosis. This rocjuina a long time; hence thdJ
process of net^rosis, the detacbnient of the portion of dead bone or*
8eque«trum, giid every thing connected with it, i» always a clirouio
uof. We bIiuII buvu to speak uf tliis hereafter, ßvfore tlie iuflainmji-
tion passes into this clirotiic state, acute stippuration continues for a
timi! after the first opening of the abscess, ^'ariüus ooinplicalions,
crcrt pysmia, may occur. WbcncTcr thcac puticata ore fcvcrisb, they
ttre in danger.
We must again return to the medulla of tlie bone, which we left
in the firüt stage of inflammation. Here, a!sn, the inflammation may
tenniuate iu tHj)>purativu. If tJie oätcoinyvUtia be diCuae or total, the
whole medulla may suppurate. This suppuration may even assume a
putrid charnoLer, and inducii septioemiiu If there be extensive sup«
purative ostvoniyelititt, nitb suppurative pcriostiUs, death of the dia-
physis of the bone is certain. Should there be only partial suppura-
tion of the medulla, or if tberv be none at all, th« circulation of blood
in the bono may bo prcscivc<I and the bone remain riublc. It may
not iafrequeotly oc«ur that, under such cireuinstances, the bone will
waver for a time between life and death, as the feeble circulation
nourishes the bone very incompletely, Arute suppurative oslcooiyo-
lUis, without pitrUüpaLion of the periosteum, probably does not occur;
ii is not infrequently combined with oateop/tlebilis, which may end iilj
putrefaclion or eujipuration of the thrombus, aud is prone to indued
iDctastatic absoesses. Another not infrequent, though not consUat,
accomjiuniincnt o( osteomyelitis is su])puriitiou of llie epiphyseal car-
tilages in pemoEis in whom they still exist, that is, till about tbo
twont^'-fourtb year. The prvecss is not difficult to czplaio. The sup-
puration may extend to tbo epiphyseal cartilage partly from tbo
ACUTE PEBIOSTITISL
2S1
medullii of tbe booe, pailly froni tlic periusteum. IT it suj^xvate,
the conttiiuUy of llie boon U dcstxD/ctl, Knd at tlic acat of tlic epi-
pbj-siatbcrc 15 taoiion, as in fracture; dülocation« mayaifio be cniued
hy contmciioii of the iDusclaH. Usually there is only one sach g|ü-
|diyw«l Bepantion of tlie affected boDe, abore or bdow ; in rare cases
it 18 double. I hiiTC oii«c »eeu this double »«pantLioD of the epiphy-
ses in the tibia; aevt-tiü times I hnve aeen aeparatioo of Ute lover
epipbysifl of the femur, once uf tlu) ujipur uimI of tiuA bone, once of
the lower end of Dtn bumprus, twice of tbo upper cod. In ooo coao
t raw epphytteal •oftening', with luiatkm of the lower end of the
femur, occur witlioiil auppuratian. It hau airesdy been stated that
tnflummation of ibu nelgliboring joioU are apt to accompany perios-
titis. Thc«e articulitr inAammationg ummlly have n rather subaeutc
course. The s«rous äuid collecting in the joint is usually reabsorbed
as tbe acute diiwaae of the bone subsides, but tbe joint often lemains
svoUen, and not infreqaently pennanently »US. 8erecal times, also,
I have Rt^cn acute periostitis nnd osteomyelitiü of tiie femur succeed
acute articular rheumatism of tbe knee. Laatly, we must alao meit-
tion that this osteamyelitis may occur in several boDi;iii at once.
The diaj^noeis ns to bow far periosteum and bono are affected in
the acute disease cannot be made vritit any certxiinty, but can only be
decided by the extent of tbo consequent necrosis ; and cren this is do
ttcouratc measure« for the periostitis may ead in euppunitioD, while
the inflnmmation in the lione may end in resolution, or only cause
same interatttial formation of bone. 1^10 process may start: 1. lu
the k>a«e cdlular~tisaae layer of tbe penosteum; this mppuratea.
If the suppuration be limiterl to lliis layer, after opening the absooss
we may pas« the finger directly to the surlaee of the boae, wbicb wo
find corcred with the granulsting tendinous part of the periosteum ;
if Iho Utter layer also suppurates, as it not inire<{uently doc«, the
bone lies exposed, and tbe suppuration may oontinue into it. Thus
osteomyelitis aocompaniea periostitis. If it hv <lfnied Ihiit tbe loose
cellular layer is periostcuni, but is to be rcganlwl aa part of tbe inter-
muscular cellular tissue (which would nut bo natural, because tbe
vesseb escaping from the bone lie c4)ieÖy in this layer), then there is
no tuc^ thing as acute penontitis ; tor the leiKÜnous portion of the
perioateom is as httle liable to primary iDHammstion as the ttvcias ootl
tendons. 2. Tbe indammaLion begias in tlie lx>ne, and thence extunds
to the periosteum aud cclltiUr tissue ; osteomyelitis is the primary,
penostitia the seoowlary, disease. Tlwn there is pus not only in the
boue, but oil its siu^'e, doeu under the tettdinous portion of the
periosteum. This is elevated by the pus, as far as its elasticity pcr^
mito; it is then perforated, and the pus escapes into the cellular tissue;
S82 ACCTB KPLAMJIATIÜNß OF TÜK BONES, PEIUOSrEÜM, KTC
Hera it cftiiSf^B mora suppurstioii, and ifaiis ti» prooeee advannea ^ i
tbc stirfucr. JHoaer asserts that in tbrsc casL-a fluid fat is pressed^ ^'Ifl
tbo strong arterial prcesuic, fcom tho cavity of the bono tJirough v^^
Haversinn <!RtialN nf tho onrliml BuImlAnoc to the Burfaci? of lh<^ ha^ ^)
so tliat vre itmy diitf^iotfu oBUforii^'(.-1iti8 from pus niixtrd with f:i(-dr^:^^
ruling {torn iukLt the periosteum. Moreover, iu a trvr case«, Jio
found a rcm&rk&Ulc elongation of the home, ard a relaxation of
neighboring joints, after osteonivplitis. He refers this to too mi;
growth of ilic nrtinilnr ligainrnla nnd rpipliysca) rartilnges.
In tbc prognofis of acute periostitis and oBteomyclitis we hnre ^"
disttngtiisit betireeii thi* danger to the existence of the bono and t^
tife. If ilie discAse induces pnrtial or total necrosis of the bone, tbtf
diieme mny be very protmcted ; it iruiy tnxt. Rovcnt) tnonthit, or orCA A
y«ir«. Aciilc periostitis miii ostcotnyclittf, e«p«'iiiliy in tho remor, ™
■tid still more when double, is always dangerous io life, beenusc py»>
tnia is so apt to occur, and in children, because of the piofuec suppo-
ration, it ia the more dnngeroiu llie longer the eondition
acut«; and tlic further it flprr-iuls.
In treating this disease; w« may acconipliah more if we «re
early; one of the nio«t effieient temediea is pninting the whoi» Itmb
with strong tincture of iodine. Tliis remedy shuuld be ccmtiiiued till
large vesicles form. Of couriKs tlio patient ia to l>c kept recutubCTit,
wbich in most cases does not nec4 lo be urged, as the pain keeps him
ijuiet. Siniv ronnnencing this treatment I am so well sntisfieii with |
it, that I liave almost given up the other anliphlogisties ; ru]». leecbcs,]
Tneronrial ointment, ete. When the veaicles formed by the iodioel
dry up, you apply more. iJeriration to the intoirtinal caiiaJ tiy e«Iinej
pitrgatires aids the (rentinent, as it does in all acute inflamtnatiocuLl
Some »urgeons greatly praifto IliC loodl application of tee at titc com-
mencement of the disease. Should suppuration Qo^'erthelesa occur, ^
and distinct Suctuntion be felt at the thinnest part of tbc aliin, we H
may make several openings in euch a way thiit the [>us f^ball cscnpe
without being presspd out ; then the swelling usually f:Mbsides qalek-
ly ; it id most favorable when the fever ceases early and the disease
becomes chronic. If the ferer continues, the suppuratiuo remains
profuse, the pains do not ei-iise, AVv may try to relievo this condi-
tion by continued appHcHtions of binddem nf ice, with which tre also
try to alleriBtc any inflammations of the joint that nay oeeur. 1 Iinrc h
also derived great advantage from the applicotJon of a fencstnitcd I
plastei^flplint, which ahoulci }m supported with boops on accnurtt of
llic large openings that must be made in it ; in cases whete llierc la
detachment of the epiphysis, it is absolutely necesMry that the limb
should bo ßxod, if only to render the diiOy dressing less painful.
ACUTE PERIOSTITIS.
38«
Many surgeona do not fc^kiiv this treatment, wbicb is boclced by a
ecrics af broniblu coses. Some reoommocKl ittalÜDg Irg^* deep in*
ciaioDS down to the bone at tbc vcrjr start, or at least u soon aa
suppuration bcjfins, Sucli oxtimürc wounds aro bad in feverish pa-
tients ; I am salislied lliat, under tiiesodrcuinsUiiRes, tbis beroia tieat-
mcQt readers tbc condtlion worse, it increases tbo predisposition to
pjraemis. Tbc idea that in amie oeteooijelitis exattiuubttioa ^ould
bo taaxhs at onoe, ai otbcrw-iiu) pj'xmia is unavoidable, seems to me
even more errooeous. 'Hii» iK-lief i.^ «-rtainljr uuUue, and under
auch «routnstanees amputation is not indicated, first, because at the
onset the diagw^isis of OBtcomjrelitis 1& not abeoliiti-lv' oertuin, as tbe
case mif^t poaaibly bo ono of simple aeutc periostitis; sccoDfllj, be*
caiixo tlic progDOsi« in cxarliculation of Urge Untbd, if douc for itcule
^scnse of tbo bom*, is always very doubtfuL In aeutc penustitiH and
oateomyclitis, of tbc tibia for ioBtance, I ahodld only amputate at tlie
tbigh if tJto suppuration were very excessive, and acute suppuriition
of the kncEvjoint should occur. Should the disease affect tJie femur
and run an unfavorable couree, I should snaroely hope to sttve tlie pa»
ticnt hy an operation eo dangerous ad ainixntatiun at tlic bip>joii)L
yVo maj accomplish much hy jfrcat oare of the pntients, who are gen-
oralljr youtbful. A young girl with oateimiyeHii.i. »ii'l perioatiüs of
the tibia had stxtven chills in twciv« days, and nevi-rthclw» rocorcred,
although p%Tt of the tibia became necrosed, and tbc foot was anchy-
loftcd.
I will here add a few remarks about Nippurativc periostitis of (lie
third phalanx of the finger, which ia, perUap», tbc pla«» where it most
frequently oci^urs. As this iufiiuniiulion in the bond and Giigera is
usually called ])anaritiuin,thts periostitis of the last phalanx U termed
panarUium periottai^, Tbia, lik« any periostitis, is very painful;
it is a long while — somctinM^ fight or t?o days — before llic pus pci^
forste« outward. The termination in partial or total necrosis of the
phaluns is oommon, and cannot bo prevented cvun by an early tn-
ci^ion, although we often hflvo to maUc one to rchcve tbc disagreo-
able, throbbing, burning pain, partly by the loois of bloud, portly by
aplitting tha periosteum. As tlie termination in suppuration can
scarcely ever be avoided, wo try to induce it by cataplasms, lumd*
batlis, etc., and thus hasten the course.
Thua (Ar WC hare only apokco of acute inflammation of tlie peri-
osteum, and mcdnlla of the long bones, but h»vo nnt considered that
of tbo s/wjtjry fione«. Nor have we eonsidiTMl the question of in-
flammation of the bone-substance proper. Is tliero such a thing ? I
tbbilc this must be answered in tlie negative, for I consider that dUa>
284 ACCTE IXFLAUVATIONS OF TUB BONBS, PERIOSTECIT, KTC.
tation of the ressels, oell-infiltralion, and eeroits imbibicioti of the tic-
sue, in tlieir vxrioufi comliinationii, constitute th« eatenoe of acute io*
Bniniimlions. In tbe ccmpact bone-suletance fas ia Uie coiiicnl \ayvt
of ft If>n^ boiic) all Diese nxjuironirnts rannot occur. In manv piMSM
at 1v»»(, llio capillary vesaeU are »o doscly embedded in the Barren
nino canals tlint tbc3' cannot dilate niucli ; a certain amount of Bcnnis
Entiltration of the bono is imnf^lnabV; but the firm bone-etibstanco
cannot possess nntcb c!i|iabilitj of su'i-Uing. If the term Jnäanuna-
tion be made so ^ciii^niJ us to include crcry quaQtitativc and quaüta»
tire disturban«) of nutrition, it vould be a. very |>ocu]iar tow, in
wbicfa I do Dot participate. Ei-ery tissue attacked bj iDflammatlna
clinDgQ8 its pliyüiml and <:liomiral nature, and in acute inflammatioa
of th4> Koft ptirtft this tAkes pW^ mpidly; tbe oontiectiTC tissue e*-
peoially 18 quickl^y rbnnged to n f]^latinouR,a)huniincnu sutistunoe; iht,
tissue of tlic cornea and cartilage may also Antgß vcvy quicklj. Fo
clictiucal reasons tbi» is impossible in bone ; time is required for ihtn
ohalkjr salta of the bone to tliesolve, and the bone-eartila^ left deii-
qumoca like other tissue. IIcqcc, inflanimatjoa of compact bony
sue, serere tliouirli it be, cannot run its course very rapidly ; it alwa;
tabcd a lonpf while, llie above refi>m nnl j tn compaol bone-nubstanee ^
tpon^ bou«s may readily become iiillMmed, tliat is, there may be in*
flammatjon of the metiulla contained in the apongy bones irbich bM
the samepecnliaritieeasthal of the lon)r bones, only it is not collected
together us it i.t in tbeni, but it h di.ttribuled in the tncslies of
the buTics ; each fipa<« eontain<i many capillaries, oonnectirv tiamr,
fiit-eells, and nerves ; acute inflamnuttion of the sponf^y bones first oe-
cuni in ihpMt interspat^en, and gradually r^ctontls to tho bone proper.
What is calleil anUe ostiti* of a spongy bone is at 6rai only acute oa-
teomyolitii. This irhen idiopathio is rarely acute, but is usually
chronic, sometimes subacute. On tJio other haii<l, there is a trnmnatis
Acute osteomyelitis of sponjty bone», »bout which wo ahall hero say
•omelhin^, although we have discussed its more important feature»
vhen treating of suppuration of bone. Imagine aa amputation
wound closo below the hnec: the tibia has been »awed through ital
upper tpongy part ; traumatic iu flamm at ion occurs in the mcdiüla of |
the btine, in the meshes of the Imne-ffub.slnnre, with proUferatioa irfi
vesÄcIs, cell-infiltration, rtc, ; this leads to dii'elopment of granula-
tions, which grow out Iroiu the medulla and soon form a granulating
•urboe ; this cicatriaos in the ukuiiI manner. But subseqticntJv, if
you have a ehanre to cxnnime such s stump, you find that, at the sawed
surface of the bone, the meshes are filled with l>onc-ftuliMan''C, and
the outer layer of tlie spongy bone is transfonned to compact bonyl
substance; that \», the ciratriic in the bone haa oftsified. Tlihi is tli»i
LVrLAUHATIUN OF TIIE J0IKT8.
285
Bomutl ferminatioD not onlv of traumatic but of spontaneous ostitis :
the bony cicatrix o&sifiex. There may also be Kuppiirntion, putre£u>
tion of the laedulla ors{xi»(fy bones, a» lu hag bouesj oeteophlettttis
and iU conitM]u«n(;efl may ulso occ^r. In tlic lecture on suppuntloa
of boQD (p. IdT) and lieMlliig'of open frartun» we trotted fully of the
ch*nj;o8 which occur after tbu bone htul lost its periosteum, of the
devctopmcnt of granulation« on tho mirfure of cxunpact I»oiic-kuI>-
stattce^ and of llw lux-onipanyiug superficial necrosis.
"We now oome to acute it^fiammation* o/tlte JottO*. As we have
prBvioildj spoken of trauinatio articular inflamntationa, jon already
JcDOW »ome of the p4!<niliarities of diseased joint«. Vou aLto know
tliat serous inHnmniationa liave a great tendentty to exoretc fluid exu-
datiou when irritated, but that Ihi» cxudution may also oontain pus,
if the inflammatory irritation lie vory intenKC^ As there is a pleuri^
'^rith e0u&ion of scro-fibrinoiu fluid (the ordiuniy form), and a variety
"with ponilcnt cffuaton (»CMxlled empyema), so ill jobts wo speak of
serous synovitis, or hydrops, and of purulent synontia, or cinpyem«;
lioth forms of the di^^as» may bu eitlK^riu'iit« or ehrooic, and they io-
dnce various diseases of the airtUufce, bone, articular eapsule, pcrios-
-teum, and sunxmuding muscles. You will see that it is aln'ays more
cornplicat«! with these diseases tJia more eomplicated the aOet't^Kl
part i». Of late, great importance has been attadicd (especially by
French 3uiK<^ooa) to a|x-akiiig, tirst, of diseases of the syporial mem-
1irsDe> then of thaie of the cartilage, artieular capsule, and bone, oop'
respoadiog to the anatomiral conditions. Correct as this divisiott
vcrald be, if it were ouly x question of representing- the patholof^ol
anatomical changes, it Ls of little use in praelioa The siir)^>on ul*
ways views Inflammation of tlie joint as a wluile, and, alUioujjh bu
should know- which part of the joint suffers most, this is only a part
of what he should know ; rourse, ttjmptoms, and onnstitmiona) etato,
equally demand his attenliou, and determine tlie tnntment. HenM
the entrre clinical appcazonec will determine the dirisious of this, as
of many other diseases.
At present wc arc speaking only of sppart-otly spontaneous acut«
inJlsrainstioos of the joints. In niany «isca they are evidently due to
ottchiog cold, in other cases their causes arc obeeure. Some of the more
subacute cases are of metastatic nature and appear as pj'n^nift. Hut
at present we shall Sfieak only of iho idiopathic ioflaauoutious, which,
in ooDtnuUstinction to the traumatic, are termed rAeuniaff0,os thcysro
oftaa due to cold. Patients requiring your aid for sucb acuto inflnm-
niatJons of the joints, will present somewhat diflbrent symptoms. If,
Sga ACCTE mn-AMMATIONS or 'THE BONES, rERIOSTETll. ETa
for illuatretiotif we a^in take the knee-joint, you will hare aWut tht
following picture: A fitrong, otlierwUe beailliy man ban taken to bed|
because for a day or two liis knee lias been gwolten, )iot, anrl painful j
jou find Uiia on examining the knee, you also find distinct DuctUKlit
in tlie jniiil, and that the palelln is samewliat lift»] u\\, imil alwn^l
riseÄ »gniii if pie»»e<l down ; llie skin over tlie joint i» not red ; the'
patitiit liva willi his leg stretched out. iu bed, lias »o ftrnrr, and, if yoa
ask him, cnn bend and extend Uic knee, thrvii^^h vitli some difficulty.
You bvru have an dCMft^ «frou« tyitovilis, or ?it/(iroj>s i/fnuaeulua. TIiqI
oiiatomirnl condition of the knee is as follans ; the sypoinalmembrano]
is alighlly swollen and moderately vascular; tbo articular eavily fuUJ
of senim, which has mingled with the synovia; there are a few floeculi j
of fil^rine in the fluid, the rr^t of tlie joint ia]iea.ltby. Anntomicallyj
the atu.1« in just like a subacute bursitis tendinum or n modcr&tol
pleurisy. Thi.s disease is generally eured without dilRcuIty ; qiiiot^ r^
peatedly painting with tincture of icliiie, or a few blisters, or com»
prcasiou with Met baiidagt-s, suffice- to reino^'c the nffeclion in a few
djiys, or ut luiist to t:<ke off lis niiut^'iiesK; «11 the syniptonis of the '
acute iaflammatton may subside, the patient may go about witli
scarcely any difficulty, but their rcDiains too much fluid in the joint,
a. hydrops chronicus of the joint is left
Voll mity he failed to another patient with inflammutjun of tbo ,
knee-joint. A few days prci-iously the young man lias caught cold ;
•oon after thi» his knee lias begun to pain, liigh fever has come on,
perhaps a heavy chill ; the jciint has constantly grown ntore puiofu!.
Ilie pati«>nt livt in UhI, with the kiicu flexed so that the thtgh is
«tnwigly rotated outward and alxhictci) ; ho rMiat« every attempt to
move the leg, as it csuscs lilin terrible pain. Theknee-jojntiagreatly
swollen »lid feels hot, but there is no fluctuation, the skin is oMlematoua i
and red about the knee, the whole log also is a;dcmatous ; on accotiiit
of tlie )uuu it is itupQsaible to extend the knee or to Ilex it more.
What a contrast to the fnrmcr case! If you have a rhance to examine
»he joint in this stage, you find great swelling of the synovial moo*
brane; it is very red, puffy, and mieroseopieoUy appears infiltrsted
with plastic tnatler and sentin. In the joint there i» usually a Uttlc
tloecident \»m mixed with tlie synovia, thcr« may also be p^iro pus.
Tlic snrrnce of the OHrtiluge looks eloudy, and microseopicully perhaps
shows little chunge iK-yund turbidity of tlie hyaline Kubslanee; possi-
bly the cartilage OAvitie« »re somewhat enlarged and fdled with an un-
usual numlx^ of et^'lls. Tlie tissue uf the art icular nipeide is acdematcua.
Here you Imvc ii puntlent vert/ acute sjfuovitie, in whicb the carlilago '
threatens to participate; should the disease eoatimic, and the pus in
the joint increase, you may correctly aiU it empyema qf thejoitU,
IKFLAKUATIOX OF TIIE JOINTS.
287
Tlie difference betwiwn Um finit anil second fnnns of wrute syno-
viüs ia essentially that, iii tiiu eccutul, tfac tisaiio of the »ynoTÜl
membrane is deeply aflVvfed, while in tb*> first tJie in<!rt>u«>d secretion
is Üie pbief fenture. Between these two fonna are subacute caseiijiii
which tb« secretion beoomrs purulent and onllcets in grvat quautity,
nithout tbcie being any j^eat desfnietion of ihc H^novial nn'mhrana
JS. Yulkmaiin call» lliiit "oitarrhiil intlnnimatiou " of thu joint; it Is
soniL-what more painful tluiu uniiimry ami« hydropA, Crom which the
catarrhal purulent form tnn; proceed, tbougli this ia raretjr thö case.
1 hare already &aid nliut was nooeBSOiy «bout the oourso and trest-
mmt of acute hydrops. The course and re&ultA of tlie more panro-
diymatous syaovitii, which ia predia|x«ed to suppuntioo, depend
j^really on when tho treatment is begun and what it is. Uaually •.
few leccbrs »re applied and then the joint is poulticed, from an idea,
of thv old srlH)ol, that rheumAtto articular tiifliimniBliotia ühould be
troaled with warm npjillcntions. 1 consider Icechc» aIiiio«t useless in
Ibese affectioas ; perhaps ihcrw may bo a que^tiou about keeping tbo
limb warm, for this is often pleasant to the patient; it ollcviatea the
pnin in infliiintnntions of the senniB muiiibranr«, often more bo than cold
does ; at least the hitter must act for some time before liaring a tavor-
able eflect, I explain this as (tdlows : The worm applicationa induce
fluxioa to the vcss^ of tlie >0;in, and thus empty those of the syn^
vial roembtane ; but this elTect is not lung ei>ntiiiued ; fluxion to the
inflamed deeper parta returns Ofnun, and is atrongcr than to tho arti&
dallywiirmeu skiu. Co application of a lar^ bladder of ico to tlie
joint, tlu> Tesscb of the skin contract^ and perhaps drire the blood to
till." vessel» of the inflamed part more strongly than before, till ^^do-
ally the cold hiut its elTect on tht;!se alao, and if the cold continues tho
efiect becomes permanent. It seems more rational always to use eold
in tlteae osca; in very acute inflammations of the joint the employ-
meat of ioe-htaddcnt has also proved very practical. Besides u»iDg
Olid, rou may ulso induce active derivation to the skin by strong tino
ture of iodine, or by a large blUler. Unt besides these rcmeditii it is
nost important to brin;;tb» joint into a pivpiT poaitioo and keep it
th':re, for, if wo do not obtain a pt^rfi^ct cure, and tbc joint remains
atiff, ttie fiexcd position of the knee, which is so frequent, ts ivery nn-
fortuDote addition to the stiflnoss, aa it renders the limb nearly if not
cTitirclr useleas. Why the acutely-diseased joint, especially in intcoae
suppuralire synoritis, alinoct always invniuntarilj aiuumes a flexed
position, is a difficult <(ueation, irhidi may be answered in various
ways : it has been said that tliere is a sort of reflex actüui on the
motor musoulor nerve from the irritation of tlie sensory nerves of the
synovial membrane, and tlut this is the cause of the muscular ooq>
20
S88 ACUTE IXn.AltMATH)IIS OF THE BO^ES, FEKIOSTEini, ETC.
traotion. JJonnrf, a TVench mirgeon, wbo liaa doop much for
trMtment of diseases of tlic joinU, thinks that in great disteDtioD
the joint with pus, or even by sw*?Uinjr of the BjnioviaJ membrane, the
flcxctl |>o«itii>n nmy Un rauseil u>e<^1ianioii1ly, an Die space in the joiot
in grcuter in thv flexed thftii in the eAtended pnsitioii ; lie lins tried to
prove this hy injecting the joints in the cndnvor, and hy filliiif;^ them
oonipIet»ly bv liiis hruught tlieiii intu tho flcxoiJ position. Aguiitet'
thia it may be snid thiit iu hydrops nvutuj;, where there is usually more
fluid iu the joint than there i» in purulent eynovili», the flexion does
not oft-up, nnd also that in »uufe inOaminatiuiifl, where I could satisiy
iiiywif of the non-existcnco of fluid, there was flexion. It Becms to
me that tlie acut«, pufly, painful swelling of the synovial menibnuiQ
is the rhiof cause of the flexion, hence I should incline to the first ex-
planation, nfcooling to which the pain is the IrritnlEon that induces
cxintmotiuit of the mu.-snlc-a uf the Limb: other muscles oImi, in parts
Butfering from aoiite pain, eontmcf, ait th« oervieai miiHelca in deep-
seated abficessea of the neck. The malposition should be reliered ;
this should be done for each joint in such a way that in raee of «im-
pleto Blißnei^a its position shall be most favorable. The hip and knee-
joint shciuld ba extended, tlie foot and elbow at right angles ; tlic
wrist and slioiilder do not get oiit of pobition ; the fonner usually re-
mnio» extended, the latter usually titkes sueh n position tlint tiie arm
lies ag^iiiist the thorax. Tlii-r« is very great diffepenee in lhefrequ(?iiey
of acute disease in the different joints; the knee is most frrquently
aifcctcd, then the elbow and wrist; acute ioflanimation of (lie hip,
shoulder, and ankle, is rare. Acute artieular inflammations are more
frequent in young persona than in old, but hardly ever orrnr in ehil-
dreu. But, to return a^in to the iniprovemcut of the position of the _
jnänt: you will tell me this is impnsaible. (?hlorofnnn is here useful ; ■
this reinedy has liccome most important in the treatment of tnfhimmk*
Uone of the joints. Vvu nurcotizo the patient divply, and can then
more Uie ]iinl> without trouble; llie mugcloa, which prCT-ioiwIy oon-
tnictedon the least touch, now yield without difficulty. If we continue
with our former hypollictical case, you extend tho knee, envelop it in
a thick layer of waddiog, and a]>plj a plus-ter^plint (mm tho foot to
the middle of tho thigh. When the patient awakes, he will at firat
complain of severe pain ; give him quarter of a grain of morphia and
apply one or two bladders of iee over the plastewtplint to the knee ;
tll8 eold act« slowly, but finally prores eflective, and in twentj'-four
hours tho patient feelii t'llenibly cumfurtjible. Tlie slight compressioo
made by the well padded plastersplint also ha* n faromble antiphlo-
gistic action ; if there be fever, you may give cooling medieiues a>nd
saline purgatives; but tlie patieat needs no further trcntment. Ue*
IKPLAinUTIQSr QP TBB JOINTS.
S6d
*fore ftppljni^ the dreeshiff, you m*^ hare the limb nibbod with iner>
cuiial ointment cr psintird wiüi tincturt) of iodine. It ikbesLtunpply
the dreasioi; crcn ta tha moet aculc; stage ; of uiurse it must bo done
veiy c*refulljf, avoiding any strangulating pressure.
If called to the case earlr, you may sometimes not oiily arrcet tbe
noute xi^ge of the riisca*e, Imt may preoCTve to your paticot a mor-
sble joint. But, ei'cn if called late, tlio aboro treatment should bo
pureued. If the puin is rcUcvod aiid the fevsr oemw, you may re>
more tbn drL-ssin^ iii a few wi-cks, for the dJamse laats 861*6011 vreeks
under any circunmtaiicce ; perhaps three to five mODth« may elapae
before the inflammation entirely disappears; gradually the normal
condition and the former mobility return, then the patient sliould be
eaniestiy warned ag;ainst taking: rol^l or exceasire motion, for a second
attack might not tiini out sn \\c\l.
Supposing- the acute proce$« d'jie« not »ubside under tli« treatment
instituted, but coutiuues to pru^^ess, it may pass into a chronic fono,
or remain aeuto ; wc flhnJI herejifter treat of the former case. I>ct lU
at present suppose that the pain, instead of subsiding, becomes more
■CTcre,aiid you are obliged to split the dressing along tlio front; you
find the knee more swollen, distinctly fluctuating, and the patella
very movable, while the patient has high fev«r. If the disease con-
tinuea, tbe fluetuation may extend farther and farther, upward to the
thigh, for inAtaace, and the subcutaneous cellular tissue of the thigh
and log may partleipate in the suppuration. Formerly tliis extension
was attributed to siitiriitaneous bursting, or paitial suppuration of the
aynov-ial sacs around thi* joint, esppcially of the large one under Üic
tendon of the quadrioeps femoris, and of tite bursa poplitea ; to pre-
vent this misfortune it was <.vin»idered tulviaable to tap tlie joint with
H trocar, in the aborc stage of the disease, to let out most of the pus,
and Ihcncarcfully close the opening. Frommyownerpcricni"ei»hould
consider this operation as rarely indicated, for I hare convinced my-
self, by careful examinations of patients, and occaainnally of the
cadaTor, that these periarticular alisoc.'fsc» in tl>e ooUular tissue, oo-
curring in acute synovitis, and al^to in ostitis of Ovi articular extremi-
tiflC, form separately, and brejik into the joint late, if tliey do eo at
all. With tl»e deTclopniciit of these abscesses the general oondition
of the poticnt is tisiially impaired; he has high fever, witl» intercur-
rent chills, his cheeks fall in, bo emaciate«, loAe« his app«ütc, and
bceomcs sleepless. Quinine and opium finally lose their elfect, and,
unless you amputate the thigh early enough, the patient dies from the
exbauating üuppuration and continued fever; perhaps, al*o, he may
have metastatic abscesses. If, by the applications of ice, by one or
more incisions for evacuating Uic pus» by quinine and opium, you suo-
290 ACUTE INFLIIUUTIONS OF THE BOKCS, PESIOSTEDK, ETC.
oc«d ]n breaking the acute ftt«ge of the diseuo, and making H diroD^*
}'üu will not olituin it moT«b1c jolut^ but even if it Is flexed at m r!p:lit
angle, the ieg will bo usc^ ; this is tbc best result tbnt wo can gain
after diif s and veeks of aiuciol}' and care, if tbe iiitlatuumtioQ rcacbes
the above grade. The anatomical cliang;es ia a knee-joint id litis
tinge of iufltiimnatiüu are as £ci]lov>3; The juiutü filled wilb ibicb
jollow ]»ig, tnixf^I with filn-inou* fini^f^iili ; tiio ^piovial metnbratKr it
corercd with doiae puruleut fibrous rinds, under u'kii:'h it is rerf red
auJ puffy, partly ulfcnited ; tbc «irtilofj« in partly broken dornt into
pulp, partly necrosed and pocis off; the bouo undc^r it is rrrv rod at
iiifiltnLted (Osteomyelitis ; usually in tbese cases a secondary, rarely a
primaiy diwiuw).
Tho prognosis of tliis disensc is not toiy bad in young, vigMons
pprsoii.i, w lien tlie pi-opfr trealinent is resiirted to early; ft is very
bud, abiiust ub6uIutL-)y fnliil, in uld, decrepit peraons.
Tu the. nbovc I Iiave pictured to ymi typical oases of tlie <Tro for
of »yuovitis, thu serous uud parcncbymatous (punilent), and am aati*'^
fied llial iu prad-iw} you wUl rcudUy n-oopuizG these pieturen again*
and you will haie no ditürulty in applying what has bcrn emd of the
knee to oilier joints. Xow I muat add that tlionj i& etill anotbec,
neutc or subacuta form of articular inflammation, vrhich offers
pecaUariüesL T ref^r to afrute articular rheiimaiitm. ThU \'eiy p&
CUlikr disease, vrlilch will be treated of more ftdly iu the leclumt on
intemnl mnilicine, is elinmcterijied by its attacking seretnl joints nt
once, and il^ tendency to cautte inflammations of ollior serous mem-
branes, »ueli as tlH! pcricnniimn and cndocaidium, the plcum, and
rarely the pcritoweum and arachnoid. This simulumcoits disease of
these mcmbrunes and of tbc joints marics tbe aifection as one impli-
cating tbc whole boily from the start ; iudeed, from the impor
of the ot^u affected, the (XTicurditis and eiidoounlitis aiC oftoD
prominent, aud so much influence tho trciitint-nt, thut the sui^fic
treatment of the joints ts a veiy Bccoiidary matter; this is tbc more
apt to ^x tlie case, aa tliia disctun, altliou^li rcry painful, mrcly provoej
dangerous to the limb or to life. The chief cymptomR of the k
affeotJon, Iwyoud wliicli llie disease rarely ]>roee«(1s, »re, great pain in
tlio joint on every motion or tourh, ecdcma of the surrounding soft ,
pftrts, and rarely redness of tho skin, From the few autopsiea tba
bare been made, it oppfars that the sj-novia increases Bomcn-bat, ia
Bomotimcs mixnl with flocruli of fiMS, and the synovial mciiibrune is
Bvollen and red ; the cartilage is aeldom implicated ; the coUeclioa
AOTTE ABTICTLAB BIII^L'UATISIU.
491
of fluid i« not oflcu so grot »s to csuso Hiu^tuation. Acute rhcimia-
tbm is verj frequent^ but it ia rnrcljr ht*l, so ttuit tbe pntliological
anatomical Mppe«ninccs uro little known. Fivin aJl tlio symptoma of
this diseast^, it is evidently a ajiecilic, limited (license, of a pficuliar
character, but with a courae !>o atvpii'a], ami cnuites »o olwcure, titat
it» a<-ttKi1 diameter Las not jet bcea dvtvniiiiif J. I have m^ doubts
wlietluT, h<>»idos tliis fiobjartleular^ wo can speak of a m«nartici4laf
acult rheiiiiiatistii, for it is jiist llio mulliplicUy of Hip points of
iaOmnmatioii, and tlicir EÜgbl t^Midcnry to Euppuratc, Ibiit cbarao-
terisee the «liscast^ ; at all eTt'nt«, I should not consider an inflaniitutioa
limited to one joint as a symptom of acute rbeamatism, unless plcu-
risy, pcriconliti», or somn otlirr complication peculiar to rbcuioatisin,
also o«ourr«d ; shou]dnan<>of these come on, the disease is purely Iocs],
a simple inflsmmnlion of tliß joint, n'liicli i» prulHtbly eallf>d rbvuinatio
■imply because it is supposed to be duo to catching cold. In acuta
riicumatisiu, tLe resolution of the articular inllaasiiiatjoti and the rc^
toratioa of the joint to its fiinctäons are so common tliat wo rarely sctf
any other le rminatton. Tlmt the diüease is tedious, sod geueially
lasts six or eight wt;ek;5, is not so much due to the duration of the
affection in a siuf^lc joint as to its atlsfbin^ first one joint, then an-
other, and exscerbnlions readily ooourriiiji; in joints that hud recov-
ered ; thus tho disease proves tedious, both for physician and patient,
and ibo prcateet watchfulness and c«ro are neceasaiy to ovoid all
sources of injury that may afi^in arouse the disease. It is eseee<ling)y
fare for one of tlie affected joints to go on to iutense suppuration or
empyema ; more frequently, in spite of the subsidenoe of the disease,
»joint remains stiiT nnd puinful, and ]>!is&t>s into a state of dirouic
inSammatian. You see ihat the prognosis of this disease, as far as it
coQccms the joint, may ho called very favorable ; without any inter-
ference from the physician, the joint-inflammstionR gien^rally run a
bvorablo course. Hence all that ive do for the local disease is to en-
velop tbe joint in wadding, tow, oakum, or wool, to jnotect it from
ehattj^eaof temperature. Mild cutanooiis irritants and painting with
tincture of iodine may also bo useful. Por alleviating tlie pain in tlie
joint« and hastening the course of the disease, Stromtycr aad others
repomnwnd the employment of bhidders of ice, and genetally keeplag
the joint cool, rather than wnmi. But I think this treatment will find
few dtsoiple«, (or it is <iuito Irnuhlcflome, and expericnco shows tliat
the erticukr isflammntions get on well without such Applications,
tntemally, wo may give diureties, diaphoreticji, or cooling salts ; in
lieart«ffccliona, local antiphlogislics, digitalis, etc., arc indicated, as
will be taught you more particularly ia special pathologies, and in th«
medical ctiaie&
M* ACtTTB mrUMMATIOS'S OP THE BOKER, PERIOSTOTM, ETC
, Next to Bcutc rlicuniktifiaj oomcs acuto arlfirUie inBammation of
the joints. The attack of pocls^^ or cliira^fra is also speciGc and
belongs to trup gout ; hen?, »]so^ tlic articular jnflanimation is an acute
serous sj-QorUts, Init with very liltle sccrelion of fluid in tlie joint
But one tiling ppruliar to acute nrlbritic inflammation b the never-
Eäiling coiixrident iiiflaininattnri of the &uiToiinding parla: tlie peri*
OBloum, nbcaUu of tlic teridoo», but especJafly of tlie skin; this
aln-ars i^dotw, bocomc» glistening nnd tenw, as in ery^ipcla«, and ta
very painful ; it evun desquutnotvs otxiisioiially after tbß nttadl.
Acute arihritic artirular iiiflamiiiat ion ia far morn painful tlinti rlicu*
matic We »hall bereafter speak of tUe treatment of artbritia und tbc
artbriUc diallieHia.
Tlicre is i)tiU auotlier variety of acute articular influnmatioin, tlio
metastatic, about wbicli wc sliall bare something more to say wliea
trcatiog of ]>ya;tiiia. Acute or subacute metastatic iuflanunatioQ of
the joint is usuaUy iit first tieruuB, but bodu purely euppuratiTe sjmo-
Titis. Several forms may be distiiiguishcd :
1. Qonorrhfecd injtammation of t/tt joittü. lliia occura in nwa
BuScring from gonorrbowi ; ooi'ftjsintiiilly, alKfi, it fwurn after (lie intro-
duction uf bougies into tlio urethra ; it attacks the knee-joint almost
exrlusivcly. Some autJiora assert that it is especially apt to derelop
when the gunorrlKjva is arrested suddenly. This is not my own ez*
perience. In proportion to tJie frequeney of gonorrha», it b wry
rare, but I have seen it (jiiite frrrjueiitly when a patient with actire
gonorr)i<ea lias caught cold. The iiicuniprcbeiisiblu oouncctiotl bo*
tween purulent catnirh of the urethra and iitflanmmtiong of the knee-
joint mi^bl bo dciiieil, and thr> simul tuiieon:« occurreuee of tbo two
diseases be considered us aocidciital ; but the expcricaoc of too many
Bur^geons, and also cases where inllunimatioiis of tbe knec-joiot oocur
afWr other irritationa of the urethra (as by Iwu^ps), apeak in it»
faror. Qonorrh(rul gnnarthrilis ufliiiiLly atlack» both sides, and ia a
subacute sproua aynovilis, which goueraily soon disappear* tmder
proper rest, avoid«nco of new irritation of tbe urethra, blisten, tino*
ture of iodine, and slight comprcsaion of the joint ; and, after ru«b-
sorption of the fliiiii, it ends tn perfect pure. But irritability of tbo
joint IK n[>t to remain, and nut unfrequently the same person glutting
another gonorrhtca is again attacked with inBainaiDttoD of tbo joinlo.
In come caeca chionii; articular thenmatism is said to follov gonor-
rhocai gnnarthritis.
2. Pj/temie inflamvuiiioti also occurs vcij- frequently lu one knee,
as well as in the ankle, shoulder, elbow, and wnat ; ron-ly in the hi}\
TTJSmü AXD POBEPBIUL ISFLAMlUnOü OY TBS «01KT& fi»!
from t
Hkaoerai
£
U a pnze puruleot «yooTitis, AubAcfiuently aooGfOpMÖed hy Buppu*
itiott of the periArticulftT coIluUr tisL&uo, but ntnftUy vitll eubncuto
eoura«,aii<i liPiice we do not ulways ßtti] it fully developed at the time
of autopsy, Pyaimio pktionta ilo not always die with suppuration of
tbo joint, and I have witnessed rcabsorptiou in ca&es vrlier« tli« patient
Jived tliroufjh tlie punil(-iit inftwtioti. The treatment does not differ
from thi: abovo ^veii ; if the collection of pu» is (^xceRsivc» ptmctura
relieve tlic pain. Supimnttioos ul the joint due to injuriei», and
tioos of the uretlira by earelpsa catlieterbntion, tuid usually
iinnanie<l by chills, are of t-tmrae pyicriiic, not gonorrliccHl In
Bcriio I treiited a yuuii); man wbo bad u rujiturc of tbu urclbni caused
by bougie«^ and coiiHcqiiL-nlly nn alit>ci?t» of the left shoulder, with
nippunitioa of the acromial joint of the claiHcle, which induced sub-
luxataon of that bone. The patient retxn'pred perfectly ; and, as
the abscess waa not large, it w&s not opennd. A year later I saw
the young roan again. The abscess bad betxime somewhat smaller,
fluotuntioii vrns still iliatiiict; but^ as Jt cnuaed no dtsturb«ucu of
function or othor ditTiculty, and the patient wa« blooming and
healthy, I aroidcd upvniog ihu ubsu-s8, und lulvise you to do tho
Burni-* with cold abscesses which cvidcutty cominmiicatc with a joint,
u the opening docs litUo good aad may do much harm, by pos-
sibly inducing acute inäammiition of the joint and very diaagreo-
•ble resulLi.
3. Puerperal ittßammalion» of th« joinU, Puerperal ferer is a
irra of pj-a-mia that niiiy cic<riir aflor [inrtiirilion. Hence, the auppu-
itire iutlammations of ihe joint« ocx^urriugal that time come under
the above category of pyarmii::, suppuratirc synoritis. But not unfrc-
({ueotlr, the third or fourth week after purturilion, there is an acute
suppurative iaflaniniation of the knee and elbow jointa, which has been
nCeiTed to various causes. Some say iL is a simple form of acute
artioolar inflammation due to catching oold, to which women are par-
ticularly liable after confinement, l>eraitiie they pcrapire so much.
Otbere oni of the opinion that these late inflamiaations of the jtuats
are also symptoms of pyninia thnt hare been orerloolccd find are
boUuM, and bcDce consider tbein as metaataLic Let this h« as it
may, it is at all events certain that these cases have nothing spccifuc.
Hiey run either an acute or subacute course, and, under suitable treat-
meat, may be so controlled that the joint will remain movoblc ; but
•oraetlmcx a more chronic coune begins later ami terminates in
aochyloftis. Hie prognoeis i* not rcry bad. Tbey rarely reach the
highest grade of acutenes«. The treatment is the same as that
already ^ven lor acute suppurative synovitis.
I would also mention that purulent articular inflammations oceor
294 ACUTE CT FLA If KATIONS OF THE BONES, PERIOSIEÜU, ETC.
in the pyseinia of the newly-bom ; children are even oocasionallj bom
with them, as lias been witnessed bj myself and others. Inflamma-
tions of the joints may develop and even run their course during foetal
life, as is shown by the cases where children are bom with joints fully
developed but anchylosed.
CHAPl'ER ill.
«
I
LECTURE XXII U
t Canpmi*. — Immodl&t« CuuM.— Ptwmm orUetAchmeat.— Varietiei «r Qan-
KNtM Meordinft to th* R«inola Cuuxa.— 1. J.odb of Vitality o( th« Timu« tn>m
UmImb!«*! at CKamiuI Obum«.— 9. Complut« Arrvil «r the ARIui ui<I EOIux oT
Blood. — InMfMnUon. — Contintnul Prwiftuit.—IJtoubito«.— tit»t Tcntiofi of tb«
Tiwo«. — 3. CoiiifilclB Acnt»! of Ilia Supply »f Aitiriiil BlooJ. — UotigrcDB Spoa-
teiM. — Omumu &«uilU. — Er^oÜMa. — L Xaiaa. — Guigrcns iu Vaiioiu Ulood-
DUatMfc— TrtaiUuQUt.
K
We Iiavo already spoken fnvjuMitly or gaof^ne und roortiEoation.
V)u know in gnnenil wliat lliey mean, iini] linve slready encountered
■ aeries of Coees where tlicrc was loctil (li'utli of a piut ; but tliere are
nanj other eircuniiilancM, with which yo« are not yet acqiMtotcd, '
which £uvor gun^^'itf ; all of which nv nhaU iucludo iu tliid chapter.
Voll already know the word i/anf/rene to be perfectly synoniinotta
Iirith iiiortiJication. Ori^ioally it n~aa only ueeil to express tLo stsf^e
^bure the dying part was still hot and painful ; that is, not oompletuly
dead. TTi» was eallcd "hot mortification," while the moist "cold
mortiiioition " was called by the old autliora aphactUu, The word
tnummificativn is also employed for dry gangrene. From the mocnent
the drculalioii ceases, »101^ ganynne is perfectly analogous to ordi-
naiy putrcfiujtion. Althou;^ it cannot alwajtiibc certainly stated why
dry gaogronc occurs in one case and moiM iit anotlter, wc say gener>
ally tint when thu clrcidution ceases suddenly, esptwially if tbo parts
have been preinoualy ioBamcd or tedcniatous, moist gangrene occuib.
Diy gangrene — mummificntion or shrinking of the parts — ^is mon> fro-
({ncntly due to gmdual d««ath, where the cireulation has continued
feebly in the deeper port«, aiid (be M-ruin liaa Iwcn carried off from
the gradually-dying pnrls by the lymphatic vessel» and veins. Rapid
enpOTHtioD of the fluid alsu induce« gradual dryness. It is ccrtaiuly
2d8
nAXOBEN'B.
^rue that even in moist gugreuv a superficial dryness sf the skin may
occasionally )>o obiuinoil by removing the Lunl layer of Ibe epidenuis,
wlich n-'Bclily peels off from tbc ilcix>in[iosing limb; we may «lu
greatly fiivi>r tli« dryiug by app1i<»ti(>ns of substaocca liavitig a stroog '
sffioity tor wau-r, auob na alciohol, solutiorta of corroeire Biibliiiiate,
■ulpliuric acid, etc ; but nc r»nnot obtain fio complete a niuinmifici-
tion as »oiiietiineft ocriira ^iKiti luncuusly. Hence, ilry gangruiie is txit
a ümplc piilwfncHon, btit a rather oniiipliratod proecsn, which gnidu*
tSSy leads to arrest uf thu c-iri-iilatioii.
Tlic iiiimccliato caiuc uf dcatli uf indiiiduul (laTlK of tlie body is
always the complete ccssntioa of tbc supply of nutriment consequcul
on arrest of circulntioa in tlie capilluries ; under some circumstnocM >
tl»^ rliit^f arteries nr veins uf «n exti-emity may be locally ol«*!!!^!«!,
and, nurertlivk-»», ttie blood lind« ild way by neighboring brancbcs
into tlieir lower or upper part«. Heope, obstniction of so UTtoij eta
only be the immcdioi« cause uf ganprenc when cullatcral cJrculattoo
is impossible. This may be due partly to anatomical oondiliona^partJy'
to grv&i rigidity of th« walls of small arteries, partly to veiy ext«n-
tive de»trui'tii)u of the walls of llie arteiy, as when tlie femoral is
otistructM] Ihim the iK^nd of the leg to tlie foot, tlie nutrition only
ceased wlion tho capillary circuluiion i» renderfrl impogiuble by tbrso
cin!um»tanoe». But it is nut always Tiecessary that cessation of cir-
culatioii in a »intill ca|üllary district, or in tlic parts supplied by one
Bmall arten-, aliould caus« actual decomposition ; under sucli ctreuin'
Btfliiu.w the diMurbauce of nutrition may assume a miUW fonn, expo*'
dully when this limited diMurbunce of circuliitton cuinea cm slowly
ftnd gruduully. In this cosc there is molecular diaintcgratioo of tiseite,
whifji shrinks aud dries to a yellow cheesy mass, in abort, ther« is a
series of ntctatnorphuses which in tlic radaTcr appear as dry, yellow
infarctionn j this is eSAenlially merely a sort of dry gangrene limited
to • smnll spot. If tins disturbance of nutrition and molecular diain«
tegratiun of tissue take place on a surüice, we call it vlcvr^tQn / the
whole M'ries uf so-called utuuio ulcer», to whiuli we »liall bcreaJter
rehir», arc mosUy due to i.uch «^iiantitntivc disturbance« of nutrition.
Hence, intiinitt«} as is the connection between the cause« of dry gan-
grene and ulceration, elill, the rariuus forms of gangrene aro ncU
nulted and peculiar, as you will see from what follows, as there is
generally not only molecular disintegration of tissue, but death of
whole shreds of tiasue, or even of an entire liniK A priori, it is cer-
tainly suppusuble that complete closure of all tho veins returning
bluod fruiD a lim)), slioulil indurc complete stasia in tlie caiüllnries ;
but io practice this is very unlikely to occur, for the TWiia are ao very
DuraeroU6, and in almost all parts of the body tbcre arc two waya Cor
PB0CBB8 or DXTACIIUENT.
29f
lio return of blood, vii., the deep and subcutaDenus veio-i, which
caniinunicatc fnc\y ; if oue way be closed, Uie other will lie ivt l«ast
[lurilv open. \\'Ii<;ii dry panpfrenc occurs in the skin and deeper noft
parts, th<!y usually ussuiiiv a gruyisli-liliick, then n ooal-hlac'k Luv. lu
cu«« witere the parts were previously inflamed, the skin ajipcar« ai
Grat dnrk Wulut, the» whiliäli yellow, it oiily becomes browni»]] or
grayish block in case of piirtiiil dryitig; dead tendotis aod faficiiB
obangc tli^ir color little. \V1ien, from distiirha.nce of the circulation, a
ooaaidcrahlc purtton of tis^uu ceasen to be nourished, the border be-
tween dead and living rc^larly becomes more dixtinetJy marked ;
amiind the dead skin there funiis a brig'ht-red line, the »M.'aUed fine
(^f denuirotüiOTt, Tliis rmlnoss ia cause«) by distention of the caiülhiry
veaacb, vhioh is partly due to collateral eireulation in them, partly to
fluxion induced by the deooinpowiij^ fluiilj«, and exaetly resembles tJie
rcdne»s around the cilges uf u wound with lossof substanee, e9ix.'cially
of a contuse^ »"oimd, a« wc bare alrcafly explain«!. Alonjrwith these
changes in the vessels Uktb is an aetiro cell-infiltration in thu line
of deinareation, by which the tis-sue, whatever its nature may be, is
portly softened and dis&olvcd. All over the borders of (lie living
Hsanc young cells in the fonn of pua appear in place of the lirm tissiUB,
and then the coherence of the part» cease». The dead beconiea de-
tached from ihc liviuj;, nnd on the horden of the latter there is a layer
of tissue changed by infiltration of phtstie matter and celasin of the
Teuels, gr^oulalions. To exjiress tliis simply in surgical language we
»ay; Tin.* dead tissue miwt lie thrown off from the living by free sup-
purutioD, aod this detachment of the dead ttisu« is followed by active
granulation« which ciuitHze in the usual manner. This prooesB repeaU
itself in all tissue», in nil forms of guugrcuc, sometimes quicker, some
times more slowly, in exactly the same way, ovod in hones, ns you
know from the necrosis of the ends of tho bunu in open fractures. But
we shall not here tre-it of gangrene of bones, aa it in so intimately
ooiioected with their othcrchrotiicdise&»es that weshallbaTe to speak
of it witcn treating of thorn. The time required far the detachment
of thu dead tissue may vary greatly. It de])e»ds : 1. On t)ie size of
the dead portion; 3. On the vascuhuity and consifitcnoc of tho tissue ;
On the strength and vitality of Iho patient.
As gangrene is usually the result of other diseases, it is not always
easy la correrlly group the symptoms which are to be referred to it.
If the line of demarcation has Formed, and the process of detachment
is going on, an vffect on tlic general health is apparent when the
gangrrne alTccls large extremities.. Then there is a getM^ral miiTasmiis.
a gradual lti«s of strength, dcprcssJoQ of the bodily temperature, small
pulse, dry tongue, a half-eoporose slate in which th« patient grows
8M
GAXGREN'a
wcslcer aud weaker, nnd luiolly «lies, witliotit our he^ag able to <]ia>
corcr iti the cuduvi^ nay piuiicutiu- L'uu^e of deatli, luUiouffh in utlicr .
cases piitriJ met«statiti ubeccssc^ nre fuuiid in llieliiitgs. These east«,
are one formof chromoBCptiöemia; 1 liave iiodoubt tliutthc repealed Ij
absoi-ption of putrid matters, during tlic dcrclopmcat of gaiigrcoe, bf]
the blood and Ij-mphatic oircutatioav,-hieb partly coutinue8,mnj be tbs
Cftuse of dcatli. I propose to retuni to tbia questioo io tbe next
Bcctioti.
After these general remarki^ we mutt $tw\y nH>re carefully tbe
different Tiu-ietieii uf gHD;rrene,uccofdis(|^ to tbeir remoto and. proai*
mate causes, and their practica] importance:
1. Complete loss of vitality of the tissue through mcduitueal or
ohefliicfd action, auch aa rrusliin|^, contusing, great heat or cold, caus-
tic acids and alkalies, onittlnucd contact vritb aimnoniacal urinr-, with
carbuDCulous poison, poiäoas frotii ccrtaia serpcutt), putrid mAtten
that act II» ferments, etc., coine «indcr tills hciuL Wc have alft-ad^,
spoken uf KOtnc of these vuneties; we shall shortly coine to otlicn of
them.
S, Complete arrest of the circulation, by circular compresüoo or
other niecbnnionT cause, is in many cases the cause of capillary stamfl-^
and gangrene. Fur inätatic«, if you stiTmund a limb ümily with a
bandage, you will hnro, first, venous congestion, then cedena«, uid
finally, gangrene. Lot us take a praetiol example: if the prepuce
be too sninll and be forcibly drawn back over the ghuis so u to
cause a parupluino^is, tho compressol glans, or in tbis case DM»
frequently the coinpreseiDg ring, beeonies gangreuuua. The moilifi»
cation of strangidatod herniB dept-oda on the same cause.
Coalinued pressure also, by arresting the afflux and efflux of blood,
may k'a<l lo gangrene, especially in pewons in whom tli« lienrl's aottoa
is weaken«! by long disease, or who by guucral KCptii; iuloxication
are already dispusod to gaogrcne.
JJecubitfUy the eo-eiilled bed-sore, is such » gangrene caused by
eontinited pressure, but all sorts of bed-sores are i>ot gangrenouB firotn
the tint, for in eoine cases tbey are latlior to be compared to
ft gradual tnnccr«tion of the epidermis and cutis, as a result of «OQ-
tinually lying in a bod wet with sweat, urine, and other liqulils. Xit^
cul»ttis is j»articulurly fi^-queut over the sacrum, nod may tberv attaia
a fearful tiize, all th« soft porta becoming gnogrcoouB down to tJie,
bone ; it may also occur over tiie heel, tbe trochaaten of tho femur,
bead of Ibc libiiln, soii]»uIa, or sjiinous processes of tbe Tcrtebm!^ ao-
cortling to the |}o&ttioii of ttic patient. Tie same thing may bo eaused
by badly-a|^liod dressings. Tliis disenso is the tnnre uopleaoant, as
it usually oome« during other exhausting affection». Although no
DECÜBITFS, GAKGR^XA SE.VIUS.
3»»
discnso in wbich the jnttcab is oandcmncd to long, absolute quiol, u
CTtirelj expmpt from ibe disagreeable MKompsuiuteul of a Jeoubilus,
BttU sfMnc peculiarljr dispoisc to it, diicf «mong which is lyphua; in
iticnts wilb scpticicmiu, di^cuhitu» ocours very narly,ofteii even after
to ßv« diiys of quiet ; it usually begins with a very oijvruinscribed
3iig««titin nf the sltin over the SÄeruni, while, with ]»ro[X'r c»r(\ con-
aniptire piitients keeptiicir ImmIs for luuiiths uryiun, witJiout haviiij^
Thüt (li»eiise is pnrlicularly truuhlvsome fur tlia patient, because,
ij in dironic maladies, it may be anoompaniccl by great pain ;
fieutc «ISC« of typhus and sopticiumia, on tho contrary, tlie patient«
BomKtmüs do not fool it at all whsn tlicy liave a Tery liirg«! bed-som.
This fonn of gangrene is particnUrly dangeruiia when tlic exciting
causes cannot be vntircly removed, ami it becomes progresaivc; the
prognmis i« wone the more exbnu8t«tl the patient ; not unfivquenilj
bed-sore 19 the cnuse of death, as it notttinucs to (yitargc in spite of
treatwicat, or it may be the origin of a fatal pytcmio.
Tbo great tension of the tissue, causing great distention of the
la, and compressing some of them, induces, on the one hand, a
nished amount of biriod, while the pathologi<-aJ requirement« of
nnfriment am inereaaed; on the other, a coagulation of blood iu tlie
kpülaries from the tncreased friction, TliLa ia the cause of gangrene
ring in inflammution, and whtcli we hare already inenlkiiied
rh/^n speaking of phk-gmnn, hut it must not be aaid tiuit every stasia
the blood in the capillaries that may occasionally occur iu inflam*
is to be referred to great tension of tlie tiaaucs, as tbcre are
other cau»cä. It would lead me too far to enter on theorie«,
Specially aa yon have already hciinl l-hcm in tit« coune on general
pathology. Moreover, we shall return t« thb when treating of tluont*
buÜB of the Teias.
8. ContpUteoTTVeto/tfietujjjJif of arterial Nood^whicU is particu-
lariy dne to diseases nf tlie heart and arteries, must alsn sometimes
lead to gangrene; in this cla»s bclmig tlione caHca of gangreoe
called ganynsna ipontatua, or oftener ffanffnmta aeniih, fmoi it«
more frequent occurrence in old jiersons; thU may ct>nie in various
ways and forms. The causes may vary tJiua: Tlio coagulation of
blood may begin in Ihe capillaries (mnrasmic thromboei« a« a restilt
of debility uf the heart, or insufficient roniluction tlirougfa the smaller
arteries), or as an independent thrombus of tho artiTy, or, lastly, s
thrombus from embolism; exoesairoi eootinuod anstmia also, vrilh
gii!at ooQsecutive oontraetion of the arteriea and debility of the heart,
and, lastly, continued spasmodio oontraetion of tiic arteries, may ia-
duoe gangrene Uangrecna senilis proper is u di*eaM originally oc>
m
GANGRENE.
oiuriog in the toes, rarely in iho 6ngen, m I oik« mw. There ««
two eiiiof formii: in one at Üiem a brown spot fomiB on one toe ; it
BOOD beooRioa black, mid grmdiially spreads till the wlrale loo hecotnes
oomplctclj dry. Id fuvoruhle c&»c« ft line of demarcation iottaa at
tlu> plmlurigo-metatarsal nrticulation, tlie toe falls off, and the wound
cicatrizes. But the muinmilication may go liiglier and t!niii itself in
tbe middle of the foot, above tl)c muUcoIi, in tlte middle of the Icf,
or just below tbe knee. 1» aiiuthcr series of «isi-s, the disMse b^
gins Willi sympboroa of indammolion, onlcniatous swelling of the toe^ ,
veiy great paiii, aud dark, bluisl^rod color, wliieb subsequently b»-]
oontcs blaok ; t]icre arc stages of the disease where, by the bli
mottled appearance of tiie akin, we inay see tliat in one place tbs d^*
culation is carried on with tlte greatest diCBculty, wbilc elsewhere U
lias already ceased ; this stnifiglc between life and death Oie Fretteh
buTc not inaptly compaied to death by asphyxia, and termod utpfitfria
tocaff. In this fosn of mnist, hot gangrene, tbe disease usually attarkl i
several toes at once, and extends to the foot, tili in tlte oourM of a
few weeks the entire foot, porlm|M nl»o llie leg, beoomea gnogicoo«;
nt tlic üamc time dooompcaition aoon bej^ns in the <.e<lemntitus 5a1>
eutaneotifl cellular timue, and the danger of absorption of putrid mat-
ter through the l^-mpliatic vessels is much greater than in the proeess
of mummification. The seatof thediBeaseortliearteriesthat leads to
spnntimenus gangrene raric« ; in aciUe (marnsmic) ffonffrtena aatilt»,
the primär)' coagulation due to fccWo circulation oecure In the capil-
laries and thence extends backward to the arteriös. TIhi feebleness
of tbe arterial circiihition may be due to various cnuaes: 1. To di>
nuDtshcd energy of tlie heart'» action; 2. To tbirkening of the walls ■
of the nrterie» and eoiitraction of their calibre; 3. To dog«nermtiaa
of the muscuUr coat of tbe smaller arteries. In »omc caacs all of
these causes unite, for, in old persons with feeble ]icart«ctioD, disease«
of the arteries are the most frequent ; liestdes, aßbctions of the beait j
and artcrieji usually have n common constilutJonal cause, "niis i» not)]
the place to discuss extensively how far rigidity and atbcmntn of ihit
coata of the artery are to be referred to inflamniation, or to bo re-
garded ns a iM-culinr disease; nor can I pennit myself lu discusa
further the distinctions of the finer liistologicul {»ints, of vrhicli we
shall have something to say when treating of aneurisms, but wiB
simply mention lliat in old persons tli« coats of the arteries are often
thickened, and deposits of chalk form in ihem tosuHi an extent that
the whole artery is calcified and the ealibre considerably diminii
by the thickening of tbe walls, and the inner surface lMH*omos rougll^]
so aa to dispose to the fixatkin of blood-clots. Hie original qualitioa|
of th« arteries are thus lost to such on extent tliat they arc neither
H
AßTERUL TDROllBOSia
801
tic DOT oontractilc, and licnco, parilv from tlio diininisliod calibre,
purtlv from the lack of contraciility, the onwnitl movement of the
blood, nlrvnily uiurcd less forcibly on account of tho fcebl« actio« of
the heart, i» rerj- much intpeded, so that it is eaay to auderstntxl how
coagulation occurs in such rasea, especially in parts dintanC from the
bcarL
While the castas just dcscnlied am with itome juittü>(> termod srnile
gao^rene, and tlieir connection with arterial discaws Iws In.'«! p^n-
erallj rrcognizrd ainco the timn of J>tipuyircfit (hern is another form
of spontaneous gangrene, vbich occurs in old persons, but is distin-
giOBbed from the above, because a large portion of an extremity, as
of the leg as hi^ as the calf or the knee, becomes gangrenous at onoe.
This takes place as folio«-« : In the chief artcrr, «aj tl>c femoral, nlong
the thigh or in the hollow of the knee, a firm elot forms and adheres
to tlie wall of the vessnl by rough prominmrps on the internal coal,
due to prvceclent atheromatous disease, or else forms in sao-Iike dila-
tations of the artery and gradually grows by nppoüition of new fibrine,
so as not only to fill the calibre of tlie artery, but to plug up the whole
peripheral end of the Teasel, and e\'eii ii [kmümi of the central end, by
the fibriuoitt clot. The consequence of this stoppage of the nriery by
a llirnmbus developing on the wall, which gradually arreats the col-
tattrai circuliition also, is usually gangrene of the whole foot and part
of the leg, which is dry or raoist according to the rapidity with wbidi
the clot luL.4 d>^velopf>d ; it is ooaurinnally possible to trace tlie grotrth
of the thrombus by the spread of the gangrene. Not lung since I
observed an old man, who was taken into the hospital for spontaneous
gai^rene of the foot. He wa» so thin and the arteries were so rigid
that the puLsalionsof the fcmoml could be distinctly followed into the
hollow of ttic knee, Subsequently the gangrene progressed, uikI at
the same time the pulsation in tlie lower part of the artery cM>aaed.
About a fortnight Inter, shortly bnfore death, when the gangrene had
advanced to the knee-joint, the pulsatioti bad ceaacd at Poupart's liga-
ment. The atitopxy confirmed the diagnons of nnmplete arterial
thrombosis. The gangnriious leg was so completely nmmniißed that I
cut it from the body, and, to prcserrc it from further destrurlion and
worms, raniishc«! it. It is still in the sui^cal museum at Zurich.
Another case of arterial tbmmbosis is where the primary stoppage
'of the artery- is caused by an embolus. A clot of fihrine, in endocarditis
or detached Crom an aneurismat sac, tnay beootne wedged in an arterjr
of one of the cKtrcmilit« ; this inditees further deposit of fibrine. Of
late, there is a tendenej' to refer most oosesof softening and desiccation,
OS of the In&iu, spleen, etc., to such emboli. In our clinic we saw a
interesting typical ease of this rariely. Six weeks aiter oonfin»
SOS
0.OIC1KENX.
ncntj ft yoimg woin»n had gttttt swelling of tlte toft l«fr, Triiicb wm
sooo followed by a dark-blue color of tbc »kio, md oonipk-t« patrda»
ticn of tlist part of iha boclj; thoro was gmprnl neptio jtmeouiag
•when llic paticut entered the hospiuJ. As tliere wa» no exceaaiv«
«nvmia, and no disease of t he arlerie» rould be discovered, I mode Ibe
dta^osisof PiidocanlilM-wilh Übritiousvei^Uitionsoa tbcmitnl valve,
and dctaclimcnt of one of tbtf«e wgt^tioiis, with it« lodgtncot at the
bifuKatioQ of ihu left popliteal nrtory. I held tu this dia^-nosis^ al-
though no abnomiBl murmur could be diHcuvcrcd, for it in well known
that soine cases of endocsrditi« iiia their oour»e almost without symp-
toms; the rapid putivfnrtion of tb(> lej^muAt have had a 8ud<l«i) caitsc.
As no line of deiii)irr»tk>ii fornieil, and llie geueial conditioo dail^
bvL'amc vrorae, we coultl liai'c no hopes of saving lifu by amputAting ;
death look place about twelve days after the first symptoms of gan-
grene; the autopsy fully conlinneil tho diagDoeie. It seeins remaik-
nblc that no enllatcral circulation »Imuld develop in such nuiee, aa
does after ligntion of the femoral artery. I can only explain thi» <
the ^ppofition that in endocarditis the heart's action is neakcDed,
and consequently ilie presaurc of the blood is insulTitieiit to dilute the
Bmallcr coUatcnd arteries.
Very turo are tlie eases where from oxccssivo atmniia Uic: :
are so muck contracted that but little blond ciirulates throtigb ibe '
smaller ones, and the nervous excitation of the heart is so «li^lit that
its eontmeliona are incomplete. Case«! of Hpontaneoua gangrene frota
this cause are more fr<viuent in slemler clilorotic females tlian in men ;
the patients, vrho are generally young, often suffer from li^dily of the
hands and fi^et, fuinting-lita, and fatigue. This dixnase «ppcnrs to
more frequent in Franee than in Gennuny or England. There is
cxcvUent work on the »abjcot by AaynuMdi entitled "Dc1*bs[)1ij
locale ct de la gangrene symfitriquo des extr^mitSs," 184>S. A» ii
plied by the title, the gangrene is usually symmetrical in tlic 1%
limb». I liave only sfcn one sueh case; a young, very anvmio
without any apparent caudi", bad tirst gan^prene of the tip of iJie
then of hotli feet. After sutTering for month«, he died ; as on Ibc
tient, so on the cadaver, I could Und nothing morbid beyond tlie ex-
cessive, inciplieable auiemia.
The fonn of gangrpiie Keen from eating spurred rye is referred to
permanent epasmoilic contraction of the smallt-T arteries; rxpcrieoo»!
hlio'vra that thi» 8iibf>tani^e induces contraction of the organic muftotili
fibres, e.4pe(>ifllly of tliosc of the uterus, and it is supposed of th«
uterine arteries alsa
J$purrt)J ryt^ ttcak comvtmny m a diveusvd grain growing in tj»
ear of ryo (sccnlo ceroalc), in whieh is developed a peculiar material,
SSGOTISkI, WATEB CANKER.
WW
etjjötin. If bread be made from such grain, persoiui ontiufT it are
affeclcd with peculiar »yinpioins, wbidi ai-c (vniprisod imdvr tbc tiame
erffirtisnWM or raphania. As the above <lisciusc of tbc groiu ia usuall/
limited to certain rv^ons, it maj be mulily tioderstuod tliat tfa« di«-
e^se »hould occur c|»ilcintt^lly in moo and beasts. It has Iweii k»o\ni
for a long lime, but the first aocurale descriptioos »re of an cpidctnia
in Fr»nce in 1630. The disease seems to have oocurrcti rarely- in
Gentiaay, Eiigluid, or lUlj,*. Of lat« it Iian]lj- ecer occurs, probably
becuMC tlto disawod grain la better kuovrti atid ia no kioger used lor
food, and becauM leu of the grain is grown sinco potatoes have oontc
iato cotntnoa use. From fonner descriptiotui, Tariom forms anil
coonea of the disease may be distin^iii<iheil, of which Minctiincs one
and sometimes another prevailed in the different epidemics; possibly
the poison is not alvrays the same, or is at least of variabie intensity.
In the acute cases, tbc patients were soon attacked with severe gOD-
end cfatops, and deatli n-suUed in from (out to eight days ; cramps
only ooeur occasionally; nt the sairo time, and prcriotisly in the pro-
dromal fiUgc, there are great itching and crawling in the skiu, but par>
tJcuIarly in the hands ; there is also a feeling of deafness, of ano^the»
•ia in the ends of the fingers, rsrcly moist g-.mgTend of the skin, then
of whoU; cxtremitiesL In more chronic cases, the result is usually
bronble, altlioujirh He7cral fin^n or toes may be lost.
4. Wc hare »till to speak of several forms of gangrene whose
(■uses arc nut t^xselly known, in whleh probably several iiifluenciQs
unite. Among these is so<-alk-d wnt«r-cankcr, uoma, a spontaneoot
g^gnmu of thu clieeks, especially common in children, which is most
frequent in dtie« along the Baltic, and more rare inland. Very puny
ehiMren, living in cold, ilatnp dwellings, are particularly prone to this
disease, in which, wilhoiil any knovra caufie, a gangrenous nodule
forma in the- middle of the oHcek or lip and sprraids rapidly till th«
child finally dies of exhaustion. It \a doubtful whether this is due to
aniemiawlth feebleness of the heart, tomiumatic influence, orto some
peculiar disease of the blood. In oooasional remarks about eepti*
enmia, wc have already stated that certain morbid states of the blood
predispose to gangrene. Under this cause we must cJass the coses
ooourriog after typhus, intermittent and exanthematuus fevers, in
diabetes mellitus, morbus Brightii, etc. After and during these dis-
eaMR, gangrene of the tip of the nose, of the ear, checks, hands, and
feet, occurs ; and in rare cases an exanthema of the sldn may pass into
gangrene. In such cases we may consider that the miasma wbieh has
ioducod the constitutional disease also infiuences the ooctirrcnoe of
the gangrene ; and, on the other side, tfaere seems reason for the idea
that theee eases we mo«lly the result of tcMe action of tho hcwt,
21
»M
0AS6REM.
Induced by the long illn««, whicl prove» iiieuflicieTit to carry tlic
blood to lire remote parts ot the body with sufficient cncrgj- ; *M;<;ord-
ia^ to this vicfr, ikis ganpese would be du« to marasinio cupilUty
thrombosU. Doubtless nriuiu drcuiiistnnccs act more or Ics« promi-
nentlf in individual «uo», » tlint no definite etiology can be given
for li>C3e nm: forms of gtngrtne fmm intenia] causes. I may aJflo
tneotioD tliat stomatitis, ftnm excessire use of hrtpuit, also Iiu k
great tendeficj- to ptngreue. Wc sliaJI hereafler »peak of n jtwuliar
form of gangrene of wound», tlic so-called hoi^ital gangrene.
Totere «re oertain important prophylactic rules for tbc prcveJitlcm
tgangrcoc, especially of deeubitua and other fornig due to pressuix; ;
^■©renÄWiÄ'W' from inflammation may 8onii>Umt's bo [irpverited, hyiv
Jtenag the great tension of tlie tl9»ue and tlie venous congesiion 1^
£D Inrinion nuiJo at the piopor ilmc. Be conEtantly on your guard
Against bed-«orpj in all discuses nt all dispoeed to decubitus; turn
your attention to Uii» point early: a wcll-stnffrd liorae-hnir mattress ü
the be»t »irk-bed; the sheets placed over it Ahoiild ulwnya he kept
amooth, eo Umt the patient shall not lie on wrinkles. A» soon as any
redness appt'ft« over Ilie »«rrun», you ah<niUI be doubly careful about
the paesuRes of urine and fteccs, so that Iht bed may not be wet. Let
n lemon be cut and the reddened «pot rubbed daily with tbe frcah juice
from tbc cut surface. If there be excoriation over the sacnun, place
iJic patient on a ring cushion, or, if poasible, on a caoutchouc, aJr, or
water eushion. Tlie ejicoriation may be painted with nitrate of silver,
or covered with leather spread witli lead-plaster. If the decubitus be
gangrenous from the first, and this begins to extend, we should rcaort
to the ordinär}- treatment of gangrene, of nkicli wc aliatl speak prcs-
catly.
T^t local trtatmetU o( gAngrvnehhstvro i:\nci obyeiM: 1. Topro-
mote detachment of the gangrenous pirt» by exeiting active »uppura-
lion, whii^li is acoompanicd by arrest of tbc gangrene ; 2. To prcveot
the gsngrenouB parts decomposing, and thus acting injuriously on tbe
patient, and infecting tlic chamber too much.
For the first indication, moist warmth i» the form of cataplasms
wa» formerly employed. But I eannot find tlint they are peculiarly
cBBcanous in these rosea. If tlie gangrene be moist and llie gangre-
nous parts are much iuclinedto decompose, this would only bo favored
br the applicftt'o" of catiiplasms ; for the detachment of a dry eschar,
u'bich doeü not smell badly, mid wlieii the line of demarcation is al-
ready formed, it is hardly worth while to hantei) the jiroces» a little
bv warmdi. Hence I prefer eovering the gangrenous pnrts and the
I
TREATTreST OF CIXGRE^IE.
m
«
bcKden of the healthy tütsue with compre^RM or charpi<>, «oaltetl in
cUoriiiP-wster, ami thun in moist ^»»f^reiit; I also dimiiiisb the bad
■mell of tho dcoomposinjf nibstAnco^ For tlie »»nie purpOM, wc m»y
Dae craosote-u'ater or cnrbolic acid, or dilute purilied p}ax>1ignv<ous
■rid, Tcry strong alcohol, spirit« of camphor, or oil of lurpcntiac.
Cbaioool-powdcr abeorba the gases {rotn the deconipoeing eubelanccs,
but, as it soils the parts vptv much, it IB perhaps too little used. Other
'Wcrful anti»cpiic-8 »re arctat<? of ahimina (alum 3 v« plumbum accti-
§j, aqua, Tb l),tu)d coal-tar with plaster; both remedies are
jy serviceable, but, tike all Kimllar one», miiitt bi! fn?ithly applied
several time* daily to remo\-u eiitin-ly tlie smell of thf dccuinposing
part«. Of late, pcnnanpuutc of potash (gr. x to ^ i wntcr) hnsbcca
grenlly praieed as a local antisopliu and distnfoctant ; I liave made
several triaU of it, but have found it far inferior to the remedies pre-
rioualy mcniioacd. Conceotrated »olutions of carl>r'lic arid in olire-
€ai (aay j ij to lb 1) caase syraptoms of poisoning (olive-green urine),
benoe tfiey should be ii8«d carefully. As soon as tlit) gangrenoua
maas has become somewhat detached, the shreds shouhl be removed
vitli the Bciasors, without cutUug iuto the healtliy parts ; thia in foz-
icularly important in gmigrone of the subcutaneous cellular tit^ue,
hieb is often extensive, ns after infillrntion of urine; at the same
Umu tbe local ontisvptim slioiJd be oouliuued till healthy {rntuulatiuna
art«e. Led liy the aniitoiTiioul oondilionx In i^>ntajieous gangrene, it
lias been advised to break up tbe ooagnilatioit of blcx>d, by stroldng
•od rubbing tbc limb ; from the pain and swclUag of the parts, this ia
t»r«ly practicable ; in cases where I hare had it done, it has bad ao
elTect on the progress of the gangrene.
If tiic gangrene affect a limb, as in the various forms of sponta-
leoua and senile gangrene, I strongly urge you not to do any opGra-
tioo till llie line of demarcation is distinct If there bo merely gan-
grenc of single teas leave their detschmcnt to Xature; if the whole
foot or leg be affected, do the amputation so tliat it may bo merely
an aid to the normal process of detachment, L e., on the borders of
the healthy parts you try to dissect up only enough skin to cover Uie
itump, and saw tbe bone as near as practicable to the line of demai^
cation. TliiiM you will occasionally succeed in avoiding a new out-
break of tlic gangrene, and in tut\'ing your patient's life. If the patient
dies before a distinct lin« of demarcation baa formed (as is fncquenÜy
the case), you need not reproach yourself for having neglocted nm-
putation, for you may rest assured that the patieot would liave ilied
even sooner if amputation bad been performed. The prognosis in
gangrene from internal causes (as the older surgeons termed tt) b
loendty batL
306 OANORENE.
The intenuU treatment should be etreagtheoing, in some cases
even Btimulant. Nourishing food, quinine, acids, and occasionally a
few doses of camphor, are proper. The severe pain in senile gan-
grene often calls for large doses of opium, or subcutaneous injection
of morphine. For gangrene in stomatitis, after poisoning by mercury,
ve hare no decided antidote ; the use of the mercurial should be at
once stopped; if mercurial salve has been employed, the patient
should be bathed, placed in a fresh, airy chamber, {»ttvided with clean
body and bedclothes, and have a gargle vrith chlorate of potash or
chlorine water. Nor have we any antidote for ergotin, which causes
raphania ; emetics, quinine, and carbonate of ammonia are chiefly reo
ommended. We could only put off the continued absorption of putrid
matter into the blood, by amputation ; but we have already mentioned
that this is a very precarious remedy in spontaneous gangrene.
CHAPTER Xin.
ACCIDE27TjiL THAUMATIC AXn IITFLAMMATOnT
IflSEASES, AXD POISOXEJ) WOUXßS.
LBCTUBK XXIV.
L X«c»l Dt*«wes vhicb may KVomiMUij Tound* uiil OÜi«r PotnU of InQwnmfttian:
1. PrO|[re«rive Parulenl «nil PuTuIjnt Putrid Diffuse InBMnmalioo or Cdloter
Tluao-'-S. IlocpiUl GDSgrvDe. — i. Trauniitic Erjaijitlu.— 4. LjiuphuifhUk
^V Gextlkubx; When speaking of traumAtic iaflamtnation, I told
you that it did not extend bej-ond Die bounds of the injury, and tliat
thii ms only nppiircnlly tlic cuse ulicii wv cwild not nvcurstely ex-
uoioe tbc injured part I still maiDtuiu tbe truth of \Kia. I3ut we
hkre already addüd that, from various accidents, cither imniudiat^ly
after tiie injury, as in cnntused irounds, tb«re may be veiy severe
progrcssiTC inSaminntioii, with putrefactioD, or that, later, Becoadarr
ioBatniDatioas mny dorclop around the olreudj gmniilntiiif^ «mind
I from cause which we müntioncKl at the timu (page 149). I mint oov
Icll roa tiiat ntUI another scries of peculiar partlj ioflnnunatarf, pattij
gaogienou* |)roc«s9cs ooeur in the wound, vhioh c&uae soriero, osuallj
Cereri«b, oonstitutionnl disoaM?«. SoniE> of tbe latter may also ooour
vitliout any thing peculiar being observable ii) ^le wound. I.Aatly»
mbataaocs may enter a wound already cxistiiiff, or at the time of ita
ooeonenoe (aa from tlte bit«.' of a puiounous or diseaHod aniiiuil), which
may induce both sevpre local inflaramatioa and general blood-poison-
ing. In this chapter I shall speak of all these things ; I will try to
give you a general riew of ibein. We tli»U Kpeak first of tho local
symptoms which acddentally aocompauy a wound, or an inflanunation
I other cauaea.
308
TBATTilATiO AND ßTLAMUATORy DISBASES, ETCL
t LOCAL DISBA8E8 WUICU MAY ACOOIIPANV WOüSDS AtTD OTBEB
POINTS OF I^■FLASIMAT10H.
1. For th« «nice of ruoiplctcne», we bete mention agoio pro^ies-
tivtf mnpumtivc and sauiopurulirnt difTuse inflamniBlion of tlic cellular
tissue. Putrid msiU-m which fvnii un fr«»b wound} DvBi gmagreoo
of the »orhoe* of tlic wound, and umy diffuse mpitUy i» ilie mcabe»
of the ecllulnr tiBsiu!, oceinooaltjr cause, on tbe Mcotid, third, or fourth
day, those forms of inflammaÜoo of tlio ooUular tissue that are chai^
acterizt-A hy npid decomposition of th« inflainnuitory product and hy
rapid «xt«nsioin. Sul»equently, when tliere is already suppurotion,
mechniiical trritutiou, foreign bodies, »truiig fluuOQ to the wound, or io-
fecüon of the wound mtb phlogo^nous subetaMjet, at any time wliile
the wound is open, may indue« phlegmonous suj^uration uiound the
woun<l. änm« of the ahore causi?a may ogam excite infUiniDaatkiQ,
and «11190 tlie apread of any nou- traumatic local intlamniatiott which
Vaa alr('adv healing. H«it>oval of lUe new causes of irritation, and
cooling the inflamed parts with ice, are Uie most im^mrtant tuoat rem*
edies in auch cases.
2. I>ipfUhtri<t of Wotmdt ; Mospital Gangrene, Gan^rcma
JS^oaoeomiali« / I*ourrit\ire dea Jlöpitaux. — I will first describe the
disease, then add a few reinurks alx>ut tha ctioli>|0r. At a certain
tinw we notice, especially in ho«pitnl$, that a number of woutxl«, a»
well tiioso tama reoent operations as thos« Üiat were grauulatJDg aod
cicatrnUDg, without known cause, become diseased in a peculiar maif
Bcr. In some cuaea the graoulatinj; »orfncv cbang«s partially or ett-
tiroly to a yellow smeary pulp, whidi tnny be washed off from the
nirboc, but more deeply it is firmly adlirrrnt. Tliis mctamorplioai»
extanda not only to the granulating eurfac«, but to the surrvutidiog-
skin wliieh was previoiwly hcnlthy, whieh Ix-eomes rosy-red ; tlii« also
animies a smeary yellotrish-gniy eolor, and i» from three to six days
the surbco of the original wound ulcnost doubles. The incnrose in
depth is less in th{> so-t^alted pufpotui form of hotspital gangrene, in
other canes a fresh wound, or a graiiuUtiiig surface, rapidly asauntea
ft enter shape, excrctea a scro-putrid fluid, after tlie removal of which
tbo tisauea lie exposed. Tlie sumiunding skin is slightly rcdd«iMil
The progress of this muIecuhiT diiuniegralion to thin Ichor is usually
in afaarplycut cin'lcs, so that the wound may acquire a horseshoe or
trefoil shape. This uleavm fonn of ho«pital gangrene progrcaeca
more rapidly thiin tlie pulpuus, and extends with eapecial rapidity in
deptft. Allliougfa both of the aboro foTTDB oocBatonally occur se|M>
ratcly, they arc also seen in combinatioo. I hare sceD the pidpoua
furm oftencr than the ulocrous, but acknowledge tlutt my indiridtial
oxperioDce of diphtheria of wounds Is based on a small number ul ob*
HOSPIT.it GAXGREXE.
19. Hospital gatiif^iie does not attack chiefly \uge wooads,
ntliLT iiisij^iifiuiiit iujiiri«8, sucli aa Ivvcli-bitus, cut-cu|u, erco
the portions of skin d«»ii(l*xl by A bliiter, wbilc it never occurs on an
niDinjured patt of tlie skin. Tlie rf-itt^mbluiioe to dipblhvritic iQltumnu-
tJOD of the tnucunus niL-nibraacs 15 vtiy »triking in aomc castas. Thero
ace at tlie same time constitutional symptoms: at first tbo IVjvcr ü aot
generally iwrere, but then* is mare ur less f^astric affection^ tbe tonguo
is coated, tliere is iiiclination to vomil^ and general depression. The
diaeaar. may prorc dangerous to old or debilitated pcrsoDS, c^MidaUy
if it eats away small nrteric» und t^uiipa iLrt«rial hnmiorrbagc. The
targe «rteries often resist bospita) giuiffrem.* wonderfully. I once saw
a man, for wbom an inj^uinal uhscoss bad been opened, attacked by tbc
pulpoiu form of the disease ; the skin of the |>Toin to about tba size of
tbe hand was destroyed; the disease had adraiteed so deep tliat about
an inch and a half of I he femoral nrlvry lay exposed in the wound,
and ooald be distinctly s«cn pulsating. I detailed a nurse to stay
with tbe patient eonstaotly, and to make instant compression if bleed-
Log shoidd occur, as it might at any moment. TIio pulp was tlirowu
off, the wound granulated rapidly, and complete recovery took plnc^
though not for a lonj? time.
Views as to the causes of boMpttal gaiigrrne I'ary; this is chie6y
because many living surgeons hare had the good or bad fortun« norcr
to have seen the disease ; Uius in Zurich it bus ne\'er licen seen, la
hia maxims on military surgery Stromey«r states, as a 1,-ouiig pbysiciao
in tbu Berlin Cbarit^, be hod only seen one caao of hoejntal gaiigreo&
Sttrgeoos who hare not scon tliis di-'tcosc, or have only s««a sporadio
eases, think it is due tu groBs nt-glect, dirty dressings, etCL, and regard
it 88 little more than an ulocr of the leg that ba« superficially become
gangrenoua from dirt and neglect. Other surgeons suppoee that hos-
pital gangrene is, as the name would indicate, a disease peculiar to
some hospitabi, and tlint its oceiirrcnec is oidy promoted by neglect
of the dresBingSk Lastly, a third view ia that this form of gangrene itt
due to epidemic inlluences, and that ita name is in so far incorrect, as
it occurs outsidv uwl tnüide of hn^pitals at tltc same time. In the
hospitala it probabiy sprunds by inocubitien, IW 1 do not doubt that
matter may bo carried from gnugreDOiis to bcaltliy wounds, by forceps,
dhsrpte, sponges, etc., and there excite tbe disease. Von J^itha and
/^Tclr have expressed tbe belief tliat it is an cindcniic-miaamatte dis-
esfte. In the surgical clinic at BtTlin with ForJ: I oluerredanppidrmie-,
while tlie disoaio was seen, not only in other hospitals in Berlin, but
in the city, in patients whn oould not be proved (o bavo hud any thing
to do with a hospital. The disease appeared very suddenly, and en-
tirely difiuppuarad in a few months, although the treatment of tho
sto
TItmUTIC AND INFLAUJIATOBY DISEASES, ETO.
WOUDcis had not been at all chanf^cd, nor could anv changes bo mad«
in the hospital itself. I'his sc^ms to show tbot tli(> cnuKt« do not lie
in til« bos[)its] iLsclf. Epidemic tio»pit»1 gitn{^-tii* inig^it uccur from
certain smull or^nisnis, wbidi ar« rareljr developed, n-hjck, like u fef
mcnt, induce decompoaittoo iu tbu wound and gniiiulatiDg tissue^
hence I should preferably compare this disc4i8C' of vruunds with blue
«oppuDition, which causes no injury to tlic wounde, but, aicconling to
JjQckc, like blue iDtlk, is caused by small orgnnisms and can infect
other woiinda. The requirements for the growth of these Rniall bodies
arc probably purticulnrlj- favortrd by oertuin «Imosphciic iufluenrcs,
hence the discaeo spreads epidemically. All this is hypotbcsia ; but
it is certain that the transfer of bos|)ituI gaiigretic pulp or putrid mat'
ter to hcnlthy wounds usually (always, according to fHtrker) induce«
hospital ganjn^nr, and this is wry iin{Kirlant iu practice. From my
recent exgwricDCC in the Vienna GcncrBl Hospital, I am nioro and moro
convinc«^ that this dise-ase rexnlts frrxn Rpeciüc cautu;«, entirely ind^
peiidcntly of py:emi:i, septicjcniia, (^ryxi peius and lymphangitis, although
it may I« Adtowcd l»y citlicr of thrüc diseases.
The first point in the treatment is strict iM>liittoin of the patienU,
who should have special nurses, dressings, and instruments. If this
docs not entirely prevent tlie spread of Uic disease, as tlie contagioD
may posaibty be curried by the air from a diseased to a healthy
wound, EtlU experience shows that It interferes with tlie spread, la
some epidemics in military hospitals it was necessary entirely to to*
cote certain localitjc». Locally wc should apply strong chlorine- water,
or spirits of camphor or tuqientine, to these wounds. If thifl does not
answer, wc may cnutense with cAintio potash. If this also prove in-
effectual, it haa been recommended to bum tlie wound down to the
healthy tiaauc, so that the slough shall remiiin attached six or eight
days, as in a heatltliy woiinrl. I find it just as effei'tual to cauterize
the wounds with fuming nitnc acid or airbolic acid, Iiut these cauterii»
tions «1*0 should extend to the hpalthy borders of the wnund, and be
repeated till iho slough rcmniiis adherenl. The gencr«! trL'Ktnient
ehoiilJ be strengthening, or even stimulant. The fever occurring in
hospital gangrene is due to rcabsorption of putrid matter, and does
not differ from other forms of putrid ferer.
3. J^rj/sipelaa tntumatinum. Krj-sipelas, as previously mentioned
(page 250), is classed among the acute exanthematii, and is cliaxnc-
tetiseed In' a diffuse swelling, rosy redness of the akin, and pain, as
well a« by the accompanying fever, which is nstially severe. Erysip-
elas has a peculiar relution to the otlier exunlhemnta; on the one
hand, because it often accompanies wounds, although it may appar-
ently come spontaneously ; on the other hand, because it does not
ERYSIPELAS TRAÜÄATtCTIir.
Sil
^enerallj spresd by such aii intense oontagion m metsles, scarlatina,
•«tc ; Isstljr, also, because, Tchca onv has had tliU disease, bo is not
^miy not safe from another utUt'k of it, but iii sonu> <Hts«s is cri'ii pecu-
liarlj prediajMis«^ to it. As I daro liurdljr assume that you have al-
Teady studio^ äkin-diBcnBcs caicfuUy, nc will here brielly review (bo
«ymptonu ef this disease.
Its «iminencemcnt ni»y vary by the fever preceding llie exantltenui,
or by tiieir simiiltAiicous «ppi.'amiice. Siip|]U!tt; you hu>'v a patient
wiüt a siippuratinjif wound of the head, and, after he has been prcvi«
ously mil, atul the wound u-as healinf* nirtly, you find him with high
fever, which may have been preceded by a chill ; you exatnioe the pa-
tient, and can find nothing but some gastric demngement, as evinced
by a coated tongue, bad taste in tbe mouth, nnusea, aod loas of appe-
tite. This titate is present at the onset of so many acute diseases,
tltat yoti cannot at oho« make a diagnosis. UeaidM tlie poaaibility of
•R accidental oomplicatlon with any acute internal disease, you would
think of pbldgmon, ly mphaugttia, and erysipelas, Perhaps twcnty^nir
hours later you find the wouimI dry, discharging a little serous secre-
tion ; for some dtstaneo around there arc tiwelling, nslness, and pain,
or the granulatioas are Iftrge, snollcii, and croupous ; the redness of the
akin is of a rosy hue and everywhere eharpiy b<n»ndcd^ the fever is
still tolerably intense ; now the diagnosis of erysipelas cannot be mis-
takco, and we arc well mntent that wc have to deal with a disease
which, alÜKiugh iKit free from danger, is one of tt>c less dangerous of
the tnumalio diseases. In a second series of cases tJie erysipelas ap-
pears with the fever. We may for a brief period doubt whether tbe
case be one of lymphangitis, iuflammation of t)>ä subcutaneous celluUr
tissue, or of erysipelas ; but the course of the disease will tioon show
thia; (he extent tliat tbe erysijielatous iiifUmmutiuii of the skin has
tbe first day rarely rcmaios the sbidc, but it usually apmuls farther
and &rther, in such a way that the rounded, tongue-nhnped, projcet-
ing IxndefB of the inflamed skin are olwiiys shar]>ly txiuiided, and we
oao aocoratcly follow its removal from one »ide to the other ; in many
oases the redness advances like fluid in bibulous paper. Thiis the
prooe— may extend &om the bead to the neck, thence to the shoul-
dm, nr the anterior part of the trunk, or rvca pass dutvn the arm,
aud finally may even reach the lower extremities. As long as the
erysipelas spreads in this way, the fever usually remains at tbe same
hdgfai, and thus old or debilitated persona arc readily exhaiist4xl.
Mo«t c*ies last from two to ten days ; it is rare for one to continue
over a (^rtnigbt ; the most protroctctl case I have seen was cxie last*
ing tturtytwo days, and recovering. In this «rytipflaa ambulam or
Ml]»»« you will notice that the same gmdc of itiflammatioa of tbe
81S
TIUUHATIC AND IXFIAUUATORY DISEASES, ETC.
lUcln onlj coDtinues a ccrUin length uf time inonepla««, sotlist, wlieD
tlic i^rvsi|H^tiui ad^'B.nccs, tlic whole Buriooe is nnt iiiflamed nt once, but
unly a port nt u lime U at tbe acrae of the local inaammntioa.
Aflur tlic inflanimntion has remained at tlie mliiic point uhout
three (lays, th« rt'diu'ss grow» Ic&a, the Rkin deMjiinniutti), pailly ns a
bran-like powder, or in scolcs oiid inga of epidvrmijk Id eume cascG>,
even nt the coinmi'iiwrnoiit of the erjitipoia?, the epidonnis rises in
Tesicles, which arc 61led with serum {^erytipciaa trutlomtm). Bm this
cryBipt.*las tit not a peculiar form of the disease; it oaly indicaten rapid
exudiUiotl. We not un&cquontly see resides appear on the fae» in
Hysipel&s, while on tlie rest of tlie body the disease has the usual
form. If erj'sipelos attack» the scnlp, llie hair often fall», hut grows
again quickly. According to my experience, the diseiuie ia most fre-
quent on the lowor limhs, then oil the fnee, upper extremitii^«, breast
and hack, hc»d, neck, and helly, 'I'liia scale of frequeney probably
depcnda on the proportiooatc numbers of injuries in tlic different porta
of the body.
ErvsilH'Ias, like other exantbem:nta, may be aceompanied by TEri>
ous iutcninl diseases, as pleurisy, unci cryjtipKlit» c»])iti& by menio^tia;
but, on tho whole, these complicntions are rare, and vrltcn they occur
arc usually a n-xult of the diw^ns« ad^nneing to the deeper parts.
The course of erysiiwlasisiisuiilly favorable. Of one hundreil and
thirty-seven cases of the uacooiplicated diseatH,*, which I obei-rred m
Zuricii, ten died ; children, old pcreons, and [HLlicnts de))ilitate<l by
previous dise&se, are moRt endangered, and, according to my experi-
cnoc, they usually die of exliaiislion from the continued fever; on
autopity, we find no renmikablo i^liango of any orgnn that «m be re-
garded as the cHU»e of death. Cloudy swelling-, and partUd granular
dcgcnctatiou of the liver, kidney», and epithelium, and sofbie»s of the
aplsen, ore found in cnses of fatal er}-sip(>lu8, as after all intense blood-
diseaKeK. Tlie natiu« of prysijjelas is not fully understood, a.i its cause
anri the mode of Its ])rogrcs» are not quite clear. DilatAÜon of tJie
capillaries of the cutis, serous exudation in the tissue itself, and on
active development of the cells of the rete Mnlpigliii are nil we cau
find aniitorniiraf/!/. 'I'lre disciute rarely eitciids to the stibcutaocouH
cellular tissue; it is true, this swells euuniiously iu sooie places, as
in tlH* eyelids and scrotum, being pfreal.ly saturated with serm» ; but,
iu most cases, thi» u-dcinii recedes nilhout uuy sequehe. In rare cases
this (edema attains such a f^de that, as a result of ibegreat diftention
of tissue, the eirculntioti of blood is arrL-gted, and the parts (as the eye-
lids) may become wholly or partly gsngTvoioua. Should all ihe ekio
of an upper or tower eyelid be lost in this way, it would cause great
deformity; hut usually only small portions mortify, and, in the tipper
KRTSITELAS TRAüMATlCtTM.
SU
lid particulsrlj', the »kin u my plenty in most persons, that the defect
is subsequently but little noticed. In other cases, aflcr the sub&idciicc
of the erysipelatous inflaiiitiiutiuD there remain« a sw<^lliD^ of the sub-
outaneou» tissue, in which wc may distinctly feel fluctuutioD, and by
iociöion ^nay cracusie pua.
The causes of erysipeln« evidently v«ry ; that occurring without a
woumi, spuuluut-oits «rrsipcUs capilis, is Kitd locomc most frequently
skiter catdiing cnl<l. Some old persons arc siiid tu Iiuvv this disease
every year, in spring or autumn ; psychical iiiflu(;iicc» ato olfio bhimed
tor it, cepeclAlIy tvrrur, particuhirly in womeu during their menscMi.
X cannot Touch fur the latter, but think it may b<>long to medical
'traditions. Distuibunccs of digestion ore abo regarded as causes.
X very much doubt whether erysipelas ever de%-olop8 without starting
from a vound or previoiuly-exiAting iiin«niiiiatioii, Erysipelas may
xesult from retention of the secretion of a wound, and consequent
xe«beorption of a »liglit amount of putrid substance, in which case
ät IS so much like lyni])Iiungitis that at tlie commencement it is often
difficult to distinguish the two diseases. In many sporadio cases no
<ie6nite cause can be found ; in other cases epidemic tulluencea wem to
cooieintoplay, Carat the same time a large number of wounded patient«
are attacked by tJie disrCase. Crowding such pntients in badlyvcnti-
lated places also develops a contagion, conceniiug which wt; are
doubtful if it acts only on wounds, <v, being tnkeu in by the lungs,
may iodtx» erysipelas iu the wuuinl; the Ulter is not ivry probable.
FVota what I have seen of erysipelas traumaticum» my idea of
Cijsipelaji is as follows : I consider the local affection as an intlamma*
tioa of the oiiti«, in wliich the inflaninmtory iiritatiou grnduallj
i^Kcads through the lynipliatio ncl-works ; Üie way in which the in*
flsmmatory redness spreads, and is sharply boundoil, shows poetitJrely
that the prooess is limited to the vascular di»tricU ; by close obserra*
tion wc may see that very often, cloetu tu the border of the redncas,
Ibero form» a rod, round spot, at fu^t circumscribed, which soon
unites with the previously-reddened portiuus of skin ; tbesa oewly-
foraiing red spot« evidently icprrscnt vascular diEtricts; wc »ce
something aiimlar when we inject the skin tlirough au artery ; tjieo,
too, the color bom the injection fiist appears in 8pot«,aud oidy uniles
wben faesTy pressure is made ou the sjTinge ; now, as the venous nad
lymphatie districts in the skin arc to some extent aoalogous to tlic
arterial, the irritating poison causing tlie dilatation of the blood.
vessels might circidate in one of these trocls. Tlie «rteriul and
Teoous tracts in the cutis hare few connecting branthea paiall«! to the
Buriace, while the lymph»! Jc ve».H.^1s have very many, and but few
bnocbes going down into the subcutaneous tisBus \ thus the exciting
31-i TRACMATIO AXD IKFL.*HMaTORY DISEASES, ETC
pot50Q mar K-adily lipivud Bujwrfiuinlly in tbe cutU, like liquid in bibu>
lous psptT, bill it bIso cnlcra th« mibcutanrou» l^-nipliatii-s, and often
citusca iiillBinmiitk)n there, as well as in iJie iicipflibonn^ lymphatic
^ndif, striated rcdnc« of thn Hkin, and swelling of the adjuent
IjtnphstiR glands. >\'Tieii I here speaV oi a septic or other simiJw
poison «s a cau« of eryiiipclaSx I refer only to tmuoiatic erysi^xrla«,
for I think I have Mtisfic<l mys«lf, by observation, liiat thi« is alwuy»
of toxic ori^ii. Concerning Ihw nature of thia poison, I may say :
1, It i» chiefly blood mixed with drcompoHing secretion from the
»vound timt indnoca cn-sipek», irliich then appcttrs the a-M^nd op
third day after the injury or oi>orntion. 2, There i» probably a dry,
ditst-liko »ulwtanoe, which, coming on the wounds, whetber fresh or
gmnuliiting, miiflcs msipclas; this substance cling» especiiilly to
sponges nod drest^iiigs. T b«v© often obseri'ed that patieiitii opcrntcd
on after each other, nuder the? same circumstaDeeg, in tlie same
operating' room, all lind erysipehui on the fresh vrouuds a few houra
afltr Üie operation, without retention of secretion from the wound,
ftHhoiigli they lay in perfectly «epnmte warils of the hospital. Kry-
sSpelas thus liecomea dotpesticutcd in the hospilul; the iiif(?ctitig a«l>
stance may be transported on the clothes of the surgrxtns inakiiig the
dressing», it may adhere to inatrumentB, beds, or even to the walls.
The more accurately I esainineil ilie oases of erj-fiipelfU in the Ztlrich
hospital, and in my rttiiii: in VieiiTi», the more evident is its on^uf
rence iu groups — an oceurrenoe entirely independent of all otlier
morbid iiifluem-es outside of the hospital. From Elatifitics during
two years, supported by »•cirttrihn lions from the physicians of the
CuntoD Zurich, I have found tbnt during that tine eryaipelaa liad not
occurred epidemically in tlic country or city, but that, like other
acute diseases, it was particularly frequent in autumn and 8]}ring;
hence erysipelas epidemics in boepita] must defiend on circumstances
that are to be sought in the hospital itself, and whicb I have already
indicatetl. Here arises the question, whether the poison whieb cxoiteB
cr^'^pclaa is always the same, whether it is specific. This eannot be
aeeurntely answered : in itg farior iti the fnet that the form of the cu-
taneous inflammation induced is alwHya the same, although varying
in intensity and extent ; agalnai it wo may say tJiat erysipelas is
probably caused by various kindt of putrefaction, by miasma, per-
haps, also, by some animal poisons. Possibly in all of these poison-
ous substances there might be one certain material wliieli induced
«rysipclas, particularly a variety of mnterial which liiid a specific affin-
ity for ibc lymphatic vessels of tlie skin; it nnist be acknowledged
tJial, under ccrlnin cirnimstanecs, existing at some particular time,
such a materia] may develop more ivadily and cxtcnsivcJy than at
BB'reiPELAS TRÄUHATICÜIL
315
other time«. Hie <Uft«a»e always begins witli a rapidl^'-iocreasing
f«vcr, whidi «jiitiauM m luu^ as tbc eruption lusts ; it maj he cither
r<eiuilt«tit or continued, soaivltmcs tcnuiiuitea nitli critical sytuptouia,
aometimes gndaaWy, I haw no extensiire cxpcrienoe of the Ko-cnlled
idiopatliic erysipelas otpitis et läciei; rroiii vrbat I bave »eeu, it secuu
Ao me wry prvbaUlc tb«t tliis «bo start« froi» aligbt wouiuLi (cscoriu-
lions «a tbe bcuil or face) or iiiflamntalion» (nasal catarrh, angitta),
ia also cbivQr cif toxic origin.
Tho tnatmtnt of cryaipc-las ia chiefly expectant. Wc may try
bylflxia, by can'fiill}' clc-nnsii)]; tlio wound, and thus keeping off
every thing thiit can favor the occurrence of ei^'sipelas; aud, when
sCTCEal rases occur in boepital, wo should carefully guard against too
nany of them boing io one ward, and ocx^aaiooaUy some of tbe wards
shonlcl bo entirely racated and ventilated for a time, to prevent the
derclopmeDt of a more intense erysipelas contagion (littte as vre cor-
^t^inly know of it),
^^^ Ac to tbe local treatment, a aerie» of remedies has been tried to
^flnirout tbc advance of tli« erysipclatous ioflimunatiun and arre^l tbe
iUMft»e at it« commciioeinent. For tliis purpoec wc oircumsorilw the
borders with a »tick of moist nitr.*tu of silver or with Htrong tincture
of iodine. According to my cxpcrieuop, this docs Ultl« gwud, bo tliat
of Uto I have entirely left off this treatment. Older physician«
tbou^t that coid miglit force the (nitaneous iiitlummutioii buck, aud
thus greatly £iTor iiidanimation of the internal organs. /VlllfOugli
this cannot be regarded aa proved, a «ericB of (acta renders tbo use of
oold apparently unadvisable. We have already mentioned that the
occasionally great oedeiiia may induuc gangrene, wliicli of course would
be greatly fiivured by intense oold; and the application of bladders
of ion to a large surface, as to tbc bock or tbc whole fnce, is scarcely
pnctioabte; lastly, tbe cold does oo good, aa.in si>ite of It tlio dis-
ease runs its ty^ncal oour»c, for bete aUnoett more than in any other
inflammatioa tho local process and general infection go hand in
hand. In tbe aflccted skin the patient has a disagreeable tension,
a slight burning, as well ss great sensitiveness to draughts or other
obanges of temperature. Hence it is advisable to cover the diseased
skin and protect it from the air. Tliia may be done in varJoua ways :
tbe simplest, whicli 1 usually employ, is to smear the Buiface with oil
and apply wadding ; tbc patients are gettemlly satisfied with thi&.
Olbeia sprinkle tlie inflamed skiit witli flour or powder, or scatter
findy-rulibeil campbor iii ttm wiuldiug lbi(t is to be applied, tliiaking
thus to act specially on tbe local process. If vosiclos fom, tbey sboukl
be opened with fine ueedle-punctures, and tho loosened epidermis be
left to diy. If gangrene develop anywhere, moist wunuth iu the
sie
TBACMATIC AKD INFLAMMATOBV DISKASES, Eta
tona oF roni<.'nl«tiotis or poulUoes bEiduIcI bc npplk-d tili tlie eBcha.rliaa
dctACJicd aii<l Iicftithy siippuniti.>n bfpjn, which is thtm {avcrcd by
dresKings of vlmrpic dipittt] in diI<iriiR--wätc'r. If, ofler orj'sipelas,
nbsccsM-s form in the Bubcutanpoua tissuo, thcy shoult] bc opirncd o«riy
and lrpat<?d like any suppuratinc wound.
Among ihn internal reniedios, wo ]mvß una ivliicli may perhaps
arrent tlie cierelopment of nomn casrs nf the disease If in slrony,
oÜierwbc liculthy ]xmoils, in mIkmh the gasUio nymptoniEt are vvry
proniiiK'iit, WC give an enietir, Ihp advanoe of the errsipolas is often
check««]. Tili« is not «Iwoliitelj reliable, but you may try it in suit-
ablccBses. Bubscqucntly you employ only tlieordiiiarycooltngrenie-
die*. If iymptoms of debility show themsolves oml the diipnBP drag
OD, you kIiliuIJ begin \rith touics and xtiiniilant« ; you may daily (five
a few grains of cnmpbor or quinine, or sotnv wine.
Tbo infiammations of internal organs occasionnlly complic&ling
en'sipelBH are to be treated {ej/e arti», and in in(;niiigitis you must not
bc afraid to kprp n bladder of ice eonstnntlv or the head, cxvn if the
BC&lp is uffccUid by the crvsipclatous inflauiaiation.
4. Jjifiammaiion of the lymphatic vesaeU {fympfianffitis), aolual
Inflam mill ion of the lymphatio vessel», occasionally occurs In the «x«
trcmiitics under rariuus ciroumstunccs, whidi will be nieationed im-
mediately. The symptoms, in tho arm for inslnnop, arc as follow«:
Then* is a wound of the hand ; the whole ami bt'comes painful, e«p«-
clally on motion ; the axillnty glands swell and are scnsilire, vren on
tho slightest touch. If wc Inspect the arm «irefully.wc find rw] stritp,
espedally on the flexor «iile, running longitudinally from tin- wound
kiwnid tlie gland» ; thcM reddened portions of skin nre very scdbi-
Wvc, At the same time tJicre is fever, often a coated tongue, nausea,
loss of appetite, and general depression. The tennination may be in
one of two direction»: under proper care and treatment, there is gen-
enüly resolution of the iiillnmnuition j tbe »trite gradually diaapiiear,
as do also the swelling and pain of the »siilary glmids; liie fever
censes at tbc snnie time. In other cases there is suppuration ; the
skin of tbc ann reddens ^n^duully and cKlensively in a few days and
becomes («lomatous. The swelling of the axillar}' glands ioereases,
the ^-«r becomes greater, and there may even be diilU. In a few
days Buetuation occurs, most frequmtly in the axilla, occasionally flae-
where in tlio arm, the abscess opens spontaoeously or is incised, and
pus, Bucl» as is usually contained in a cirminseribed abacesB, is eraci^
ated Then ilie fever sulwiiles, a« do also the pnin and swelling;
and the potieot speedily recover» from bit diswise, which is often very
pninfiil and trouhlesome- The termination is not always sofhvonible;
but, in lytnpluingitis from poisoned wvunds, pyitiaio is occaaianaUj'
LTJIi'DAXGITIS.
ai»
cleve1(^>eil, in Uie subaeulc fortn most fr«({ueatlr; of this RKirc here«
after. In one case with lymphan^tia of thr 1«^, wlii-re tliv patient
"hmd dirouic iolIiiiniuaLiua of the klJiievH at tbe iMkiiic> timt^ I ann* tliv iu-
f^imJ glandü nith tbt> superjncnnt .ilcin txM'oine ßnTi|;ri>i>uiift,nrtcrthcj'
liad bee« eiitwiiwuwly swolVii. Tliis teniiiiiutSon iavfryran.', nltbough
-the pus in these iniLimm&tioiis of tbc lym^jtiutic tcsscIa, rspcrially
after [)oi»>nin<^ with «ulavcrii; tiuittcr, is occftsioDalli' putrid in cbar-
scter. Acute inflatniiuitiou of tb« l^rmphatio fflanils^ tenuinatingiR
resolation or suppuration, ocxura oa an idiopathic discwie; in such
<maf-M vre cannot aec the conncudnn, by red lines along the I^inphatini,
Iwtwi-vii a wound, or another point of inflammation, and the Ijinphst-
ic glands ; this may be bn.'nuac only tlie eupcrfieiiil vesseht appear as
red oords in the tkJn, while the deeper one», «veu when inflamed, are
not recognizable tu the sight or touch. Heriee in the patient we only
know superficial lytnpbungitia. One of the peculiaritira of iIiir diA-
ease is, that when it o.'oars io the extremities it rarely exteudä be-
yond (he nxillary or inguinal glnnds. Onoe in a casf> of lymphangilJa
of tbe ann anil adenilLs of tlm axilla I saw pleurisy occur on the
Buneaidc, which ]XM»ibly tuay huTe ^esulu^l Jroin extension of the in-
flammatioit through the lymphatic vpssels.
Wo Tcnow Tery little of tJie palliological anstoiny of lyinphan^tis
of the subeulaneous tissue, soarcely more tlian wo cao sec with the
nulled Gvo on the patient, for this diaease is seareely ever fata) when
it ordy attacks the lymphatic veasek, and in aDimals it can only be
Ycry iniperfoctlj induced by experiment. The cellular tissuo imme-
diately around the Ijmpbatio reasels is deddedly iraplicatod, the
capillaries dilated ami distended wit^ blood. Wo cannot decide
whether the lymphatic vessel is uhstnictcd in the later stages by
ouagulating lymph, or whether eoagula form in the lymph at iho start
and irritate the walls of the vosAels. tf we may transfer the obser-
Tatjwu on uterine lymphangitis, which so often occure to puerperal
fever, to th« skin, in ccrtaiu stages there is pure pus ia the dilated
lymphatic vessels; tbe vicinity of these vessels ia tnfiltmted with
senim and plastic matter; the plastic infiltntion of tlie oelliilar tiasoe
incieaäcs to suppuratirc iuliltraticD, ur even to fonnation of nbsocss,
in which the thin-walled lymphatic vesRelg tiiem»clvea disappear; the
finer the net-work of lymphatic vesseh, tbe niore difficult it is to dis-
tinguish lymphanptia from inSanunation of the oeUuIar tissue. I^Vom
the illustrations of Cr\tneiUii>r (Allan, I,ivro 13, PI. 2 and 3), we may
derive an idea of puerpernl lymphangitis, ttnd carry this to the same
affections in other jiarts. The red striiD that wc sec in tho skin can
only be caused by dilatation of the hlood-vcesels araund the lyniphatice,
not by blood forcing it« way into the latter; henee in patienta vra
318
TRADIUTIC AXD ISn.AMMATuRY DISEASKS. ETC
reall^r see the symptoma of pcritynip)i»ngitiü imluced hy contact with
the iK>i»oi] sLr«aiuiii|f in Uic Ijuipbalk rcNicla. Wu luiuu- Uie clumg«»
in the lympltatia jftuncla rattier better. In tlirm ihc. %'ftft$4>U 111«
muoli distendtsl, ami ihe wliole tbsue greatly iiifillratul with »eruni;
quuntitics of celU &Ü tlie ulveuli tensely, vrliiuh prububJy at first im-
pedes nod finally urcsts iiItO|i;cll>6r the movempnt of the lymph in tt«
gland ; this bluoUiiig up of the gland will to some extviit prevent the
ext^'nsioti of the morbid procca«.
L.ymphuigitis may occur ia any vronnd or point of inllummtt-
lioii ; but in tny opinion it is always the result nf irrritation from a,
poison pauiiig' through tlic lyiciphatic vcüspI». Tlie nature of this
poison may vaty; it may he dt-composcd sccrctiou from d tvouad,
putrid matters of all Mrt« (i-spveiully thut from iIk; i^odaver), or
matten which from exccmive irritation form an inflamed point. We
have alrrady etatcd that the friction from a boot-nail may excite a
simplo excoriation into a dithise intlELmmatiun, in which a (phlogistic)
poiaon may and often does form, and excites lymphangitis ; the same
thingoocura in points of inßammatinn from other cauaee ; by increased
iiritation a material is foimed in the intiammatory focus iLielf, which
proves very irritant to tho lymph»tii.< vi.>asoIs and their surrouudiugs ;
even a poison encapsulated in un inÜämed port may by increased
prettfture of tlic blond be driven into Ü10 lymphatic vesaels, and
thence into the blood, allhough without this cause it miglit have
remained quiet, and bt-on gnuluidly thrown off or eltiuinoted by iiu]>
puzBttoo. The following case may scr^-c as an UluBtration : One of
mv colIcagui^H ha<l a slight inflanimntion on the finger, from a dis-
aectiiig wound; Uiij* inllammatroii Wiis jiurely local, scarcely obsenr-
ftble; un a »hort trip in the Alps he became heated, in the evening
he bod a lymphangitis of the arm and high fever ; the active move-
ment and ootiseiiuently increased action of the heart had driven the
poison, previously lying quiet in tlie circmn.scribeil |x>int of iuflatuma^
lion, through the lymphatic vesaeis intu llie blood. ^^Iiy, iu the
different rases, wn have sometimes diffuse phlegmonous inUHmmation,
somctinieit erysipcJas or lymplmiigit!;!, oaiumt be o^-rtainly elated,
though it may Im due to purely local cnuses, and to the character
of tlio poison. From our present knowledge of the passage of cells
out of the vessels we may imagine that pus-cells developed in the
woutid thence pass into the l^-inpbntic Teasels, wander throi^h tlie
walls of these vessels, and as bearers of an irrituting substance excite
peril^'mpliangitis, while the cells, flowing more mpi<l!y in the oentre
of tie vessel, enter the blood, and thus perhaps induce fever before
the local diseiM ha« attained any considerable extent.
The object of tnatmmt in rcocnt case« of lymphangitis is to ob-
PHLEBITIS.
S10
t»m molaüon [f possible, anil to prtivcnt suppurntJon. Tlic pitimit
should keep the aficctcd limb as quiei aa possiblr ; should there be
gastric d^nmgentent, on cuivttfl is rery bcaeficisl. Tlie diaense tM>t
ilRfrer|iH>ntly subsides after tho purj^tion »nd sweatioff induced by
the eiiK'tic. Among tlie local mnedi«», rubUng tlie whok- Umb \f-ith
ntcrcurial oiiitmvut is p&rlioilarly i'ffiuuüouü; then the arm should
be covt*TV<1 tritrnily i^O a« to tnniiiUiiti an i-levatod, n^ilnr tompcni-
ture. Fur this purpose vfv ma}' employ wiuldiiijj or moisl n-artiitli.
Should tlic inDammution incrcaec in spite o( this treattncut, and dif-
fiise redness aiid swcllitii; occur, suppuration will take ]>lso« at some
■pot, Tbis ditTuse inHantmiitiun is no longer limite«! to the lyniphalJci
Troirlrt, but tlie entire sulictitaneoua iisaufi {mrticipatea in it more or
leoL As soon aa fluotuatioo is distinctty p«rc«--ived, an opcnin^f
ahould be maile, ami the piu ei-aouatcd. Slimild healtnff W relorded,
it nmy be hastened by daily wrarm biiths ; those are partii'^iilarly uac-
whcre there is a (j^rest tendonoy for tli« di»ea«4; to rotuni to a
il onru allacked, A septic poison eiiC3|Mu]atod in the lymphatic
inds, if forcL-d into the circuliition by Hunion to the K-lnmls, may in-
new lrm|>ban(^tis and phlc^ionou» periadenitis ; tbis expliitius
repf-ntt-d lelapsL-s, and the latency of the disease after infc^itioii,
lly in diasccting wounds^
LECTURE XXV.
K l*hMiltU; ThromboiiU; EKbolwni.— diuMftf VenowThmnbiMi*; VarioaiU«t^
■MipkoM* of the TbfAinbiu. — EntboIUio. — Bed la&Ktion, £iit)MUe SUtaitalia
AbMMM*.— Treatia cut.
^B 0. PUtbitts ; 77irombo*iji ; Embolism ; EmhotU MOaatatte Ab-
^Hmssm, — Besides tho nbove forms of inlUmniation, there is often
PBuiotbM phlebitis and tliromboaift, whieh, starting' from a wound or
point of inOaniniBtion, is at first local, but afterward spreads io « pe>
collar manner to sotltsI orfn^tta. In jicraoiis dyin;; from tbis disease
we findpus, friable, purulent, or putrid olot^ in the thickened or paHIyw
suppurating Teiiis near the injured pnrl. Often, »Isu, tliero are ab-
soeosee tn tb<^ lung», more rarely in ll>c liver, spleen, and kidtwyai.
CruvtiUiitr jtroved that tliese metastatic abscesses were connected
with till' pus in the veins ; but the mode of tbis eonneetioo \ras not
[plained till subsequently.
What I shall tell you to-dnyon this subject is Uie result of oumer-
fuTOStifpition^ and ex|)(!rimcnt^ for vrhiuh we are indebted to
r, and vrhi< h have been so often re|iesti-4l and conSnncd bj
28
S20
TBAtntATIC AND IXPLAUHATOCY DISEASRS, ETC.
diffi^rcnt persons Utiil Uicre oaa b« no doubt of tlicix correctness ; I
have nyBolf «ludied the »ubjoct a good deal, and dull at the proper
placed state wliere I bar» »rrivcdiit liiffenMit results. It would lead me
too far to follow this ^rcal work of I'iivAow bwtori«illy, nnd to give
^u on epitome of it ; I must Icav« it to jour ovm industrr to study
these works, and coDlent myself with giving von a short rixumi of tlic
positiTC rcsultik
Tlie first important question ia, WImt is the rulotion of tho oo-
agulutioDof tbc blood to lliP inflanimatioii of the vcsoet? llie fonner
view, that the coagulation ia du« to iIk; infliimmatio» of the wall uF
Uie vessel, i« purely hyiK)thctit.'al, and not eusccptiblc of proof. On
the contrary, wo know from the investigations as to Iho fomifltjon
of tlironibuii after ligation of arteries, and of the process of healing
of injurvd wins, thai tlierc is immediate t-oiigulation of bloud in the
Injuro«! vessel, befor« there ean be any inflammation of tlie walls of
iho vossi'l. Tlic Wofxl-i^lnl forming in win« aitvT tlicir iiijurj-, and
constituting their tbrombu», is uauully short, it is true, but wc may
readily imagine that it should increase in size front continued de-
posits of Gbrine. Vou know, from your studies in phyaology, that
we cause coagulation of llie fitrine by whipping the hlood. Duriug
the mntion of the blood tbc uoaguluting fibrlue de|)uaits like crystals
on a rough botly, and yo« can readily wilicfy yourselves cxpcrimeat-
ally tliat suoh a l>ody, as a cottoo-threiul, iiitrudured into iho vein
of a living animal, soon becomes covcrvd with fibrinc. Thus rough-
neaies of various kinds in ihc vessels may givo rise to more or
less extensive coagulations uf the bluotl. Tlieso mugbnesse» may cer-
lAJnly form on the Inner wall of the vein as a rrsult of inflammation,
and «oftgulation of the blood may thus be inducoti. Projections into
tlic calibre of tho veins may be e»use<l by 8moll abscesses iii the
walls ; formerly, it wus supposed that there was a ßbrous coagulation
on the inner Eurfaeo of t\\n inllaincd vein, as on an inflamed pleura;
it can scarcely be decided whether tliis r<_'nlly occurs; what was
formerly ronsiden>d as such has been found to be a diiieolored pe-
riphrntl layer of the hlood-clot At all evcnl«, inllamniatii^rn of the
•walU of the vessel very rarely causes tho coagulation ; much more Crt-
quontly the clot forming in a vessf 1 after injury, under c^'rtiiin not aeeu-
ratelykouu'n circumsfanccji, fonnsthe storlinf^polnt for further coagu-
lation, and finally for inflammation of the wall of tho vessel. Besides
injuries, tjiere is ntH^cond fiielur from which o'jagulatiocis nxny result,
viz., from retardation of the current of the blood from friclion, aa in
contraction of the vessel ; this variety may be called thrombus J'rom
eompresaion. It also Is iodependctit of innamutation of tho wall o(
the rein, but may result from inflammation of the perivonous tissue;
THROlTBOSrS.
tti
for io severe influnmatiua a tissue, cspcKÜBlIjr when it is under Uie
pKSSure of n. fnsoift, ratty srrcU eo mudb, parti/ trom SCtOos, portly
bom plastic infiltTalioi], that the vessels wilt be compreüaed, Bnd giati»
and oo»giU>tioa of ilio Ittood l>e llitui iiuliic^rl. Those thrombi, from
oomprcasioQ in very acute inlliiinuiatioD, mid cspeciully in ocutc a<«i-
dentiU inffairamation of cellulnr tissue firouiid vrotinrU, iite more frequent
tinn pdnutry troiimatio thrombi ; it is tlic most dangcroua variety
of tltTombuj>, as it \a n)o«t U«b)c to purifonn dcliqucaccDOC. In rapid
diUtatioD uf It vessel, mloo, nuvrding to physical laws, tlio curretit of
Uood is much rctanled ; tbcQ coag^ulation takes place at the point of
dilatation ; as we shall herefter see in aneurism» andrsrioes, these are
CAÜed thrombi from dilatation, f urtherrnore, the current of blood
^may be retanled from innuffldent contraction of tlie heart and arte-
L's; a$ this occurs cliiefly io prrsoiui debilitated bj age or severe ex-
hausting' diseawe«, it is called ntaratmü! t/tromf/ut. This, also, is evi-
l^deatly iudependeut of Jnlla mutation of the veins, and occurs most fre-
quently in parts distant from tlic heart,
Tou must remember that in all thee« coses the thrombi arc nt &ist
Rraall, and gmdually grow from deposit of more fibrine. ]l has uot
been proved tliat, in naaoa where the thrombus atlaiiis a eonstderablc
extent, there is anyabnormal inorea»eof fibriiie in the blood, altboi^h
this might be supposefL Wkt/ traumatic thrombi shotdJ extend so
br in aonie casea of injuries of the vein», we am only understand in
aacs irlicre extensive ruptures of the veins are caused by extensive
0OBtusIon8,niMl extensive disliirbance of the circulation is thus inditced.
But, ta cas'cs where a widely-branched thrombus reault» from a puno
tured or incised wound of a vein (as from venesection), it is often
difficult to explain the cause without resorting; to disputed 1i vpothcse«.
Thrombi from injury' nntl compression, and their scqucliP, particularly
doim oar attention, while those fromdilatationiuid marasmits we rarely
meet in surgical cases. It has been obser^-ed tliat venous tlirombi
ending in suppuration are far more frequent in hospitals tlian in
private practice, and lliia lendcoey to ooagulntloD of the blood has
been referred to the hospital atmosphere and tlic miaama it contains.
That hospital miasm (itself a v«y indefinite ami very variable thing)
should directly induce coaguliition of the blood, can neither be proved
^^or denied. According to my idea, the connection is probably only
^^Bidin>et: toxic-miasmatic infection of a wound, whether induced by
mstruments, dressings, or otherwise, as previously stateil, excites acute
SuppuraUvo ijillaTniiiHtions aruuml Die wound, sometimes ns ordinary
llular inHamnution, sometimes as diffus« lymphangitis, etc. ; thrombi
Dm compression are CJiused by these influmraatioiis, just as hajipens
I acute phlegmonous inflanunatiou outside of the hasplUl ; hcoco the
$22
TRAUMATIC AND INFLAMUATORy DISEAfiBS, BTa
influenoc of miasmatic pcüsoning in inducing vcnou« thromboüft is not
dir«cl, btit indirect, acting through tbc inflammation.
The Dfxt(]ueAticm ifl,\Vliftt Iiccompa of tlicUooclcxngulated in tlie
vcMcle, na<l what i^ il« rclntinn u> tli« wait of ttic vosse) 9 From tlic
injuries of arlvricK iiml vuina, we »tc only no(]uaint«d wiilt one mctu-
morplio&is of tlic thrombus, namely, it« orgnniiuitiuD lo connwrtiv«
tiasue, lu exIuuMve vcuous tknjnihi this is a great raritj, and leads
of oonrw» to oompleto ol)Iiteration of the vein. Let us take n vcty
aimjile cäiie, a Ten««ectioii tlirtimliuü. An<>.r a bleeding, ray from the
median vein, irom an ncutu inliiuimutiuii of the oultulor tiuue Uicru i«
« coagulation of blood in this vein, nnd alxo in the cephnltc and basilic
veins, down lo the wrist and up lo tbo axilla. From the dislurbanoe
of the circulation thus caused, there is great cedema of tlic whole arm ;
when tliia subsides, we may difitioctly feci the subcutaneous t'ciu« «s
bard cotda. The course may var}' : first, the ftlTcctioti may possibly
end in resolution— under timely tretiltncnt this is usaul ; the patient
should be kei>t in l>od, n» he ia usually forerisJi ; the arm should be
Itept absolutely quiet, and eoTored with a eomproas thickly coated
with niercuriul ointniont. At the snnie time we give a purgative, and,
if the tongue be coated, tin fiiietie. Under this treatment, the swell-
ing of the arm usually decreases, and the fever suhMde^ Then tbc
firm venoua eorda can be ßmily fell, in sii or eight duys they become
softer, and Giially ceaae to be perceptible ; vra very rarely have the
oliimce to examine such ra^es anntomically in tlie early stages. Ilcnce,
we cannot dedde to what extent, if at all, the walls of the rein parti-
oipate in this coagulation of the blond ; but, from the symptoms and
the cxaiiiiniitioii of tlio patient, it would u]ipi'ur that the übrine txiugu-
lated in the vesiiehi is gradually roab.torbAd nnd mingles with the
blood without injuiy, like other blood thai hjis been diffusely exlravs'
sated in the tiuuc. The second termination of inflammation of the
arm after Tcncscction, complicating thrombosis, is the formation of
abseesK. The trat ajinptoins are those above described ; but then,
cither in the bend of the elliow, the arm, or the forearm, a RKtte
circumscj-ibcd inflnrnmatorj- tumor forms; this iDorcoses gradually,
and iinnlly fluotunte-'« distinctly. On inrituon, pu« is evncuatf^l frcm a
larger or siiinlliT cjivity, Uie swelling of the arm then gradually do*
creases, the abscees hcala, aud complete cure may result. Anntomic-al
examination of these cÄses shows that there has been suppurative
indammation in the connective tissue around the vein. We also find
that Üie ooiit« of tho thmnilKJfled veins arc greatly thickened ; tliis is
to be regarded as a result, not us a cause of the thrombosis. I wQl
here add tliat the ding^nosis of a venous thrombus cannot «Itraya be
made, from tbc vein feeling tike & bard cord; for occasionally inflam-
TRBOJIBOSIS.
8U
Btttion in the cdlulnr lissuc arouiul tbc vt;in mny extmi), and cntue
CxMiddaMlion aiitl tube-like thi«l<t'itin^ of tbc sticntli of t)ic tc4»cI,
vbich may readily cause it to bv mistakon for thrombuii, tlioagli it
dt>es not nw^rssnrily Iciul I« iL I bave tirice seen this mistalcc of
prriphlcbitic- crJluIiir iadunilion fur tlirombus of tbe n]>]ictKni8 reiD,
and 1 consider it impowithle to make a c<>rlnii) dingn^is in nil nwos.
Tlie &ct that sndi a. iK-nplilulMli», wliicti is porfL-ctJy anulo^us to
perilymphati^tü, and ia wbicb tlw walls of tbv Tcitis ccrtaioly parti-
cipate, can exist vrithovit tliromboaia, provps beyond .1 doubt that tbe
latter is not nmsewarily llie ause of inflammation of the veins, as was
formerly supposed. Anotlier poa&ihie metamorplinab of tlirorabua is
friable disiateKrotion. In this, softeniafi; of tbc olot usually begins at
the point where the tbrondH» liegnn, tiiat uj^ot the oldest part. The
Gbrinc breaks down inh> a pulp, whicli is yellowish or brownish, and
amcary iii proportion to tbc number of red blood-corpusdoa contained
in the coagulum. Tliis disintegration spreads more and more; even
tbe tunica inlinu of the rein does not eaoope, it beootnes wrinkled
and tlii(:keiw-<L Tlie tliromhua ehangea to \mxa, wUdi minglus wiUa
the detritus of the fibrioe, while tJie wntli of the veins and surroun ding
cellular timuo are greatly thii-ketiwi ; n<Tns.ionnny, altlii>u(ib mrely,
■mall ahsccssea fismi in the walls of the vein. Hence, here the inflaui
malion of the wall of the rein is to be re^rded a» the result of soft-
ening of the thrombus, and (ho pits wlueli wo then find in tlio reia
doca not come from tbe wound ((be old idea), but fonns in tbe vcm
from the blood-clot. Often, also, the puriform äuid is only fluid
fibrous detritus, while in many cases good tbiek pus, with fully-dcvel-
opcd corpuiadefi, may be found in tlirse veins. If the wound he putrid,
tlie fibmus ilctrittia in tbe vein niay also assume n putrid diameter,
putrid fluid hein^ taken up by capillary action of the thmmbua from
the wound and «rting as a ferment oni tbe disintegmted libritK. Tills
capilUry aelion of tbc thrombus might abo be supposed to raiisc an
action of the decomposed seerction on the blood. Of course there
can be no extensir« flow of pus or other secrution from tbe wound
ink) the vein, aa the opening in the Tcascl ia plugged by tbe thrombus.
Should there be a rapid disintegration of the venous thrombus from
the pcripherml to the central endü, wliieli is rare, there would at onee
be venous hiemonhage, snd the fonnation of a new thrombas, so that
even then tbe^c oould be no entrance of the pus from tlie wound into
the vein, or of that from the vein into the blood ; moreover, the pa»
forming and coDected in tbe von is ao abut off by the centra] end of
tlic llirombos, that it cannot min);le with the Mood; at least thu
could only happen if the central end of tlie thrombus should be entirely
broken down, but this probably happens veiy exoeptionally, for in
321
TRl.tJl[ATtC AMD IXFLAHMATORT DISEASES, ETC.
most cases there nre constantly new deposits of fibrine, wliil« dlttit^^^^
gn^n gW3 oil froni tbv uldc-at purts of th» tbronibus, Vou will tli ^|
iindcr»Uiii(] tbnt tliv cnlniiicc of piis into tlic Injuroii r«in cannot nw. — 4^
ily occur, but tliat, as n-tll be soon stated, tbe oircumstanoes must W*c
YCTj peculiar to render tliis po&siblo. I niiiAt here bricfljr 'ia\«TTKCpi
the deMriptioo, to ntatc that Virchow does not distinctly acloiowled^
the tnnüfortnfttion of the tlirombus to pus ; I Itavc no doubt OD tUt
point : if tliu btoo(l>ci;tls io the tlkromhus \\a\tt tlic power of incrcnsing
•nd clinsgin^ to tifteuc, us «ecinj mo»t probftblo, tliorc ts no reasoa
for not rcfurriu^ Io tbpri the fonnatiuii of pus in tliL> thrombiui, just £S
■wc do to the white cells wnndering' out of the rcsscl», for the coagv-
latioa of the blood is not iirni enough to cutirolj prevent ccU-ltMT^
mput. That the thrombus may change to true pus by dirinton of the
while lilotid-cells doe» not apiiear Io ino disprovod ; vre have already
mentioned that this pus, which is usually cncapaulfited, doc« not cnler
the circulation, or docs so very rarely, and hence has no direct coo-
noction with pyjnnia. To resume my experiences of renous thrombi,
and the history of thrombus, they are to the effect tliat mnat veDom
thrombi are the result of very acute inäammation of eellulor tissue,
(especially under fasciie, or teniae idiin, and in bono), and that the
coagiilum undcr;^es the snme metainotplioses as the inflotiinislory
ocw formaUoQ. If the latter lead to formation of liesuc, tJic thrombi
are also organized to connvelire tissue ; if the iiiQutnmatioa goes on
to suppuration or putrefaction, the thminbi also suppurate or putrefy
and break down. This ia the caster to uiidt-rstiind,a3 wc know, Uxmi
Von JtwklinffAavsen'g and Itufmoff^a investigations, tJiat the eella from
tlic tissue may pass through the walls of tlie vein into tlie ibrombiu.
The walls of the Tcin have the same fate as the thrombus aod bw
rounding tissue : they are infiltrated with plastic matter, and becoine
thicker, or they suppurate.
Thrombus, with phlebitis, may also run its course aa a purely
local disease, na not wifrequently happens after Teoeseotioo, uid
in some other cases. Then there can only be further danger «lieii
die tlirombus is fiiäble, or when there is purulent or putrid deatno-
tioQ of the coagiilum. Tlie central end of the thrombua (aa «re
Btated wht^u speiikiiig of arterial thrombus) usually extends to t3ie
point where the nt'st bmncli joins, and has a conical end, which
project« a little (Fig. 59, a), niid, if the coagiilum loses its firmiieao,
a portion of the eoaguliim may be torn off by the current of blood,
and pass into the circulation ; this passes into the larger veins, tlieoce
into the right lieart, thence to the pulmonarj- aricrj-, in xrhoae
branches it in finally arrested at some point of bifurcation, as its aiae
does not allow it to pass fartlier. Thb branch of the palmaiiBi7
rnsouBosis, khbolisu.
39«
arterjr is row closed by a clot of fibrinc, as by a oorit, a io-called
emiolttt ; tUu immcdiiLt« cxKucqucncc ia a lack of Uood in the parts
of the lung provioiwly stipplivd by tlio pluj^ged
arteiy. ITii* local lack of blood (ischjemia of F». Bfc
"Vir^hoxf) docs not usually last lung, but blood
entoT» tin« ütnply artery troin small collat^nd
arteries ; it Is tnie, !)lood may thus again eater
Ut8 reia, but it count;» from the small colliitrral
branch«», aad flow« rcry elon-ly, and may at lust
atop altogether, aud ooagulatio» exteod bock*
ward through llic rapiUaricn crcn into the throm-
bosed arterial braudi. Tlius, as a result of cm-
boloa in the artery, the whole coTTt'sponding
rasoidar b?iTiloiy is llirombosed; lh<.Ti; may also
be niptorua of the riascla, btumorrhaifea ; as the
arteries of the lungs, splL*L>[i, and kidneys, mn-
stantly divide inlo smaller branches, and thus
the vascular territory constantly ciilai|ccft towani
the periphery, and reaemhlGS a cone n-ith the
apex in llie organ, so the part in which the
above coaguIaLlon oocura must be ttlinped likt- a niwraa: «.«»nmiradirf
• vtonn* UiraUbM pi^
JiKIlnt tntn > litn
trank : h. i bntnrh wltE-
(lalthnnnlian : thRhlood
flawing ihioiurii II aiay
iTriarh uid <xnj loio tM
cinuJailnii tiM) and o(
tlw Ihrombaa ».
'k
wedge or cone. In pathological anatomy theao
ooagulatjnns due to emliolism bavc been called
** red or hiriiiorrliagio wedge-shaped infarction»."
FWquently as these tredge-shaped luiarc^ons
oeeur, they are not a ncoessaiy result of embo^
Csm ; for, when the arterial coUateial circulation b strong rooqgh
in tho isdicmio purt tu drive tho blood through the capillariea,
aa is the e&%vt in utlic'ru'isL- iR'nIthy person« and in nnimals, aa well
aa in emboli causing little met-hanit^l or chemical irritation of the
tissue, tbcre is no infarction, at all evcnta no considerable dis-
torbaneo of circulation, but we have simply to consider the kvoal
prooeises around the embolus, as foreign bodies in tlie braacb
of the artrry-. Theao local prooeeses depend on tlie character of
tho embolus; if the latter be a pure fibrinous clot, there is a slight
thk-kfoing of the wall of the vessel at the point wliere the embolus is
located (usually where the artery divides into sinallcr bmnches), and
the Utter may have new clots dcpo«itc<l around it, and bo organized
to connective tissue, or be reabsorbed. Sliould the embolus cousbt of
a fibroua dot impregnated with pus or putrid matter, it exati?» suppu-
istiTe or putrefactive ioflammation, not only in tho wall of Uic rcesel,
but also in the parts around. Hie metamorpbnats of llie red inlaro*
a in part depends on its sze, putly on the grade of the circulation
826
TRAUMATIC AND INFI.AMMaTORY DISEASES. ETQ
■lill conti II iiinj^ in partic of it, and pnrtly on the eFtnbatuü oiising the
troubti;. If the latter be iniKK-uuiis «ikI tlirr itifarciioii he stiuill, or if
it 1x) still oourialicd by some vessels nul thrüubuscd, lli« ouugiiliun
(bmiing Lho tiifarctJuii nmy ugniii li« dii<solrod, or el^ Ijocoioc urgan-
aed to a connortivc-t issue dcaliii. If the embolus bt- innocuous, but
the throtiibus extending coraplotely through tbc whole infurctina, tbc
liffnia *nd coAj^uIum slowly disiDtcgrnte to a yellow, granular, diy
pulp, which htfvomes encapKuhiled, iumI may c:ali^ify ; tliix ix ytBaw
dry ir^arctioH. If timvniholuii he iniprvgiintcil with ])utri() roalUrror
pus, it excites puliid or euppuntttvc influinmati'tu all fibout it; the in-
farction aUo l>epu[iies putrid or punileiit, and nbsoessvt) fomi. Aft we
were just Hpeaking of the lungs, we nmy here mcniina tbat tkcsc bV
Kos&es, wUich are usually peripheral, often excite pleurisy ; that they
B,re most frequently multiple in both lungs, and may even induee Bup>
puratimi of the pulmonary pleura over llie abscewt, and may tliu«
CKcaMuually cause pnc-uuiolhurax.
Vou can hardly imagine, gentlemen, wliat la)>or it costs to domon-
stmto this rannoc'tioQ belvreen tcdüus thronibi and abseess of the
lung, 6o that I can licrn announce it to you as a slmplo fact. You
will read tbc classical works of Viivhov, J\inum, O. Webtr, and
othcn, on this Bubjei^t, with astonishment ; it would take too long for
me to cuter iuto the subject more fully; wc »hall here assume the
right of only taking the fuots from these work». \Vc now underetand
lung iufarctiunit and ub!>ee&Hes; but how is it with those that occur
under like circumstances, although much more rarely, in the liver,
spleen, kidneys, Biid muscles; arc these also always depeiwlunt on
emboli ? A few years eiiice wo eould not have nnswcred this qu(^a-
tion with Certainty; dow we may alhrm it. From experimental in-
Tcstigatinn.s especially those of O. Wtier, it is eittablühcd that ccr-
t&in fonns of emboli, especially floteuli of pus, pass the pulmonary
capilliiries without difTieiilly, mjiy enter the left heart, and thence the
systemic ctrculation, and be arrested in tlie spleen, liTer, tddtkeys, or
elsewhere, and cause abaoesaes. Tliia explnintt Uic mre casea where,
with venous thrambus, there are tut abscesses in the lung^, while they
tstist in other organs. If, with abscesses in the lungut, there an; em-
bolic infarctions ur abscessea in |)art supplied by the systcinio circula-
tion, they may be attributed to the formation of renoufl thrombi
through die piili:ioii;iry abscess; portions fnim these thrombi pass
into the left heart, und thence fnrtlicr. As regards liter^aliscesse«,
Jitaeh lias obscrircd that retiuigrade movements of tlic hiood from the
Tight heart take plaoe in the vena cava, and in th is way hepatic emboli
may occur,
'Hie embolic origin of owtaetatUi aHmcetxn is now bo undoubted
THBOXBOSIä, BMBOLIglf.
327
tlmt. from tJie existence of oti'J of tln.-,v*, wi? decide wrUiinly on u
Tcuous thrombus uuiter;g^>ing putrid or suppurative liquefaction. Tbc
discover)- of tlie ooonoction may be easj in same cases, very dilBcult
in otliers: rery easy in case» of tlirfitahus of large vcrujiis tniiiks, ami
embolism- of brandies of tlie puliuouury artery tlutl uMy be readily
rmclicd trith llio sdnon; very difficult where there it» «imply coagi*-
latioQ in some small Tonotis net^vroric (as in plile^DOnoux inflammutioa
or decubitus) and embolisni of capillaries of tbv lungs, spleen, kidneys,
lirer, muAcles, etc ; still, these Utter onses are almost innumerable.
On fiiTorablc objects (as in eerebral espillaries) it has been prored,
beyoixl a doubt, that capillary emboli exist in aonie oaaea; it is also
rcrtaia that small Tciii:i become thrombosed )□ all suppurative iufiam-
mntions; it is very diffir-ult, often impossible, to demonslinte litis
anatomically in every case. From what ayraptoma we ronclwle
witelher a co«gtilum ia old or recent, will bo taug-hl you in tJie lec-
tures on patbolof^iea) anatomy. Here we are only spealctn^ of metas-
tatic circutnscribed indamntations, of inläretion<t, and ubsiHisae« ; these
■lone are oonneoted wiUi venoiis liirombi atid vmbull For diffuse
metastatio iaflamniatioas aaotbcr cxplanatioa must be sought; we
■hall treat of tfaU more under spptie:nnia and pynmiia. Nnr ahull wo
heradlaruKi the qucation of fever in pblcbitis and in iJie fonnation of
metastatic abaoesses. As pliIelHtia, witb its results, so very often
eomos as an addition to already-oxistinj^ aeutc inflammations, it in dlf-
fioult to judge bow far it of it»elf oxritos ferer j metastatic sbsoeftses,
litco all other points of inflamtnation, undoubtedly ioduoe fever; we
aboald searccly eicpect fever from a s^implc thromlxis of the vessels.
llie tnaimt'nt of phlebitis and tlirombus is the mmc as that of
Ij-mpbangili« and ntlier similar acute inflamtiMtiont. CVn*ful frietions
Willi mercurial ointmont, or, if we fear detachment of tbc coof^Ium,
eovorin^ the port with oompresKfl fmcarH with mercurial ointment,
or with bladdets of ioe, and absututo rest of the affected part, are indi-
oatod. Under pyDemia wc shall speak of the diagnosis and treatment
of metastatic ab9ce»B«s. If phlcbilia and thrombosis eauite local sup-
puration, tbe absoeases shoiüd be opened as soob as roc»^ia.<d.
338
TRAlDfATIC ASD ISFLAMlIATORr »rSKASES, ETC.
LECTURE XXVI.
n^^-OmAftil Awid*iiUlI>U«aM«wIiialiiDB7-Boocaiipin7^ Woonda anil I>M*t It
tlon*. 1. TniutuBtw nod InMimmMorj Fcrcii S. &«ptw Fotm ntd Se
9. SuiipunMir« Fcvor aod I'jwmik.
a-OENBItAI. ACCIDENTAL Dt»SASEH WnirH MAT ACOOXPAST WOtTillS
OTHElt LOCAL D{PLAMMATION&
TiTB locnl accuU-ritHl traiiinatio diflßOHea wliioh we hare so fiir de— 1
scribed arc ulways accumpaditiii hy coiistltiiUoDal diaease, vrhich i*
ßbiefly thuugli not ulvrays ft-vurisli in its anturc. Kev«r is sucli k ooio-
pliL'atioti of s^-ntptomH that it may sct-m vltj- iliff«rün( oix;onliiijr tn
the »ddition of one or other sjfiiptora ; now it is jt*^"^™"/ dctcrmiaeii
oulj to say that tlicro ia fercr wlion tho temperature of the blood is
elevated, and to measure the mtenstty of tlio fever by the height of
the temperstur«. I do uut tliink it »ilvisihle to combat this jKwitioDf
for by nliaiwlonin^ it wc should lo*c the common idea of what we call
fever, atid throw it bach ioto the ohl chaos. tViit I must uA\ you tliat
there arc many and very dangerous general disiMiscs in jwticQts with
wounds or other local inflammations, in which no chanjcc of t<-mpeni*
t«re of the blood can he discoi-crcd ; hence llie lattor is wily coniti-
tiuoally a measure of the patient's dnnger. Bestdea tlie eleTnttoa of
temperature, in fcrorwchavc thcfullovriu^ cliief sj-mptomS : InctCAaed
npidity of cardiac action and rcitpiralion, lu!^ of sppctit«, ftvqoeotlj
unusco, feeling of weakuc&s, great sweating, not uufrctiucutly trcm»
bltng of certain grou]» of musclce (in chills), more or less mootal
ezcitemoiit und blunting of the senses. Fever is a general disoaae,
whtoh may r«>snlt from many causes ; in other words, the nnml>er of
pjTOgonous, like thut of phlogogenuus sub8t«nc«s, is iunumcndilb.
AocoRling to tlie r|iiantlty aiid quality of thesis snbstanees (which we
term poiAOiu) tluit have ontori^d iho blood, one or other set of syoip»
torn» is more prominent: thus there is fever with very high temperar
ture, while all other s^'mptoms nrc slight ; fever with great bluatin^
of tlie senses, and but little elevation of bodily temporaturo ; fever
whoae prominent nymptoin ia severe shivering, Ho^dled chills ; ferer
with dieturbnnoti of the gastric functions, f»tigue, etc., fur tli« chief
symptoms. Why, then, should we not have fever (a stal* of iiituxi-
ciitioQ caused by niatcriuls absorbed from wounds or point« oC iaflnin-
mation) with all the symptoms, except elcratiuii of tbc icmpcrature
of the blood? From some cuugc or other this |)arliciilar s^-mptom
might in some cases be concealed or prevented from appearing. But,
as already slated, we etiall accept the present view ot fever, and only
TRAÜIUTIC AVD DTfLAlUUTOBr VEySR.
SM
ippoAO it to cxiaf wbcre wc &nd clcvalioa of tempenCure of tbe Uood,
"but must tlieo add that tlH?rc are caspi of nerore f{«ncnil, neoidcntal
Iniiinalic and tnAammalory disea-si?» which run their ooitrse wllliout
fcvcr.
But there i» nnothcr common factor of tbcM gvociml diseases tliat
wp sltouli) bear in mind, viz., ifaut tliry nre »11 due to reabsorptinn of
matters that furm in tlic wounds or the parts around thetn, or (wliat is
about the same thin^) in a point of inßamaiatioCL On this point we
agree with the present views, as &r us concernjt traunrntia ferer, in-
flammatory fever, pj^mia, aod septicaemia, teu so p^rbups as regards
Ictitnus, di>lirium potfttonim, delirium ncrvoeum, and acute m«aia.
But mnnjr im]iona»l rcnsons fnvor tlie view of the lattpr disfMaus be-
ing'also of liitmoral ori^n; hL'nce I slisll make no further divisiCMis
tmutoff tbo abot-e diseases.
1. Thtumatie and Jt^Utmmatoty Fever. — It has been nlready
explaioed (page 82) that the fever appearing in wounded palieuta is
{Nully due to the blood takiDg up maturiaU resulting from dccompu-
»ition of mortified tissue on the suljstarvoe of the wound, partly to tbo
ibsorpLion of nmtoriahi formed by lltu traumatic or accidental inflam-
mation; IicQcc, in tlio latter cnsc, the nature of the tmumatio and
inflammatory fcvcr is pcrfMtly obscure. On this supposition, which
wo pfpx-iously tried briefly to [jron?, it will dt'pend partly '^n the looal
kdvnntages for rcabsorption, partly on the qiiidily and quantity of
|>yrogciK>u« material in question, hoir great the poi»oniug will prove,
Tliere are cases whero tlio vesHels oiMriiod by Iho injury close so rap-
idly, and the whole traumatic inflammation terminates so quickly, that
there is no general infection or fcvcr nt first, and they may not occur
at all ; such eases are nre in extensive injuries, they are the ideal
of the norrtial course; in tlicra the plastic infiltration on the edges of
the wound leuds f[\ückly »ml thmiighoiit the wound to solid orgauized
new formations, growing firmly in the edges of tbe wound, and paw-
ing cm to cicatrizatjuii immediately or after preoetleut granuIatioD.
If wc assume this case as a normal tj-pc, every traumatic fever »a a
patliological accident. Wo roust acknowledge this in theory, but in
the great majority of cases, in wounds of any size, fever occurs sooner
or later ; heiioc we ron^dered it advisable to treat of trauniatio fever in
tbo previous description of tlie genenl condition of the wounded pa-
tient. Wc have still, however, to oild somelhing to what was Hien
said, which at that time it wuuld have hoeu difficult for you to imder-
staad. Lei us first speak of tho period at which tmumatio fovor
usoally appears, and of its course. In many cases, especially where
the injury has affected tissues previously healthy, the fever does not
begin (ill tlie second day, iucrceses rapidly, and, with eveiung remi»-
330
TRAlTMATTC ASD nTTLAHHATORT DISEASES, ETC.
sioDS, remains for nomc; dny» at a r«rtain beifH>t> and then cckMs
gradually (rorply witliin twenty-four lioura). Acpimliiijf to my
numerous übsorvalkiiM, in far Uie greater laajorily of cas«is tlie limc:^-
inatic foTcr tx^iu witbio two dtiy* »ftcr tlie injury. Tliia fcTCr b
usiuUy r«ppes«it*d grsphicaHy «« follow« :
rM
. M.
D«ti of Ihe iXKV««. 1
m-
/.
a
h^ — ■■
■
i.
s.
c.
7.
\
A
— /
^
fl
— -
^
s—
M.4-^
^
— — -
L
FcVfr-Cnrrc sfTrr •mpnlallin nflh« im. Rnrororr. TMi anal lh»> follnwini tmT-rmmit «I«
Arrnii],-«^ on Uw «ml-xir Crlilur'a IliffrntaiAoUr. Kach <lvK'Tg I* dliiilnl lututro naito,
IlioliurlmiiiiildlTliIoni liiiliiriiii' lAc ilnj of IhoAiwup : theoiir* l> nijtil' inunllnit la (Iw
nnmlaiT kiul rvcndi^ intn>iirpininti': Ihr (wo hcAvy JIdcb umIImu Iho nulmau Hid
iiiliilu)iuniiufiiuiUriiipt;nii.LLreora bullli; iiction.
Tlio ctuTO »hows thni, sftcr no mnpulalion of Üie ami, rendeml
neoeMary by an injury (measuroraeat was accitlenlally Dcgtect«d tl>e
first (lay), the fpver ditl not bof^n till tlie third ility, tiwn roDtinued
from tlie fourtli to tlie .srvcniti iliiy ; »ru-r tW vijrhtli dny the pnUeut
rcmuincd free from fever. In other ctutcs, Iiowcrcr, scopnOary fcrcr
oft^n oiwiirg imnietliiLtiMy xflor nmputulion. Siich an uvcnrrcnce of
trautnatic fpynr is quit« frequttit- I explain it u follow» : ImmedK
atcly after the injury the tissue of the rd^rra of the wound was closed
by in6Un>tiDn of plastic mutt^; the third day this Mmrnvnced to
break down into pus, and to mingle with decomixwed ithreds of tlsaue
on the surfHoe of tha wound, thus indiicliig a niodrnitt-ly cxtcnaire
inflammntion of the amputation ntiimp, with rcflbsorptJon of pus and
other products of decomjiDfiiijon and iuflamtnation ; this r^abfiorpliun
f^oca on till diccked by wjmc mechanical cause (diminislied pressure,
TRIVMATIO AND IXiXAUUATOKT FEVER.
881
llickcain;r und partial daiureof the resseb, et«.). In other cnics,
the (erer hegizis tlie very dt,y o( the injury- ; we see Ulis when blood
hiui bci^n cncltKM.'Kl bctn*«.-!! Uic flnj» of tliv unitct] wound mtd it hiu
npidly dcooToposoiI ; frcqiicntJy, nlsi>, when operations have hccn
done in tissues iofiltnitcxl with the producta of chroaio iiifiltnittaa.
"Hie following caso {Ftg. fil) nujr tmrva as an iUtLitratioii of this
Bccoad claAs;
iri*.M.
$V
^9
3Ki
M
3XS
37
if
Hav of thr IHsfune.
1. 2. 3. i.
S.
S.
H-catTo «flar fCMClion of a CMrlon« wr1<l. «ritli gn«! lulUlTallaii or the luR pan*.
Rttorrrj.
Tn infiltnition of l1io tistiue from chronic iiiflaTninatiou, the finer
ipbstic capillaries mnybv contnictrd and to eomc extent closed,
.heiK«, for som« time, may not have carried off suifieiont scnim
tram the tissue, but the medium-sized lymphatic vessels, like the cof^
lespomliug ri-ins, which in chronic inflammation Iiave h>ng been l'x-
pOMd U> high pressure, are undoubtedly distended, perhajM even
gnpin^, from rigidity of th«ir walls; lience, if not quickly filled with
fina pWlic infiltration from thi^ sliirt, they take up a good deal of tho
wcrption from the wound ; morcorcr, on the eitgcs of wonndt« in nior-
btdly-in flit rated tisane, morliücafion is particularly apt to occur. ThUi
explanaltoii of the late and early oecurrenoG of traumatic tnvp.r L»
purely liypollteltcal; but it is token &oin and lias been induced by
numerous obscinitioDs. It might also be swumcd that in one ew»
sss
TRACMATrC AND ßTLAMMATORY DISBASES, ETC.
tlie fcTmtmt absorlx^l iiito the l*luod acted verj* alovrly, ia atMtlier
very quickly ; iiottilii^ (I<>fmite can be «lid od tliis point. Aa I fcir>
merly bclii^vctl Llmt tliu {wvi w&s iilways caused bjr nervous initatii:
it was nrccssaTV to suppnsn that Uiia imlabUity waa Twicd, and
tli« febrile «ßeot might occur at very different periods, but I have en-
tirely abandoned this theory.
Traumatio fever usually laftl« a week ; it is rarely longer, without
bomc visible local coiiiplicati(>iL
Wltcn tburv is au »ocirlont«! inflitnimnlinn of the cellular tissue,
lymphatic rcsafis, or vein», about o wound, revuruocurs simultaneously
witli this inHamciiatioti, or apparently precedes it (coming us aa in-
flammatory secondary fever, either immediately after the traumatic
fever or when »everal or even many dnys have pas«ed irithotit fei-er).
I any it apparently precfdes, bt'cnut»; tilt? fiivt fs'\gD!s of tbt; local affec-
tion may have escaped us, as they may powibly have ]>rc«cntcd no
sensible Bymptoms, or because the poisonous laalcrial may have in-
fected the blood sooner than it did the ]>arts imniediatcly nmund ; llie
probability of the Ulter idea is based on the fact that iM>iaoii, taken
into the lymphatic veaseUor vcinn with the lymph or lilood, flows more
rapidly in ihL- ceiitnt uf ihc? vessel than alunj; its nrsll$, and thus quickly
reaches the Inrpc blood-vessels, while llio fluid, moving more slowly
along the walls of the vessels, only p^dually passes into the perivas-
cular tissue, and there induces inflammation by the phlogogenous poi-
son it ronlaina; tJms fever (tlic blood- 1 n fectiou) may appear before
erj-sipelas, lyinptiniigHis, or phlebitis (from the local infection), is pei^
ceired. The course of this secoadaiy fever entirely depends on that
of the local iiiflararafttinn ; a» the latter begins, the temperature rises
npidly, often with an initial chiH. The longer these «ccooilmry fevers
continue^ that is, the longer the poison is kept up, llic moro danger^
ous the oondilioii becomes; rapid emaciation, great sweating', sleej>
lessncAH, and continued Insa of appetite, am bad symptoms ; usually in
these secondary fevers there is absorption of pus or infection frtun
wltliout. rronoimeed erysijX'Jas or in flam nmt ion of tlic lymphatic
Tcsseh) or glands arc thi: relatively most finxjnible fonns of the »cci-
dental inflammations, as sooner or later they gcnc-mlly lend to a ceri&i
usually favorable term in a lion, »nd thuä are somewhnt typical iu the
course, although the duration of on eiysipclas may vary Irom three
dayfl to three Tveeks or more, and prove very debilitating ; at first the
fever-cwr^'c rises rapidly, then remains for a time at a certain height,
usually with moniiug remissions ; not iitifrequently the temperature
falls rapidly ; the same is true of lyinplttingitia. fortunately, it in rare
for lymphangitis and erysipelas to extend deep into the cellular tis-
Eue and under the fasciae; in such a cose the disease would be classed
TKArXATIO INI) ISFLAMJIATOnT TEVT.TL
S3S
among the severer inSatnmations, and would lose ita somcwlmt t^rpicol
cbar«cler.
Id diffuse, deep inBammation of the cellular tissue, with or without
rcDOUB thrombo&is, tlie fever docs not t)eg]ii so suddenly', btit, front tlie
Crvt, iJwaf 9 has n decidedly remtUent type, aud, like tJie locaJ uQv«-
tions, is incomputable iu it« further course ; the loss of strength, the
Tt».ta.
Dai/ of the DUfase,
1.
2.
€. 7.
S. 19.
S9.S
3S
J^
»
_xs
sr
X4
3e
y«iRr<DrTealacr}«lp«t«a UiomalJciiinamtiaUtislbclel, capitis ctuiIll,fiiIIoiiiDi> oiUipilimi
of BOJiwcorth« Up. KAWvaij.
rmsctalton, swofttinj::, scnsilivencs«, and ex<^lo!)ilily of the [lalient,
attain the highest gradi). Iiitcmiitteiit fc-ver and mctiislatie inflani*
mAtiona, the chief ayinptonu of those malignant traumatic forcrs
«Ucll wo call " pyaemia," aro groatly to be feared in such cases.
In aD these fevers the ijuantity of urea is increa.<MMl and cxoeeda
Üie UDOunt uf »itrogtinous food oonaumod; at the same time, acc'Ord-
ing to recent investigations, the wciglit of the body diminishes eon-
siderably.
As loDfc iLs llic ooii^lJlut tonal Symptoms, capccinlly tlinsc due to
the fever, do not extend hcyood the above, and especially if the dis-
ease does not prove latal, we are generally aatisfied with the tenns
" traumatic, suppunUvi.*, or üecoodai^' fever." Ilut, if other (i_\inptonig
occur, and dcnth result;«, these severer infL-ctionx have two other
same«, "scptioRinia" and "pyooiiti,*' VTa follow this common chiasi-
Scatiou.
3ä4
TRACSUTIC iXD ISFLAHMaTOBT D!SEAEES, ETC.
Ä. Septic Fever [Seplüxemia), — By Bepticjemiu, we uoderalAnd ■
constJtuüoQiil, gencnill/ ncut« dittease, wliicb Is du« to ibc ahsorpiio«
of nrious ptitnil sub^l^ncea into ttio lj)ooa}, und il is ttKtii^flit tlint
tliMC «et u fcniicuU iu the bloud, iikI spoil It so llmt it cunaot tiiltil
iU ph^r^iulugicul funi'lions. Tliis (liscmso iiuiy be induced iti soW
mal» br iujccttn^ putrid mutter inio tbcir blood or subcutaneous liv
euc, and it Iias been found tliat large aninials (l''^ 'l'^KN honM^i etc.)
nmjTf under certain circuinstauoes, live tlirouf^h tho putre&i<^7o blood«
poisoning, allbougb it malcc« Lliein very »ck. Ccrtjtiii circiimstaDOGS
ate neceasaiy fin- putrid walltT to bu Uikcn into tfa« bltxMl of man ;
such 8ub«lancc« aic onlv t^ki^n tbr<>ii,i;b the li«a1thy skiit and mmioiis
membranes whea die [lutrid Kub-ttuiicfs have n dL«lnx.-tive or caute^
aot uL-tiuo, or an »cLivv power of pcnutnitinf^, like fungi aod infusoria.
Ditossod skin or wound siirfacoe take up euch putrid mattere nioru
readily, but cren thvy onl}- do so uuder certain cimirastaueRa ; for
instance^ tJie^' do not readily pa.*» throu^^h well-organized, uiiiiijun»]
gtanulatiotia. If we drxMs a uicoly-f^nulaliug' wound on a dofr with
diarpie dipped in tlie IHiliieüt putrid matter, if the hitter contain no
cauterunt sulntunue that may dcslrt^iy the jininulniion surGacc, tbcani-
tnal will not sicken, nothing; will be absorbed. UeiiccI cooeluilo tbat
the poieou must iu Bume way bo preventod fruui uoteiing ibe blood-
v«x8el« in the surface of the granuhtiuiiM. If ibe septic pMsoa Im.> in-
IcTxluccd into the fri.*sli tiasiie, it not uiily vxdtes hl-tctc IuohI inÜBni-
nntion, but qiik'kly induces jfcncral fcter. From thcso peculiar coa-
ditioDS under wliich infL-ctiun from putrid subslaiioes tutially takoa
place, it seems to uie evident that the paifion 15 absorbml chiefly by
the Ij-mphati« ve«(rl«, ns I hnt-e nlmndy menlioncd. Bemendter, nlao,
that, in eontuacd wounds, deeoinixisiTig slireds of Jirm connective tis-
ane, especially of tendons ttnd (iisciir, ofti^n lie for a long tiino on
f^imhttiiig wounds, without any ecptio poison passiuf^ from tbcm
throuf^li ibe superlieial resselü of the gmnulations iiilo tlie lilood ; tUis
obser^alidti verilies the cxperiiiients made on dogs. But, if the iMuson
be not taken up by the blood-vvsscU, or bu taken only under «niain
circunwtanees, it is very iwolntble thiit it« absorption is chiefly through
the lynipliatic vcasels. 1 will not deuy ttiat possibly in certain swol-
len Stat«« of the wall« of the blood-vessels, as well as from eapilUuy
attraetion, und iiliuj throuju'b llic tliroiiibi of the Tcssela, infectiouii mate*
rials wmy reach the bluud, nor that etills lake up septic molecular
GubetAticc« and may wander with them into the hlood-vcKscls ; but, nn
the wWle, I consider this mode of tnfeetiuo «he cxcq>tion, cs|x>einlly
if the infectious «ibstunce be not dissolved, but rxiüt hs very (lue
molecules ; U^ lor ioetODce, it be token up in the lunn of dust. Of IJie
healthy parts of tho body exposed to the air, it has only bcnn proved
SBPTIC^MIA.
9SS
tluit tlu»l4ike bodies (ns oinl-diist) eali^r the lungs, Kiid ina^ llicnce
rvai-h thu brvncbiul glaitds (llien«: dIko tlic blood), whilo a stinUar
absorplMJU fn.wti llii> u-itll» uf lli« inu^st in«« has not yet hoca obeon-^xl
or exporirtwutallj provcJ. Siiould tlio mi&imata rraüly be stnsU funffi,
Üiat 19, molecular bodk-s, from wlmt lins been eaid, it n-ould seem very
ptobubli_* Uiat the infvrtion itiay take* pla<N> tbroupfh Ihe respiratioo ; if
this should bp prov«l, it might be of great practical conjiequenoe.
Of liUC) many attcinpta liavc boeu iiiadu to dclerniine what sub-
stance in dccompoaing animal tüsue is the traf, poisonoiu principle,
and for thi» purjKise putrid fluMhi have been treated chcnii«*lly ttU
0OCDG one body ahould be found which in the nmnllvst doev eliould cx-
Öte the «ymptonis of «cptio poisoning. Thus ßer^mann ha« procluoed
a body of this naturr fruin devomjwsiiig' y(.*ast, vrliich lie onlU aepsin.
Tu proTc tliot this body a/on« (whose presence J'ueAfr could not
I>roTO 10 iIc4X>inpoMng scnun or pus) is tho poison, it would be iieoc«-
saiy Id prove tbo inuoCTiousne«» of all other Ixxlies chemimlly formed
during putrefaction. But this cannol be done ; üulphurettcd hydro»
gen, sulpfauret of amtnonium, butyric add, Icucin, and some other sub-
stances, forming during the piitrefactitm nf or^ganio bodies, also net as
septic poisons when injeiled iuto tlie blood, so tliat I eautiol oiitür
iatQ the laborious search for one body in the putrid fiuidis which nhall
bear all the blame of th« injtiritnis eflectft. Il ia rery probable that
in decomposing fluid», according tu tlieir qualities, degree of conceit-
intioa, temperature, etc, very many different poisonou.i substaoeea
may form, which I further imagine as going on changing till they
nurh anmc 5nal terminiJ stage ; ileeomposition is analogous to fer>
tnentation. altltnugli much more complicated.
After these general obscrvationa, we shall oonsicler thoae nurgiooJ
csaes that give rise to septic infection. First como tho cases where
ihcrc IS deeompusiLiou oit recuit wounds; it usually iippears nithin
the fif«t three days whether in such cases there will be intense, uo-
uaual, local, and gent-ral Inflation. If the local infection merely evince
itself in moderate inflaminulion, which soon leasts to circumacribeil
suppurjtioo, if the general infection bo followed by moderate fever,
the afffi-tioQ would come under the head of trautnatic fever, lint if
tlie local infection he v<*ry extcn.sive, with phlegmonous inflainnuition
and putrc&ction, and the general condition aa^unte a dwtacter eooa
to be described, we call the «täte septirarmia. In other cwte« the re-
Absorption of putrid umtior takes pboe from a truumatic or idiu[<uthio
cxt«a5i%'e gangrenous sjiot (as fiom gangrene due to di&easu of tho
arteries) ; this is more frequently tlic CMO in moist tlian in dry gati-
greoe. In tlie same way the rc<iuiieinents fur the reabsurptiua uf
putrid subatODccs exist, if after delivery the placental surface of tb<t
23
336
TRArHATtO AKO IKFLAMMATOIIY DISEASES, ETC.
utMniftltecomes gatn^rcDORs^ somo of the cases of pucrjwni] fever are
«eptiaciiiiii.
It will be crident to you timt the temi septieaenua eeecntiall^ do
pends on iho etiology, jiwt tike the (Houp of "typhous" discuses;
and that milt! «pptip-trauninlif fever hu the snine relntion to «f-pti-
oemia tliat typlius fchriculn bna to typhus; in fact, the niune "«cptic
febricula" bus be«n proposed. Still, a» typhus iu itst difFcitiit fonns
is chnrncteriMK) hy He symiitotnntolojry und pftthnlnpcul nnatomy, this
18 ahiO the case in M^ptittemin, although in it tlie patholoffico-anatoimcal
appearance« are slight. Koiv, -wJint chBrnctctizcs *hc coureo of sppti-
cjtmia? 'HienerrousByniptoni? deserve the firat meotion: tJ»e patients
are apathntir and uleepy, if not entirely mmatose; rarply Ihrre is Tear-
ful exeitemfrul, nnd occasionally maniacal (Ifliriuin; at the («tint; time
the «ubjeolivc feelings arc ffoo<I; the paticotsdti not suffer raucli. Tlie
tongue is diy, ofton as hard lu wood, which renders th« speech very
FcTrr-cnm In tcptlcsBiU iftcrtuctfrntlaiiof nn Imcons« llpomft, tram betircra IbGionKin
at ibc thicli. Ucatta.
SETTICiBinA.
88T
later the »kin is drjr and flabby, llic urine la »cuity, rcr; coDccn-
trat(>d, «nd opcasiotinllr albumitious. As tliv disCBse progresses, the
putietit [iwuir« his tirinn aiid Ceces in bed. Üe<t-soreB ovpt the sucnim
occur f«Hy. Tlio fw^er (a» shown by the bocUly tenifxiralurc) n! firet
rise« high, in «cut« pure «eptiwc-inia intoTcUTTcnt chill» never occva in
the eouno of tha (Iiscu#o, »nrl initial ctiills aro very rare; later in the
(Us^rasc llie tempnraturc Iblls to the iiormal or vvcd below it ; usually
the [tatieut dies iu perfect collapse, wilb n tbrcad-Iiko, ?ory bequest
piibie; ohco the ojfony lasts over twenty-fimr Iiours; tlie low tompenip
tuie niay generally Iw measured by tlip cx>1[li)efi8 of tlie eitreniiliea.
This is the usual cuursc of acute pur« evptiiteuiia from rctviit in*
jiirie«; but. the patit'nt itmy die in tiw first stages, with rising tomppra-
ture. C'&M-s uUo o«.iir wliorc the onset of tho fuver is scarcely marked
by uQ elevation of tctnpcmturc, and htstly some cases run their course
without foreror vith abnomially Ion- temperature; the latter occurs
espwiially in old persons with spontannous gnngn'm'; but the other
»ymptonis above menlioned usually citst. From lliis and particularly
from the above curve, we see that fiillinj; of the temperature of itself
18 by no mean« a Kign of improvement, but that tbe other constitutional
symptoms (stmiglb, muntal state, tongue, pulse, etc.) must also be
taken into conaidcration.
I hope that, from what has been said, you hsTc formed ■ true idea
of »eptieiPfiiiiu M"here the symptoms of tl»e diseaso are marked, iIhi
progiioiiis is very bad ; we aliall speak of ibe ln-«tnient at Uio end of
this BCdion.
We now come to the poat-mortrm appearatife». Orasiunally it
is difficult for us to reeofpitze on the eadavcr the u-domatouN infilrration
and brownbh discoloration of the skin that we observcti atKiut the
wound during life. In other cases that had a loBg course (six to ci^t
days) we <ind the subcutaneous tUaue infiltrated with bloody, aerouB
fluid ; where the course is still longer (two weeks or more) the discaso
shows itself mostly by eslciisivc suppumlioo of the cellular tissue,
with mot« or less extensive gangrene of the skin. Pre<:{uently tho in-
ternal organs preseitt t>o tnorbiil ap[ieaTsnces. If tliere was continued
prufuMC diarvhcca during; life, ytiu und swelling of the solitAry and
eonglohate intc«t)nai follicles. The spleen is often enlarged and
softened, rarely It is of a normal size and firmness ; the liver is usually
fuO of blood, relaxed, and very friable, but without further chan^.
In tite heart tbe blood is lonpy, half-elotted, torry, and rarely firmly
coagulated, buffy; io most eases the lungs arc normal. Sometime«
we find difluso single or double pleurisy of moderat« extent, attd also
truces of pericarditis. Under pyieniia wc shall »peak more fully of
these diffuse uietastatia inOanuiuitions which arc not due to emboli;
88fi
TRAUMATIC AND IXILAMXATORY DISEASES, FTC.
here it U oot very uc<v«siiry to do »o ao^ mora tlian it is lo irvAt of
embolic infarclioudi intl pulriil ftlMnesuvs, wfaicb mm cxccption«lI^j
fouDtl ia »epticKMnia when tlic pntiviile rcsUt tbo disooee b long timp^j
ant) venous thrombi have occumil about the woimc] or^D}i:n>uou!t itpo^.
A» tmlbing special lias been found on clicmical aimlysiit of i\iv bli
irom tiic bmiics of sucb caac», it must bv ocknuwlcilficd tliat wh»t «e
find f <w( mortem 4dd8 Httlo that is cljaiaeterUtic to the picture of Lb«
dbeasf», which is psM?nti:i11y etiologico-symptonmtolfjgical ; if wo hat
not nef.n Uic patient iliiring Itf<>, ^vc «ball often examine Ibc ileud bodj
io Tain for »oiu« pnlpablc cause of death.
3. ffttj^mratitx >Viwr, Ptf(nnia. — f 'vienna (the »aiiie wa* funnod 1
Piorry from iriw. pus, and alfia, hluotl) is a diM^asc M-liicb wir su|:
to be due to the nb*orj)lioi> of pu» or its conetitucttts into the blood;
it holds the samv relulluo to simple inflatnnuttory end euppunUre
fever tbnt septicemia does to simple priniaij- traumatic fever; U
symptoinatologicallj cbaructi^med hy iiitcnniltval attaeks offerer, and
in its pntl]al0j];ienl anntnmy by the froquonc^y of metaatatte al
and metastatic diduM; iiiQamniat[uii& Other niunea for tliis dinease arc:^
mctastiitio suppurative (l/Bcraain, pu», disease, pundctit diatfanJfi,
To pve you at onco an approxiaialc piettirc of this disease, I wil
deacribe for you a case of pymmia.
A TTOundul pHlient eilten the hospital with a rompouiid fracturol
of the IcfT just above the nuklc. The injury* has resulted from iLe]
fail iif a heavy bridy. Vini examine the nouixl, fiiid an oblt(|UL> Crae-I
ture of the tibin. but consider the iujury of stich a nature that it maj
Itcal. So you apply a drcsaiog ; at first the patient feels very wdl i|
he ha« but little fever till uWut the third or fourth dav, then tlie
wound bedomea more inflamed, sccrt^tes relatively little puh, lli«« aur-
rounding ekin becomes wdemutous and red, Ibu patient f^inns \tsji
feverish, espeeiully toward evenirijf, the Awt^iliinff about the nouiid in-^
crei»e8 niid slowljt- spreada, the whole leg grows swollen and rwl, the i
aakle-joiut very painful ; on preeaure over the le;;, a thin, badlr-sniell- ;
injf pua flows elowly firom the wound ; tlie swelling remains limited lo
the leg; there is no truulile of the mind, no sign of intense, acute
septicfemin ; the patient is exceedingly sensitive to vrcry dreoeiu^, ho|
is rcctlo«3 and discouraged; thery is febris oontinua rcmittou, witlil
high evening temperature, and frequent, full, tense pulse; the appe>
tile is lost, and the tongue liea^'ily coated. Tliis would be bIkpuI U>c
twelfth day after lie injury. Quantities of pus Bow from different ,
parts of the wound; somewhat above it fincluation is lUstiiict; tluBJ
colleL-tiunof pu3 mny be evacuated through the woiuid by careful prus*- '
vre, but tlie eseape ia greatly impe<1ed, and an inciaioQ must be made
St tbo above point. This being dune, a moderate quaality of pus ia
FT^KHIA.
m
evMcnaled ; a tew lioiirs Uter tlie patient \itm a severe cliiU, tlien 'iryi
buminfT bent, iumI, litstly, proftisc inTcutiii^. Tltc appearance of Üto '
wound improves aoinewhal ; but this dors nut last long ; we aooQ no-
tice a nvw abwees near tbe wouod, hat rather behind it in tlie calf;
tiiere is another chill : more ominter-opcnin^ are reifuirt.il at ilitTfreai
«pots to give exit to tbe pus, n-liicb forma in quantities. Tho loft leg'
im the injured one; some moniing (he patient eomplains of great pain
in the rifjcht kne«-joint, which is twtneivlint svrullcn, and is painfUl od
«rory motioa. Tltc night« nr« »lecplc««, the pnticnt cats veey Uttle,
cirinks a grvat deal, and becomes much debilitated; he emaeiates,
^Tspecially in the fare, the color nf the skin ehnnges lo jrlIowL<Ji, the
<:faUl3 recur; the patient then begin« to complain of pressure on the
«sheet; he roughs some, but niiiies little eputuui; ou examining the
o^ueet, yoa find a moderate pleuritic exudation on one or both aide«,
from wliiirfa, honcTcr, tbe patient doc» not HuFTer mud), htit be oom-
plaina more of tfae right knee, vhieh is now much Bwollen, and coo-
tains »f^vat deal of fliiiil; as the patient sweat« a great deal, the
-urine bivomes very ooDccntmteil, and is ooouüotuilly albuminous.
Finally, there i* decuhit«», but the patient doM not cwnplnin much
of tbtfi; ho lies quietly, half insennihle, muttering to liitriM'ir. TliiH
wouM be about tbe twentieth day after the injurj* ; ihc wound is dry,
the [jutieut look!) miäerahle ; the face, and egpecially the nedi, is eina-
eiatc>d, the idcin is reiy jaundiced, the eyen dull, the Iremhling tongue
is perfectly dry, ilie skin cool, the teiniwraiur^- low, and oiil/ derated
at evening-, the putsc sntaU and frvtiueut, the respiintioos skiw, tb«
breath of a peculiar cadaveric odor ; tlic patient bocomes entirely un-
OODScioti«, and may, ])erliap8, remain to for twenty-four hour« before
death. On aulojtey, you find nothing pathological in tlic &kutl ;
beart and pericurdium normal; in the ri^ht auricle and ventricle a
firmly-cnogulaled, white, fibrinouH clot ; both pleural cavitiea are tilled
with a cloudy, scroua fluid ; the nnrfaces of lite Itiogs are covered with
0 tK-t-like lay^r of jaundices! fibrine; on tearing this off, under it, in tbo
suljsisnee of the lung, bul ])artietdur1y on its surface, you fiml quite
6nn nodulea, as large as a bean or chestnut. These arc found chiefly
in tbo lower lobes ; sections through them sliow that tl>ey aru mostly
aioceMea. Ttie jiareTichyma of the lungs, Mimewhatcondpnsol, forms
(he capsule of a cavity, which is filled with pus and disintegrated
Img-tÜAuc ; olhcra uf these nodulca are bloody rvd, and, on soctioo,
<fae cut surfne« is 8om«wlukt prrnnular, nod in their midst then> are oc-
CBSJonal spots of pus of various size, and it is evident tliHt lliey
change to ahsccsscs. Tliey an- the mt in/aretions, temiinaling in
abecenes, with which you are already acquainted. Some of these
afaeoesees lie so near llie aurfaee that tbey implicate the pleura, and
uo
TR.VCHATIC AXD INn.AHUÄTOBT DISBASBg^ ETC
the pleunlLa is isccuiKlarr. Tbc liver is quitti voacular and fnablo, bui
i» otherwise a]^tiriitly iionniil. Tlio i;plt>en is somewliut uiilarged,
und, Uli acctloii, sliows a few finn, wcdgi>«liapcd nodidcs, with tlieir
point« inward, and tUär broad outer eniU along Uic surface ; Lbey le-
Eeuble tb(f red iDfaTctiuDs of the lungs, and within tliev al»n hare
partly broken down into pus. Tlie intealinc», urinary anil {ronitnl
Organa, bIiow uolUing ubiuiniijJ. An inoi&ion into tjie rigbt knec^
wliioh wan pninftil iltiring lif<>, praotiat^s n quantity nf flocculcnt ptMj
the 8ynuvi;i1 iiivmbrune is strolteii, und in pnrt ha-morrhagtv, injertvd ;
tbc luelrc of tlic articuUr cartilu};i; is dullnb Exuminiilidii of the
votmd slion-6 Uttio more titan we found on tlio living patient ; that is,
extensive suppuration of the deep and subcutaueaus cellular tissui^a«
veil OH |>iiA in the ankle-joint ; the wall« of all these collectimis of pue
con»itit nioatly of hrolten-dwwn tissue, tm« granulation lias only oo-
cuired «t a few points. The fracture i», however, more complioited
tfanu had been Bupi>ose(1, fur a longitudiiiul fissure reucliea to the
ankle-joint, and on tlic posterior aspect of the tibia, whicli wc could
not examine during life, iliore arc ec'Tonil detachwl frap^ments of bone
In Ute veins of the leg there are old plugs of fibrinc here and. there,
also yellow ])iinfonn dctdtus, and i» eonie places pure pu&
Let 116 mak« some rcfli^otioii» on thin ease, nnd Ruppo«e llint you
have seen b series of sucli casus, so thai you arc oonviiux-il tliul It is
□ot an aa:idental a«»o(;iatton of various diseases, but a regular com-
bination. You have uii extensive, steadily-increasing suppuration in
nn extremity, «ith intense eontinued fever, which has exacerbatiuetL
To thia are uddcrl suppuration in souie (li»tnitl joint, and draimscribed
intlammationt<, ending in fommtiou of absce&aes in tbc lungs and other
organ». Tlioec Eimltiple points of ioflammatioD keep up the Hbvct,
and they disturb tlic functions of the nffL-clcd organs, und the pntient
dies of exhaustion. The peeultar and essentiid feature, as you will
readily ace, is the appearaoee of various poiuta of inflammation, after
die primary suppuration haji attained a rerlain grade; Yau ktiow ths
ezpliuiation of tlie Of^!0iim>iicc of nieLaAlatiu absceesea: tlicy are lU-
vays caused by venous thromhostia and embctli^iin ; it is tinneeeiuary
to recur to this. It Is uioru (liflicult to explain the disuse metatlatie
vifflammatioius tThii:b occur both in Bi-pticn>niia and pyn-nita ; tliey by do
moaDS always depend on absccjiSM of the lungs, as d'^cs pleurisy la
tbe oasea above mentioned; tJiere aru nielniitatio diffuse absceese« of
the eye, ocmbrol membranes, subcutaneous tissue, joints, perioEteuin,
liver, spl«e», kidneys, plcum, pericardium, eti?,, which are indepettdeDt
of nbeccsses or embcili. The orriurence of these metastases cnitnot
always be exactly explained. If tliu Kiclastatic disease bo nearly
tmitcd to tbc original absce«», it niiglit be attributed to 00Dduclio&
PYÜIU.
m
.^'OCiiUie iDflammutioD frum tivi lattor, possibl^' tlirougli tJie lympbutio 1
liMiiili OS ia cases vbcrc, after ampiitatioQ of tbc brcust or'csnr-
tioulatiua of llio humerus, tfavr« is ploitrUj of tlic same side, or »
fncturc of tbe lower tbinl of tbc leg is accompenicd hj suppuratioa
of the knn^vjoiut. In otlipr L'a.<T(!e it is ponailJc Ümt a jiiirt alrfjul^
dücttsed, or prcdUpoAcd to iDSammatinti, becomes aculoly affect«^, as
m mult of tbe general febrili* disturlmnc« ; for iiittanoe, itoiiiHimcs
tnetnrc <uUws saj of tbc nv(]iuc<, tliat is nlrL'tuljr tolerably Grm, sup-
purates in tlie third or fourth vrcdt, if the piitieot becomes pyemic
from 8 complicated fractureof tbeleg, or from ubL-d-scn.*. ßut thiTo ore
tnany coiwa vhcrv, as aliorc statrd, »u<:h explaDations prove insu furies nt.
Tbea we try to eatUfy oursolves that there was & predispo&ilion to in-
CJADunntion», e&]>0(:inlly to »appunitioii in rrrtnin organs, whiph in
neoeswrily aceoiiijKuiifd by |>u»-iMji>oniiig; thai tlii; pus-poisou circu-
latiitg in the blood hns n spoeilii' plilogt^gciious actioii on certain orgaDS.
I can givo you iio farther expliinutioii on this point, but woiiM like to
tetider thU hypothesis a little more pIaii«blo to you, by comparing it
with analogoua obsecrations on the speciiic phlogo^aous sciioa of
certain dnigs, of wliicli vro have already gfKtken when treating of the
etiology of inflaniinatioD, and ita toxle-miusnutie causes, and their
nolle of action (jMigc 'i5t), l}iffu»e metastatic iaflanunations of in-
tcrool o^;^)9 are rare, unless among them u-e include the <lilTuäe en-
lar^gcminit of tlie spleen, n-bicli is frtHitient, if not ronntaiit, in pyiemia.
'T\iC djaguosis of metaslatio abseessea and iiiRainmations is easy, where
they lie at the surface of ttte body and extremities ; metastatic me-
ningitis or choroiditis is relatively easy to reeogiiize. Tlie tliaguosis
of nietaslasca to thir lung may pnivc difficult ; the foci arc often so
Knull 9ud so scattered in the lung that Ihcy cannot bo detected by
percus&iun ; the accidental pleuritic effusion often aids in the diagnosis
of nieta*latic pulmonary ahAoeAsea ; if there are bloody sputa and
KTCic brouchiul ciitairti, the diagiioais may be considered certain ; the
subjective «yiiiptoiiis are often very slight ; the dyspncea is only severe
when tbecc is extensive pleuritic effusion. In pyn^mia tliere is otia\
more or less jaundice. It i» not yet fidly deteriNined whether, ui these
eases, the coloring matter of the bile i« formeil from thu rt-il cH)loring
matter of tbe blood without the ioten'ention of the liver, or if ictcnn
ever can occur without the liver baring something bo do wiUi it, al-
though moat obsen-ers regsnl it as always being ItepatogLnious. At
all evcnta, icterus in py:emia does not admit a diagtMsisof abscess of
the liver ; this may be »uspeeled if tliorc be great pain in tbe hnpatio
segion, but, instead of the expected liepatie abeeess, I have, in such
cases, occafioTuilIy found acute diß'uau softening of the liver, which
waa accomjKintcd by almost bronze-like icterus^ Euloigemcut of the
TIUmiATIC AXO IXFLAUMATORY DISEASES, ETC.
Bplooii may sometimes be diagnosed hy percoMKHl. Oc-eaHonalljr,
albuniL-ii, witi) rpilbclml luul gvlut^iioua cafilti uid blntHl in Uie urioe^
Mpeciiilly if thorc be conaidmiblo eoincidRDt doi^rease in tlti* amotrat
of urine oxcrrted, jtifliifie« a dijignoMS »r acute metustatio n4>|]briüi ;
but during lUv it cunuot be certaialy determUied u-bellior tlie
Icidnoy )iH.i nunrK'rous mctasUlic nbscescea or is difluscly inllamed,
lis inuy al»(> oci^'ur iiMflJistatlcaUj', Pulnionaiy and E|)lun!e nbsceaac«,
OS well OS urtioiilar inflanuiiations, arc tbo most frequent, whiic tboac
of iho liver, kidiii?y'&, aod otiicr parts above mcDtiooed, are tar more
rare.
Tliprr i» one symptom at pyaeniia iliat we must study Riurc car»
fullj, Tis., cÄiila. Tliey oocitr irrcgiiturlj-, rwly at QJgbt, ultboitgb
they may eomc nt nny timo of day, uml tliclr durntiofi and intenritjr
VKT^' exceedingly ; «ometiiues the iiali*.-iit only complains of >l<|^t
cbillinctui aud temporary sbivcrin^, sometimes he treinblcs and AM'
ien IiIh t««th ns hard hh in " chills and fever." At first tlio ctiills come
rarely, tlien more fi'equc^ntly, Wo or three time« daily ; toward Ute
end llipy ag'ain abnto. Tlie attacks Uipm&elrea resenihle tboM of
intcrniittent fever in regard to cliill, diy heat, and aweating; but tiHtr
the ntt:irk tliere )8 no complete c^uuition of tlie fever, it alrtiovt al-
wuya cx>ii till ties to sumL* extent. Now, wtiut is the tn>e nature of (bis
cbill ? When wc have opportunity to mslco obscnratioos on ourselves
we find that there is a Hpasmodic coiitraetioo in the skin ; we mual
spa&moilirally knork the tenth together, even a^inst oiir will; if tlias
oeeaes for a moment, wc do not ftMjl <^ild, but rather hot, mhI the
feeling: of chilliness is more in the ima^iiiilinn, for otJier\Ti»e we only
hare similar tiensafinn? and spiuimndic Imiiblin^ as an r-ITix't of great
cold. Duriti}^ the chill tlie limb» and akin feci cold, iia the blood has
been driven from the cnpillnrles by the spiisin i^f iIip ciitnneoua nnis-
cles. But if yiiii ineiisure the boilily tempcrnture with tbc thcmiotn*
cter from the commencement of the chill, you fmd that tlic tempem-
ture rises constantly and rapidly, occasionally frum 3° to 5^ Falir., in
a quarter or half an hour. At the end of the chill, and during the
period of dry lient, the Imilily teinperahirc usually attains it« hig-hcet
point ; it may rwicti 108° Fahr., but rarely goes over 104.5' Fahr. ;
from this point it gradually destines. The rapid increas« of tempcr-
nture in ittwny.t in prti|tor(ioii lu tim pbenoineiia of the ebill ; n oc^
tain irritnbility of the ncrvoi« system iilso appears neccsMry for ita
oocuireiice', fur in torjtiil or iiun'otixLHl jien^oua chills are mucli more
rare than in very irritable subject» (sec page 15Ö).
The most varied acute diseases begin with chills and fever, espe-
cially the acute eximtheniJita, pneumonia, lymphangilis, etc. ; more
mrely Uie acute miasmatic infcctiowi diseafle.<i, such as l^i'jihus, plaipj«,
PY.EMIA.
843
and oliolera. UsunlljTt howcrer, thitAc rhiUs nre not repented, but
only cbe onset of the dinewe i$ «crompanied bj this s^mptotn ; it
seems u if the first eiitrniice of oertAin pyrogwuous substnnoe« into
the blood of pcraons othLTwisc healthy unw npednllj apt to induce
chills, or ns if cerUiio infe^-lious materials cntcrinft tlie blood excited
partimlarly int(>n!%e fcvcv with obills. fleiioo, n1lhnuj|^h we «tnnot
ooiuidpr diills » chimtcteristic of p^wtnlu, still their frequrnl recurs
rrotjc, ns well aa the gcucrully intermittent type of Ibc fever, is pecu-
liar U> this dlspsse. Int/rrmittcnt fever is thu only dt»0S6« in whidi
we 8CC any thing similar ; there wc liave iatcrmittctit attacks of ferer
with regular intervabi ; we do not kuow on what this interval dejienda,
but [ ahouid con«d<>r the imm<-diitte cause of the nttaokn of fev^r to
be puroxvsutal pouring out of morbid products from the spleen ; in
mclanA-mia and pifcnx-*"' metaBtuscA wc have anatomical c\'idcncc
that in intermitlcnt fever substanec« pass Irom tJic spleen into tlie
blood ; it is Icnovm that collections of norrn:il secretion occur in tlie
pancreas and spleen, nnd are poutv^il out during digpstion ; lii'ncc, it
does Qot »ocm to me too bold tooMiinie that, with these phy&iologicEtl
evacuations of certain subtitaiieeK from the «pleen, pntliologieni prod-
tKt« may also enter thu blood. Tliuit, in piiicrnia, from tjino to time
pus or it4 conalitucnts nti^ht be poured into tlie blood, nnd under
otbennse &vorable circumatanccs fever nnd chills might he induced.
Bxti>nsiTe progremire inftnmnuttion about the wound must be re-
garded n* llie chief ouuroe of such repeatcil ptiniliMit infection ;
dMtruction of tlie frntnuUting ainfaee by frequent injury, rapid de-
itmetion uf the (rruiiidiitions by cliemicnl Hgeiits, any new jirogreniTe
iitflamiiuitiotis occurring about the wound, may open an ontmnc« for
tho pus into the lymphatic vessels which ba\'c been closed ; new in*
flmnmation mny enuse suppuration of the ooaguU in the lymphatio
veasria, and the pun from tliesc may enter the blond; it might also
be inagined, allhouf^i ditÜcult to prove, that in venous thrombosis th«
oemtral oonguln encloeiintf the pus in the vein» are torn lonsi>, and tho
pus is swept into the Uood through a passable CDll»<i.-r;il vfiu, wliich
opens fiirtfacr on ; this might be caused by muscular contractioos.
lastly, metastntic inüammations, wlielher due to emboli or not, also
induce new attacks of fever ; but that this is not the only cause is
|)n>?ed by occasional atitnpfiies on c»«e:« that luve iUe<l from intermit-
tent purulent fever, aXtex ten or twelve ehills, wher« no inetastatio
inflammations hare been found; tlio cause of the repeatml chilN may
tlieii lie iti the mode of extension of the local procc«?i, or be hi<ld('ii
in the l>oncs or cUcwherc. Statistics greatly favor the idea that
tbo cfaills depend on new ttiflammations, fi>r tliey show that the chills
(oratleaat the interaiittent fever attacks, which may occur without
8«i
TIUCUATIC AKS IN'FULMIUTOSV DISEASES. ETC
cbills) oncur &r rourc frequently in pcnwns in whom Bufascqoeiit
auto{;e]r nliovra iniliuDiuaUoD of iiiterual orgmn» iLau iu Uioee who«
thJ5 is not ibc c(t»e. It rnu9t be mentioiicil, ft* a matter of ohsrm-
tion, that cMUk uccur bIdiokI vxdiaiivel^ in tliD comnieiicenieiit of
acute iaflntiiinatioDs, end arc intcnnUtciit ouly in iotcnuittcnt tcnr
and teabeorption of pus, wbtle they do not oc<Mir in acut« E«pti>c«pRiiA,
PiobabI}' lite chemical quolitka of tlie iofi^tiog matter here pUiy an
Liiiliortftnt but unknown r^h. Unfortunatel/, expcrimeat lierc leaves
us cutirclj in the durk ; I hare Derer succeeded in eXcitii^ diilU cr
i Hiermit tent atlaek« in mbbit«, doj^ or hones, by iiiji^^lions of putrid
tubstancvs or guod pus; pus and puliid matter Imyc the saine »/>
lion on animals, as rcKnrds fever ; vre can oul; orti&cinUy excite the
intermittent cooiree of the fovor in animals by repeating tbo injeo-
tlojis.
From vrliat you hnve juft bcanl, you will uuderetniid Ikat llieusaal
method of mcasunoff tcmpcmture morning and evening con gire
no picture of the ooursc of the fever in pyvmin ; for in this way the
nieAHurement may fall at one time in the acme, a^tn in the (WlÄ-rtt»-
cence of an attadc of fever, or at another time in the rciiiiasioD(ocNii>
plele tiitcrmisgion of the fever mrely happens in pyiemta); Ihna w«
would of counw \m\v very irre(fulHr fever^iirre». To obtain an ac*
ourate picture of pyoimiü fever, it would be DCccaeory to leave the
ihemiotnclcr constantly in position, and to note the tempenUtnc
every liour or so; as this would greatly annoy the patient, and we
ba^t; enouf^li other eigta to deride the prognosis niwl tn-atnicnt, I
bnvc Iwcn unabli'y to make up my mind to do this. TIm; invosliga-
iiotis as to whether pyemic ])U)) contains peculiar sulMtanotvi, or its
qualitative compoiutiou differs from that of the pus in persons who
recover without any complications, lta\-c thus far proved without re-
&ult. The old view, thnt p^-winia is only induced when deoompoMd
pat (ichor) ia reahsorbrd, is entirely crronenusi. There arc cases
where dooomposed, putrid pus enters the blood, and which prescol a
cnnibination of the symptoms of septiciemia and [^temia (septCfpywmia
of JTatttr).
'Hie mode of onset of pya*mia ranca in some respects. Moet ftiy
quently this disease, which wo rognni as a poctdiar, malignant fona
of suppurative fever, begins when suppuration begiim, or later, wfaoa
new iiifliimtnaiions occur about the wound, whetlier they be iirnno
diately conneetcd with the traumatic infiammntion, or oceur acctdeo-
tally after Uio point of traumatic inflanuimtioit has been bounded.
Then the pyieniic fever develop« from the tiaumatic fever, or fmni the
sccoiidftiy fever, and in such coses these arc coiksidcrcd by some ob-
servers as prü<lromal stages of pyemia. The moment when the pa-
pv^iiu,
840
it beoomei pyemic cannot be decided any more Aoeorately than
oan the pusagc of primanr traumatic fcrer tutu sopticKOiia. I retain
I lie desifrnntiou " iiyajiiii» " for thediM-As«^ juet ilnAcrihod. I liarc told
yciu that the riMi))«orption of pua is the oaus^, intormitlent oourse of the
fever, with npidlyiricreasing innnu<niii*<, the cliief gj^uptoin, aiid tbe
tnoULstatic iiiflummntioii» very <-*«sontiiil uiiutODiicul ooDditiüiiB ; hut it
IS sometimes vorv dillicult to decide whether n givcu case shall be
termed serere traumatic fcvpr vr svpticwmi», or sevrrc suppuratjTe
fever, pyicmiiu Tlie cliilb mar Dot occur; tlicn it is diflioult to de-
termine Ihti interaiittent course of tho lever ; tbe metostaaos may not
be dingnosticatod durinjlf life. If you bare n ease of osteomyelitis
nrith frefiueot chills, if the patient die« aiul you find no nieta«liiac8, is
that pyemia? Or on old tnoraamic man bus a compound fracture; he
dies with fi%'mptoing of complete exhaustion iii thi> fuurtb week, with-
out liaviiig had very high {aver or chills ; you 6nd no metastases ; is
lliat pyaemia ? For tlie beginner who would like to have cver^' Uiing
well tystoroatizcd, these questions, and their doubtful answers, aie
very ombarrussing. You will llnd surgeons wlio call the nlxivc cattes
pyti'min, others who tcnn tlium simply iiit^iine suppurative fevrx or
febrile mnmsmus. If you adhet« to tlic ubofc description, snd ha\-«
oonvctly comprehended the reUtion of infection to raiioug throm*
boftls and embolism, it is to be ho]Dcd j-ou will not be perplexed ulnut
tbe names. Indeed, it is scarcely possible to make a name for every
link between septiciemiji, purulent infection, diffuse inetastatio inflam-
malions, thrombosis, eiiil>olisiii, etc For iiutaiice, septiciemia occurs
witliout a trace of mctostaaca, with diffuse metastases, with throm-
boaia and embolism ; pundent int'octioii n-itbout a trace of metastases,
with diffuse metastases and thrombi, wilh thrombi alone, n-itb thrombi
and emboli ; there are thrombi with loe^l sequences without emboli,
with emboli, with hemorrhagic eßii&ioDft, with apoplexies, etc. B«.
side« tlie vrords already given, «ome others have been introduced to
designate cum hi u at ion a of the ^iirious processes. For pure puruhrnt
infection (infection witli tbin, bad pu» — iobor) VirtAow has proposed
the name ichorrhf^mia, O. TTtf&tr uses the name «mboUvmnia for tbe
oonditioo in which cmbuli are found iti tlic blood. Tbe classification
giren by llcutcf, \n bis excellent work ou this subject, appcare to me
very practicnL In pure oises of purulent infection without metastases
he calls the dlHcn-te "pyohiemia simplex;" in cases with metastases,
"pyohieima multiplex."
The fourae of purulent infection is usually neute (^10 days),
oftira subacut« (3-4 weeks), rarely chronic (1-3-5 months). Tbe ra-
pidity of the acute case's is due partly to the intensity and frequent
rapetition of tbe infection, partly to the extent of the metastases,
84«
niAITyATIO AKD INFLAKllATORr DISEASES, ETC.
Tbc chronic cases UMially rwcar in very strong or tough potimts, wtl
the inTcctJon it> oitV modernlclj- int«ase, bimI not oftua ri.'|M:utt.tl ; U»o
tn<>tat)tiiKPti «pe in exteni»] ptiru, iwt nbsccffics in the (vlhilikr tissue,
uml suppnrstions vt Uie joints, which keep the palictit sirk after the
other result« of pumlcut iofocljou hnrc disappeared. Tlic prognotU
r?se4.'utinlly ilcpvada on the course. The more ß^quentlv tlie cthllU a»
rqwat«!, the more rapidlr strenglli ia lost ; the earlier the »rmplontR
of inU'rnal nietAsta^e» present therasclve», Üie »ooticr the pstitiul wifl
die. The longer the intermissions between tbe exncerbatlons of fev^r^
the better the «trenglh is preHerreil ; Ute longer the tongue mnatut
moist, tliu mure hoi>e vfK hnve of the potient'tt rueovety ; he is not out
of immcrh'atc djinfjcr till th« wouml »jfiiin looks well, till ho h*« bee*
entirely free fnini fever for seveml tluys, niid ha« otbem-ise the ap-
pcamnee of a eon^-alcscent. It is exceedingly mrc for a patient who
presents all the above aymptonis of decided pywniia to roi.'ovcT,
We must now go aomenhiLt deeper into the etiologi/ of tmuroaÜD
infections fever. At pmcnt there ia probaUy no doubt lliat it b
usually due to TeBbseq>t!on of putrid 6md or pus; that it U aitrayt
Ko, i» indei-d disputed. Muny iiur^-uii!< Hssert that pyuini» ven* fre-
quently rcMult« from miasma, especially from a miasma nhich develops
from tht; wounds of many patients lying together; this view i» besed
ehioBy oii the fact that wher^* many sevew surffieal m-scs lie logetlicr
(as in large hoepituls. espe^-ially anuy ho»pitalK), many of lliem die uf
pjiemin, and that even mild c&fm, patients with ciuatrlcing gnuiiilft»
titig wounds, become pyemic under such circuiDslaQOce. This is no
plaee for polemiee, henee I mu§t be eontent with giving you ray own
view.i nn the .subjert. I ran entirely a^ree to llie raianinalio ortgiu of
pyiemi», if by miasma is understood what 1 understand by it la Uu)
present and some oilier case», namely fhiM-like, t!rie<l eonstlluctils of
piiK, atid pdRsibty also aceompaiiyiiig nmiute, living, very iiniall cir>
giuibitis, whii-h in bndiv -ventilated eick*rooinR are niqwodcd in the nir
or adhere to the walls, bedelollies, dressings, or carelos&ly-eleiuied
iDStnmients. These bodies, which are in some respects of difTerent
iinturn?, arc uHn.illy pIil(>jr*tg(fiKiu», nil i)yro're«oiifl, wlien they enter tb«
blond ; of eourw they w i!l eolloct chiefly where there is the best oppoik
tonity for tbuir dereio[)me[it and nltaehmeut, that is, in botllyventi-
laled sick-room», where the patients are carelessly attend««?, wliere
there is deficient cleanliness, and the patients remain sometime« iu tb«
same apartments. It is impossible to say whether nil pus, moist or
dry, is alike iajwrinus; cxperimentaon animals give us no informatioa
on thifi point It is pos«ihle tlmt dry pus, as well as mMSt, act|uirca
peeulinrly injurious qtirilttioK from curtain minute organisms, animaJ or
vegetable. ItiicJcv has given us some very exact inrestigatioiu about
n
i
ui
PTÄMU.
847
peealiar naUite of these minute organisms aa tlicy exist in blue
puB, wo bavo already spokva of thvni (pngv HO) ; titey color the pus
blue witliuiit injury, tboy (.lo not (lc\-oIo|t ou nnii m the frramiUt ing
»urfacp (the pus is uut hluv whtrn it voinca frum ÜiCK''iiuuLitJons),but
in tht) charpio nad roinprcsecs by which tbo pus it ukoorhod. Hence
^serioof peouhar circumstancea must join to (avur their pleutiful
BTelo|Mneat. The »ame might h<> tnie of tbg drctiniatatK-fA faYoring
the devclopmcDt uf iutcusvlyiQfcctiiig pun or pus-tlust. We are liere
floating entirely in the region of bypothcse»; even assuming tJie ao-
tton of thcsn small orjranisms in the deorhfjmteM uf pyn^min, tliu quu»
ttnn as to tlie mnde of their action arises; pofwihlr tliey ioduoc a sort
of f«niiVMt«tivu ill (he pus of the iroumJ, inilamniation and dcstnio-
tkm of the gninulntiuna ; possibly tliey foroe tlieir way into the
giBDulatiun» ; [KK^S)bly, vAaa, ua previously ineiitioiiod, thoy enter tbe
blood through the lungs; possibly even whua in the blood they are
Dot alike dangerous to all persons; all llic&e things aro unkuovu.
It may be aaid. Of what good arc these fmicies ? If no new ob-
servations or investigations arise from thcnif tlicn indexed such ideas
remain &nei«>s and words; but the thing is, to find ideas that have
facts attaehed to them ; new fiu't« grow frtwrn new ideas. I coniudeT
the idea of animated, dust-like miasma a very fruitful one, aud, if in
any of you it calls to life new (hrtugliitt, whioh leiul to nt^tunl studies,
the oliidf aim of my exertions as tatrhcr is gained. The old doctrine
of the gasemis fonii of minsinnta has always led us into deep water;
nany shrewd pL-nous hare exiuiusted titeir brains on this point, with-
out adranctng it mucli. Anulbor common qtiestion ia, Xa pyatmia
eonbxgioua? According to the rii'w I have just given of pyemio
miasm, this is answered to some extent both in the affinnatirc and
negntive. A fixed molecular miasm, originating from a siippitratiug
pyemic patirnt, must at the same time bo regarded as a fix«.-d con-
tagion; but, aooording to my view, this miasm may just as well come
from n non-pyemic patient ; tben it cannot be termed cootagioua in a
specilic sense, fur a c(int)t<riun »lusys intluoes the mme disease. Vou
see that tbc strife as to thu conU>pousness ur nun-conlogiuusncsA ot
pyirmift must go back 1o tbc \-icws as to the nature of the disease; it
is only important for those surgeons who regard pyannia as n peeuliar
specific disease, not related to suppumtire fcrcr — a view which I re-
gard as groundless and practically useless, and against which I have
long fought, and I hope with Kuiiie siieoess. WiUt all ihvff tbing«
arise« the question, Doc* pyannie miasm e»Ur tka boify oniy thrauyh
the tooundf or aUo through the dein and tnticout membranes/
Although Iho latter i» nnt ini[iossible, I have not yet maJtt any «Ttain
obaenratioos by which such an hypothesis can be coouädcred proved
348
TRAUMATIC AKD INPLAUyATORY MSEASKS, ETC.
or even probable ; but, from my experiettce, I hold to tli« opinion Ihftt
tbe iafeotion of the whole bmly ranws fmm tlie wound^ wlietlier Uw
poison lit:(U circumsUincea fiivonible tu its (Wvt-lupmcnt in the voaiid
nnd gufTounding port«, or ivtidher it Im iiitTXMluixd into the wollDd
ulresd}- develuped. T iiin tiotsliskeii in tliis vihw^ eren bytboee tub
enacts mUwx) there is »oTiaiblc lianKc, or only very little, in Iho wound
on commencing pyitmia, for possibly tbe infecting body h*« very littltf
if any plilogv^gpiious itrtion, and hence may enter the Wood tlirougli the
wound, iiiul have m pyrogciioiis anion, without causing any t-hniigti in
the wound at its cntnnce. Sex seems to bare very liltte influcooe oo
the frcqiiuncy uf iiireeiious diseases of this clam; pi^issihly t4>Ripcn-
tncnt, thf ciicr^ and frequency of the cofilracUons of the heart nod
ftrteric», niny L»vo more inSucnoo on the rc«b«orplion of the dot«!«-
rious subfitunoGK. Jud^np from ginieral imprcBsions, chiltb«a seem
Ida disposed to pyannia than adults. It would be exceedingly (UA>
cidt to make glatistlcs ou this jKiiul, as so few eever« injuries ocvur to
women and ehildren as comparvd with men; coniiefiwenily, llio fiict
that so niRuy more tneii die of tratiinntic-infcct.i«u (ever of coutae
proves nothinff ohout tli<; preiliE|)usitioik of either clnss to tliis ilifieaacw
O/vi wcinndfl of bono partionlnrly dispone to py«pn»ia ; judging from
my experienre, ihoae wounded in the lower extremity are most, tlioaa
woutideil in the trunk uru least, in danger of becondng pyaemie. So
far aa 1 have seen, the time of yew nod the collcetion of Hjrcircly
wuunded in huspilals hnve little if any direct ifinuciioc oo the dcTdop^
mcnt of pywmia,
Lastly, I mwtt mention the so-cnl)ed Fiiontaneous pysuniia, Casea
occur where mtiltiple a1]ee»iSL>s (of the aubeutatieous tlMoe, for to-
ntaiice), or even veoims tlimmbi with cnilxdir iiietanlatic abacewes, ap-
pear witliout our being able certuiidy to detect any piimary- point of
suppnmtion; tliene caws, cspooially if they tun »n acute course, are
exiled flpontnneuits pyi^tnin. Tliere in no rcaitun for raiaing a new
theory for these rare eases, where we simply fad to detect the priinaiy
point of inflammation; 1 doubt not that there wilt hereafter ho In»
mention of these case», which, according to old theortCB, wore veiy
enigmatiral, a» we are coiiM^intly learning to olwcrve more accurately,
and, on more onrcful examinntion, ehall usually find the conoeetioa of
the symptoms.
From the intimate retatioo, wliioh we nippose to exist, l>ctwe«D
traumatic fever, aepliejpmin, anil pyieniin, it m>ciiis oorrcet I« spenk
of tlic (rmtincnt uf these disenses under the eumc head. Tliis may
be divided into prophyUxi«, and the treatment of the developed dift-
eatH'. Tlie former is by far the moüt important ; it cootiat« in avi^d»
TREATUENT OF TllACJtAnC FEVEB, ETC.
34»
ing every thing th*t may faror the discaic Even in oponttioos there
too some points to be o1>Berrei1 ; all the instnimeats used, the liunds
of tbe operator anil liis asstatantH, and tho sponges (wliirh should
citbcr W iR'ri'ecily new or dlioukl b« replaced by moi&t conipresft«),
sliould bo perfectly clean ; Iiipmorrhaifpa shoulcl be enlii-elv aireJited,
especially if sutures nre to be applied, ami the wound is deep; if tlio
wouitd beats byeuppumtion, the rompreescs should be moistened with
ehlorintswater. In accidc-titn) injuries, all deep wounds, particulorlj
If cnutmeil, should he kept ([utet by dressingti; iiU that is neceMarjr
in compound fractures has alrculy been euid. Every thing' that can
excite «ecendftrj- inlltiniinnttnn (page 150) should bo mo8t «iTcfully
avoided ; the patient sbmild lie quiet, and as comfortably as possible.
I would remind you of the treatment prcrioHsly given for contused
wouwK Of course the greatest c«ro must be used in dresftini^ tbe
wound [ here the greatest pedantry may be very beneticial. Hospital
{nRiience», which 1 only touch on here, are peculiarly intvrL-»ting.
Altbongh few of you uiay have tho fortuiio to control civil buspit4ils,
any of you may desire knowledge on this point diu-inj;^ war. Of
counc, hospitals »huulJ only be located where there is no uiArsh
mia&in. Tbc hospital should be placed in a large, open space, with
tTe<es planted about il, and sboidd have pTU)K'rIy -located odorless wa-
terK^oset«. Of all artißrial systems of vcntihttion, I ihhilc that Van
JIeJü:'« is the only one worth any thing. In it tbe vrall» of the whole
hutldinf; an* travetseii by canoLi, opening into erery ward. All these
canals «t»rt fnim cro8S-[«ssnge8 under tlie building, at whose |K]ints
of intcisection there is a sort of wind-miU, driven by steam, so that
new air is thus eon«fsntIy driven into the wards of the hospit«! (pul-
uonssystem). If them he no arliücial system of ventilation, we must
do OS well as we can with the sn-<nlled natural ventilation, i. e-, cor-
reepondin); draught-o|>cnings should be made above and below in
door« and windows, sn that in their lieds the patient« may esea])e tho
dniug^ht as much as possible; these ventilatovs should »ever be en-
tirely cluecd. An excellent English sui^^cou, i^wictr \Veiis, says :
"Tliere is only one Inie means of vcntilntion : tho impoesibilily of
dosing doors and windows." I consider a |>ro]ier use of tbe wards
oa important as their ventilation. No surgical ward shoulil lie used
more than four weeks in eueoession ; it should then be emptied for a
few days and carefully cleaned ; the walls sliould be painted with oil-
paint so thnt they may be washed, or else tber should be while^
washed at least two or three times a. year, more frequently if neces-
sary, Tlte IxhIs should be frequently airfid, shaken up, and siinnml,
and tbe straw in tlie sacks often renewed. Evciy Huqical division
thould bare one, or, still better, two superanniemrr wards, so that
S60
TKArilATlC AND INIXAiHtATOKT IHSF.lSKS, ETC.
they in»y l>e r4>giitarljr (Kciipicd hi lunis. Witli ilie nme object,
there ehatilci not be muru tliuii six or eii^lit beds iu one wiinl, m Unt
enough patient» may bo (liK-harged every xrveV to ein]>tT one room.
The new ]Mlients should aUvay» be bitiuglit into the vranl luL
cl«4in<Ml. Tliia i» tlie only nay 1o prevent tbo extonsirc de^'clopment
of miiuni in liospiio). To attain tbe best posBibU results in hoapita)
we must, liuvc plenty of Toam, and plenty of money titr nunc», Umu, .
ctr. We c&n tiius use vvMi \ii\'\[y-]v<:Mt«t\ hospitals. Lai^^ vaida,
witli twenty or thirty bcil», wliicb, from press of paticiil» and other
causes, eaunol he emptied at will, are very unsuitable. Tbe tliroctor
of n. Hitrgical division aliould, above all things, ]iave nt hi^ dispoaal a
lan:e nimil^LT of well- ventilated rooniti of luudiuin size, n-hicb ciin be
f.iiipiio'i nnd {■It^anrd at certain times. Jinil hospitals, and c«pecianj
budlykopt ruuins fur siir)ficuJ patietitA, are irors« than tlm ponrest
tfrncinente ; tliey nay beentne slau^bterpcns for tite vrouixkid. Su^
(feons should never forget tliat they themselves ure often to bLitnc if
tlieir {latientH have cryMpEflas, hospital gangrene, diphtheria, tfle. ; for,
if, after old (ni»t<:jms, wc ascnbL-d every thing* to tlie invisible, oniiü-
present, intangible, ethereal miasm and genua «pidcmicuii, it wotUd b«
do»th to all our fiitun> ])rogr«ss.
Coming DOW to the trL'utinent of tmumatic feitrr, aupticmnia, and
pyaiiuiii, we may say that, tor simple traumatic and suppuntiw fwcr,
wbieh does not pa^s the usual limits, «*(> generally use nothing but
cooling drinks, fever diet, and n little morphine at night tu secure
good rest, if tbe fever lasts longer, im- asauines a (»eculiar cbaratitcr,
we may resort to febrifuges IMgitjdis i» here of little tifto, on account
of its slow, uiKTrtnin action. Venitria reduces tbo temperature, but
ap|)Cnr» I« d« Uttl« good iu toxic traumalic fcvere; still, further olioer-
vations niu^tl be made on this point, especially iu pviemia. Tbe ao
curate studies of Binruitr show that this remedy should tx; used vpiy
carefully. Formerly aconite was highly rrtxnnmendod in pyu-raia by
Tfxtor. I have seen no good from it. Quinine is the tnuat eflica-
eiouB remedy for the interniil lent suppumtjv* fnver, c^pm-tally in caro-
binstion with opium; 6-8-18 grains of quinine in tho course of tbe
afternoon, and on« grain of opium ut night, often arrcst the chiils ; in
severe ftuppunittve fevers I employ these remedifts witii lK*ni.*fit ; in
decided jiyii'mia they do less good. After fai-cfiil obstrvuliuu, Ltgber^
mtiater fuuitd that ([uininc only shoM-ed its antifebrile action in typhus
nnd other infectious dispnses with certainty when given to the extent
of fifteen jrmins or more «laily. Tiiere aw plenty of ohservations, too,
oil reniudica for lUrcctly ojiposing the blood-poisoning, 1 linvc found
no i-ffoot from thu nntisoptie internal remedies, the adds^ cblorioc-wa-
t«r, and sulphurots of the alkalies (which arc greatly praised by Potli),
TRSUTMKNT OK TRAPHATiC FEVER, EXa
881
^But we mnj &Ibo tue other remediets intended, hy increasing the
buigY: of tisHUC, to separate the oi^anic poisoii from the blood. See-
ag the profuse diarrbsa in do^ &rti6daUjp made Mpticiemic, tad
fiiidinf; ibeni 1o recovt^r frvfjuently aftvr thev^ «liiirrliieiw, we might
ini|i|>06e Uie potAmi to b« most tuiliinilly cxcrvteil tlimugh the iDtec«
tinal cn»al. In fact, JintUiu K«s hud luvorabl« rubults (una repeated
doeee of bxatJves iu puerperal fever, i am sorry Dot to liav« bad
nmOu* experience in pj.Tmiii. In tJit» d!Me»«e diarrtiu-a is a severe
oomplicatna, vrhicb quicklj induns collapac. It niigbt also be
Ihougbt adrisable to increase the secretory activity by giving emet-
ics; but tbev aie follon-ed W sticb oollnpse that we muat be careful
io tln'ir adniini-ttraliun. I» septic«eiiiia I h».vu often tried to induce
proftuw- penpJration, when tli«« jiUin was very diy. Thi* vm oocaAioo-
slly (lone by a w&rni buth, Ustiiig for an hour, and then wrapping in
Uanltcts. IHiis occasionally dues firood ; indeed, I think patients have
thus been saved that I had thought ijiirarable. Further trials should be
made with this remody. t.^opioua diuresis also may be induced by
plenty- of «Irinlt, but it has not much effect on the gen«a.l coiidEtiotL
Lastly, we mi^ht think of arresting the furthvr Bb94>r)>ft(>n of inju-
rious subfitancm from the injured or influtned part by amputation,
even after the appearance of severe coustitutional symptoms. In
acute cases of septicicmia and pyaunia this vrry rarely has a perms-
ttently bcneficioJ «Sect, although ther« is almost always temporary
impruvemeiit. Hut in subacute and chronio pyiemia amputation
ay, indeed, save üfe ; unfi>rtunately, however, such oasca are mre.
So we finaily come ba«k to what we said at first, that mwib may
done to prevent severe traumatic und suppurative fever, liut that
is little to be hoped from treatment of thcsu discusc-s vhoD
Jy developed.
LECTURK XXVIl.
. TatsBiM; i. DalbiiunPctatoniinTraiinaUouni; t, Uitliriuni Ktrvntmn aod Manlo.^
Appendix to Cbtptvr XiU. — FolM>i)it(lirounii*; IntvM'htl*«. <SnBkv-tiit«a; leSta-
tioB ftwB iDaMoltDg Woiud*. — OUailan. — Carbunol«. — Itjdropbobtji.
Thb group of discaitea which belong to the tnURMtio and phlogiatio
infectious conditions, and of whioh we still hnvo to speak, comprisas
tetanus, dnmlcard's madness, and the psyehioal diAturbHOoes which so
nm-ly tx\'ur after injuries anil ofMrrations. The views, as to tJicir ori-
gin, vary greatly; as, from their symptoms, the prooosses in questioa
would he referred to irritation of the brain and spinal cord, their cause
34
35B
TTUrUATIO AND INn.AlHIATORT DISEASES. ETC.
is usually nought in tlic nerrous n^dtreH. But it is known ibiit by
bloud-poiHoniui;, with stryvlitiiiiv, severe Epusms, uid nith alrohol,
psychical dist\irhances (drunkenness) may be induced ; hence, it is
very poHsible that the following fonn» of disease may result from
poisoning with peculiar substances, wliii^h |)Oft«l)ly arc very rarely
fomied in wounds, and tlienc« absorbed, while in druukitrd's maiÜB a
series of ordinary pyrcifrenous matenals may cxolte eerlnin dLstur1>
ftDoes (tiuim^ly, fever with peculiar, firedominsni psychical dinlurbauccü)
in the organism already poisoned by alcohoL Tbc symptoms that wo
BhaU see in these diseases are all present in ordinary- fever, although
to a slighter and less pnimiueiit degree; in the combination of the
affected muscles, chills have an undouUed 5imilftnty to tetanus, psy*
ehical disturbsnces, «Ten to maniacal sitncks, ocnir as so-called fever
detirium in some cases of septieu^^iia, but et>pecially in typhus. In de-
Ecribitig the individual diseases, we shall occnsionally recur to these
remarks, for which, unfortunately, we have uo expcrimento] loundatjou.
4. TVatimatie Titanwi {TritTmu). — This disease, which ooosists in
apasms of the miiM-los of the juw alone (insinus), or of all the muscles
of the body (tetanus), themuM-lesof the extrinnitiesbein^inostufTectird
(ometimcti, at others tho«e of the front or back of the tnmb, occasion-
ally occurs in the wounded ; thouyh it is rare in proportion to the
traumatic di»(-ases above descrilied, it oiicurB still more rarely in per-
sons without wounds. In large hof>pitaU, year« may poss without a
case of tetanus being »een ; a^^n, at certain times, numbers of coses
will appear, so that there has been an im-lination to seek an epidemic
cause. The diECiisc is by no meuus ootitinctl to liospit&Is, but
cither in or out of them. However, before disciosuting the etlolc^, '.
will trj' to give you a brief deacriplinn of an acute case.
The third or fourth day afte-r an injury, rarely sooner, ofttoi later,
you find that the patient cannot open his mouth well when ffK-aking,
and coniplnitiK of tearinj^, drawing pnln«, and of stÜfness in the masti-
laitory niuack-s. In very acute coses there is high fever even with
these first eymptoms, in other cases the patJent is free from fever at
thig stage. Tlie lines in the patient's liice gradually asBUtne a pecu-
liar, stiff cxprc&siou, the facial niiuicles being to .tome extent spasniod-
ially contracted. Subsequently tbero arc tetanic »(«»nis, which may
affect the trunk or extremities; in some eases these 1a*t several seo-
oQds or minutes, and are induc«d by any external irritation, just us in
hydrophobia. These spasms arc Hecom|uiii icd by severe pniu. Occsr
«ionnlly, from first to last, some groups of muscles remain n^nlarljr
but painlessly oontnietcd; in some piitieiits the twitchings (shock*
ot JÜ>m) arc entin-ly absent, and there is ornly jiennanent contractiou
of more or lees distinct groups of muscles. Not un&equently tho
TETANüa
3SS
.(.
patient'sbodyisballiediD Bweai, his mind beni(f clear; occasJonalljr Uta
urine ooiitains albumen ; Bometlraes tlie ferer rises to a height that
is rarely tteuu, crea to 104° Fulir., or ovvr. But I hare sveu cacM
of triMDii» [irovr niptdiir fnlal, williout the tcttipemturu beooming elo-
ratinl ; Jtote hiis nuide siniiUir ohacrrntiona. Death may cxrcur within
twcuty-four bours from the oomiiicnccmcut of the discaec, but the lat-
ter may also htst with considerable severity fur three or fuur days ;
these cues also are to be rlasaed among the acute. 'Hicrc) ia a more
ibucuto vT chronic furm uf trittinus, and of Irismua and tetanus, ill
lich there is merely a gradual derelopment of a moderate trismus
'and of eonttacttoim without (wtii, extending lo HingW groups of uiu^
cles of tb» injured limb. In Uie»i± chronic casut fuver in ueually en-
tirely absent It is rare for an acut« c«ac to become chronic
All the Symptoms iudicate titat there is an irritation of the spinal
medulla und of the portio minor of the Hfth pair. The symptoms rc-
•etnbl«, iilthough remotely, those which may be induced by poisoning
by stryebnia. Unfortunately, the resultfi given by autopsy of lliese
patii-ulj» are usually very unsatisfactoiy ; In tlie acute cosch, especially,
Dothiug can be found lu the spinal medulla ; in cusca of ttomc days'
daration, Rokitanaky claims to havu livvn a development of young
oooaectire tissue in the spinal medulla, which would make it appear
that there was an inRawmatory affection of this ncrve-centrr. My ex-
aroinstioos of the spioe and nerves in tctuitug iiave thus far given only
negative resutta. Li preparations made from cross'^ectioiis uf the
■pinal medulla, and scut to me by excellent specialists in examining
the nervous system (Dr. Ooff, in Zurich, and Dr. Meyn«rt, in Vienaa),
I saw the o<.inrK>ctive tiiutut' remnrloibly developed at some places, it is
true; but, ts there u'as nu collection of young cells, I was in doubt
trltctbcr this increase of connective tissue was really new formntioa,
or was duo to mere aoädental swelling. The symptoms during Ufa,
in cases where we find decided evidences of spimil iu flam mat ion, are
so different from telanu.*« as to render it iniproWlile that the latter de-
pends OD myelitis spinalis. The diseovcrr of small extravasations of
blood in the muscles and nen'e-jtlte^lks, on autopsy, shows little about
the nature of the disease, for they may he caused by ruptures of tbe
^capilUiric« during the great muscular coatrmcttoos.
llKre are many views as to tbe causes of this disease, as there
Uy arc about aScclions with ik» anatomical, pathological cliaiao-
ics. At first, it was natural to «xainine tbe tierves, and in tnany
cases the nerve-trunks are crushed by the injury, or torn or irritated
foreign bodies. I myself have seen some sucli cnsi;s ; a few years
aoe, I saw a sporadic case wherv, in an open splintered fiacture of th«
' end of tlie radius, the median nervo was half torn througl) ; ihc
«Si
THADMATIC AND INFI.AMMATORT BIKEASES, ETtt
third day trieniuri and tetanus sppt^ared suddenly, and proved tnlai in
eiglitccn lioiirs. It is on use to build theories aa to how this particih
lar rarioty of injtiry of thft nftrr« should induce tetunio »piwtns, while
thtfy are very nm; afWr simple diviiiiuii of the tiervos, fur tliere an
many cases where tetanus has arisen from simple »'«>unda of the slito,
from granulatiug surfaces fully devclope<l and eit.'atnzin^, or cna
aft^r a bli»t/>r, the sting of a bee, etc. It U, however, nunorkable that
the disease is pHrtJnjIarly frequent after injuries of theextremHies,
cspt-ciaUy of the hand» uiid feet, while it is rare aftirr ounädcnbla
injuries higher up tlie limb and on the body, I alsothink tbst I btve
found the cases, where tetanus dGvelo]>ed from grantilating vroundfl,to
be more chronic and milder than those wherts it has drvclopeil sona
after the injury. Kogi thinks that tetanus appear« porticularly m
OOKCK that are treated badly or not at all ; my experience w opposed
to tJiis. After applying in vain to tlic nc-rve« and tt^odinous tissue.
th<' vnricHW chnnge« of tcmpcratane were resorted to to explain rl»e
ocieuiT<.'rK.-e uf tetanus; some fuiid that it was hvorvd by hut, huIut
weather. I cannot altog^ctlicr deny this vtow, for hitherto T hare ouly
fleen mimerous cases of traumatic tetanus in hot, auhry weatlivr, hut
•mall ejdderaiea of it have been neen in winter. Others a.<u:riiiin ihe
chief lilanie to cittrhin^ cold from drauglita or to rapid changi^ of tem»
peniture. Finally, there arc still others who do not bolievo that the
DervDUfi system is primarily affeiled, but think that the blood firtt
beooineK diseased and acts seoondanly on the nervous system. Within
a short time Jioee lias resurrected an old ides, that teUmis, like hydro-
phoHa, is to be regarded as a primary blood-disease. It eanoot be
denied that the two diseases are much nlilie ; a [»oof of their being
Bfitutilly analogi-i«» would he most sLrikinf^ly givt-n by inducing faydrt^
phobia, by inoculating nnimahi with the blood or «>cn.'tions from a
tetanus patient. Of course, we eliould not think of inoeulaling another
man. At present, I strongly incline to the humoral view of tetanus
as due to a peculiar poison, although I liavc no proufa of it. At nil
event«, the blood of a totanus patient should be injected into a dog,
to show whetlier letanus may be transferred tlimugli htiman blood to
ft dog, and also whether it has a pyrogenous action; should tclaaus
ftppesf in Uk^ dog, il might be regiinled as piovLx) that letanus was a
liuiiiorul disease; tf the experiment b« negative, it prorea nothing
against the humnral eausra of Ictanua, it only shows that tlie blood of
ft man with tetanus will not induce tetanus in a do^j; it would still
have to bo decide«! whether the blood of a <iof/ with tetanus, trans-
ff^rred to anuthcr doff, would pro\-e as inactive. The bet that tetanus
may be confined to one Hmb, or oven to one hand as I have seen H,
s|)(.>aiks in favor of a local cause, which may be limited to the oerres ;
TETINUS.
U9
but Uiere »re also a loualizLxI lympbatigit», localized erysipciu, etc. ;
lite tbct itint, sftrr nnipuUitiou, icff instamt*, twiu^niif^ not uufnxjtKniOj-
OOOUn ill tlte »tuui|> bcfuri; Lhc HpiLsniH become geocral, mi^lit a.I&o
tndicste Umt lli« tetitniiM-poisou fonDod in the wound lint irritated
tbe nioiKJra and nervi» of the stump, and then p»sRed to tlie spinal
medulla. Tlicrc etUl remains much to be invratignl^l on ttis point.
The tiigb fever in moat castas of aeute tetanus, and the fact that the
tempeniture rises even after their death, ha« greatly occupie«! )>athul-
ojpata ; this bommc still tnorc interesting when Xeydm showed that
great cJeTation of the temperature of the blood was cawsed in a dog
ID whieh telaitus bad been artificiallj iudueed bj pasiung a strong
«un«nt of etectricitjr through tlie whole spinal medulla. A. FieJi
•bowed that a sur|>lua of beat ivas fonneil iii the muscles, and tbcncc
distribated tA the blood; aUothitt the elevation of temporature, noticed
in the rectum aftrr death, was due to th« equalization of warmth
between the muscle« and the rest of tbo bod^. If these px|M:rimenls,
which I bare repeated, prove that tctanie luusoular contractiond con-
■idetably elevate l.be tK)dily temiterature, they do not sliow that in
tmunwtic tetanus in man ihe high lenipcmtiire Is siilely or rbicfly
due to the muscular contrtctious ; this view is opposed hy tbe fact
that very acut4> eases of tetanus may nm their eourse ahnest wttJiout
fervr, although this rarely happens; here, too, there arc many enigmas
to solre.
Unfortunately, in most cases tlte prognoti» is bod ; very few of
the aeutc cases recover; of tlie chronic cases, which last over a fort-
night, aomc get weU. Unfortunately, the latter arc proportionately
r}
Vtom the taek of knowledge about the etiology of this disease, the
'^tataitHt «in bc^ odir svmptotnntie. Numerous rvmetUcs \mv^ been
leoommendcd at various tiinea. Generally, the treatment most resorted
(o is by nareotics, with opium atid eliluitjform ; this is tbe plan I have
adopted. Opium is giren in large doses, as high oa fifteen grains or
Biore inn day, or a corresponding (jusnlity of nior|>biiie may be given,
best by subtnitanenus injootioa ; someümes this arrests the «pasiM,
lime« it d<x>s no good. At all erents, the sufTeringD of the po-
i are Icsseiiod, Ouring tbo altaeka the patient may bo i;rcatly
Relieved by inhaling ohloroform to narcotism. Under ibis treatment
mat^ cases bavo recoverwl. The general aim of tlie treiitment is to
■Ueviate the aeutc ccnmc, and make it more chronic, a» thü giree
more hope of recoveiy. Among other modes of treatment, 1 may
mention tbe frequent employment of warm potasb^baths ; and the
ap|ilicntton of Mnmg irritants along the spine, large blisters, moxn,
hot-iron, rcmodies from i^iicb 1 uaanot promise any good effcots;
^jomei
■ttent
8S6
TRAUHATIO AKD INFLAUUATORT DIl^ASBS, ETC.
ftnd, liwtly, the CTirarc, whioh is of lat« oi-oaaionally used, has not
answoml iht- Itopve that »oiiif hud of it
]n Uir cliranic cases you nc») not employ any spccinl trt^tmeiit ;
the patient remaios in bcd,and aboiild keep pcrfoctly quiet; hcahould
be fruarded ag'^inst all injurious inlluuiic««, esiwcially Iroin pliyait^xl
or Dit'ntal rxciLoment.
5, DrunkartTa madne»». Delirium potatorum traumatic
JMiriiwi trrmena. — We now come to an enemy of the woundod^
which, fortunately, is not vviy (langeroua. Ti'ou have doubtlesa heard
of delirium trcmen:<, the acuUi outbreak of chronic alcoliuliu poisotiiii^,
which may eomc on «pontaneounly, or frrim snmft aeiitA rliiu<iue«, ok-
peciaUy pneumonia. Iiijiirica are a Irequciit cause. V'ou will hecoine
hcXtcT aixiuninted with this disease froni tlic lectures on mcdieinu ; as
the attacks, from whatcrer caus« they anee, are inuch alike, I shall
be verj- brief on this point,
The dispute geuenilly breaks out tritliin two days after the lujujy,
ia some rare cases it h lon^tcr. It oidy attacks palicots who bare for
ypnrs been awustoined to the free ««.'of nlcohtit, cspofinlly of sehnaps
and rura ; but it ia an error lo cunsidcr beer and wiiic drinkers exempt
from delirium. Tho first sytnptoma are aleepleEBDeoa, ^reat restleaa-
nesit, treroblinf^ hands, unsteady took, toii<t!nf;( about in Iwd, and talka-
tiveness and tht^ci il«-1iriutii. TIio piilieiilN tiilk roiiKtniilly, »ec «mall
animala, mi<l^:4, flien, ete., snnnuin); alvuut them; mice, rats, mar
tins, fo«-!i, .-to., erawl from under tlieir l)od« ; lliey think tWy arc in
a smoky at muK]>berie, »rid feet dizzy. The delirium ofleii has the
most eointc'ul form ; a soldier, whom I treated in Zllricii for deljriutn
tremens, snw numbers of other soldiere In his waler-glasa; when 1
entered the room, liu spoke lowly to my assistant, taking me for his
major, etc. Gencmlly the hallucintitions are of a hajipy nature, nm-ei^
thelesA, Uie piitientu are ItirmeiittM] with rcsth^awteHS. ronsUntly toss
about in bed, am! winh tn ffel up. If we hnv<> not two stniit nt
to hold these juilieiits, there ia often no way of avoidiug the a|>ptic
tion of a strait-jacket and tytiijr thorn in bed. These pntJents
usually poi^i-natiired in their delirium, and if spnken to emphatically
tiiey gi\-e sensible answers, but soon fell back into tlieir wanderings.
Of all kinds of injurie», fractures, especially open fracture», most fre-
quenlly ^vt rise to the oulbrMik of Ihe diaeast*, and, before we had
firm dreRMups for siieh patients, it was a diflicull Insk tn fix tlw? bcoben
limb, us the patients did not notice the [xiin, and moved the limb so
forcibly that any splint» were loosened in u few hours. Even where
theT% is marked delirium, the pru^noeis is not unfnvomble, seconling
to most snrfFeon.q; from my sutiiewliHt meagre observatioos, •] Cannot
agree in this opinion : of the patient» with acute delirium Iremcna that
DELIRIUM TRKHKMS XKJi KEBVOSITII.
S8?
[haii*o it«]iiod,»t!«&«t Lh<>!inlfb»ve<lic(l;tlM!y often dccltiipd siiddonl^,
brcime unconscious, nur] soon died. Otht^rs recovered, cniK-dally when
it wu possible to malcr them sleep b while; tbi» in the object of the
Ireatmotit ; opium in lurge doses is tlie ahiiust universal renteür, for
it we may substilulc small dose» of tartaremcttc. After thia the
pstienU fall into * eomslosc state, from which m favorable cases tbcr
nvake cured, but eometimes sloep on till death. I o»n reeommend no
better remedy than opium in delirium trcmenn, althoujarh t must ac-
knowledge that is large dosca {gr. i\. — vi. every two hour« till sleep is
induced), I do not connder it free from ilaiififer [of lata, hydrate of
chloral, in (li)«ex of gr. xx, — 3 i, i» »aid to have been given with g^^At
benefit in such cases ; it is claiintTd th»t it nets well not only on the
deliriimi tremens, but on the fever whieh äo ofti^u netyjmpnnies the in-
jurr]. Of late, tJhere has boen a great outcry in England agaiimt the
opium and tartar-enietie treatment, and a mom expectant treatment
has been reooramended. Others have had good results from digitalis ;
moat Hurgeons ure well iuitiK6ed with the opium -treat men I, and the
eoinrident administmiion of strong wine nn<l co^n.ic lui» bee« highly
L^QOOnun ended, l^e more chronic cases of dcliriutti |>otatonim, with*
lit maniacal uttaoks, have »cemed to me of more fnvuralik* prognosis;
tbciv, strong grog is useful ; I give the folloning mixture: one yolk
Kof egg, one ounoe of artack, four ounces of water, two ounces of sugar;
this does not taste badly, and may oIbo be used as a stimulant for old
penuitiK (n tal ilesponiifiil every two hours). I inu.it n-ani you againtt
klwtnicting bl<Kfd, whicli i» very d4iigm>us in ilrurikanlti, and not un-
frequently induce* colhipao teraiinaliog in deatli.
Autopsy of patients wlio have died of delirium tremeos showa no
spcrtal cause of death; wc find the change» common to topers;
ehnmie gaatric catarrh, fat^ liver, Kright's kidneys, thickening of tbe
meninges of the bmin, biit no constant eJianges in the bmin*Mibstanoe
proper.
6. Dfilrium pmtikm)/»» an<i ptycM^vit dUhirbanef* afitr injury^ —
By deiirhim n«rvim/m traumaiit^ma we mean a state of exoessive
nervous exaltation without Jcvcr, occurring after injury; tliis is aaid
psrtjcularly to affect bystoricnl persons. I have only 6e«n one case to
vhtcb I could apply this name: a man twenty-four years old (from
Canton TTiurgnu, the land nf perry), who had ncTcr been accustomed
lo (liiiiking, after a fracture of the leg, compliuntcd with a slight
wound, anon had delirium without fever, like an old toper ; the fan-
cies referred to tlie same subjects a» in ilelirinm potiilorum, pa?«sed
off under quieting treatment and i^ium, »"^Ihout mnniacnl attacks;
tSter fbur days the delirium cea»ed, and llio patient remained reason-
able. Lastly, I must mentJaa those rare and )Dteie«ting caacs where.
ate
TEäCMATIO and JKFLAlUUTOBy
mi
rnRtr opttstioi» in otfacnrise bt^Üir penons, pejri^hieftl distiirt
develop, cue» wblcfa cnulc all BKcmpis nt nplanatioo, uid nie onl]
aoalogou» to cues whcr«, nhci aniie dist^ascts Bucli u pat-uincmiat*
HCute rfaeiunatiira, or typbus, the development of trtic nibaia ts oth
«rri'ed. In the Berlin surgical clinit- I uw two suA CM4*e, in both
of which, mfl4-r total rhinophusty, them wu melwicboljr with rr-U^ioua
hnllucinati'^s. Buth patit-nt* were Oktholio: one, a young inan, ia-
< uasantJy worried himself trying to undersi&nd the idea of the Tritüty } ^
the other patit^nl, a youDg^ woman, aou^t by prayers and ca&ligatk
to atone for giving way to bcr vanity bo ^ as to haT« a new
made lo replace the one lost by lupus. In the yooa^ man Uiere weni
frequent outbunt« of rage ; both patient« pe^fe<^tly mxirerecl iiAcr a
few weeks. I have heard that Von Janffcnbtcky in Berlin, had aa-
othor such cmc nftrr a plastic operation, and Von Gräfe and £f-
march huve hud them after operalionK on thv eye«. But these eases
arc vpjy rarft
APPENDU TO CHAPTER SIIL
Wk h«TC still to treat of uome vurietics of injuries, where at tho
time of the injury |>oif^» i» inoculated, which sotoetimes induees
«evere local s\*mptoinft, wLimeiiiues dangerous general disease^ It Is
well known that these p()isuni> arc- peculiar to sonic aiiim»li<, and in
others they develop as a n-miilt uf certuin disvasc«, and uru then traua-
ferred by the diseased animal to mstt
The results from punctures of a large number of small iosects are
scamely in proportion to the alight mcehaiii<-al irritation caused by their
stings; ilmay, it is true, dejH.-iid partly on poculiiu stueejitibilily of the
akin, if persons have exteusivr temporary' iuflammutioos of the skin aftor <
bdtcB by bujfs, mid^tt, or Be»*, while others arc not affenlod by Uieii
A needle-pimrture i* a miieh greuler injury tlian a tiea-bite, but iht
latl«-r is followwi by ttehiiig and Imniing, and the formatio» of wheals
on the skin, while the result« of the fomi«r atnotint to notldng, Hence
it is not improbable that in the case of the wound made by the insect
some irritating substaooe enters the skin. As is known, tlie stings of
bees and waspn excite even gn^ator disturbances; oocasioiully there
is on extensive, very painful tuSaiuuiation of the skin, with great red-
ness and swelling, which usually terminates in resolution, and does
not prove dangerous, bul inny be very iuinnying. A large number <
sunh atings at the aame time is not altogether frw from danger; si»
WED TTOUin«.
959
stings on the tongue, in tb« palate, or on the ej<>U(U, innj fruni tJioir
locaJity cause oertain dnoget« b^' th« nwelliiig iiiducnl. But, as Üicsc
inflammation* subaide in a relntirelj »lii^^rt timo, a pliy«i<'iaii i» rarvly
caill<?J; th« pupular trcaluivut is by \*iLnow( «Hiling r<Mn(.<die& to alien-
ate the pain, oinon); which I shall mcrcljr mention the application of
moist day, raw mashed potato, cabbagc-Ieave«, etc. Ii» more »evens
inDaiamalions, lotioiks of lead-water and otJier antiphlcigiAtJc reiiiciiie«
^^Dajr be rmorteil to. Still more severe tUait the »ting» o( \ivc» himI
^Kaitpa (uc tiiosu frum taranttUa and deorpions, tluit arc soen in southern
oountri^s. The-yurr rolluticd by more cxtctisivo infiammation of theskin,
with severe burning pains, uccasiooall^ hy formation of reMclen; there
iiiur albo be fever, but there is usually no danger, unleaA it ariue from
the locohty of the injury. The ireatineot should he that above given.
Forlunalely, with us there are few varieties of pommov» ttrf^tit»,
aad even Ihcy an- nui frequent. Ainuug them »re the Vf/zcTxi Jfenu
^^croM a<ldcr), and Vip^ra Hedii, with two hook-like, cuncd fangs,
^HIoDtaioing tlie exerelory duel:» of 8niull glaiiils, which, at the time
^()f the bite, pour their p^iison into the wound. The bite of these ser-
peats is not so dangerous as is supposed; according to statistics,
about two die oul of sixty persons bitten. The pain is very severe;
^Bthenr an.' great inflanitiintion, tension and swelling of the sidn, vritli
^^kgh fever, great nuxietA-, depression, vomiting, and oceui>io»ally
* slight ietoru». Tlie l>^>t ireatmpnt is w nuck oul the wound at onoe,
Hia (lie poison in nut abMjrbed by the gaalHc orond niuonus inembnne.
|lic wound should be niuhcd al once, and it i« advised to ligatc the
Lnjur*'d limb above the wound to prvvent the übaorption of the poison ;
but thi» has tuunlly t^ken place by the time the patient reai^hpx lite
smgcon ; it is u difipiitcl point whether tlie applicttlion of ci^is, llic
cauterisation, burning or exei-iion of the wound, bo now of any scr-
Tiee, but I afauuld think its eauteriviliori wlviMible. TW locnl cutano-
ous infUmmataoo is tx»au-d with special attention to tlie t4-nse pais;
by appUcatioofl of oil, protecting the skia Irom the air by various retn-
edieti, with which we became aequaintcd in the Ireatment of super-
(icial bums. Tntemally we usually give an emetic, then antiseptic
remedJee. Of all snukc-bites in souÜiern oountrief , those of the rattle-
snake nnilAiost dangerous; sometimes they prove fiital in a few hour«;
j^^he load inflammation of the skin, which is very severe and cxLerMtvc,
^|noi un&equentlr ends in gangrene; those bitteo die wjtli high fuvcr,
delirium, and M>por. |rrof. Ilalfonl, of Australia, tivam soalto4iit«s
by injecting dilut<^d licpior Hininoni:i.> into the veins. See Loodoo
Sfadieai Time» and Gatette, 1U% page 133.]
Cadaoerie poiton is a very phlogogmoiu subMtanee, which prob*-
Taiics greatly in its ohemieal oompoaitioiL Some uf yuu niay have
aso
TBAUMATIO AND tKFLAJJMATORY DISEASES, ETC.
alreadjr had sume ex]N>rieac<> od tliia point, ia the diBSRotinf^roottuL
ThLi putrid poison develops in tfic rorpnes of men and animxl!«; if, in
handling thette, eome of the jiiice from the dc»d tiiKtui- uuLera »inidl,
tDnfpiilicaiit, and scarcely noticcnhle injuries of the skin, very dis-
&pnM»ib1« Hjinptoms may derclop. Tlie resulting conditions are furi-
ous, aomctimcs very malignant, Cuscs occur which were ftinnrrly
se^n particularly often inEnglntid, vhcrc at Bret lliero is liltle pain in
the wound, but then! nre great depression, headache, Icrer, and nausea;
then ooine delirium and sopor, and in some coses death tAlces place in
forty hour». It is asMTted that tht-su worst casee of »cptintmia vent
most frequent, from autopsies made soon after death, on bodies still
warm, and it was doubtful if in these caxea tJie 8ui;gtnn had not inoo*
ulatcd himself with morbid matter developed in the body while still
living, for tlie state »isually termed putrefaction oiild not have begun.
As a eoatrsAt to this malignant itcule form, we may regard thoM nutes
where the poison \\aa a purely loeal nctii>n. In the course of twenty-
four hours iJicrc are nioderote pain and slight indurution in the iajured
finger; then a dry swib form» on the woxiiid; under it there is always
some pus. The sciib forms as often as it is removed, the part remains
painful and bard ; in the course of time the epidermis thickens over it,
and it forms a painful, wart-like nodule, moist on the surface. One in-
clined to thit* pur«ly local devetopmeut is usually less dtspoKetl to
genera] infection. Between these two forms stands a third, wbere an
inflammnl ion of tlic lyinphati« ves«rls and axillnry glands aocompanics
the loeal inOaiiiniation; under early trx-atnient this may end in resolu-
tion, but it often leads to abscesses in the arm.
For the first tn.v>tmcnt of the part poisoned by cadaveric mailer,
I advise you to let cold water run on the wound for a long time, and
not to check the bleeding, if tliere be any, Tn ninny ea^en llie injurious
matter will be ai onoc washed out, and there will be no further infec-
tion. Should the pnrts around the wound redden, you may caTit^rize
with nitmte of silver or fuming nitric iieid ; this is very painful, but it
acta well ; not unfrcquenlly pus form« again under the resulting slough ;
in this case you remove the slough, and cauterize again, and repeat tliis
till no pus forma under the slough.
Cauterimtion immediately aflcr contact with tlie poison, from a
considerable exficricnoe on myaelf and on my ^ludcnta in the course
on opcrntion.H, I ennsIdiT unadvisahle. Small, lacerated wounds that
do not bleed, and excoriations, are always more dangerous for infeo-
tjon than deeper incised wounds; the anatomical rcaaon for Ulis is
that the lyinphatie not-work lies chiefly in the most superficial layer
of tlie cutis. M()ir<*Dver, the susceptibility to the poison varies with
the individual ; repeated infection» appear rather to increase than to
DISBKCTCtG WOTTNTiS.
te\
^iminisli tW prr«li»po»ittciii. Sboukl l^iiphangilis begin, the ann
^Itould firat of all be placed oa u splint to keep it quiet, and then the
^reKtiiient prcvioutilr n-commeml^ for Ivniphan^tis instituted. Yoa
Knay consider the course in the appranmetr of the above morbid »j-mjH
-torn» to be as followe ; A frnmll ijiuintity of liquid &oin tlm caduver
(or even of putrid pus tmn a livinp; pntient) is introduced into the
'«round ; the Ijrmpbiitie oupiUaries that have been opened take up l)iia
putrid matter and jki«.i it into the trunks of the lymphatic resKels;
«soaj^Iatton maj ciuieJcly toko place here, and then the putrid mailer
atrls as a »[»eoitie irritant oidy on a small part ; in other cases it acta
CXI the lymph as n ferment, and the lymph magulates in the ooxt
lymphntic plandf, or else the swelling of the gland eompresKS the
Snlra-glandular lymphatic vessel» and so obstruct« Uw> paüsoge
'tJirotigb the gland; in this raw also the diseaae reniaiiis loeal, al>
<bough extending »i^rae d!»tunce, Aud not unfrequently lcadin|c to
anippiiraiion witli ferer (n« in other non-spi-dfic tnflnmmationg).
XbmIt, the rarest cases : the fermented lympli, which cren yet acts
»a a ferment, posses into Uic blood, and there excites chemical
changes. Tlien \ro have a ffj:>tierpmia, fmm cadaveric poigon. From
the case» that end io recovery* ne see that the injinioiiü subst^neea
dcrclope<l by the procefis may be again cUmiDated (mm the body by
the secretions and excretions, but we do not know in vrhiit jHirtiou-
lar way this Li done- In some cases »ome putrid substance is eocap*
9titate<l in a tyinplintto gland or otlier inflnine«! pnrt, and may Ütere
lie harmle«! and after a time be gradually eliminated ; but on active
movement the ]ioison may be again driven into the lymphatic vessels
by the increased pressure of the WixmI, and tliTc induce new, acute,
loöil, and general infection. If indurated lyropltalic gUnds remain
after infection with cadaveric poison, daily u'ami baths ore the best
means for promoting the excretion of tite poison.
r We have still to treat of Aome poisons which hi certain diseases
I fjerdop in animals, »ml may thenoe be transferred to ma». Under
I fbta b<id oome ghnfi^rf, cat^un^e, and hydrophobia.
GUiulers (mnlisHmus, morre) is a dir^eaxe which develops prima-
rily in hoTM's nad assa. It ir. an inflammation of the na»al mucous
locmbrane, in which this membrane becomes very thick, and aecretes
a thick, tough pus, and where, by the bn-aking down of caseous ncxl-
nlca, ulcers with a rasrons liase form ; swelling« of the l^-mphalie
glands, occasionally tuliercle-like nodides in the hmg», and ac^ite ma-
issmus, oeeur, and acute case» are umally tatai. The more chronic and
milder fonn of glanden la oaU«d " farcy ; " it U rarer, and gives a
962
TRAUMATIC i.XD IKFLAUVATORY I^IREASER, ETC.
better proj^osäs. The g'laRcleni and bicy of nnimals are (uily cxxi*
vejrcl to mun hy anciiicitld inocrulation. If aome of the )>ua of u ginn-
dcrvd bore« entere u wuuiid or uxcon«t<,-d »pot on • nimi, or if very m-
teoM poisonou« glftnder^UK full oii liiv uninjurvd skin nt s point iv)i<?r(<
the epidermis is thin, tiicn: may Ihrverv ocutr inflanimiitioD n-ith gcn-
entl scpticaMuia, which tu most cases proves (»Ud. Ttic chronic form
of gl&ndere is rare in mmi ; the symptoms aro abieüy pustulous inflam-
mations of the ttldn, and farTna.tion of abscesses at diftfTciit iioiiit« ia
the ftubuutonuouB tissue ; it is itot so tlongetous. In some paeea of
acute ((londor- poisoning there is lyiuplianf^Ci» nnd suppuration^ limited
to the injun.fl cxtieinil-y ; in otiiera ti dÜTuse cr^sipolafjtiii ru'liie»« of
the skin with grvut nw-clliiig derelops quicklj, while at the same
time there is very iiilen&c feror. The local inflammation ma; go ou
to gangrene ; thero is deliriunij aud soon coma occurs ; there may
also he diarrbtca, purulent dlichargf: from the nose, and pain in the
mu»cl<:-s, »ith which symptouLS the patient dies. The ditM^ute may
ntn its course verjr nipidly ; I rememlH'r, when a student in the GOt-
tingeii ctinie, seeing; n etrün;;, n>bu<^l iiiuii die of glanders in a few
dajit; hut patients with ucutc glautlera may live from teu to Iburtoen
days, and all the symptoms of pyairma may develop in them, and «i*-
merous biemnrrlixgic abscesses form in the muscles, which are so
dianict^^ristie of giniidcrs tJmt they eonftnii the diagnosis. In rare
eases aeute, rapidly-fnlal glmidcrs way develop from the chronic;
the reverse is iilso Been. Of eourse, persuuü tliat liiivc inuch to do
w4tb horse« art^' oliielly exposed to this disease, which never occurs
primarily in man. Unfortuiiatcly, then- in little hope from treatnieul
in lliis disejise; us in acute jiyiemiu, we truat the must prominent
symptoms. Iodine, arsenic, and creosote, have been recommeiuled u
antidotes in glanders.
Carhui\^e {anthrax, pustula maligna) is n disease which primiirily
occurs oftei test in eat tic. lii ita acute form thin disease is allied to
typhus; in the subacute and ohroniu form there are earbuneulous in-
flammations of the ektQ, which arc cireumacrihcd and soon become
gangrenous. Tlu> u>nlagiou6ne»s of carbuiide is even stronger tlian
thul of glanders. If the Kircrction from a carhunculous pustule, or the
dried shin of the slaughtenTd animal, come in contact with ihesklii of
man, a pustult*, at first insignißoant, or a diffuse iiitlammatiou tn the
akin, soon developi<. witli eousiderable fever. This eutaiiaou« inllani-
matioii sooD assumes the chumcterisLivs of a carbuncle, quickly coding
in gangrene; the course is that of the previously-described malignant
carbuncle, and if left to itself the di»;ase Is often fatoL Internally
the ordinary antisejilii's are adminLitered. Tlie antlirax itself is vncr>
geliudly attodiud with indaious, and the hot trou or other caustic ; if
HTOROPHOBU.
m
ibe patient be subjected to tmtmeat euij, before intense blood-in-
foctioD haa developed, tbcre is hope of a cure ; whor« thie form of
cnrbunclt! snd s^^plioannic apnptoms sre fiillr dcr^Ioped, death is ocr-
t-om. It is still a diüjiuled point whether this carbunci» mav d(rv<>1op
spoutanoouftly in inao, whether the prerlouslrtkeurilied (p«ge ^62)
malignaitt orbund« is always caused by infection or muy also de-
velop spontatiieously from the game etii^ogical (little Icnown) drcum-
■tances as in cattle; excellent French surgvxins and rnttl(>docrtor8
hmre studied this point; experiments of inoculating animals with
the matter fmin mnlij^nnt ptifttutes on mnii huve hf^a very unntrtain ;
ibe obsOT^ations w »otiiu extent coiitra'lict each tJllier; in short, tl«
relation of tbcäc different forms of cajbunclo and puatulv to cacb
otfapr as refrards ctiolof^ ie not yet fully explained. Of late, the idea,
tlist this dtsense depends on infection by certain omsll organisms, is
ootutantly gminittg ground.
Canine madt^aa (hydrophobia, lysaa), -which is transferr«d from
animals to men, is better known and more frequent than eitlier of the
■bore diae&se». From unknown ren^uiis, the disease appears to de-
velop primarily only in do|^ but from the bit« of this animal, and the
entranoe of its saltra into the wound, it may be transferred to any
animal, and, apitarenlly, the po].<wni does not decrease by inoculation,
but is always propiLgat«d witb equal j)on'er. For instauoe, a mad dog
bit<«aen[; the disease develop» in tho luttfr, and she bites a man; an an-
imal bein*; inonitatei] with tlie iraliva of the man will have the diM-ase.
Hk symptoms in the dog arc described by tbc \'Ctcrinarians is
fcOows : Wo dietinguiuh a mring and a qutet madness ; previous to
both of tbem, the dog is downcast and eats little. After this state
baa lasted about a week, the raviiig madness begins; the dog runs
about ill an objoctluss, unsteady way, apparently urged by some io-
wanl anxiety ; if irritated, ho bitea at any thing coming in bis way ;
tbc mouth is dry, he tries to drink, but aoon runs from the water without
taking it ; ho emaeiatea, lie totters, then his hind-legs become par-
alyzed, his barlting rbangea to a kind of bowl, twitdiinga cnroe on,
and in three or four days are followed by death. In tlic still madness,
paralysis of the musdcs of the lower jaw oocuni i>nrly, rendering bitiog
and eating impossible. Ttie other symptoms are the sumo as just
described. Some do tiot consider these two forms of the disease as
distinct, but as different stage«, only tasting n longer or shorter time.
Oq autopsy of animals dying from this disease, we usually find the
gastric and intestinal muoous membrane much reddened ; this is
pnibably merely due to the various foreign bodies tbat the dog has
swallowed. Beyond this, we find nothing ntinormnl, espeeially in the
bmin and spinal medulla, but wu must add tbat hitherto do micro-
364
TRACKATIC IKD INJXAMMATORY DISEASES, ETC.
«■.■ojiicst oxaniiiiiLtiuiis üf tlu»e purts liuvu been made, white it is very
prubablc tlutt, in cuacs wbtrrc panilysia very cividrntljr occiira, tliere la
dpgcnerstion of the spinal medulla, altbou^b otbenviec tlie pt%Uoim-
nant cliaracUT of the cÜBeasc ia humoral.
Ab irganis the iranufcr of h yilniphobic pni»on to man, it is a ri.'lief
to knovr that ^1 tliosv bitlcii do ii'jl b&cotnt.- sick, but Uiul uuly alx>ut
one out of Lnentjr cnses bitten is uttitcked. Uäitiill}' tbu bito bonis
reaHlIly ; mure raivly it suppursU^s a lung time, wliicb is to be rL-^iuTltx]
w very furotmblc ; tbc IockI rcuctioa la tic%'i.-r of »ucb k nature as to
^rontoo tlungur, iiiid in thi» respect the bydropliobti« poi§on tlifferB
essentially from the animal poisons berutofure meiitionetl; it is not &
p]ll(^ggI^□ous poison. The outbreak of tbc disease rarely oscois ID
teas than six weeks aft«T the bite, frequently oron later; a ease bos
reoently been observed wbei« ttie dis<>aKe first appeared after six
months. Older writera give a still longer period of iiinitmtion; tliere
is a popular belief tluti the figuj>c 9 pinys an impoHaiil r^ ,' it is
eiiid tliat the disoas« nppeais tbe 9th duy, the 9th wcok, or the 9tb
month after the bite, und that bcforo the end of the 9th year there is
DO security that tbc disease will not appear. Tiiis is cortaiidy a fablej
wbiob is readily explained by the foot that the long duration of the
inmbation 18 very .strange-, and has given rise to the various stories,
^^'lK*n:^ tbu poison remains hidden during this lung Uine, wlielber io
the ciontrix, in tho next lyrnphatie glniidn, or in thff blood, ic entirely
uiitcoowii. Ill a ievf cases uuly it bus been observed tliat^ shortly
before the outbreak of tbc diseafie, the paticmt had ootii>cd a sli^it
redoeas of the cicatrix ; then th« first eymptoms were gvcx^t irritability.,
excitement, nnd restlessm-ss, and, in rare eases, oxen in this stage,
tJiere were spasms on attempting to swallow. Tlie irritjthility coo*
stantly increases; the light, every noise or draught, paiua these un-
furtiiiiatt! palioni« and may cxeite general spni^ma and tlie pains on
swallowing. Now, very grAflunlly, llic fear of water appear» ; the
patients snITrr from unspeakable thir«t, und as soon as they sec any
liquid tbey arc attacked by horrible anxiety and spasms ; aceasionallj,
attaoks of deep spiisniodic inspiration follow, the putient oaniiot
sleep, and is in cnnsljmt dre«d nf the least sound, as any thing excites
the coarultaons, wbteh finally affect the whole body, and then lead to
uc-tual mudtioiw, with the nppeaninoe of most fearfid anxiety. Btil,
on the whole, itte patient» may be readily nilmed by quiet and by
speaking to them, and become cither perfectly resigned or uiubincboly.
Oecasionaily they warn those about them not to come too near or they
may bite them, but they are not at al] malignant, as tliey were ibr-
merly rk^seribed. Grent tMilivatioti and foaming from tbc mouth do
not begin till toward the «nd; in some oases, death is preceded by
HTOROrnOBU.
36S
■Ottt wvereAt teUiüo sp»»in», othent die ttter the oonruUions aud ih»
fear of water have completvl^ ceased, and vrbcn tbo patient and sut^
f^Tpon faav« been Ut) into vuin 1iu|m.<s. UnforlunaU>ly, patholoffiool
jattatoiny givL-s us tio i^xpluiautjoii of tliia tvondcrful and fi*itrfut iliseAse.
luru cttn be no doubt tbat the spinal medulla is aflTected, but it bus
^et b«>D determioed whcthflr tite ncnre-fiubstJiiicc itMlf is di»-
As regunis tbe progiiusis, in tbose piitieiits where the disease has
lirokoo out, then; ia no hope It may bo considered proper, ia all
«■seSf to cauli'rizt- or biuii out the bites of mad ardmals, and to k««p
^bem suppti[aiiD){ a long time, at leant tbU is the nnlv rational trrat-
xncnt; it cannot bo oortainly deeidH from paat ob6«rvatioii^ whetHer
«xcbiioD of such s cicatrix can be useful after tbe disease lias alnauly
broken out ; it would at oil ovents be a ratioimt trealincut. [u the
developed disease, almost all tbe powerful remedies in the materia
medira and in Ktitgtvf liare been tried ; all the narcoties have been
Rsed in larf^ and »nititl doses; opium nod bclladoona especially,
used in almost poisonous dosca, and the artificial be-imtiibiii]^
tt the patient, have nt le'siit alleviated their sufferiof^, if tbej have
ttw nn other good. The limb containing tbe cicatrix has been am-
ited in vain. In one patient, J^icffenhaeh trieil traiittfiisiuti, in
in. Where there is dread of water, some fluid may be introduood
jh a tube; the patk-nts are most comfortable when at abMjbitu
nt in a bulf-darkeued room; in combating the oonvuliuoiis, chloni-
nafoosie has rcpo-stcdly proved mo«t sernoeablc, and patieoU
•Iki Iiave once become aotjuaintcd with ibis rmnedy beg for it again.
II But Ulis comprises the little tliat we can do fijr these unfurtuaales.
^^P The three diseases lost mentioaod enter so much into the domain
[ of veteriiiary surgetr, sanitary regulations, and internal medictnc, tbnt
h^oould here give you only a slight sketeh of them. Vou will find
^^^Die aocurale information on the subject in Fi'rcAoic'« special pa-
■ tLolt«y, [)<l. IL, Section Zoonosen, where tbe special Uteiatura is also
ITtiD.
CHAPTER XIY,
CMROyiC nf^FLAMJiAlIOy^, £SP£CIALLY OF THE
SOFT FABTa.
LECTUEE XXVIII,
Anfttamv: 1. Th.bJtt'iting, HjiiertrAphy ; 9. H]ppar*n«t«tlän; S. SoppcMtl^n, CaM
Alix^'ti*»!», l/iiriiccAtivo Ab*ca**tfH, Fiatuliv, tUcatvtiou.-^B^vult* of CtiTODio loAftcn-
lUfttiuii.— Ouuunl äj'uif («iiutclof 7- — C«uni.
OxKixEMGN : Hu%'iiip tbus fur attutitlcd nlmost cxrluaircly to acute
»ffectJons, we now como to the ohronip, and fir*l of all to chronic in-
flammnticin. But I shall here take x different method trom what I
h.»,w. r<iniit>rly donr, for Isliall noi now eittcrat nnrn nn the indindiuü
forms of chronic inflamniation as tlioy occur in surgical pmctice, but
first ffive you n general exposition of the ]woc<'ss itself.
The nnitloniic&l conditions in liciite itifliiiniiiutiuiis «re, on t]ie whole,
very tiimplc; there is, simply, new formatiou uf tissue, which cither
iDdiices bcalliif; by the liret iiitentiun, or diruct urfpinic union of th«
separatee] surfaiMW, or effect» this indirectly by formation of granula-
tions and pus. We God the eanie process in chronic inflamntalion;
but tliere are also some other appeajancea. Etiolngically, the oon*
dttioiiK in rhmuic inflamniation are munh more cnmjtlicated ; for (here
it ia not niuräly a queuion about an irriUitiuii only once, as an injuiy
or a bum, and their sequences, but wc have, 1, to explain the cau»
of tlie iDflammation ; and, %, why it umumos a clironic chancier. I
shall finit explain to yoti what iinatomioal chanf^'fl take place in thf>
tisauea during clironic inflammation, in doing which, just as wo did iu
acute infiaminutiun, wo slialt liere take the c^Junective-U&aue as the
ordinary scat of the disease. Besides the distention and multiplicatioa
of tiir- e»pillary veswlft by fonnntioti of loops iu acute iriflatninulion,
we found serous and pljislin infillnition of the tissue to he the essen-
tial aualoiuical appeaxuQces. la ühronic infla.iniuatioQ, disteutiuo of
uvrEBTROPinr.
367
tlie cspillanr vl-sscIs, or fluxion, is a less prominent ctymptotn, vhile
tbo DL'iv Tomintion of tissue and serous inBJtmtion seem U> ptaj k
iDore imporUnt r^lt. Tlic cell-infiltration o( the ti.oAii« takes pliice in
lew osea, as it dova in ami« inlkinnuition ; but tliu individual cl-Us
ofien atuiin a mtlipr moro (»mplctc dei'clopmciit. In thi« procCM of
develnpnipiit the iiitemelliilur 1i»«ue changes; tlio connuctivi*-ti£me
fUumeuts lose tbeir tutj^li filamviilurjr ucituislency, ihc distrrusibility
WK[ elutitnty of tlict «tihtiitAiicotix tiMiuc nrt- impaired, nnd the ronsc-
qu«OC0, ft« njgBrds the uoaist-r, paljrable, and visible onusL-queDces, ia
ihat the tissue btxomca more swollcm and iatijr, and less movable
-thao tKirmal, This is iW (irst singe of erct^ chronic inflanmiation,
Tbe course amy vary as Sniiavr» :
li Tbe tissue remains permaiiendy In tliis (ttate of serouEt, «nd, to
Bomc cxlCDl, plastic firm itifiltrution ; akin and »ubcutuncous cullulw
ti^xiio, Krti<;u]ar capsule, lendoiii^ lipiment«, fosciiu — in shurl, all these
ooanectirotisituc ounslitiients of ihr bcxly which arv in th<; abm'c
Btata — on section present a rather homogeneous, Intty ajtpcarnnce.
' In diseases of the joints and thuir vicinity we bcü this most ftetjuently,
and, as this swrlUng of the joint gr>rs onwillmut any reddening of the
okio, it was formerly callcil tumor <iihu»^ a name whiili tellü nolliitig
of the nature of the process, but which, limited to certain forms of
]olnt-disen«e, is practioully w^^rvioejthle. You in»y readily imagine tliat
tissue which has been httle altered may retiun from lliia »la^ of tlie
difieAse to its normal state. The infiltrated serum is re»b«ir!)ed ; the
cells, which have newlyentcrcd the tissue cw Imve newly fornieil there,
partly beoome coaneotire-tissuo corpusclee, and are portly destro3rcd ;
tlie coniiectivc tissue itself returtis to il4 fonner condition, and, if tlte
Btate of aSTnirs tie not exactly »a it wa», it is nearly fto; oceasinnully
a state of rinitnrinl tJiicltcniiig remains ; during the dei'plopmenfc of
tbe dux>nio inäammation there may also ba\-c been email cztravosa-
tkma or eseapea of red blood-cells thn^iigli the walls of tbü vessels,
from tlie increaaed pressure (accxirtÜDg tu Cufmlteim) ; these change
to a browiiieb-re<] pigment, which, when present in quantiiirs, gives a
yellowish or giayish color to the tissue that has been diseased. As a
re«ti)t of the conlinned cjceew» of nutrient material, wliii-h »nmelimes
flows to the dtseasetl |iart in chronic inflanimiitiuu, Uie limiie-eteitientfi
may beeomc larger and thicker ; the whole tisaitc may increase ; it
passes into a state of thitp/g hyperirophy. But Komcliineit the plastic
(cellular) inlitlTBtJon in chronic inflammnlion may attain a particuhirly
high grade; from the intiltmtcd young cells new connective iissuo
ftirtux in tbe okJ, so tJiat the skin may be thickened to three or four
times the normal extent ; thi<) deposit of new tissue of similar forma-
, ia tliu old, is culled hypirpiaria by the imtltolc^ical auatomlsta
25
808
CHRONIC JNPLAMMATJOS OP THE SOFT PARTS.
Wlien the tbickening or tk« skin assumes n noclulnr form, it i« umoll^
termed «l^hantioäU in the most geticrul sense of tlic tenii. Sucli
hjpertroptiios ntiil Iiyperplasuu of the connective tissue, wbtdl may
ßsrm in the course of a clirooic iottaminatioti, hardly wvor recede en-
tirely, but oflL^ii reuinin in tlie same state, ereti when tlieir CKUses
hare been iKmored.
"i. If you ima^nc the chronic intUimmation, so fiu* M yc/a nt
present knou- it, tmn^^fiTroil to a mucoiH or serous rii«.nnl)miK\ ynu
will Ackiiowlcd^; tltat the secretion cunnot remain uoniml during the
patbiplogical changes which affect the tissue of tboeo membranes.
Usuallr it increases, there ia hypersecretion / chronic iiifliimmation of
a sj»(n*iii] or niucoim membmne ma^ evince itself chiefly by this
hypersccrcti on.
Chronic «itnrrh of the miiooi» nicmbmnc« may aSccfc chi«fly Hie
epithelial or tlie connect ivi^-tiMue layvr or the glands of the mem-
brine ; i:i many cases «U three suffer to fin equal cxteut The same is
the cose in thu synovial uembrone of tlie joints ; some fonns of chronic
articular Jnlliunmntion arc chielly nniiccuble from a very &tw secretion
of a watery synovia ; iii others, there is mnre thicltening of the syno-
vial mf^nibrane- anil but little increase of ftecrelioii.
3. Chronic inflamma.tion tnayabio be accompanied by supptiration,
and its finer elunges are just as in tlie neiite disease, except tliut
every thiti<r is slower. For insUiuce, supi>oae there is at some part of
the body a collection of wandering cells with a formation of Quid
interi'dliilar wibRlance; at Ifie same time, of coutse, the tissue in
which these cell» are intiltraU-J dies, as always happens in circum-
scribed ccU-prolifcratiODS, The tissue surrounding the spot first dis-
eased is gradually itifiUrnt(.'(l with cells ; and it also goes on to form
fluid cellular tissue with the cliar^eter of pus; the inlillntted tissue is
tJic more disposed to suppiinite »nd brctik ilown wbeu its vessels are
little developed and do cot supply sufHcienI qiialttat ire and qullntitati^'0
nutrient muterial to maintain the further di^velopment of the exoe*-
sire cells. In abscess, n circumscribed cavity containing pus is thus
formed, its wall« are constantly being changed to pu^ aiippurüting.
All this takes plac« very priidiially, and fri«()nenlly ihe symptoms
usually appearing in inBamniation are wiiiitiiig ; often there is no pain,
redness, or elevation of tcmperatun;, lu the atfisrtod part, and usually
tiiere i« no fever. Jlenoe this variety of abscess, which comes on
ohrouically, is calleil coUlahset«»; fortius chronic suppare^oo we use
the term ulcemtiou (" Verschwörung "). We might also tenn the whole
cavity containing pus a hollow ulcer ("hvhlgcschwur") ; but to
oommoa languap^ this expression is applied chiefly to small eavitice,
while lat^ger, slowly-foniiiiig ones arc called cold abscesses. If you
COLD ABSCESSES.
S69
exftmtiie tlie pua from «iidi uii abscess microecopically, you will find it
rich is £tK molcnüca, but ratbor poor in wcll-ttcvelojiett pus-cells.
Tltis us bocau&c the pus has toD^been eodosed in the bcxijr, an<j is
cbangLid by disintegration nf tlii^ pi]9-<;cllH to molncult^s, mu] by clieii>>
ical decORipo&itioD ; by the lat(«r rich excretions of fat, rapvciolly of
cbolestcrine ciTStal«, ■«• formed. Tlie sppcttrftnt^c of tho p09 to tho
naked eye is also cliangt^l hy the!>e nii.>tuinoq>hoK(.'s, for it is usualljr
fJÜRoer and clearer than in tlic ucutu disraisc, and has a disagreeable
odor like fatty acids, and may contain 6brinous flocculi and shreds of
ncc«j»«l tissue. Sometimefi it is months or years before the suppu-
ntioD uf the walls of a cold abscess lias gone sn frir as to cause pci^
foTtttion of tLc ekin. In some ca»e!i it even biippeued that sucb aa
Blwet.-s8 has existed for yoars, that the uleerntton of its w>iI1h finally stope,
and the latter are tiansrorined to a cieatricial capsule, and the pus is
tbtU oomplctcly cncapsulutcd. If we bare opportunity to cxamin«
such an abscess, we find in it an omulsion-like fluid, occasionally eon-
taJQg crystoJUtic fitt, aod sometimes witliout a trace of pu»-cc11s, so
tiiat, frum the appearances, we nould hunlly infer tlint t)ie sac ia
queclioD had been an alMcess, if the whole previous course did not
■bow iL Much more rarely, in the course of lime, when tlie absoeu
has CCTficd to grow, there is rcalMorptioa of the fluid, u cheesy pulp
beinf; left, if the abscess has perforated outwardly, the pu« is eract>-
ated, and, under otherwise favorable eireumstancei^ tlterr may be
facaling, as wc shall soon describe. But, for this to occur, the ulcera-
tion on the inner wall of the abseeBS must cease, which generally only
occufs when there in a tiiifllcient development of vejiscla in tlic walla
of tlie abscess; under tlieir influence the inner surface of the abscess
cfaiingcs to a rigorous gTsnulation-tissue, and then it ooudcsiscs and
■trophies to ciealriciul tissue, and the opposite walls of the eai-ity
unite, aa la the bealing of acute or bot abscesses ; the pus escaping
from the opened cavity grow» le»», and fmnlly ceasca altogether.
Eomo time subsequently wo may still feel the subcutAneous cicatrix
of tb«! abscess as a callous lliiekeoing ; but, in the course of time, tliia
alto paaaes olT, and the ab.sccss-cicBtrix again assumes the chsracteris-
tit» of ordinary connective tissue. I will now make you aoquaiotcd
witli n tet.'linicul name used for those abscesses which do not nrijnnate
at the p(]iuts where first seen, but which liare mored partly from
rinking of llie pus, partly from the ulcemtion having progressed
ddefly in one direction. For instance, there may be suppiu^tiun along
the anterior part of the spinal column, whicli, following tho loose
ediular oonneetive UastK beliind the peTitonAum, and travelling along
the dtcsth of the pnons mtiscJe, finally appears as an absoess beneath
Poupart's Ugamout, Tltosu an<l similar abaoesaefl ate called conge*-
370
CQKONIC INFLAMMATION OF TBS SOFT PARTS.
tiec oAscej^e«. The niode of Leuliu^ above iTidlcsted docs not laike
flucti wiLh ilcsiniblc rnpiditj, but, unfortuiiitvly, ttiv gcocrot ami kicnl
conditions uru uccmtioiially of suoli a uatun) tliut, after the cvacuatioo
of tbc pus, acut« inBsmmatiou, nitb fever, attadcs tli« aboceaa, uvl
pyaeaüa or febrile ntarasmus cooies oiii or rise, in apite of the eTarua*
lion of the piut, the ohronic ulceration goes on slowly but stea/iilj in
the vails of llie (svitj. In such cases the opefllng« of these lorgv,
often decpl^-soatvd cavities contitntally pour out n thin, bad pus ; the
openings of such abacc«sc!, whether of sninll or large dianictcr», ue
\'ou iDuj also imagine the above process of i!U]ipurut Joa or ulcem-
tion OS traoefL'mrd to it surface or mcmbrauc ; then »c ehould bat« •
flat or open vtcer^ but, as this is an object of special aud gn-at pmo-
tical importance, wc must treat of it in hh independent chapter.
4. C3uonio inflamniation may talce another coww very tike flup-
piirittioii, liiiit is. : . I . lii'gfiienition of the itillninnintory ticopluia.
ln»i^iiR',)ig'»iii, ;t _ i> . : > 'Uucliuii uf young cells, aud suppusc^ further,
that ia Ihe centre this Rioup lutdcrftocn molecular diEÜitcgratioo, and
forms a cbccey pulp without separation of fluid interocllulur subfitaocc.
PlaAtic infiltration goes on »Ion-|y in the periphery of tlie cnsMius spot,
by the collection of wamlt'riiijj; cell», but the iuGltivtcd tisauo also
passes into the eascous mctamorphoeis, and thus the ccDtml focus
constantly increases. Here, also, as in suppuration, the Mlure of a
va»cuhu-i7.ali(jn keejiin^ pace witli the rell-fonnatinn i» the Incul cause
of tltc dieinte({nitiuii ; liere ia n forui of ulccraliou tbat may be termed
" eoKCnus ulceration " (a rnscular, dry necrosis). Wben tbcso ^*uIlow ^|
spots are fnunrl in the ca<^l«vcr, it is ofleii supposed tliat Uiey corw
»[loud to adrt<:d collection of pus, but this ts not true, or, at least,
very rarely so; most of Üietw cheesy eoUoelioiis were from llie firBtin
miniature what they now are in gross, autl were never fluid pus. It
may very readily be proved oxpcrimontolly that these caseous spots
may proceed directly from the inflatnmatotj new IbcmatKm without
suppiiruUon. If, for instiuice, by introdudng a fore^:n body (as a Mh
ton) into the aulicuLtneoua tissue of a rabbit, you excite contioued
mllnmmatioT), in the conrAo of a few day-i a yellow, cheesy mam form*
uiound the foreign body ; it is True tht8 is the same for the rabbit as
pw! is fur a man, but It was never fluid pus. 1'hcre arc also moilnd
pToccssce in man la which, during chrouiv influumatioo, this caseous ^
IranKformation occurs instead of eupptu'alion. In man, the further H
faie of these foci varies. If the proce-ss tahc place in a part Dot too
for below tbc sur&ec, it may, by advancing from within outward, catue
perfomtion; tho pulp is cvaeuittedf and the cavity may gradually
close OS a cold absoesa does. When this is the tennittatlon, it Es U8u>
LARDACEOrS IHSEAi^E.
371
ally aooonipxnicr«! hy «rcondary »oftening of the nuaa, wliid) b at first
dry and chemy, uid tliis fluid pul]> umler tbe micnwoope is iouad to
be composed almost entirely of mrtUvtiliir graoulc«, sotae fat, sliricds
of tissue, ami half-atropliicti cells. Thv nl>uTt> proonu may Im? sm>u
especially often in ohmiuc inflammation of the lymphatir glands ; t>ut
ia tlicm the sponttin<x>u;# tbrovriiig off oC the Cdscoub dc'iK»it tukcs
plooL' VLTj- slowly, hence tli<-«e tistulie of Iftnplintie glands often re-
main statiottoty for muutbs or ycare.
Another tcnnination is for the caseous deposit to attaio only a
flight extent, then to «tro]>)iy entirely, and to tiilte up such a quantity
of llrnc-salt« as to finally form a cAalA-y eoH<v*:me>it^ wliieh is coix^en-
tricoUy enclosed b; a <;icatrix. Out, as was slated, this only occurs
in small catcolu deposits.
5. There is still another fonn of chronic iiiSamtnation, which is ae-
cominiiied by the deposit of a peculiar substance, die (Kxallcl larda-
ccoud or amyloid, from tho blood. But I sbuU not enter into tliis
subjeet further, for this form of disease oocura chiefly in the Intornnl
organ«, and hence has only an indirect iiitere*«! for lut.
First, as regards ttii'! results of clinniiu inflarn million in a purely
liistological view, they rary. The cell-infiltration and the ttcoplastic
pmcefis goc« «i chioßy in the connoctivt! tissue, and iift^r tis termina-
tion tlie final result ia cither a retiitutio ad tnlegritm or a cicatrix after
the yxrX has been degtroycd by ulccKitioo. When this process attacks
muscles or nerves, the tissues suffer severely secondarily. Tbe cou-
tractile subsUDCO in the muscle, hs wril as the axiiKylinder aod
medullary plicalh of tlic ne^^■e-^i!BmeIl^, isnot unfirwqucntly dcatroyfrd by
molccuhu* disintegratiun or fatty degeiteraliun, due to tho distiirtance
of nutrition. Hence atrophy of the muscles and paralysis may residt
fiDmclironicittflamtnatk)». Ho«* farthc regenerative power of musrlee
and nerves goes under such circumstances is not decided. .Xfolcculnr
destniction um) Cutly degeneration msy also occur mthout inflanmia-
titm of th« connective liasnc enveloping the muscles and nervt». But
I do not think iro arc justified in tortning sucb a procMS of latty
disntegiatiou of the protoplasm inflammatian of the muadps and
nerros, as tum been (lone by T^'rcAow in tlie mu»cl«i, «I least, ulthough
It mttst be acknowledged that, iti tho great majority of coses, the ap-
pc&rancc of fat-granules in th« protoplasm may be regarded as tho
first oxprpssion of pathological (but not always rotrogressire) prc^
ecssea in tlie body of the cell {Strieker). The latty disintegrottoD of
a ti&sue may be tbe result of inflammation, or may even accompany
it; bot to seek in it the nature of the inflammatinn, and to regard the
latter «a n disturber of nutrition to so wide an extent, does not seem
to render it more oompfchenslble or of prsotieal benefit. We regard
S72
CHBONIC IKFI-AMMATION OF TBE SOFT PARTSL
every iuflaiamfiüoa as aocotnpanied by infiltnition of tlie tisAUe wlUi
cells.
Aßcr t]i«so gcocml noittotnical considcrationg, let as briefly ruD
thruug'li Ibi» «1/mptom» of chronic U'finmwation, Tht-y oro tlie saine
as in acute inflnimnalinn, only thi'y often cotnc in a dificrmt order
«Q(l in otEicr coiiibiiuitioiis, and are usualiv less intonae.
Üviväing of the diseoacd part is usiially tho first iiotioDabb H^-mp*
torn ; il depends piirttjr on Bcrotu, partly on plastic infihratioiL Ths
porta fcfl doughy, and at first tjuitu ünn ; if an abevr ss futin&, as inay
happen in the <x>ui-so of vpoUb or months, fluetnation gradually be-
outnos mcjix; (.'Vtduiit. Wo sliull unly perceivB rwfnew of the inflamed
part«, wlicn tbry lie on the aurfacr, fr>r, an the vceseU are occaaionally
but little distended, it is not very intense or extenvre. We tnuy
readily detect chronic influinnintion of the nnsul niurioiw niembmiK*, or
of the conjiiiK'tiva, by tlic sui-lliufr, n.*diieM^ and iiicrcaatid scorctiun.
QiroiiicaUy iuÜamcd skin graduiUly ossuint^s a. bluisli or brownlsli-rcd
oolor. But, if the inflamed parts lie deep, the skin is not disoolored,
and only beoomea red whrn tlirt tleep chmnio inflammation finally ini-
plicates the skin, as in tbe perfonitiuii uf culd abscesses. /'<iiVi isonu
of the symptoms of chrcmic inHnmmntion that varies most; in tome
very tedious casus it is untircOy nbiM.'ut, but in utbor eases tnay be veiy
■cpcre, having a tearing, boring character, sumcUmea appearing spon-
taneously, at utbi-rs only on pressure, or on tiiirrely touching tbc parta.
'XVe functional iliHurbane« depends esaentially on the pain and on tiic
anntomicul changes io ibo parts. HtM^ 'Civs temperature appearing
elevated triicu the hand is laid on the part, is not usually marked, or
is very eligbt
Fever is a symptom not neoessarily pertaining to (jironic inSam-
mation; it usually appeura only when the inflammation ussiuoea an
»ciito cbaiBCtcT, OS not unfrcquently occurs during its course, espcdnlly
when the body ha« been much delnlitaled by long-continued suppura-
tion. Then we liavo the so-called heciic fevtr, a febris oontinua, or
mmpLy remittent, with great differences in the morning and evening
tempciature of the botly, a fever with steep curves. According to my
idea, this hectic or eonsmiiptive fever resultn from continued absor]>
tion of the products of inflanimation, especiidly of dbintegratiou ;
hence it is moat frequent and most intense from rapid breaking dowu
of the itmer u'hIIs of large abscei^oK, and in rapid progrt-Hsire ulcem-
tion. This fever often runs its counwi wilh rapid emaciation, nighl-
Ewcats, and diarrlitnü. Few patients stand such dironic suppurative
fever long; though I observed a boy fourteen years old,wit)i a fistula
remaining after resection of tJie lieail of tlie femur and general lanlap
COÜRgE OP CHKOSTO INFTAllMATIÖlf.
SM
disoaae, a wbole year, during vlücli lie had a continued febrU
remittcns; tie finalU* dicil froiii frfiiml dropyr.
Hie eourte of cliroiti^ iulluimiialiuii utny bu clnMCi) under two gen-
era] heiuts. In tlie finii ciL«e, even the comniieneenMrDt of the cliscaso
is IndtKliiict, Hüd can scnrcely be stated with tiay certainty by llie pa-
ticot. Sometimes it is a »welling, a modenile {mio, or a slight dia«
turhanee of fmictiou that has ealled attention to a inoriiid slntp, C<a«cs
whieh bare begun so insidiously usuttlly mniiitaiii itiis elmractor tn
tfaeir furllier oourae. In other cases, the cUrtniic inflammalion u a
remnant of in (wnic process ; the chronic flOursc is interrupted from
tiino to time by ucuto uttai-ks, with ft>vcr. We can say least that ü
definite ibout the duration of ehnmic mflunmatiaa in general, as
tbis shove all thin^ depends on tlie exciting causes, to which vre
shall Boon come. I only entreat you to bear in mind thut chronio
inflammation, lilte the anite, bus a lenilfiiry to terniiuutf, to hnvo a
|iypical end, for tlic new furniation never (foca beyond the dcTc]o[h
sat of ccrtiiin ebamcteristic mctumorpliuses of liesuo, which lend
'lo development of conneotiire tissue, or of a cicatrix in some way,
unh-ss tlie diaeaf«d tiaeue is destroyed by diaintc^^ation. \Vhy it is
important to remembcp tJiia will be clearer to yo« when wc treat of
the Gmitation of otlier new formations, such as aoliiid tuninn^ Of
ooun« the uew fontuitiun attains no typical end when its causes can-
not be removed, or do not »p(Hilaneou.ily disappear, and when organs
UD destroyed that are nccesuuy to life, or when the stri^agtli ia cx-
fanistcd by Buppurntion,
LBCTUBB XXIX.
G«a<nt £(Jot«K7 vt Chronic loSaoiBMilloii. — Ext«rt)ai Cevtuia«] Irritation.— Ctraao* la
thsBodf.— Cmt^riol Um of DImBmU mi<1 P;M:ruU.^lc«cnl SjiapKotatMogj
aadTraätiaeDtofMorliUniaÜiaMsaadDjrKrMl«. 1. Tli* Lympbati« VUthMb
{BcnM*); 3. TuUrculouaDyncrmils (TubervvloaU) ; I. Tkc ArtbritU: Dktheda i
^^ i. Tb< fiooibutic Vjraonsia ; B. SyptiUllIc DTMnaU,
^B To-DAT WO come to on« of the most important parts, not only of
^BHin section, but of all medicine, that i«, to tlie cair«t> n/chrvnic in-
Jhmmatlon. W'r- saw how acut« inflammation residted from an irri-
t«i)t acting ouee, and varii:d aocording to llie aD»U>mical condition of
the iiritiitccl part, and the nature and extent of the irritation, but that
it ran a relatively short and typical ocnirse. Now wo have to deal
with inltamniations tliat last »evcnl months or years ; here there
iBittt be a continued cuttse, a loog^acting irritation, or soniu alntormat
reifitioD to aimpte irritalion. These ountiuucd irritations may bo of
874
CUROKIC ftTLAMMATlOX OF THE SOFT PARTSL
a purely local chamcttr; let us coiuiidor them for a moment. When
small animals, liki> tlio itrli-iiuteot, tnkv up tlii-ir uImhI^ in tlm skin, as
ihey (U{j ljurrows like n badxcr's in th»; tupcrfiriiU layers of the cutis,
lt,y eggs, and there lead tlicir laborious life, they <au&c constant irri-
tutioTi of the ekin; totliis is addod the sorut^lün^, and a cliraiuo in-
flamtnittioEi of the ski» is tliiis caused and Icejit up. If spores of
fungn» locate in Uic cpiil«riiiis, niit] there begin to grow aiid to mul-
tiply to millions of small vojp.'talilo urj^niüins^tlie skin will W jiUcwl
in n 8t«te of continued irritxtion bjr these little {oragavTS ; «nd va-
rious chronic cutmieoiLs ei'iiptinns will result, such as fä^iis, herpes
tooaurous, pityriasis vereicoW, etc. If a pivs&ure or friction act
modernk'ly but continuously on ibe sltin, it also is a olimnio irritation,
which is piirticularly apt to induce tliickt:iiin^ of the purt of akin uf*
focted. Ti]c callous spots an the heel aud many corns arc the result
of the continued frittioti mid prcssiire iiidueed by our modem fbol-
oovcringK, Tn the sainc way the workman nlio uses axe and Itammer
a great deal has calloaities in Die liand, the »hocitiaker haa tliem on
the outer giile of the little finjjer and hand where he daily Hmws on
tho pack-lJiread, etc. [We »eo the tuiiDC thiug much more markedly
OD tlic side of tlic left tliumb and forefinger in phu^tercra, from bold*
log their pluatcr-boiud; aud at the upper and posterior part of the
fijont lefi i>f some horses, from lying on their ir«ii shoes.] SometinuÄ
foreigTi hollies in the tissue keep up a contiimed chronic irritiition in
the fturruuDtling purta. Continued or often- repeated chemicul irrita-
tion <if the ti*»ue- nmy »Iso inilufc chronic inflammation ; for iiwiance,
chronic gastric eutarrh may be caused by tho rcjieated use of ««'hunps
or Btt^uj; liquors. Continued Stagnation of blood and lymph, as
well as their cong;ulation in tho vessel», first induoea h^'p«rp1asia of
thß walls of tile vpssels, and of the parts immediately nroumt them,
di^itcnlion and Lnrtno^ity of the ves.'^els, luxl thickening of the tissue;
the akin of the h-ff is particularly exposed to this diseuiM when tliere
is any eontitiiicd opposition to llie esca[)C of venous blood from (he
cxtnMiiity.
Wheu wc have to treat chronic inflamniations that may be traced
to such external continued irritations, of ■which many more iUustra-
tiou» might be given, tlie results will be favorable. Vi'e get rid of
the animal or vegetable piirasitcs, the foreign Itodies, tlie c^ntinuetl
presaure, chemical infliieiices, ete,, and the <Jironic infinmmalion will
disappear spontaneously. So far we have supposed a local irritation
actiii;^ eontiiniously ou Iiculthy tissue; if you suppose a tolerably se-
vere irritation actinj;; once on a tissue already diseased, you cunnot
eKjioct tho conditions to prove as favorable as in a simple traumatic
iiLllammatioa of healthy tissue ; but it is probable timt the lesulls,
CAFSCS OP CHBOSIC rTFLAHMATTOir.
il6
even of tl» single imUlion, will be diSereat, possibljr mote continued,
bccaiu« UK txjaditioDS iu the tissue will unt bo eo fiirorablc for tvpicikl
rcmovml of tbc disturbstu«, Supposo a pniiion of Bl;in alT«s<Iy suf-
ferinff from clirouic tanamtnatinn to Iw HUjicrfiL-tallj contws«^!, tliis mo-
glc inilation may induce chronic «uppunition, or even pro^^»sive ul-
ccrntioQ, which, tindor normal conditions, would quickly h»ve ffonc on
to new ibrmation of rpidfrmiR an<1 healing.
Tlie CAoe» where we find such purely \txa.\ uauses Terr the origin
aod oontinuaticc of chronic inflanimation &k oomparativcly r%rc In
the gTL-at majority of casc-s the cause is not so evident ; Ihe case
TBOUt 1>e watchod and trird in ^'nrintLi way» itefoit; we can obtain any
cleiT to the «tiolo^y of most clironic inflammations and disc«««». W«
linve not here mentioned miasm and contagion fmiii the domnin ei
gtmi-ral etiology ; aiiJ we may l<.-are them out of thu qutfstion, for
there is Dothiut; to show that chroalc inflammation may »rise from a
sin^e action of contagion or miaem. It is true llior« ar« chronic
malarial dispasos, surh us inb^rmittciit», ct<*. ; but there tha cauae of
injury acta o»ntiiniou»)y, and not un frequent) v the dtHoaAO- ran onl}- be
cured by reoioring the patient from tlie miasmatit^ almoflph(>te ; hence
da caao corresjtontls to a »Kntintied pxtrntal irritation. Tlie Hime is
of repeatedly catohiiij; eold, nhrrc the tiew uttaek ußecta (lie
body already di«ca*«d, and thus indiiees ehronicity of the prooej».
But all this does nut suHtce for the etioh)gy uf chronic iiiflamni&t tons ;
we nmit also look for the causes in eertaiu congenitÄl or developed
«joditivo» of the whole body. Let us hear what cxporieoco teaebes
oo this subject.
On careful observation we first notice that certain forma of chronic
inflammation constancy recur in certain organs and certain parts of
I the body ; that at ibe same time they show themselves chiefly ut oer-
kill agea and in perwitis presenting some similarities in tlieir external
[■nditioiiB. lliua we see children of the same class, who urc pocu-
iiriy disposed to elirrinic swellinj^ and suppnmlion of the Ivniphatio
glaniht, joint», and lx)iie», other pemons who are chiefly affected by
insidious inflammntion of the lungs, otliefs who aro particularly liable
to colds and have ]>aiu3 in the diflennt tnusdc« and j<»nt!<, Wo also
see that Kiieh [x^rson.«, who ate constantly behig nttiickod In the same
way, timiisfer tbeir individual pathological peculiarities to ti>eir de-
scendants ; that tUoue leaving such legacies have in thm turn rec«ivod
tliem from tbeir fathcre or m<ithera. To obtain some ole-ir idea of
individual morbid pr^Jispoaitiotis in this cIjhos, persons predisixncd
to certain chronic diseases were divided into groups ; thus, in a purely
emptrica! manner, men were divided, «ceording to morbid disjiceitions
or dinlliese», into lymphalic, scrofulous, tuborcutoii», rlicumatir, etc. ;
37e aiRosic isnuMiiATiox or tde soft parts.
terms urbich at first mCTely mcHnt that tbe wrofulouK, for instanoe,
veto especiftUy prcdispoeed to glandulaj- iltsewtea ; Ük tubcrL-ulous to
the development nf ulcerating nodiilctt, vie. SulwequenU^ litis group*
Ing was cauTtcd furilter, lutil ii niu concltttlvd that a ceitalo luurltid
condition of the plivsiolufinCal proccsei» uf tbc entire bodj must ha at
the root of sui-li predispositions. A morbid mulurial, or essenoe, a
materia peccans, vtax auppoeed to exist in l)ie bodj ; tlic most natonl
bearer of this was the htooil, for thia pasacd lltrough the rutin? liodri
und iU condition certainly gave a mcaaure for U>c more or le«s aorma]
or pathoIogii^J con<lition of the enliie body. Tlie word dywrasi« (a
bad uixtuiv) indicated sucli a putlioTo^cal conditiuu of the blood;
bene« a scrofulous, tuborculoi», etc, ily^cmuM were spoken of. It is,
however, a strange idea to btirdt'ii Um Mood alone nilli thu patht^
logical changes of t]ic vrbolc body, and nssume, as it were, that iiif<tx>
tioo of Iho whole body resulted from it. This could only bo acknowl-
edged in rases when> an abnontul material «as iotrodured into line
blood fmni without, aa we have seen to be llie rase in poiermeU
vouuda. Out this is not the case in tb« dyscntsia: under ooAsidcratioD,
or at leiwt it is only j)nrlially so; biit the morbid dispiwitians derelop
in the body itself from eatmea little kuowu, if they be not liniided
dowD as an iitlirritanoe from the parents. The blood is uo innm
absolutely stable timn any other liitsue of tlie 1x)ily ; it is constantly
being renewed, partly used up und again renewed, etc. ; we do not
ocrtoiidy know the Bouroo for the renewal of the blooil-oorpuadesf
you know from phyeiology that tbc senim of tltc bl«xl i» coostwttly
being regcueraled from the lymph, and thu again from tlw ebyt^
vessels of the intestines, and you also know that fluid constituents
frotn the blood arc excreted by kidneys, lungs, and akiu. Uow Unic
we kiKiw of these things, nnd how compliented eren these little af5iin
arc 1 I lead you to this consideration to wld tjiat iionnal blood c*a
only form firom a hoallliy body, und the rererve; hence lliat we
eaiiiiol phrviiikigifully 8[>euk of a onesided dis«4utc of the h1o"d. Hut
there woidd be no use waging war against and Iryiitg to niot out the
words dyscnutia and diathesis, now firmly embedded in incdirnl lan>
giing«. It would do acience no barm to use them fore^'er nnth the
above meuning; we must liavc a name for thcso things, for they are
iK>t mytlis, but »re facts tbat hare been obser^'ed foi* centuries altboiigb
tlieir sigiiiGcauee boa varied greotly. \Vc may go too far in classify-
tng persona in this matter, if we awrribe to every one a jiathologiual
dintliesi», or try lo pliiee every patient in oim; of the cliief diviaiuna,
Altliough there migiit thooretioally be a certain amount of eonvctncsa
in «apposing that in our pref^ent state of eultivution there win no such
thing an an abaolutcly health}' man, ntU), it would be very ecnsclcsa
I
DUTHBSES AXD DTSCRASLe.
877
lo try to maintain this in practice. And jrou must oot suppose Ibat
it i» ilwBjs 80 easy to clasa every patient i» rartain grauiie, just aa
pUats itrc analyzed nod their giy»t«in!i dotcnnincd, for all olusoes of
men may brvLtl ivitli cac^li utlier; tnorcover, sonic abauratallj'-fonnod
iodincltmls iniiy bct-orac pcrfixrtly normiil in the course of time, nail
tfae rercrs«; thus a number of middle forms uuturally result, wliicb
defjr any clasai Beat ion. There are Don*, B9 there have at all times
beeo, physicians who anr too skeptical alwut the pxikloiic« of a gt-if
enl morbid dJsftoaitiou to uertaia forms of disease, aud only a>.-kiiowl-
edge local ind partly only accidental jrritatiutis as caus«». Such a
fayperBkepticat current ran ttiroiigh luodeni medicine a short time
since, und was perfcclly juatiEed, for the oasi» dwtrinc had Iwonmo
BO luxuriant, that there v\s scarcely a ruricty of inSanimatioD, scarcely
a diaeaae, in &ct, which was not hiise<l on some specitie crasis. \\'lio-
erer observer independently and carefully, and at the sMine time tins
tli4 opportunity of seeing a t-nriety of patients, will certainly nrrivo
at the correct view in the eounte of time, and will ndlher throw hiiiH
aelf too uurcsen'odly into tlie anus of the crasis theory, nor set asido,
aa itluaiotts and deceptions, tb« expericoces of centurie». It ia aquc«-
tion vhether it be of any pmcticat value tn use su<-h temi» a« ftemfu-
)ou> or «yphilirir iiiflaminiition, if it would Dot be twtter ti> rc^pird
the chionic inHammBtory proccaBc» without any regard to their origin.
Tho future will decide thin (|iie»tioii ; at prcjsont I deem it my duty as
teacher to clear your views on thesu points as much as posaiUe, and
to place you in a position to Ix? able to under»t«nd nil your oolleuguca
speaking on those subjects, no matter to what school they bclonfif.
But enough of this general explunatioo ; let us draw a brief sketch of
the different diatheses luid dyscrasiie :
J. Tht i'jmphtUic or »croßäou» dia(h<ii« {«crofufa), Tliis tcndcnoy
to disease exists diicfly during chililhoud, tbmigh nwrc advuncvd a£|M
aic not free from it. Persons with this diathesis, c^spccially children,
are greatly dispotied to chronic inflammatory swellings of the lym-
phatic gland.i, even after iiK-oiia id arable irritationH, lo certain iullam-
matioQs of the skin (ei7^ma, impeti^), especially of the face and
bead, to catarrhal iuQammations of the mucous ineinbratK«, especially
of the conjunctiva, more rarely of tlic intestiiuil cunal and respiratoiy
organs, to chronic iiiflmnmatiuns of the pcriostcimi und of the syno^öal
mcmbraoos of the joints, As regards tho swelling of the lympltatio
glaod«, especially of the submaxillary and oocipiial, it has been asserted
that it is roerely a result of irritation D-ora ileniition, or of tho
ecaematous eruption» on tlic l^ad, of the inHainmntiona of the eye,
ear, etc. \ this is partly correct, but even talcing this view, that all
awellings of the lymphatic glands are secondary, even tlien for the
878
COROXIC INFLAMMäTION op the son PARTS.
glantU to swell 9.ttet deuHtion^ fur Instance, Uiere must bo an alioor-
mal inilabilit^ of the lympfaaltc ajTBtem «ucli as docs not exist in aü
childrco; moreor«, auch local irritations ninaut always be found for
die Bfli>€tk>ns of the bmncliialsnd mes^iitem glands, whicli nre almost
as frequeut. It is oho ft morbid stato for Lbe swelling» of U»e
l^phntio glnnds to lost longer than the itrilation; and «r<ni snbw-
qiumtlj to increiixe wtlhont iijtpnrent cnusa It mnjr l»c ncknowliüilged
tlrnt sumo of tlie abuve ufTnjti'jiit«, for iiisi«ncp, jHtrt uf Ili<; scrofutnos
dtsesses of tho joints, arc caused by injurio«, <«ntu«ioo8,cto. ; but tbe
fact that thoy take a cliroaic and to Bume extt-nt entirel)" peculiar,
ronHtant coirrsc, is due to abnormal condition of the tissue, wiiirii ab-
normal iMiiditioa ie so epix-ad over llie entire body tluil it nnnut be
ro^krtled as a piir4>ly lorail, but tiiust be oonsidnred a universal oondi-
tioii. Attonipt« linve been made tu diagnose tlic srrofuloiis diathesis
ftoni the gi;aerul oppcoraace and condtf ion of the child. Ilic fbllmr-
in]^ is the pictmv usiinlly drawn of a scrofulous child: blond liatr,
blue eyes, very white skin, with thick cellular memhrane, thick lijK»,
pot-belly, romcious api«:titc, and tendency to cooEtiputiou {torpid
scrofula). In practice you will meet some uf the orifpnids of this por^
trait, but you will see many other cases not at all like il, which t»erei^
thelcAs sidfer from typit.'nl (tcrofula. I do not attach tnuclt importance
to thc«c external symptom*. In regard to the course and t^rminationfl
of chioniu iufl^uiiniHlions in scn^fiiluus children, we may mnke the fill*
lowing rciniu'ks: In n few coses, the eliroric inRammntory »welling
fiooncr or later subsides entirely, and the parts Itccome perfectly noi^
mal. TliG course trith suppuration is the most frequeot, and acconl-
ing to the spcrial niiture of the rase tins may be quite acute, a5 It ia
iu inlliimmfttion of the submnxillary glauds a&d in iufUmnmtiotkS of
the joints. Often the (lispn.ie remains chronic for yearn ; abüoesKeK,
fistula', ulcer», ett, fonu. Early suppuration occurs, csiieciall/ In
sonwwhat cmadaled, debilitated, badlyuourtshed children, who arc
very liable to fever [fret/titie scrofula), and it« prngrwds is very bod.
The tcrmniation of the inflammation in caseous degeneration is not
ran', it is particularly frequent in the lymphatic glands ; of oouree, it
must have a very bad effect on the general nutrition, when the mcseii*
terio glands arp degenerated in this way, and the chylc^ueW (bus
mootly obslrufted ; inciiniblc atrophy of the entire bixly inny thus be
induced. The lymphntio diathesis is in most cases congenital, »ikI is
transmitted from generation to generation. But it may also be dereJ-
oped by improi»er modes of life; among the most injurious causes
arc. giien : cliief or exclusive diet of potatoi», flour, or sour bread;
unhealthr, damp dwellings; laclc of elcftoliness, fK«h ah-, cte. Ifcls
indeed difficult to piore if all this be correct; at all events, if lbs
MBOfinx
97»
abore eauae alteays induced srrofula, it wuuld be much more Sequent
thuQ if. now is, tiniong Uie i>oor.
To Ktutc ID a few W4;rd» what is al preseot uiiderelootl bj* * lymphat-
ic oi>iistiliili[Mi, or «•rofula, it mny be ooDiidercd — 1. As a disiKwitioD
to chronic indamtiiHtiaD of the skin, hones, and joints, m wliidi the !u-
flammalioQ may lead to dcTclopmcst of grimuJatiooE, of piu, and to
ooseous dogpucralioii ; 'i. Pcnwim m whom swelling of the lymphatic
glands, even if indm«!! by temporary irriljitioii, long continued in the
aaine iilate, or cwo iocrcaae without new peripheral irritatiun.
Wc bhall hero pus at once to the treatmtnt of scrofula iu general.
First of alt, tht! diet should bo rG|gulato<I ; good aoimul food, e^s, and
milk, well-baked wbcatcn bread, occasional hatha, residence in fresh,
healthy air, a hardenitiic mode of life, aix! the most imporiant rcme-
dii'ji, hut from tlto circumstances they are often the niotit difficult to
employ; in prescribing the diet, spei-Jal attcalioii must often lie paid
to tJic iudi vidua! cusv, c&pcciiilly aa to whelLcr Ibt^rc la a tcudcncy to
Uidaccous disease or atrophy, whctlier tbe diffcstiTC or^Eans are nor-
mal, or were ruined in youlh by ini[in>per diet. As the disease is
vcrj- common among the poor (without the rich being frco from it,
however), these dietetic and hygienic rule« arc particularly diflScult to
follow, nie nurober of internal anti-Bcnafutous reuiedioe is very great ;
the object ia not, as was formerly supposed, tti intmdtice a sftccific
remedy as an antidote to some unknown poison circulating in the
blood, for the latter docs not exist, but the trentracnt should be puiely
symptonutic, and usually general. From the above, you sec that
EcrofuU is not a materia pcfxutns iu the blood, but <Mily a debility of
tlie orgiiiiizutiuo in some direelion, a more or less intcuKe prediK|>oei-
tioD to peculiar forma of disease. This is a decided difTerenne frusn,
and an advance beyond, the old view of ll>e disease. From my cx-
piunatiun you may also understand those recent skeptics, who think
that all L-lironic inllammations in elitlrlren are of siiiiilar orifrin, and
tliat it is consequently unnecessary in each case of chronic inflanima-
tioD of the lymphatic gloods, or in articular ioflammaiiou, to add that
it is serofuluuR, or depends ou a lymphiitio diatiK'sEs. Possibly these
cxpTcssiüiut may disappear in the cour?*«; of time, us tbcy will be ren-
dered unnecessary by greitter de-ameas of ideas, but it is not ooneot
to say that all chronic infiammations in children liare the same origin,
for some of lliem nuiy be due to heri(><litary or dertOoped syphilis ; sod
in adults tliere arc fo many other coiisiitulioiuil prrdispofiitionfl boaidos
those that have hitherto been tettncd scrofidous, tuberculous, and
which consist in tbe predisposiUoa to chronic intlainmatious ending in
suppuration, caseous degeneration, and ulconttion. It seems to nie
that there can be no doubt that these pivceases are, to a certain ex-
SSO
CUBOSIO IKFLAUUATIO.V OP TUE 60FT PAKTS.
tent, oppoud to other forms pf chronic Inflammatintt, for inctance, to
these depend! ngoB itituretitl&l prölifenitionof cooneetive tiisuo (eiirho
ft» of ilie Hrer, morbus 6rifi:btii, gny drgimcratton of tbc medulk
spiuulis, etc).
Mnny things Jiavo been tried to improve the Ijmpbatic diatliMif r
Ibrtntrrly purgatives vren occnAiouully given, and iu ]'^iglan(l particu-
lar! j- small doses of mercury were KltniiiiisltTed ; tbi* is well suited to
&lf serufulous oliildrtni; biinit 8]>oiigt', folia jug'landis n:^iP, hfvta ,
jacea, arom-caffcc, and bitter medicine», Vfvcc recommended, *nä ate '
still used. At ]Kcsent, cod-Hvcr oU is most used *a aa aiitiscmfuletic,
as ii i* not only eonmdered to have a speoifin aetion againrt the flcmfu-
lou» diatliesis, but is very prnperly prized u» exce^iiigly nutritious,
and hence is et^periully »scd iu cmaeiated, scrofulous children ; in ht
children it might even prove injurious. ix>mc of tho preparations of
iodine act very well in xerofuls; but they should l»e eniployed c«ie-
fully, and in fat mtber than in atrophie rbildrcn ; iodide of iron is beat
in pule, fat chüdrcu, witli fuugous influmnuttioud of the joint«. Tbc
«asily-dif^ted preparations of iron are very vahuible remedies in
serofiilu piitienid with unit'! mi». !^lt-wuterbaths also aet beneGci&Uy;
tlicso may cither be ust-d at the springs, in Gcnnauy, for instance, at
Kreu2iiach,Rhcme,Wi«ekind,Coblenz, Tolz, ReicIieiihaU ; in Austria,
in Hall, I^ebl; in Switzerland, at RiieinfeldeDiSrhweizerhanfLavey, or
Bex ; or, lliey may lie prepure<l ttt home by adding from, according'
to the size of the batti, one to thr«w pounds of »It to a wnrei batlu
For a bi rye child, sea>1>ath8 may be reeom mended ; for ircakly chil-
dren, wartii batJm wilb the adulitiou of malt and aromatic bcrlia. In
fat, «cNifiilou« childri'U, Memf^tr recommends wrapping Ibc «hole
hotly in wet shcL'ts; I Itavu seen gucxl results from this in aomeeu^CK.
Some physicians also recommend sulphur-springs, es{)ec!iilly the botj
ones, ill sciofuloua diseases of the joint»; ao far, 1 bore seen more
hnriii lliiin good fmrn them. You sec there is no lack of rpme(Ii(>s;
Stil! %Te ntn'ly suwenl in improviug tbe constitution by ihcm, and in
preventing rclitpse» in all cases. Sometimes, too, tbc local process
attains sueh a grade a» to be of itself daogorous to life, and tho loosl
reniedlea must he moölly relied on. As before slated, tlie tendency
to these diseases greatly decreases in tbo courae of years ; Ixjt many
children die of tlie diseases of tbo liones and jointfi.
2. 771c ttiberctilotit dyMeratia. Tubtrttilmh. The name of thi«
disease romes from tulicrcidum, the nodule, because c^mntc influn>
mntionit, due to this disease, appenr m» small nodides, or tulxrrrlc«, at
first scjircely as large as a millet-seed, oft4>n mieroscopic ]f yts^
analyze one of these nodules with llie microAcopr, you find it io eon* i
sist of ft number of mcdiumsizod, round cells, whicb increase En the
TUBBBCCTLOSBL
3S1
penphety of tb« noilulc, while in it« midst Uic ebort-livec) cells have
already brokmi down to a &av, molecidttr, dry ]ni!p, whidi, vrlicn t-ho
nodule is very Urgn, becomirfi tcHkw and casnoiis, nnd. like die prod-
ucts of chronic iaflsmmation )^i)crally, sori<-ti »ccoiidnrtjir, ur, U the
growth of ihe tubercle be arrcitted, it Atrophies or becomes uilcanioits;
tlieec more miiiitt« tubercles develop most fri-quentljr in the Bbcalbii
of the small biood-rcueck {Hin^citcli), Jt Is not merely cascotis de-
g^ntiratioii tliat chnmcterizes tiibi'n-Ie, for jovi already know* ihnt this
opcurs in otiier forms of chronic inflnmmiition also, bitt the combina-
tton of thu abot'e-described fonnatioii of iioduU.-» with tlic caseous
do^t>eration and its variotis termtiiations forms tbe diE>lingui»lüu|7
anatomienl peculiarity of this disease. A imiUiple formntioa of nod-
lilee, with different termiiLations, may also orciir in other diseases, as
in cancer, l\iberclcs are most frequently found in the lun^, espe-
cially at their «pires; there are usually raunyiLl one time; (hey unite,
the walla of the bronchi arc implicalcd in the proiv?M, they are de-
stroyed, and the c^ascoiiH, piirtially-softcncd rontenta of the Inberclee
are couj^hed up; sometimcR blond-ressela are ruptured, giving ri«e to
Bpitting of Woo<i or pulmonary liiemorrhage. A apace thus left by
softened tubcri'Ic is called a «retVy. It is not our object to cuter mtJFL'
into detail j you trill hereafter Ie»m enough of this unkap;^ disease
in the dinie. Xeit to the lungs, tbe most frequent loeation of the
di5ca.sc i» in the laryngeal mtioou» membrane, thcni in the inteittinni
mucous lueiubntne, even in tbe rectum, ■fthero the tuberculoi» uicerö
■sd «bsoesses alxo acquire a surgienl interest. 'I'ubercles al-'*o oor:ur
Id the bones, especially in the spongy ones, such as the txloaneus,
bodies of the rcrtebrr, and upper epiphyses of the tibia. Although
tbe lymphatic glands arc often diseased in tubereulosis, miliary tnber-
eiB proper is hardly ever seen in thorn ; but lo its place arc large
CMCona spots.
"Hie ricvH as to the etiology of tuberculosis have changed wooder-
iVilly of late ye:irs. Formerly it was not doubted that it was partly
SD idiopothiü disease, partly due to hereditär}' |>redispoKitiun. Hcnee
wo spoke of a tuberculous as wc did of a scrofulous diathesis, and the
two were considered as rc-lated, although nut identical. JjaertneO
started the view that the Kmall no<lular neoplasia (gray miliary tuber-
dos) were the primary dei-elopment, and by confluence and growth led
tr> the destruction of the affected tissue«. Tlie division of tuhercle«
into miliary gray points and into eheesy ikhIuIcs, tlie verj- jH-culitir
•TOto miliary tubereulnsia, IIki connection of tuberculosis n-ilh oilier
and especially with ehronio suppuratiro inflammations uihI those
tending to caaeous defeneration, were gradually developed and in
many phioes remain obecun*, although the idea of tubercle baa been
383
CHBOSrC LVFLAMIUTION' OF THE SOFT PART&
rciidi-red inort; Itniitetl ftiid preciftC hy Vircfiow, »o tltat at present
cvciy ticvr furmatiua iJiiil biia uuOcr;gui)e cueous dcgcoomtioa is not
ooiuiidcnid us titWrcIo. Il was reM>r%'U(l for Buhl^ hy carHiü experi-
meDUjtoarrivi'attlK' idea lliul ac-utu miliary- tuberculous was tbeprup-
ei' typt! of tuWrculoua disease ; be found it «Iwa^rs coDibiued witfa old
CAseous or purulent ia6amtiiiitorj foci; be made the bold UAcrtioO
tliat it nltvuys rc»ult«d from absoi'ption of »ubftUoccs frutn tbesQ focL
Acuonliii^ tu tbis, tuberciiloois was »n infccttoiis disL-as«:, a snrt vi
iioduliu exontboniu on und in inti-'i-nol orfr*ns, caused by Ibo absocj>-
tlon of an iiijurioiu Hutistauo>e, ptirlic-ulitrly from old caseous points of
inflammatioQ in tliu Iruiphntii: f^liiiids, lunjre, bouc, etc. Invealigl^
tjoofi of lato /csra hare shon-n lliiit munv destructions — in Ibe Int^B,
for instanofi — wbj<?li pn'viouslv had been conüidered due to mlllaty
tubcrculoaia as a mnttcr of coutap, are inspif««tixl, caseous, and portly-
soft«ncd spots, tbat must be regarded as ilie result of a simple cbnntic,
ulcerative inflammiition. It sei^mn, indeoil, that even in pulntooair tu-
lx.-rcutij»is the furmatioii of true liilx-rcle ia to be rt-garded as scoondaiy
and Irotiucnt, but by no nicuua ncocssarj. X'ianeffer tlcser\-e8 grtai
credit for his practicaJ application of this Tiew, according to Trhidi a
diatJittis to chronic purulent irißammationt of artafn organs but not
fhe HibereuUnu ir^Teetion, would io congcnitai. This view ia of Ule
greatljr supported by tbc fact that attempt« to render ammale, espe-
cially guinea-pigs and rabbits^ tuberoulous, hare sun^edcd. In Ibcae
little animals irritation o^Ycry »hort duration excitfs inflanimalkm trftli
cascoua pumleut products, nuj fr^ut Ihiä focus resulu u tubenmlmiG
dysorosia, which evinces itself partly in the production of miliary tubei^
clea, especially on llie serous membranes, partly of yellow nodules in tlie
lunjr, liter, spleen, cte., and causes dtutlu These very interesting ex-
periiiienls, which were begun by ViUen>in,%m{ repualcd by Lth^rt and
11 y**, Fox^ Klein, CohiJmm, 'Wa^drnhury, Menzei, ami others, wltli
the »ame result, htit with diiferentintcrpfetations, seem tome toprore,
whRt I have always mniatained, that tubercle ia merely a peculiar
torm of innamnintoty new fonriation ; that ik, that liuhCt view it cui^
rect. The observation of eurgicitl eases ^»eaks moat strongly fbr iJiis
vicnr, and in the clinic wo »ball repeatedly liavc oMatwn to roour lo
thi« jtoinl.
If, froin what bus just liccn said, we rccojrnize to the full extent
the immense progress recently made in the knowledj^o of tuberculosis,
still we mufit not fail to see that it doc» not fully explain the interest*
ing coinicction between some rhroiiic iturgicul discaws and tuhereu«
louit of iiilemul organs, especially of the lungs. Although itienr aro
a good many cases where pulmonary tubercle« folktw chronic BUp-
puration of bones or joints, and cuaeous d^enenttou of swoUea
TTBEBOITLOSIS.
»83.
Ijrmpiiatic glaniU, just ss often dcxth of tho palitmt results, after^
j-otrsof ilincas, from eshsLuatioti, and on Bfirtion we tlo not find a
tnoß uf lubeixrle. Under Mme circumstxiice», too, tlu-rv ü nu ab-
Mcption of the cuaeoua oiasses, or els«, if absorbed, ilicy do not in-
duoe tubercle. Xor must I hi<]c from you that some pathologists ouly
acknowliKlge a fh.>qu«nt coincidenw between chronic siippiiniting or
eueous foci ami lubcrcle, and refer bntli to a cninmrm, unknown cnusc
But all this cannot prevent me from recognuinf; tlie i-xcc(.-ditig vali»
of tbe above-d<?8crib«I recent nbservatioitti, unil n.-gitr<liiigtlii?ni as one
of tbe gn-alvst nd\7uices of niodeni [inlhutogy. ^Vhin^ clinical ob<~
aenrationa and experimental results rcrif; each otbcr as iticr do in
this question, excessive, buitleES skepticism seemfl to me out of ploc«.
Tbe new etioloffy of tubemilosia has given treaiment a peculiar,-
aad, at a oisuaI glance, a rhaiiged fiositioii. We now have to ask
ourselves th« foltoirin^ <|ueRtion : I» tliore any remedy or mode of
tieatraeat by wliicli we can prev(.'nL a |ht8oii, who has on or in hint
any caseous ims, from bcinft inft-cttd with luberculoBia? To this we
must at one« say da Tho mode of infection is so little know», that
on this «ceount alone we could not sppok of its prpvention. The in-
terval Jictween the development of the primary point of hiflnnimatioa
ud the succccfUuf; tuWrvulutis infeetiou is vntircly iuoomputablc.
In Bom« coses tlie furniation of tubercles in the lungs appears to fol-
low alronst on tbe heels of chronic bronchial catarrh, while in other
caXB the two forms of disease arc se)>arat«d by years. Typical tuber-
dos nay also dry up and become indurated in various ways, or they
Buy rapidly tuerea»«, unite, and soften. In «hurt, the variety of tha
prooeas is very gn-at. Hut all tlds ßi^-es no starting-point for tho
tieatnieut. As regards hereditary influence, to which ßo much iiu-
portanee is properly attached in tuberoulosln, some enigmas have beea
solved by, and some former cxpericncr» readily athipt tlieinsclves to,
the new views. If true tubercle could ouly dei'elop from infection
tlirough the patient himself, of course there eouM be no talk of direct
inberitaoce of tuberculoaia in the strict meanitig of Ute U^nn. Only
tlie lAiuloDcy to chronic iaBammations, cr>ding in auppunilton and
caseous degeneration, is hereditary ; in other words, the scrofulous
diathesis, not the tubercuIouH, is hereditary. We must bear this in
mtnd ; the osperience of fiimily phj'sieinns agrees witli il entirely ;
bat we nin^t understand that such g<>neral rules are only true in
theory. Tbe liercdilury tendency to diseai^es of certain organs, and
to certain forms of disease, is aucb a oomplicatod question that wo
^ould be very re9er\-cd in stating geueral laws about it.
If we put together what may be snid about the indications fori
treatment of tuberculosis, it would be about as follows : we canoot j
20
SB4
CQDOKIC INFLAUUATIOK OF TBE SOFT FARTS.
preveiit oitber tlic develnprnent or progre;» of lulM>rcI<>!(. Ilof
ai this sounds, it rumiLins to be luldixl that intxlicnl mre may ucocui»-^
plislt BomeUiin;;f in binderin;; tlie dorclopmcnt or those pr
which HTV so tift^Mi fulluu'L-d by lutKTculosis. The curly, <«rcrul, gee
eral dirtctic sod loc«l trcatmc-nt of chronio diecnscs of the bout-« Bnti
jouils, aud CTCU the tmputation of Hnibe, or the rt;s«<:tioa of bones
the proper time, niay prevent the development of tubercU». In thaj
Mine wny, great care of catarrhs of all fiorts, and their iDost prrfect \
removal, is undoubtedly thu moet eHuctuul iIuuj; we can do lu rvnuvOj
the tuberculous infcetitHi. In tuberculoAis tlie treiitinont is tfae sun&j
All the rcmt^dios, batlis, ami place« for treatment, that are prescribed,]
Bbvc for their objc-ct — 1. To remove or dimiuisli the L-\L*tiiij; cntvrfa
or otht-r primary disos«'i.>; 2, To improve thu tiutritton of the patients,
who are generally einaL-ia.ted ; 3. To avoid eveiy thiog th«t can ren-i
der the ptiticrnte feverish. I muni leave It for tlic lecturer on dinical i
medicine to make you belter aeqnainted with tlie important prineiples '
of treatment in this frequpnt and femful di&ease.
8. ArtlirUis, or gout, i& a tendency to disease whii;h nsunlly «p- ,
pcftis first about the thirtieth to the fwty-fifth ywir of life and later;,
it is often eoiifuundcd with rhrunie rlKtimatism,biit rvally differs from
it considerably. True gout is a rare di»coae with u», and is distin-
guished frutn rlicuiaatiatu by the (iict that it occurs in attacks, oflen^
recurti oii?y oiu'o n year, or at atated interval», while meantime thei
indiriihml rt-main» perfectly wf!!. Gont is a dtftpnujc of the rich, uid,J
»6 old physiciana who had it thcniselvc» used to «ay, of wi»o meo.]
It occurs eiiiedy in me« who lead a eomfortablo, inactive life ; it
imfrequently descends to tlio next generation, but always appean
first after middle aj^. //(iruey, St/denhitm, and many other ccle*
bntcd physicians, suffered from firout. The inilammations oocurrii^
iu gout are eliielly limited to certain joints, and the parts around ,
them. Tlic joint between the metatarsus and the first phalanx of tl>e
big toe ia affected jiarticularly often ; this is the seat of true podagn.
The wrist and the joints of the phakn^s may also be attacked by]
gout ; hero it is called chiragra. The skin over the joint is impti'
catod in these- in Oammatioua, Durio}^ the atta«k it becomes bn'ght red
and very sensitivp, as in eryfti|)cln8; and, in mro case«, ulevrs may
form during this process. Arterijil thickoiiitigs (atheroma wf the ar»
ter}') with tlieir occoaional results, cerebral apoplexy and senile gon- i
ffrcne, are not iinfreqiient in nrthrilic patients. Corpulence, diseases
of the liver and kidneys, may also accompany gout ; gravel especially,
n fine gianulnr excirtion »f uric or oxalic acids from Uie kidnoyi
into the bladder, is not uufrcquent, but, just as frequently, htrge renal
and vesicle calculi develop. lu the diseased joiuts and sheaths of
GOCT, SOOBBTTIS.
986
the tendons conudcnbid (]iuiiilitii'H of itrat«a bare been »t^n, occn-
Eiaoally in stielt quiinlitica that thvr rorcred the articular surfaces
ind rapstile ]ikc a whitf* granulnr coating. An atUrk of gout is
lunially pr«?«.-«!«! for some time by a general feeling of b»ng out of
sortB, which dissppmra aa scx>n aa the inRainmalion attacks some
extt^rnil point, umiallv a joint. These inflammations last two or
thn»e weckfi, and thpn subsUle, often leaving permanent tliirkoning
of the joint; but in oih^r ca^es the diticased liinl!» often rotnain un-
ehanged for years. In »nine old arthritic pnlienl« the»« stonc-likc
goiit*nodules an* also fomiil in the skin, as iu lliut of the ear, as
well as in the joints and shcntliH of thu tendons. If these nodules
break off, the masses of lime and urates may be scooped out with
ma eareptmn ; the complete suppuration and closure of these open
anti verj pitinfnl gouty nodulea then Iimt for month:*. Ojx'ra-
ttODS with the knife in »uch cnsea sbcuUl carefully be avui<led.
The ordinary attack of podagra never ends in aiippuration, always
in reBolulion.
The trvfllmfrnt of the attjtck of gout, of the gouty articular inflam-
mation, is to lie distinguished fnim th« gont?ml treaitinent. The
uonner almost always nins a typical eourwi, which is not materially
changed by treatment. The 6nst indicatioa for medical aid is to al-
Icriatc the pain by moderating the inflammation ; for thb purpose
ice might answer very well, if there were not certain reasons ftw
Inring it« cfiecta, for, from the frequent presence of atlieroma of tlie
mailer arteries, great cold might induee gangrene, "niere i« ant
much to be iiaid against the application of cold compresses, cold f<v
mentations with lead-water, weak solutions of nitmtc of silver, or
KmsI applications of leeches; but many gouty patients prefer greasing
the joint and wrapping it in wadding. Profnsp dia]>hon<«is, induced
bv hot tea ami hydropathic packing, is said to shorten th« attacks.
In the constitutional treatment of the arthritic di*the«i», mineral wa-
ters take the fintt mnk. (touty patients should he advised to use the
nmters of Karlsbad, Ktssengen, Homburg, Vichy, and other saline
springs, also the thennal waters of Tcplitz, Gastein, Wiesbaden, and
Aachen.
4. The »eortiutic di/KTasia manifests itself in great fragility of the
tapillarv resaels, and ounacqtienc subrutancous bsmorrhagc«, which,
aeoording to •Sfrt<^^er, also result from diapedeeis, and may be induced
in frogs by poisoning them with ordinary salt. Tliis disease is sup-
poaed to be due to dissolution of the blood. Hie disease is almort
entiivly endemic, for ioetaocc, on the shores of the Baltic, and, in n
surgical point of view, is not very intereAting. When treating of ul-
een in the next chapter, we shall refer to it itgain.
8S6
CKBOXIO ISFLAlllfATlON OP TOE SOFT PARIR
fi. The ayphilUie dyscrana. Altbou^b I do not propocc to in*
elude sypliilis in the subjeeta of tb^ts« Lecttirv», still, Tor tho 8»ko of
ooniplet«ue»8, 1 miiKt rnnke some remarks od it Tliia, like the ubon»]
diathesis, devulupci) in mitu at booio time, but aow it is spread
tirclj by inoculation. The person inoculated is »yphUitio from iboi
moateot thu virus toktw effect. In »ix^aking of s^-pbilitin diseitMS iaj
general terms, thrc-c; tiiffLTcut dibvascs aru iiK-ludbd: {\) goHorrhtea^y
a bleunorrlicoo. of tbc vngina, then nf the nrctbro, which tbcnoe ooc*']
siooally extends to ibu uxcretoi^ dticlit uf tlie t«sticlc« and prcwtate,
and may induoc gonorrba-al prostatitis or orchitis; (3) the «o/tcAait-t
ere, an uloer, usually on tbo glans ond prepuce, which fre(|ucntly,
ilirougli the lymphatic vessebi, excites an inäammatioQ of the in^tunl
gloiKls, whk^ has a p^eat tendency to go on to Mippumtion ; (3) tbs '
pcop«r «yphilitio ulc-cr, the vidnratca <fta»crt. 1» -tliis tlic gaol
dUoase ocoiir« at the time of inoeidntion, while the first Rud
fonn remain relatively k>oul. In iiioculotion with tbe secrvtioa of :
true syphilitic ulcer, Uic entire orgotiism la infected at oucc,aeertcaor*
c^tranio inflammations occur in cite most varied organs, whioh have at
first a more productive character, but anon lead to disintegratioo of
the iaÜlinitcd tissue and assuitje an uloernlivc de»tnic4ire diaiTictcr.
The following symptoms may appear in syphilis: eruptions on tbe
skin of blotchus, pupulea, desquamations and nodules, ulcers io the
laticcs, on the li])s and tongue, and about the anus ; osteoplastic and
ulcerative periostitis and ostitis, especially on tJie tibia, craitiul bones,
sternum, etc ; clironic iuflatnmatinns of the greatest variety, usually
with CB&eoua defronoration in the testicles, liver, brain, aud possibly
in the lung«. The rodular circumscribed product of syphilis is called
by Virchuio " gummy tumor," by ^. lf/j»/fMfr ''sj-philoma." Syph*
iÜs may oJso be inherited; childreo are bom with it; tlie dyscrasla
may be cerritrd by the sperm to tbc ovum, it also passes from the
mother to the eliild, as well aa from tbe fcctus to the raotber.
Gonorrhö» and the soft chancre arc local diseasoa, and are to be
treated a« such. Formurly soft and indurated chancres were regarded
aa two forms of syphilis, with many ennnectin;; links ; of Into the
dualismus theory seems to gain inoie and nuire supfiorters, altfaoiurlLJ
there is still mucb disciuaiiion oa the subjeLt, Manysurgeonseonalderl
increury as a epecilic, or as a sort of antidote in syphilitic dyscroüa.
It seems to me proved by recent ob8er\'ations that this is not exactly«
true. Conalttutioiml syphilis, which na\y attttcka a person onee, maj
in the course of lime be to some extent gotten rid trf bytbo diangool
tissue ; tietioe all remedies that grratly promote the change of tiagiu)
ace ift a ocrtain sense antisypliiütjc. Most frequently treatment by
sweating or pur^og is resorted to ; occusiuually »yphuia is curod by i
LOCAL TREATHKlfT 07 CHRONIC Drn..\)l)li,nON. 387
treabnont of eix weelcs ; in Kinie caüm thi^e modes of treatment must
be continut-d witb iiitvmipliuiis till they prore •ucceuful, au<j, finally,
eonic caso8 are cntiwljr incurtiWo. OocaxionKllj mereurii-, by inunC'
tion or inwmalljr, in vxrlous prt'panitiüiiH, contiitued u lung time, re-
itiw-c« ttue Symptoms of syphilia -with surpnabip rapttlity, «od hence in
cuecjs v-liüru vre desire to «rreet ils quickly ob poseiUe certain ulcem-
tivL" foniw, ef«p«>ci«lly in the lK>nes, it will moiutnin its I'atue. Of lute
it hu Ii<.>eii Diudi douhtcd if mercury filoiie ran cure sypliili», uu<l nt
the same time it baa been sliown -what lojury tuuy be ioduccd by con-
tinued use of mercuriul!«, by a Bort of dimnic iiiorr-urin) poisoning (hy-
Jnu^jTOKUt). The mercurinUsts and BOtt-mercuTialiats have di»puted
for a long time ; and in tlie hut dcccnnium it hiu catered new stages,
without, however, having brought all physieiuns to a coneJusion on
this questioD. I incline to the \icv» of the anti-mereurialista. In
the cuunte of yotir ttudJcs you will liciir still more about this impot^
taut und intereftting point. lodidi* of |M>ta»)i i« genemlly reeognized
as one o{ the most important and ef&csdous remedies for «ypbuitio
diseoees of the hones and glands, wh3o it does little good in other
syphilitio diseases.
LECTURE XXX.
Lowl TnataHDl of {.'liffinl« [adumMition ; Btal, CoaprCMioa, EworleaU, AaÜpUe-
Ktatto«, D«rffMi*M, PoBlaiMl«, Stton», Uox«, tba Hol Irm.
It Blill remains, at the Huso of the cfaaptor on chrooie toflammntioo,
to run through the remedies that we may employ locally, and wbidl
ore mom or lew prominent aorording' to the rase. Where we do not
succeed in finding a constitutional cause for a chronic iDfianmatioD^
we are limited to local remedies. They are not very numerous ; but,
properly chosen and applied, they may be of much M:n-ioe.
AJbtolut« rett of the in6smc<l part is necessary in all cases where
thero are pain and eoagoatioo.
Compreanon. llus is applied by wrapping tlie diseased part
with moist or elastic Innda^s, plosterdrcssing, strips of adbceire
plaster, or even by eorering with moderate weights (as In compressing
swollen inguinal ghods). Conipn«sion is on« of the most important,
and, when madu (o net regularly, is tbc most certain means of remov-
ing chronic inflnmmatory iiifiltntioDS,
Jlfoitl warmth in the form of cataplasros, continually applied, is
also very elüi'sciow), as are also the hydrti^tathtr »rap»; these «re
applied by dipping a doth, fuldod iwvcnd times, in cold water, wring-
888
CBBO.VIC INFLAyilATION OF THK SOFT PABT8.
ing it out, enveloping the affected pnrt with it, uij rorcriti^ with'
Bodac «ir-lig-ht substjince, hucIi a» nil-silk, guitu-pcrrbn clutb, etc., uul
rcQCwiug tliis üre»iDg every two ur thnw buurs. Tbc tlda, at Arat
mucli cooled, soon becomes very warm ; then the dressing bIiodIiI be
renewed, bo tliat the mtaaeous vessels are kept aetir« by ibe cfauig«
from cold to wnrin, and are tlius pinned in tbe best stale for abeofftiui&i'
In ftotnc casos these wraps are very useful. ^M
Retotttent rfmtiiit*. Fomrntations with lead-watiT, infmiOD of^
oinicm, CBmomilc-te», utv,, Imrc M^iiie reputation as rtraolvmt appli*
cations, which iliey do not, however, rlcttcpre; they rather bekmf to
the eaLegory uf iiiucttvt; domealic remeciiea. Mercurial salve, men»-
rial plaster, ointment of iodide of potossium, and tincture of iodine, ara
also nbaorbents which may bo employed altenuttely ia chronio iuflam-
raationa. I am Car from denying them aoy effioaoy in suith enses ; but
you must nut expe<^ too niueh from them. I pnss orer a scries of i
■olrcnt plasters ; they do little i^ood in this way ; thdr cBcct is fWftlj
u slight irritant« to the skin, partly »a proteotivo ouverings; in some
caaca I order such plasters to prevent the putii-nb from applying M>i»e<
thing injurious ; tacreurial pWlcr only has a mcilirinal etTect when
used for a long time. I may inonLtun electricity as a diitculient rem-
edy ; It« efleft drjes not seem to be very great, but citwa are reported
where it has been uaed willi udvautsge ; furtbtrr iiivestigstions at
be made on this point
Antiphlogistic Temediea pro]>or, suoh as ice, leeches, eupa,
about which you ivill Icam in tlie clinic, arc rarely used, and are oolyof
slight temporary bonefit in chronic insidious intlammations ; but, Ini
iutcrcurient acute attacks, they are just a& useful as in primarily-acute i
Inflam matinna. Sonic eurgoona of the present time, esiM-cIatly Fönj
£tmarch, use ice coittinuousJy in chionic torpid iuflnmmatioDs, attdj
praise thu result of this treatment.
Ikrivalivet. Thctvi play ao ext«us[re role ia the troatment of
chronia inSammations. They arc so named because they are said to
rcinorc tho induimnutioii from its lucsitiuii to other points where it will
be less dangerous ; there are remedies by which we may induce eut&oo-
oufl inllsmmations of varied grades, and which have been proved by
careriil observers to Imve an exwilent nirutive effect, Tlio phyaio-
logicJkl explanation of the mode of aelioii of these derivatives is as
yet an unsolved problem, it in supposed tltat, from tbe apiJioaÜoa
of these remedies near a point of chrooie inflammation in a boDB orj
joint, the blood and fluids are drawn outn'ard to the akin. In some
cases of inflammation accompanied by little energy or rasoulnrÜEation^J
tlie derivali^-ee certainly have rather an opposite effect ; i. e., the aew ]
aeute inflammation induiMsd in tho immediate vicinity of the chronic ooe i
LOCÜ. TBEiTMENT OP cnBOJflO KFLAUUATIOS.
360
causes stronger fluxion to ttiese purts, and aruuscfi l)io cluxjuie, torpid
inflaiumation into an oaergetic, actire »tatc. Bot wo shall not worry
ourselvv« Ir^'ui;; to discover tlie pLysioIo^ical way iu wliicli tlicsc
remedies act; tliis hn» nlwa^'s bee» a vorv tbenklcss tusk. The fol-
lowing reincdifs of tliis cUu lire pmctically ittseftil : Kitrate of allver
in coQctrntratcd Kolutiona mixed witli fut, and rubbed on tbc skin a
couple of times dailj, induces a dftrk-brown hue, with silrcr}' lustre
in the Kkin, and a slow detachment of epidermis. It is one of tbo
mildest ilcrivatirea, and i» parliculHrly (>iiitecl to the joint diseases of
ecosititrc ehildren. Tineture (^iodine, especially tlie strong tinoture
(iodine 3 j to alisotute alcohol ^jdiMolvod with ether), if applied lo
the »kin momin}; and irt'ening, induces ii tolerably shitrp buniing
pain ; if Ihi» painting be continued two or tlir« day«, the epidermis
is elontud into a vesiele, oeciisiounlly all over tfau space whero tJio
remedjr liaa been applied. JtlUtering fUaatcr» act more rapidly ; they
consist of powdered eaatliarides (lytta vcsicatorict, niuIOo vesioatorius)
nibbed up with wax or fiil, and spread on liiien, leather, or oiled mus-
lin. Well-made orditiitry eniplnAtnjin cantliariduni, in pieces as 1>rgc
S3 ■ franc or a ikillar, is fasteiied ou tlic Bkiti.nnd in tvreiity-four hours
a Tcsicle forms under it ; this i« to 1« pumrtured, and n piece of wad-
ding applied orer It ; this dries on and becomes deUiehed in three or
lour days, at which ti me the detached hard layer of tlie epidermis haa
be«! regenerated from the rete Malpighii. A liu-gc fpanish-fly bli&ter
may be »{»plied once, or a sniiill one in«y I«? appliitl new every day ; the
latter method is called vcsicaloires volantea. Lastly, nvc may apply
ploaters containing only a small amount of cantbarid«;«, and only in-
ducing continued ri-dneiis. Tiiis is the oniplaslnim catitliuridum per-
pctuum, or emplnstrum cuphorbii ; it is worn several days or weeks in
succession. ^Vlthough the favorable action of tlio above derirstive
remedies in chronic inflammation omnot be denied, I may say that
particularly tincture of iodine and blisters do much more good in sub-
acute iutiumiuatiitns, orthe ulij^ht intercurrent acute attacks iu ekrouio
inflanimntifin, than in tlie painless torpid forms,
"Die remedies still left to mention arc llio»« CuUowed by longKXHi-
tiaord suppuration^ a suppumliun wliieh is kept up by artiScial cx-
1«niBl irritaiion, according to the will of the physician. Their use is
so diminished during the last ten years that nt present very few sur-
geons resort to ihein.
Thrtar^metk ointmtnt and croton-oil. When re|MSitcdIy applied
to the skin for » lenj^th of time, in aliout six or eight days, or in irrit-
able »kins earlier, both of tliew induce a pustular eruption, which is
not un&cquently painful. Hlicn those pustules begin to show tliem-
Bclves, wo atop the aj^Ucatious and allow the pustules to beaL Cou-
S90
CBR0K1C l>'FLAMliATtQy OP THE EOIT PAAIS.
tidemblc cicairices not uiifre()iicntlj remaia ; the effect of thcee ran*
edies U n\l]ier uiioertain, so t)iut Oiey arc Dot often vaoA.
Hy fuaticulus iir a fuutiiticl (friHii foil», vrcU), we mean au iuleu-
tiontUly-iiuluccd wound of tho Eldn that U ki>pt stippimting ; it
nay be iuduccd in various way«. Vou may apply an onltiiary blisteto
plazier, tliirii ciit the bUtitcr and daily dreas the part denuded of cpi*
denoia with ointment of catitharidcfl or other irritiiting ealve, Yaa
will thus iiidu(!e a suppuration that roti iiiny l:efp up us loog as yon
ouotiuuc tliis iiioilt; of dresatn;;, Aiiotlicr way uf iiiuking a fontanel
is to incise tli« «kin and place n numlwr of pCAS in tbüi incüion, re-
taining tbeui in posttiou by adbt'sivc pkster. Tho poas itncll tip, and
lire to be daily renewed ; ikey irriiate the wound as foreign bodies; a
aimple ulcer is Ibus artificiully itiducvd. It is always simplest to
make tlie fontanel with an inotMou, but wr inay bum the skin tbur-
ougbly with any caustic, and keep tiie resulting wound supiwrating
by tbe inlruduction of pens.
Tho Mton is a email strip of linen, or an ordinaiy Ump-wiclc, whioh
is drawn under the skin by meana of a peculiar needle. Tlio HOlun-
needle is a niodcrately-broiul, rather long huii^rt wiÜi a Urge eye at
its lower end, to carry the scton, Setons aregenerally applied to the
back of tbi> neck in the fulluwing inmiiier : with the thumb nnd fus^
finger of the left himd you lift as Urge a fold of skin as possible, trans-
fix it at its base with the threaded »etou-needlo and draw llto latter
through. After tlie aetoii has Inin quiet a few days, and sopptvatioa
b(.*g!riH, pull it forwani and cut off the part impregnate«! witli ptis^ re>
peat tJiis duUy. GninulitUuna furm in Itiu whole caiitd occupied by
the scion ; these secrete quantities of pus. Tho scton is worn for
weeks or months, and rvmovcd when we wish the euppuratioD to
cease,
Another mode of inducing continued suppuratkm is by taaluag a
slough in the skin by means of heat and preventing the re-sulUng gnnu*
latiiig wound &om henUng by irritating dressings or by introducing
peas ; thid may be kept up a longer or slK>rtcr t ime, according to tbo
effect desired For tliis piu-posc there aru two modes of oporatioo, bf
the socjiUed moza and by the hot iron. Moxa; arc thus pfeparcd: n
wad of cotton ie tied together with silk tliread, then soaked in spirits,
held on tho skin with forceps and there bunied. Various grades of
' bum may be iniluced by tho longer nr nhorler action, 'fliere areotlier
modes of preparing niox^, which, howercr, I sluül not here describe,
a« moxiG are now little us«4l, Ifyouwisfi to induce ft slongb in the
»kin, it may be mo»t ttimply done by strong caustics and caustic
paettgf or by the hot iron. The cauteryirona used iti surgery, already
meotioDcd among the hemostatic remedies, are tliin iron rods a foot
LOCAL TREATMENT OF CRRONIC reFLAMHjnoy.
391
hog, vtitb vrootk'n tinndlcs, nncl with a buUon-shapc^l, ryliiMlrical, or
ptisDistic end, vrbicb is placc<l ia a basin of hot vuals lill it rcacbes
» red or white Iical. WitU tbis, various gnules of tium», even to
ofaarrin^ tbc skin, and bums of variable siw, fiirai, and deptb, tuny be
induced, sc^tjtding' as we de»ire exteiisit*« suppuntioo, or scTcral di*-
ttDCt bidbU ulcers.
It would lead tnc too far, and not be vi>rj comprehctisible fur joa
ktpsMcnt, were I li«re to untvr iotu an exhaustive criticism about Lho
d<He« and VArioiut gradattou» of l)ie abo^'v ivtiiLHlics. These are
things that you It^ra more quickly nQdeortaiJilyi]! the clinic, from the
tcouurks on an individual case, I iritl only oljscne tliat the applira-
tion of tbo tnoro int«»sc derivatives, Bucb as fontanels, inoup, setons,
and the bot iron, to rliildren and siisrfptible, drtirate po rt>onü, stiould
be BUule very carefully, and bod better be uvuided. I scarcely ever
OW the hot iron aa n derivative, tlictuf^h I sometimes employ it to
llestfoy spongy gmnulationa in caries, occasionally witli reiygood
eSetrta
Almost all classes of rcRu>dies bare for a timft been somcwbnt the
{itshioo, according to tbe prevailing theories, and so tbere was » time
vrhrn mowc, tbr hot iron, or fontanels, were praised as «nivrrrsal rcm-
e<iie9 in every chronic iufiammation. A fontanel was applied on the
arm to protect the jien^n Hgninxt rheuniatii^m, hn^morrboids, tubercu-
losis, or cniiocr, with the idea tbut with tbe pus from tbe fontanel all
morbid juices, the materia pccouu, were throwu of! from the body,
la tbe same way, fonnerly, at certain sensonä, ]>urgMtivoi>, euit-tios,
Tcoeaections, etc, were resorted to yearly. Even at present you will
bear old pracüüoncre tell gleefully bow this or that patient was pre-
served from a multitude of ilia by the application of n fontanel I
»hall not presume to criUcise what may be accomplished by this treat-
ment, fur, as was mentioned, we are far from knowing how to meaa-
u»e its physiological ctTcet ; but we Khould nüstnist the action of reme-
dies that are recommouded ngaiitst all possible diseases
CHAPTER Xy.
XTLCERS.
LECTURE XXXI.
AiiBtoia}r.— Estomsl Pmilkrltl«* vt U1c»i»; Fono «nd Eatwt, Buo an*! 8«ct«tioii,
Ktlg^s, Parts irocnd.— lo«äl Tr«iitin«iit Mcor^mg toUi«Lc>nl ContUtian «/ tli«
Ukcri Puncou», Callon«, Putrid, riiig[«4euLc, iiuiuoiw I'locn, EUvlogy, C«otiii'
u»d Itrltativn, Veooiu Coii(«*tloD, Djricnal«! Catisui.
The Btuily of iilrera natumlly followa that of Uio chronic iiiSsm-
matioiie. Pbyäiciaas practically a^-oc as to what an ulocr is, and
whetlipr any pven wounded surfapc is to be so rcgardcMl ; but, to give
a sliurt dftiiiition of it is ubout as (tifDcult ns it is to deGiie any otlicr
ubjuot in mudicinc or nnturul history. To give yuu a pcoximatc de-
Boription of it, we may any, nn uloer is a woundnd surEaoe which
sbon's no tendency to heal. Here yoii see at once, tlint ercry lar;ge
granulating' wound wilh free prulifcratiuus, wliich liulls in its profrrcss
toiraitl cure, iDuy nl«u b« regarded as »a nicer, and, in fact, KutA^ to
whom we oive our most comprehensive nümunclature of ulocrs, deaig<-
natca granulating wounds as ulcus simplex.
From pcrsonnl ob8cn*atioiifi and exaniittiilions we ooui^udo that
ult'eration mostly start« from chronic iiifbiuiiiiiitioii, and is always pre-
ceded by cellular inliltration of the tissue.
This inflammatioa mny be located in the depth of the cutis, in
tlie cellular tissue, muscltrs, glands, periosteum, or bones ; In ihe
centre of the inflanit'd a^iot there ia uuppuiution, caseous degrtaet»-
tJOD, or some other form of softening and breaking down, with gmd-
iial peripbenl progression an«! perforation of tlie skin from witliin
outwardly. The axavated ulcer la thus formed; as before atulett, this
is n diminutive cold absocss.
Ju8t as often iha process is in the 8u]M>rricial layer« of a nicmbraoe,
and wc hare the open cutaneous iU<xr. Wc will illustrato this by an
Alf ATOMY OF DLCERä
883
exBtnple. Lot ua supposo that trom uay ot tlio above montioocil
«ftuaes we have a chronic iotlammatjon in the sldn of tbe le^, say on
tbe anterior surface of its lower tliini Tlie »kin in iavpnetl by di-
lated vessel«, hence it is redder lliaii mtrmu!, iL ia ewollca, partly
from sorous, pnrily from plnstic in nitration, and It is sensitive to
pressure. \\'anderinf cvUs arv infiltrated, espocially iii the »uperiiriol
parts of the cutis; this renders the papilli» lon^r and more succulent ;
tbe devcloptnent of Ih« cells of the ret« Malpigbii also becomes more
plentiful, its superficial layers do not pass into the normal, bomy
stale; tlie connective tissue of the p<i|nllHry layer b softer and b^
comes partly gelatinous. Xow, slif^bt frictiun at any point solfioca
to remove tlie eofl, thin, hnmy layer of the epidermis. TUb uxpows
the cell layer of the retc Malpighü ; new irrilatian is set up, and the
result ia a suppurating surface, whoso upper layer oonsistA of iran-
dertng cells, the lower of greatly de^nerated and enlarged entane-
oui papilbe. If at tins sta^ the part be kept at perfect rest, and
protected from further irritation, the epidenni» would be fj^mdii^y
r^^nerated, and the still superficial ulcer vrould ricatn/e. But
usuttlljr llie slight superficial wound is too lillle noticed, it is «xposed
to new irritatiuos of various kinds ; there ore supininiliun and molecu-
lar destruction of die ex|x>*e'i inlkmcd tissue, then of the papill»,
aud the result is s loss of substsuce which gradually grows deeper
and wider ; the ulcer is fiilly formed. The accompanying ßgure is
tbe »eetion of a spreading ulcer of the ekiD; it formed the basis of
lU» description (Fig. G4).
n«.M.
^^
At a you see the cutis already somewhat thickened, toward i
its papills arc cnliirgcfl, while the VESCulur loops increas«, and the
connective tissue is more richly slJGwn with oells; at b is the fully
farmed ulcerated surfaoe; at c the cptdcimb is much thickened and
forms tbe indurated border of the uloer.
804
DLCEBS.
On the mucous membrane the process i» tiifi some: at firit Hun
is a lU'oly einigTa.tIun uf Tuuug celU uu the sur&or ; this is sotm mi>
comptmioil by a moJcmtc degree of serous and plseüc infi]tration to
the connective tissw) of tlio mucous mombTao«; the mooous ^lasds
■ecret4> plentifully. As alreiuly iitated, it nas beliered, until within a
Bhort tiiive, ttint catarrhal pus was of a purely epithelial character;
Dov then! is rather an inclination to the view that the elctnentB of
catarrhal secretion also are w-andcritig white hloodHmrpuscles. Coo«
tinm-d irrilatiuii of a iiiucuus noeiiibrane alTt-ctcd witli catarrh ia
followed ity softening and breaking down of the ti«<ue, u w« de-
Bcribod to be the ea«e in the eiitJs ; lliou wc have a etUarrhal vleer.
Thesro is anotlicr and mare acute mode of formatton of ulcers, m. :
&om pustules that do not heal, but which cnlai^ after eracuutioa r>f
the pus, and keep up aa aaite inflammatory cbatseter, as the soft
chancrous ulcer. And auch ulccra resulting from ecthyma puatulct^
without any prcreptibic »pt^iGc dyncrasia, are particulnrly ftrqueot
on the le^ of young, full-blooded, and otherwise healthy persons; w«
know notliin^ definite about their causes ; they often have » proltfen-
tiug fuDfpDus fumi, but nt otlicr times induce rapid dt-struction oT tis-
sue. Uut this acute commcuc«nieut of ulcers is much ntrer than tfa«
ebroiiic. Soiuo diseuseii are only hiJf-correotly called ulcer», as ihc
"typhous ulcer;" in typhoid fever there is an acute progressive la«
flauituation of Peyer's plaques, which Id m&oy eases ends tii gKOgreae,
witli necrosis of tJie iuilamed portion of mucous membrane ; what n-
miiitis after throwing olT of the slnugli is a granulating surface^ which
uauuUy cicatrizes rapidly ; strictly speakiii}^, this granulating sur^K«
is not an ulcer, it only becomes so when it does not heal nomiaUy,
Of this, more hereafter; wo may use these expressions more freely,
when we underätaud tlio process perfectly.
From this description you sec that, in ulctratSon as in ir\ßamma'
Hon, two oppotite processes arc combined — ncwfonnatioo aoil de-
struction ; the latter rrsults from liquc£tction of the tissues, i. e,,
tlirougli supfiiinilioii, or molceular disintegntion, or both together.
Tliere can be no doubt of the antagonistic relations of new forauUkm
und destruction to each other in the examples adduced, for it is er^
dent that liiere the former prooedcd the latter. But you may also
iitiagiiie tli^t in a previously healthy portion of skin there might bo
a dijtturliauec of nutrition of such a nature that disiutcgration of tis-
sue Is th« first step, as you hare already learned from the section on
gBOgrcne. Then on the border of the licalthy portion of ELin, whidi
retains its \-itality, there is a new formation of young crlls, and, if tlio
ports adjacent to the primnrily necrosed spot be healthy, there must
result a granulation surface; bul^if tlio ports bo not healthy, and bar«
NOlfEXCLATDItB OP ÜLCEBS.
30S
iy » stirbt «mount of vitAlit^r, tliorc «Im wo shall hare disiBtcgrar
ti<Ki inM«ad of adiTu iDilainuiiitaiy iww formation ; an ulcer «ill thus
be formed which n-iU spreat] fnnduolly. Tbio rtnintr, of an ulcer
oocurriiiK primarily with molecular diaintegmtion witliout pre^^cdcnt
i>cllular infilinilion, rarely presents itself in praoticc. Strictly speak»
log, molecular disiulegralion and ganjijerie are but quantitstivL* ^iiric*
tics of the aamc pnxx-as, viz., the doatb of cvrtain portions of ti&soo ;
caaee occur wht'rv nlccnition and gangrene are very t-Iosi-Iy as&ormtcd,
as in hos[ntal gangn-nt', of which wc have alrt-ady spoken ; but, as
bdore aaid, an inllaiUDiatory infiltration usually pnKcdca the diuD-
tegntioci.
1%« abore otKserratinnii, which show thfi relation of ulceration on
the one hind to Ui« new formation, on the other t» the f^n^rene, will
hare rcadercfl en<lnnt Iho diflicultr of prosernng xy^tt'niatio iliTiMons
of the course of this discAse. Dut do not be afiaitl that T am going
to roofuac you : wc will t.-nt<-r at once on the special pcetilinritics of
ulcers, yon will tmdonlAnd tlicn more readily ; hare we shall only add
that, according to the vital process, all ulcers nmy be divided into two
chief Tarielies, viz., those where Uie new fnniiation predominat«!),
which wo shall dcai^nutc briefly as j>r<Ai/crating ulcert, and thoeo
wbcrc suppuration and dlsintogratiua are more prominout, which we
»hall call atonic or torpid uteer». Between these two extreme houn-
djuT-poinl« of tha aoatomi(tal and vital peculiAritiea of ulcers, there
*» numerous intenncdinte forms.
To induce lienliiig of an ulcer, the first requirement is arrest of
the disintcgmtion on the surface, next that the floor of the ulcer as-
sume, at least approximately, Iho charactor of a healthy gnmuUtiog
surface, which goes on to deatrize in the usual way. In torpid, atonic
ulcers it is also absolutely necessary that them sliould lie n free de-
velopment of %-eS9«l3 and stronf^r cells, wldch do not lead to eup*
puratioo, but to conneetive-tisstie new formation; in proliferating
idoeis, on the other hand, I lie m-w formation niuät Iw Itroiigtit back to
the normal size. As you will readily perceire, on reflection, tbJs gives
ihc indication fur the lot»! treatment to be followed in either euse, to
which wc aboil soon refer.
The nomenclature of ulcers varies greatly, according to tlie pecu-
liarities that are made especially prominent. From the mode of ori-
gin, just as in other chronic inflammation«, we nitiy distinguish two
cla»i's, or chief varieties, vJx., idiopathic and symptoiimtiu ulcera.
Idiopathic ulce« are such as result from purely local irritation ; they
may also be termed irritative ulcers. Symptomatic ulcers are audi aa
from some dyscrasia appear as a symptom nf constitutional disease,
without the action of a local irritation on Ihc aßected port. This di-
8oe
VLCBBS.
Tluon of ihe came» of ulcers is, ns nlreiuly slated, tbc umc tli«t ««
hare prcrioiisljT stiidicn] in chraniv iafliiininatjoii.
Let us ftt pT«ftent leave out of oone)<Ieration these ctjologic«! oon-
ditiuns, and sogk first of alt, by alt^iidin;^ to the externa) apf
that an ulcer may offer, to ^TC a more perfect representation.
I will ouly sdd here that ulccralioii maj not only occur in
tissue hat ahio in new firowtha in tumors proper; both exesvated aad
siii>erfic-iat ulcers inay fonn in and on litem. In describing- an uloer,
the following pmrttt arc disliiiguii^hed:
1, Form and taitnt of the tUeer. It may bo cireular, cresceotio,
quite inegidar, ring-shaped, superficial, deep ; it may l»e a canal, lead-
ing into the (I(;cprr pari«, n tubtilar ulcer, a fistula ; a» 1 Iiave already
told you, iheso fisluljo result from Ihp formation of n. point of inSaai-
mation in some deep partit, in n deep layer of the cutis, in the
Bubcnlaneoua tissue, lnu9cIeJ^ periosteum, or bones, or even in the
fflanda, and (^dually uloeratinj; throiif^h til] it reaehe« the sar&e«^
Hence fiiitulu is always preceded hv the formation of an ezcavated ni-
cer, of a more or less deeply-Beatcd point of ulceration.
2, Tli< base and ttcrction of the ul(fr. The base may be flhaUo«r,
deep, or projecting; it may 1» covered with dirty, bedl^^melliBg
seroiiM, sanioiiK (Itiid, or even witli gnngrenoua tags of tissue (saoloBl
ulcers) ; an amorphou», fatty, creamy, or smeary subetaDCO may cover
it; it may iilso hare luxuriant ^ramilations with a muoo-purulent
secretion (fungous ulcers).
3, T/ie (Tt/ycs of the ulrer are flat or elevated, walHike, Sard
(eatttna ulcers), soR, tortuous [»inuou» ulcers), zigzag, ererted, under*
miued, etc.
4, 7Ä« PiWrnVy of tke ulcer may be normal or influmcd, ccdcma-
tous, indurated, pigmented, «te.
I'hesc universalty employed teehtiieal terms sufGee for the de-
scription of any ulcer to a scientific pcmoi». But, as the tcrroa ex-
pressing the vitality of tho process, ns torpid, atotiie, proltfemtiog,
fungous, etc., are briefer, they are more frequently cmployrd; desig*
nations referring to the ultimate causes, especially of Ryniptomatie
ulcers, ore also ofti;u uaed. llius we spenk of Bcmfulous, tubcrculonii,
syphilitic, etc., ulcers.
\^Tiilc we have the local conditions of ulcers fresh in our memory,
we sfrall »|)eak of loccU refnedie$, as lor as tbrir employment depends
on the ooiidition of the ulcer, A large number of ulcers, cspociaUy
of those that have resulted from repeated local irril»tions, heal very
readily. A» soon as the diseiised part« are under ferorablc extomal
cireumstAneea, aott not subject to nen- irritation, cicatrization oftea
begins snontaneously. It ist ranarkablu how rapidly the oommcot
LOCAL REltEDIBä
89}
of tho log begins to improve in appc-anncf! n* soon as the patient
hms taken a warm batli, aimply applied • w«t cooipre» to the uleer,
and remained in Ixxl quietly for tMi^iity-four Iioura. Tbo ulrer, which
prftviouslj lookiMi dirtjror griij-igli-grcon, and had a pestilent odor,
looks quite differenllr ; it has a toluntbly fair if not very activeiv ^mti-
ulating Burface, and secretes ^ood putt ; a fortnigtit's rest and f^^mt
clcsolint^ss »omctimos suffice for a perfect cure of nmall ulcvn of this
kind. But the patient is hardly dismissed, and in hia old mode of
liiic, before tlic cicatrix again opens, and, in a few tliij-a, hia condition
U as bad as ever. So it goes on : the pttwot ap^in enters the hos-
pital, and is again dismissed, to be again receivitl in a short time.
We have, however, some means of protvctiou against these relapses,
of which we »hall spcnk hcfcafter. All tilocrs arc not inclined to heal
eotpiickly; many rcqntru various romedics and a long treatment. We
aball now run through the various forms, according to their local
symptoms, and mention the local remedies to be cmpluyed.
1. TM uJcer teilh hifiamed bordergy and ihe crethUic tdttr. Fn»-
iLly, while the patient is coiulantJy going about, an uloer ap-
Tcry rvd and painful, and, aller a period of n-«t, thia slight
amouDt of inflntnmation »pontimeniisly itul)«ides. But there are otiier
ulcers whose bordem arc constantly red and Bcnsitive, the ulcer bleeds
easily, and the granulations arc painful to the touch. Such ulcers are
caU«d trtthitxc or irritabk; the highest grades of erethism of the
■ur&oe of the ulcer are very rare ; in Zurich, I had a patient, who, as
a sequent of a severe inltanmmtinn in the thigh, lost a large portion
of skin by gangrene ; after the detachment of the eschar, there was
left a very liixuriimtiy {trolifomtinjr, gntntilating surfac«, with littlu
(endency to heal, wliich was so painful to Ibu lightest touch that the
patient would cry out aiHl «hrink away. The cau»e of this excessive
seositiveocBS in such oases has aln-ady l>oc» mentioned when speaking
of nerve cicatrices.
In treating inflamed and crcthitic ulcerfl, wc ßr*t try rwild salves
^of fresh Iwitter ami wax, ungucntum cerium, then so-called eooling
Ives, Mich as those of änc and lead, also fomentations with lead-
'#at«'r; if under tlus treatment the granulatious continue painful and
Iwik badly, w)iilc the inflammation of the surrounding parts is lest),
we may cauterize the surface of the ulcer freely with nitrate of silver,
or, atili better, with the hot iron; the latter remedy, with subsequent
comprcMion by adhesive plaster, finally causM healing in the cose
above mcntioiieil. In such cases, the local employment of narcotics
b usually recommended, sucti aa cataphisms, with the atldition of bcl-
ladoiua, byoacramus, opium, et«., but tbeae remedies do so very littlo
good, that, in my opinion, their cm[>loyment is only time lost.
998
ÜIOERä
3. JFungow ultV'ra, L e., thase urbose grutulatkins ore fungous and
prolifcruliiig, «ikI project &bov-e the level of the skio. These nkoa
Bccrcte a muco-pus, ftnd are rery vascular.
Fn^ n.
:s> y .\'
,-lWv-
BloQil-tvHrbartiroIaxtiTlcii k;i"""'iit'"""«'>'»"mi"'"n (not i-i-
Oclallr InJotWfl Ö» r«l*T»rt <Kplt!iolUil cincrr. 1 ;
r of IN« lac, ***>-
11.
In tliCfte roeeG we itiiiy usd aetringent renicdies anil compresH» wt
wltli «ipcoctinn nf Peninan or oak bark, but tlw-y arc of only iBO«!milc
WitclU. It ifi beet todestroy the surfuooof eudi^snuUtions by cans-
tics; daily applications of the Botid stick of nitrate of silt-er usmlly
»ufEccs, when.' it docs not,wc may resort to caustic potash or the hot
iron. Compression with adhesive pl&ster is often vety efficacious.
3. Callaua ulcerg are most dreaitnl by RUrj^eons, on aoroiint of
the long LrcatmcDl thry require; ihey are those whose Imse, cdgesi^
and viiTinity, liavc bccom« thickened and of c«rtilagioous hudneM,
from ttio long duration of chronic in tl animation. The ulcer is totpfd,
and iiNiially lies iloi'p below the surfuce; the edges are sharply
bounded. Tlie indications for treatmculi are twofold : firvt, to sofleii
the tendinous, non-vascular tinsuc of the haidcned borders and base
of the ulc^r; and to iiuliiix' a proper nmounl of vowularity id Iheas
parts. M'e meet uluer* of this roHcty that hnrc lasted twoatj
jeors or more; in stioh eases we may cmpli>y the following treat-
ment : oompreeaion, best with 8tri|)S of adlieaivc plaster applied m ft
cortoia way, as j-ou will see done tn the clinic This drcsäinjTt which
f^hould cover not only the uW>r Init the entire lug, may at first be left
on a day or two, but later, when the ulcer begins to heal, it may re-
main untouched (or thioo or four days, or longer. This so-called
CILLOÜB ÜIX!EIta
8M
lynlON dressing of adbesire plaster ü of great scrrico in ulcers of
leg, especially for tbose case« wberc the patients are not inclined
to lie still, hut must attend to ch«ir liiuüiicss. In tlie surgical ]X)li-
clinic of [k<rlin I inodc soine observations on tliis tr««tttiei>t of ulcers
of the leg, but cnnuot report so bivonbly on it, as a mfantt nf eure,
as baa been done by otber aurgcuoa — they seem to claim that thia
drcsaiiig is an almost unireraal remcily in ulcers of the leg. I ptini
it greatly a« a protective dieasing in dispensary pmctice, bemuse it
eoafalos the pntieut lof^ about, witlinut tlie ulcer Hprcading; hut I
cannot see that uU ulorra heal particidarly well under thi» ün-«düig,or
that the action of (lie adIicsiTC plaster on tlic callous border« of tbo
oleer ts more effective thnu the remedies which 2 sliall mention after
a while. The best remedy for keeping up constant congestion in the
ul«er, and thus increasing tlie fonnation of vessels and cells, is moist
warm lb, which you may use in the form of cataplasms, or, still better,
aa a continued warm-water halh. I would particularly recommend
tlie latter to you, for by it you at tho same time obtain au urtificial
aweUiog and softening of the dry, hardened bonlers of the ulcer.
Zei*f vbo has of(i>n eniployetl the wnrra-water bath in callous ulcers
the leg, also rucommenda this treatment as one of the most cfB-
icious in such coses. It is sometimes very important to destroy the
fcallous edges entirely, or to excite in them a high degree trf purulent
inlliunmiition. Tlie former you may most quickly accomplisli by the
_hot irou, tbe latter by re)>ealed applicattoa of turtar^metic ointment
' cinplastrum cnntharidi«. If a pustulous or even gaBgrenous inOam*
ialiou of the ulcer aud its vicinity be induced by the latter rem»
die», pUcc the (bot in a watcT-balli and you will often obtain a very
quick cure.
It is not always possible to obtain healing of a callous ulcer of
the teg; and ulccra along the anterior Eac« of the le-g, extending to
tbepctioateum of the tibia, are especially intractable; those ulcers alto
which surround the leg like n ring are iimially reckoned as incurable ;
tbey lu« considered as indimtiona for amputation when they [lenna-
neatly prevent the patient from walking or attending to his btisiaeas^
B«ridea the ubove-meulioiiod circumstances there is still another, that
impedes the healing of iilcera with grcally-indurated bonlcrs, that is
that the healing granulating surface aud cicatrix do not diminish and
thicken tjy contrarüon, lieeause tbe Hrmneas of the surrounding por^
tions of skin pennits no diaptacerneiit ; while, as you know, all gmnu-
tattog woun<ls dccruaso to about half their size hy cofilmction, add
benoe tbe cicatixing sur&ee grows smaller, in many esses Hw granu-
lating surfaee of these ulcers must dcatriie throughout ita entire ori*
final extent, because it caonot contnct To render this contraction
27
DU'ERS.
pos8ibt«:>, deep indsions Imve been iubcIc tiiroupfe the »kin mound Üe
ulcer, mwl llicsc iDcifiiDua have been kcpl open by the itit nM]uct)i>a of
diKipio ; I faava oovor »een uay jj^rcat benefit from this tmitinmt.
Aa a con5m|i«?m"e of ibe rigidity iiUo, tbc new cic-atiix U not suffl-
ciontly dense and readily rcopcii», so t!i»t the ulcer once bciU«<l K»a
deTclops ogftin. To gwtxd against tliis it is bcsl to rover iho ciratiix
with n-addiiig and njiply n st.-irclfbandage. Tliis drr«sing slKmld be
woni sis or t-i^lil vreeka, till the cimtiix is 6mi and vduU organöecL
I have followed Utis practice for a Intifr titn« ia all cum*« of ulevr of Ibe
leg, and liure evpry reason to be satisfied witb it
4. Suppurating ufccr* Hi« miBt« of deooinpoaition lakini:
place on Uic surface of an ulcer arc often due to nnf&rorable 41-
tenml drcumstaiiccs ; but, in other cases, from eonstUutional cause«,
there is s tendency to more rapid disintegration of tbv tissue 00 tbc
curfsce of tlic ulcer. Solution of chloride of Umc, pyroligocotis acid,
turpentine, spirit« of camphor, and carbolic add, are the rcmediea la
lie applied iu fcui-h cuse». If the deslniriion of the tissue go »n rery
rapidly, eo that the ulcer cnlai^s frreatly from 000 day to anotlier, it
is called an Müing or pfut^fedtnic ulcer ; thi» form cloeoly rvBcmbtoi
hotipital-gnngrene above mentioned. In some cases sprinkling pow*
dcreil R-d precipitate of tntirciiry quickly arrcets the disint-egration;
abould it not do so, I would advise not to postpone the de#truction of
the entire ulcer ; free caulerization with oaustle potadi or tiio bot iron.
destro}'ing the ptigcn of the ulcer doivn to the healthy tissoe, almost
alway» prorcft effective in these cases,
.'i. Sinuoiu andßstvhu* uUtr« — ulcers with exenvatcd edge« and
ftfllulf. Tbey always bc^in a» altscesncs, which gradually brenk
tliTüug^li from within oulvranl, and are piiriicularly a|>t to depend on
chronic »nppuratioii of Iyiti)i)mlic glands. Such an ulcer will nlwai's
heel more mpirlly if you make an open ulcer of it, by cutting awny
tlie fd^-s of Hkin, which tire usuully tliio and undennined, or, if they
ore too thick for you to do this, nt least split up the cavity and expose
tbc deeply-scaled ulcer. This trcAiment also answcnt fur ftFtulous
ulceni wbL-u I hey lend to abaecsses; the latter must heal before Uio
Ssttda can close Rrinly. Let mo remark, in parcntheMs, tlio w<w<d
" Sstula " has still another menniiig, aa it is applied to any tnbc-like
abnormal opening that leads to any cavity of the body ; thiis wn
speak of IjreasI, brain, guU-bljiiJdcr, iutesLiual, vaginal, uriunrv, ure-
thml. aiul other fistulas
a
1
"Wo hare still to ootwidcr a very im)X)rtant part of the rhiipter on
ulcers, Tit, the eticlogy. I have «Jrwody toM you llwt we have to
distinguish local and constitutional causes, just as in cbronio hiftam-
CAUSES OF CLCXRSL
401
>tioii. HuQcc all lite causes that intluci' chronic inllsiiitnution are
Bgmia to be enumerated Lltc ; n-c will cull porticulikr nttcntion to •
few of tht'se. If wo Bret consider mora cspofidly the local csu9i>s of
uJct'K, tlie most important of them is cootiaiied mechanicid or cbemi-
Okl local irritation. Continued friction and initatinn arc frequent
esutes of such irritflble ulcers ; a tight boot, the hard »Ige of a ühop.
Bay induoc uleers on thi> feet ; a rough tooth or a Khnr[i |iieco of tiir>
r may cnusc ulcers of tlic mucuu.^ iiiumbraiie of the mo<ith or tongue,
;c. Ulcer« of tlii» Tarioty itfunlljf Iwnr the marit» of irritation ; the
linity is red and [uinful, lis is the ulcirr it«eir. Among tht? cheniical
irritants wc have tlie action of scbnapa and rum on the gastric mucous
^jnembnuie ; a» a rule, topera bare constant gastric «ilairh, during
ooiirse catarrhal and specific ulcers, of roriomi ldnd.s, not unfrty
qtientiv fiimi. A second and still more frequent cause of dironio
inflammaLion, rc:iultiug in ulci-rution, is cougv&tioii, espcciollv tcoous
ngcsIioH, distention of the vein», vnricose vein*. TIw?sc uro roiy
timately connected with the origin of ulocm of tJic leg; wo shall
Speak of thcni Utter ((^plcr XIX). There wc will only mention that,
as a result of the eonlinucd distention of the small cutuncous vein<t,
tlicre is chronic Horous ioliltntion of the skin, to which iü gruduully
idded cellular infiltration, thickening ; and, lastly, there lare frequently
suppiuatiun and dtsint^^ation.
Ulcere due to -nirioes, which are generally briefly lennGd varieoae
mieert, may hare rcry raricd characteristics. At first tlicy arc ordi-
nuily aimplc, often prolifcniting ulcers ; subsequently Ihcy assume a
more torpid character, and then the borders become ealtoug. "VTe Iiavo
already noticed how ipiiekly such ulecrrs change when they iirc only
treated by rest and cleunliness. In rcgurd to treatment, the ulrcady-
laudod drosrings with nrniovlee ]>hiKt«r are esoellent Iwtli for indttcing
healing of the ulcer and iimrating fiirllter »U-vclojimenl of the varices^
But in most cmcs 1 prefer nsC in Ottl, an the principles above girai,
and only suhscquently apply the adhesive piaster to prevent furlher
JDcreaae of th<^ varices.
Altliough wo have hero shown the intimate relations between
ins and utceni, and have thua cnlled attenlinn to the point
praeticnl importance nbnut lliis disease of the veiiia, you
Dnist not conclude tliat voriees ore alwai-s followed by ulceration ; on
the eontr»ry, theft; are many c«»ea of enormous variec* that are not
followed hy secondary ulcer«.
We come now to a short description of those ulcen that are dlw
to internal caunea. oud are connected with \-arioufl dyactada the
402
ULCERS.
1. First ATooag these are ter«f\d&u» ttic^r» ; th«so most froqqoatl;
oome in the neck, eadosed oollcctions of pus developing in tbe ooUa
or sulx'utjiiieoiu tissue, niij gmdually )Krl<;raüi)g out llimugh the
skill. Of coumc, this causes smutl luiutca of skiu, whose cdj^ uni
usually roil uiid wry thin, uud wrlik'h kiul to dcepl^^eatcd carities
that cvncuatc thin pu» or lissuR that haa undergone csscous dcgvn*
cralioii. The borders of thtrao culitncoDs ulcers are excaTatcd,as maj
reiidily bo slion-n by examining with tbe probe. As a rulo, these are
tjpical stoiiio ulcere. From tliis description you »ch that this form of
UDdcmiiued siuuuiu ulrcn is only duo to t]tL> mod« of ori^n, ajii) may
occsKionnlly prowmt itsdf under the most varied constitutional con-
diliuii»; although vxpt^rit^uoo teuvht-s that it is especially frequfut in
scrofulous pcizons, and this is nhy such atonic ulcen with under»
mined edges are rcfcTred to scrofula. This conclusion tfUI geoeraUy
prove eorrect, thoiigli it is not necessiirily the easie,
2. Liipotu ulcers. By lupus wu undtintand n disease which
iDBiiifests itself by the development of suioU nodules in llie supcr&dal
layer of the skin. Tlie suhseqiietit progress of these nodules may
vary-. Ttiey consist of collections of wandering cells and coincident
ectasia of the vcs^m'-K Lupous nodules luiiy (a) euhtri^ and run
toj^ether, so as to form larger nfitlules and ttibereulous thickenings of
the skin (Lupus hypertropkicvs) p (Ä) on their »iirfn-e tliei« is a frc«
exfoliation of epiiVnnis [Lupua pxfolialus) ; (c),thc aurfaoe ulcerates
{Lvpttt txuieemn*). AU three forma may combine, and some otl>ers
niay lx> added to tJiem. 'I'he ulrei-s resulting ttma the hitter form may
be anoom])ani(td by nlrongly prolifentiii|f gnuiuUtions {TMpu* exut-
ttran* fu»goii:u\ or dis|>ose to a more rapid destruction of tissue
{lAtpua ojKflfna, corax). Tbe disease is nio«t fre(|uent on llio laoe,
especially on t[ie nose, cbcebt» auJ lips ; it causes the most friglitlul
disEffUTcmcnt. The nose or the lips may bo ciitirely dcstroyctl by
lupti». I saw oiiG «Lse where all the skin of the face, uoee, lips, and
eyelids, was destroyed; both eyes had hern lost hy suppuration, and
tbe farial part of the skull, hciii^ cxpueed, preseutcd » most horrible
siffhi. Dieffenhach desciibcR such n ease in n Polish count, and coir>-
pares his appearance to ihitt of ii dt-ath's head. Lupous ulcers do
not hy auy tneuus always look alike ; but their surnwmlings, and the
general appoaranco of the pottion of skin diseased, f^'atly facilitat«
the diagnosis. When lupus oiwurs in other (nirlfl of the Imdy, «s hi tlio
extremities or mucou:« luenibranes, as tlie throat or raujuuotiviif the
diagnosis is diflioult,aiid cunuot ul»*uys be made positively. It ia not
only pardonable, but soiuetiines unavoidable, to mistake the 'lif^s^
OR the extremities for certain forms of leprosy, and in the throat for
syphilitic ulocrv. In most cases lupus is due to adyscrusiu. It is
LTIPC8.
408
nrely m purely locnl skitwHseose. It i» doubtful whotlipr we arc ju»-
Ufiod in cliiiming n pnrtictitiir lupous dyscrMii», for lupus very oflon
^altucks scrufuluus jwnsoiis, su lliat it may be rvgcatied at one, anij oiio
the worst 6f Riptoins of scrofuUi. It also romes as one syniptoiti of
rpHtlii», »o that lupu» «yphililicua and tupus scrofuloaus arc i^poken
fof. Lupus id most fnxiuont during puborty, and attacks females
ofleiH>r ttum mate»; it mure nuvljr dci'ctopa late in life; beyond the
foriiolb ycur wc arc pretty »afc from it.
In the wny of treat went I altnch most itnportancc to local trcat-
menlf enpecially in the ulc(>rattve form, for hem we mtut make every
att^'mpt to arrest the projrrcss of destruction, which may endanger all
the «kin of the face, and internal rcmedic« act rery slowly. Here, as
iu all rapidly -spreading' ulceration«, wo should rudiL-aUy destroy the
baaeand edges of the uli^cr by cauterizing down to tlic healthy ti^
Bue. We generally employ Ihc potential cauteij- and the »olid »tick
I of nilmtif of silver or cauHlie potash, pushing them thn^tigh the lupua
ilo the heiillliy (urts below. "We may al»o use the rauntic in the
fonn of poete, such as chloride<if-anc paste, M'liii.-Ii is most readily
^ldc by mixing chloride of zine witli rye or whent flonr, and making
into paste with a few drops of water, then Kpn-aditi^it on the ulcer.
To attain our object more rapidly, and let the cau&tic act more iti-
tentcly, it is adviiuble to semtch up the floor of the ulcer with tlie
dat eiul of a probe, and, after arresting the bleeding, apply the eiius-
tie. Of the remedies above meiitioiietJ, 1 prefer eauslic potash, na it
unites with the tJssue« most rapidly, and eoii«cqvieiilly the pain cease«
sooner. This eauterisation may be done during aniestbesia, so that
vbcn the patient awakes there nill be a moderate and tolerable burn-
ing. Nitrate of silver causes the most protracted suffering, but has
the sdvaDtagR of liquefying less mpidty than enuslie potanh, and lir>nee
poasessc» s{>eeiut lulvaulages fur niulcrizing some portions uf the
body. When the elougli from the cauterization is detaclied, if the
<ip«ntion was thorouglily <\iinc, there t» h?fV a good gmnulating aur-
boefVluch cicatrizes iu the ordinary manner. A new lupus is not
apt to form in tfais cicatrix, although cautetizatio» cannot prcrcnl tho
development of new iir>dulcs in (ho vicinity. Painting with tincture
of iodine is the best lucal renit^dy in exfoliative anrl by|)ertn>phic
lupus. It is well to mix this remedy with glycerine, to render its no-
tion less intens«. I Iiavc rej^catedly seen lupus nodules shrivel up
under this treatment, hut it does not prerent relapses. Lastly, in
itoroe cases, the portion of Inimun skin may be excised with odran-
_tagc. Til« unly intcnial remedy from which I have seen benefit is
i-liver oil, of whieli four to six table-«poonfuls are to he girea daily,
at tbts treatment must be continued for yean. Decoctions of bark»
404
ULCERS.
are only useful in lupus syphiliticus. Arseuio^ vhivh is lii^lily priwd
in otiier cIm>iiio t>l(i[M]i.s<>a»cs, is of liUlc use in lupus. In SwiUct^
luud tbc (liamsv wus nm. My tfX|)i-riL'U(X' uf it vnut cUicflv (Icnvcdiii
tbe Bn-liii clinic, ftdd, if I vtete to stale my belief ivgardinff tito ef&-
cacy of iDteru&l trc«lineiit, it would b« tu tliu cOt-'ct tluit t\u: lupous
(Ijrscnsia, like tlic scrofulous, ufU'^ii disuppcuis spoutuncau»ly in ikv
OOUTHi of time, but is nlso oftru incurable.
3. Scorifutic ulcere. Soorbutus, or scurvy, is a disease whicli, as at
ready stated, when fully developed, luauifeats itaclf by great iireakDesa
of the capillary reä.se)& The» are extravasations nf blood at many
plnoes fti the skin and muscles; tlie gums swell, become bluish red,
and ulcc-Ts, wliiob bleed iradily, fumi on them ; there arc alao lata»'
ttnal htvmorrlmffe«, jgcncnkl omaciation mul debility, and ninny puÜcuU
die in a miserable stale. TIiik seven' funii uf iworbutiiü ueours ebietly
cndctuically on the coasts of the Baltic, and iu sailors on Iooj; Toy-
ages. In tlic latter case the lUsoasc is usually referred to conlinuod
use of suit meat. Inland there is a sort of ucute scorbutus, comprising
morbus iiiiuMilusns, pnrjMini, etc. Scorbutu:» localized on llie gnua
ojid urul mucous inembrano is every where common amon^ ehildren;
tho gums swell, becomo of n dark bluish red, bl<M>d on Üie least touch;,
and uloers, oovered with a yellow, smeary coating of pus, fungi, and
»hn-fU of tiasue, fonii on Uiem. When the disease upgiears In tbia
form, and Is treated early, it is generally readily cured. Vou should
point the ^ums tu'ic« dnity with n mixture of bslf a dm':'hm to one
drocbiii of murtutic iieid mid an ounce of honey; inlenially administer
miucral acid« in dotic nnd form suited to the agt, aii<) order a light,
oasily-d igest cd diet. If this trcxtiiieiit bo conscieiitiouidy fallonred,
tho diseace Itoon disappears Geiicnd endemic scorbutus is difficult to
cure, because it i$ generally impossible to vrlthdraw the patient« from
the injurious eudemic influenecs. In tliis aUo the acid treatment is
greatly reeomracndeiL
4. Hffjf/tiltik ulcers. The marks that arc usu&Uy given, aa |iBrtica-
larly elmracteriKtio of syphilitic ulcers, refer almost exclusively to tlie
primary' chancre, cspeoially the soft chancre. This begins aa s re»-
iulc or pustule, dcveloj» to an ulcer as Lirgc nit a pea, with red bor-
ders and a yellow, fatty-looking base. Tlie uleer of tlie Iikdumted
chancre looks dllTe-rently ; in ihi» there is first a nodule in the metif
kranc of tlie glaiid or prepuce. This nodule ulcerates from tlto sur-
face, as other eutnneoux iilc;ei-s do. It iisiially assumes an atonio,
torpid character, frequently with a marked tendency to brealdog down
of the tissue. Broad condylomata, one of tho müder evidf^cee of
oonstitutional sypliilis, are, strictly speaking, nothing but small, su-
perficial, very cireumscribed fungous cutaneous ulcers, uhieh ocour
STPBILITIC VLCEBS.
40fi
lOtt frequenllj* on the perinarum, »bout the anus, anil on the tongue.
le so-i»ilLii (trtiary ayphiiUic ultxrt o/ the skin ofteu hare very in-
durat<^, bron*TiiRh-red border«, are circuhir, or tiorscshoc-thnpcd, and
are also atonic in chiinicter. Vou will *vv from ttiis tliat tlieappear-
anca of sypliililic uIcits also may yary Krcutly, aud hence that tlte
mere appcaruocc of the ulcer docs not enable us to judge Trith cer-
tainty of the presencu of «tustitutionnl svphills. The treatment
of true M'pbilitic ulceni should be diicfly inicrral. and be directed
ngaiost ibv coustitutionol diaease. XifycaWy mtq ^hould use inteose
icau!li(^ if ttii> destruction of tissue is going on rapidly.
I Older aurgcona also distinguished numerous forms of ulcers that
Jiave not been inoulioned here, and that were «üd to be chanu-teristio
of the causes. For iuatfinve, iu his trealise ou ulcers (Hclkologie)
Jiu»t speaks of rheumatic, arthritic, lucmorrhoidal, menstrual, nbdom-
ioa), herpetic^ cte., ulcers. But I, in citiiimon uilli oilier surgeuiut of
modem times, have been uiiablc to ijent-lnitu into the my^Jcriea of
this exact diagnosis. It is now generally considered that the old no-
menclature was based rutlier on an artificiul System originating in the
Pold humoral ]»itho1ogy titan on critintlly exact observiitioti. From
unprejudiced observation wu should unqucstioiubly acknowledge that
oertain forms of ulcers, psrtiinilaHy wlicn alTccting ecTtntn localiliea,
enable us to decide on their cause ; nevertheless, the apjioaranee and
of the ulcer arc very dependent on the anatomical relations of
bo pnrt affected (e. g., na by the course of the filaments in the skin,
VWaihtiiii), aiid on various extenutl causes, so tlmt we should fre-
[<4iieQUy be deceived if we rcLed too much on the appearance of the
doer M an immistokable exprcMioa of o specific constitutional cause.
CU.Un'EB XVI
CHRONIC INFLAMMATION OF TUE PElilOSTEUM,
OF TUE BONE, AND NECHOSIS.
LECTURE XXXII.
Clironlt! FcrioKllla ind Cl)i*a Sup«Tfiei«ti*.— eyini>toin«.— Of tcophftu— 0*(«opllMk,
SuppaMiro Fomu.— Anatomjr of CarW«. — £ tiology ■— l)tagttä»li. — CowibiiMtion
of Various f «rm*.
Qbitixeackk: Chrooio ioflammatioDS of tbo bones atwl pcriüetcum,
to which n-c now pass, are far more froqucot than the acute fonns;
t]ic more common disease is clitooic pMiofttitis, irliidi 15 ofl«D aocoot-
panicti by ostitis (rurie«) Mipcriirinlii^ In the ea.T\y »tag<>s tliis ma^
eiid in rcsoltitiuii, Ur'n jgo ou to Hiippunitioii, willi iilcL*mlion of Üie
Buriaco of tho boiic ; it may also he Hc«ini|)nnit'4l by a deposit of
nowly-formcd wsific siibstimoo on the surfaw of the bono. Pcrioa-
titüi tb»t biu( liistLt] dome tiuip will ni^vcr Icsre the Ixme unnfltx'tcd.
Let us firet ooosidcr tJic tymptom« of chronic ptrtoMUU. Titc Erst
symptoms are usually slight pain, and modoratc Bwellinf* of the [nrts
immediately arount! the afferrt<Ml bonp. These arn arcnmjuinied hy
slight functional dieturbanircs, pspccially when thn dincasR is is oae
of the cxtrcraitie«. Spontnncous pnin is uaiially slight, «■ may even
l>e entirely wanting. PreRsure iiidufrps npTere pain, and ve find that
ihf^ imprcM of the finjrer rt'inains rviiJfnt on the shin fiT some time,
nhowing that thp Bwellin;^ of the «kin i» oliiefly (»d<-matous. The dis-
ease may remain for a long time in this stage, am) may subAide as
grnilually »a it licgaii. In tnich case» you may cunsjder the affection
as located in the external loose coiin«retive tisRuc of the perioslcwtn.
Here there i» (listeiUiuii of the vevseln, serous utul plaBtie inriltratioD.
The 5)-mptoms abo'e given may alao depend ou a periostitis com*
bined with a gupf^yicial ostiti«, only Jn the latter eas« the spontaneous
{»Ids are oceasionally more intense; there are also sm'^ero, boring.
PERIOSTITIS.
<07
Icnrinfi; point at nigtit. If snifh a process boa lasted for monttis and
then iwcedi"«, llie nfft-cU?«! bone reniaiiis ihickeii«?«! ami nodtilar on the
sur£icr. If jou huvi; a cbimcv to i-xiLiuiuc such n ttuse auBtomu'alljr,
you find tbo follovriiif^ : Tho two lajcr« of tlio (lerinsteufn cannot be
exactly separated; both hire cEiangcd lo ä fa,tt}-4(>okii]g, tolernbly-
ooii&bteiiL in«j>s. (>n micmecnpical rianiiniilion you find that thi^ tia-
suc oofuiftts of coaocctive tUsuc richly siren's with cells und trarcrsed
by dilated eapillariOE in frrontur ot less nuiiitwr. This inorlndly-thick*
ened periosteum is mon; readily detached from the surface of the bone
tbau is Bonuaily the cue ; the eubjaccat boDC (\rc am supposing a
bollow bone, such as tlie tibia) has its Kiirfaee covered with sniall
iMKluIes of peculiar, oecasioiiHlIy sialactjte eliupe. If you now saw
throuffh the bone, you iiad tliat these umIuIcs on the at ill-distinct sui^
CkO of the compact cortical substanco are a thick hiycr of porous,
apporeotly young, newly-forrocd bone-substaiu*, which are very inti-
mately connected with the cortiail sulwlam-c, it is tnie, hut whicli,
ucvcrthelee^ if the process be nut too old, may be l,)rokcD off with a
chisel in ffood-Hized iMe«.-«. If the diswtfe hiis alrojidy huit^I sumo
tunc, and tue union haa bc^-otne very intimate, we Gtiil that the Hc-
positcd porous bone bu become more curopoct, especially if the mor-
pnuess has actually tL-ntitiiatod.
Let us slop here a moment to inquire tlie origin of tliis newly^
formed Lone. U may cumo either fronn the inner sur&too of tbe
pcriostenro, or from tlie surface of tlic boop. The former is the pen-
emlly 'received opinion, and it is sujiposed to b» a renewal of the
function of the periosteum, as it existed I>efore tbo bone had com-
pleted its growth, when regular hiyera of new hon« were always
fijcmed on the inner surlace nf the periosteum. Tiiis fona of perios-
titis, which is oiinhiiied with liie foniintto» of ontct'iJtj/ta (aa the
young bony substance deixxtiled during intlitminntiuu is termed), mny
be called oateo/tUittie, a luune which I shall use, for tbe sake of brevity.
Ncrerthelesa, I do not agree in the above view, that osteophytes pro
ceed solely from thu pcriuetcuni, but am satisfied that they actually
grow from the bone, as the Greek name indicates. For, micmscopio
eiamittstion shows that, in tliis case also, as in nuppumtioa and gran-
ulation on the 8urC»ce of the bone, the snuU veasek that enter and
escape from the )>one vrith their enveloping connective tiwBiie are ih**
seat of tho now furmntiim, which advances from the Haveniian cnnnls
opening on tko suriocc of the hone, and are tho point of origin for
the new fottuation of bone, which then spreads out under the perios-
teum. These ossifying granulation-nodules grow frotn within out-
ward somewhat into the periosteum, um\ then the latter takes a
port in tbe process, as it seems to inc. The form of the
406 CHIIOSIO TÄTLAinUTIOX OP THE rF.RIOSTErM, DOSE, ETC.
osU.-opbjrl^'s, wliicli is üfteu p«i-ulkr, dopenda on the amuigcinent of
UiL- viauscls nruund wliicli the vouag oiwuouii iiiftUTiitl la uupositcoL
Wo would not by any moans assail tlic iindoiibtt'*! (net that the pori-
oBteum, and other parts adjacent to llie Ixni^, may mho produoe now
liont*. »till [ aAhicrt tlial, cori-ccLly viewed, oAlvopUstic pc-rioetitift ia an
u«tc(jplustic Mtitis »uperficiulia. This subtle ili»tiiiction hua nu pnc-
tieal vslu«, no fiir u8 we now know. OMeo/tfiytea are the ftrodaet t^f
di» ii^ammaturij irritalion of the pcnottcum aitd aur/atx t^f She
bon« f Mcy are precisely what we caU «i/Zu«, in /racture«, and lAey
or« foni\*d in the tame teat/. I hen? remark that ppTioatitis, ncoom-
psaitsl only )iy fornuitioii of o!*lMipliji't*>!', uithtutt iiny »iippuraliun, 1»
»pccJally peculiur to some forms of voiistituliuiiiil »ypliiUs. The
dolores ofitcocopi, nliioh xaity be to torturing in tli« bead Mid slno-
booeft, in t«.>rttary u^-pLLUs, are almost alu'uys due to osleopliutic
perinsUtis and ostitis.
According to my experieuoe, almo»t crrij obroutc perio»tilis b at
first fvttcoplastio ; all othpr t<vrminations follow it mor« or loss dOMlj;
Till) Mijij/ttratitre fonn is aUo wry frequent ; it may run its coinse
uilliout the boD« bciiip much nBcct«d. Ifrcull the e^-mptonis already
mentioned : ccdemaloua swelling of th« skin, pain on deep preMUre,
and B. slight amount of it cin nrnvinff the limb, litis oondition r^
niHiii» long tJie same, but is g-raduully fuLlowal by more »vrelliog, ly
aa immovable, duu^liy tumor, nut |>erfect1y but still tolentbly well
definod. ]3y degrt'OH Uie skiit rcddeiiK, aud tliu tumor fluctuates de-
cidedly. Four to six mouths may thus pass, and then the luinor
remains for a long time unrhnn);ed. The |rain baa probably incrraaed,
und the function is marc disturbod. If tlie diflease be left to itself,
the cokl abscess, which now evidently exists, will oppii,nnd a thin pus
mixed witfa floccuii or «heesy subslam-e wilt esatpi'. If, throuj^h the
fine opcDinfc, you pass a probe, it will cuter a cuvity lined wttb grnn-
tdatiuns. If you do not wait for the spoiilnncoiiH opening of the
abst'ess, but make an incision through the tliin skin, it is pcxwible that
no pus mny e8i-a)w, but that you will IJnd the nuctunling tumor lo
consist of a gelaliuous ranss of tv*\ f^nulntion» ; in other cases thofC
Is some pui« ill the centre of the swelling ; in stiU others the entire
tumor is of pus. From what I hare already told you of the aoatotai'
ioftl conditions in chronic inflammation, you will readily undenUnd
these different states. If, in the periosteum, iiiriltrnted with serum
and plasm, you ima^ne a r\c\\ development of vcMfls, aud at tlic
Bunie lime an iufdtmtion of wandering cclls,and trnnsformatioaof the
eonncotivo Ukruc to a gi-lntin' ms intereellular substance, the formor is
metamorphosed to a Hjxinffy mass of granutations. This may snotier
or later change to pus, and an nb»cc» is the ßnsl result. If the whoto
rw.«.
40»
process afibcts only tlic periosteum and supCTJaccnt sott, parts, the
bone {s but liltle ohanged; some inclination to new fonnatiuu i« ox-
Inbited on ila sur&re by Uie {irofliiclion
of a la^'cr of oäloujjhjtt-s under nud in
tht? fiwipbory of tfio part affected wiUl
pen(i»iitv<. Novorthcless^ there is a
poesibilJtT of llic aliso(!S!i healing slow-
Ijy after the pus Uaa be«n evacunlcd,
mad at a rotum to tlie prerious uonnol
fltate. Such a rei-ovcry of ))crio6itti»,
writhout implicnlioQ of tliu booe, occ*-
■ionally oecurs in pructico, but it Is rare;.
It ia far moi« ooinmon fi>r the bone to
Iw also affcctodf pcritaps oaly auper-
fioialljr; that is, for periostitia to b«
accompani««] byOMlilts; nolnnouify
ing, but a ihruiiic, mippiirutiv«;, ulcer-
■tire oatitia — ft earies aupfrßnaid.
Before the abscess has opcuod, the
Bjinpton» of such a carirA iM-arrcly dif-
fer from those of eiippuratire perioA-
li«. If the ahseesa has ofxined, we
J pan ft probe Into tlio surbce uf
lo boDC, Tvbicb wo feel to bu rough
and ^anod. The cari^^-u had existed
aoniP time, and was eccrntlv eating into
tUe boue before the alMceas o|>eoed;
it ptobdbly existed n-hea the perio«-
leum only appeared infiltrated, nod
was stQl in the stage of gt^Litinuus
gmnuUtion. Hence, suppiiratioQ i«
not neeeaurily eoinbtiMrd vrilh cjiriv«,
although it frequcDtly uccompauiea it.
To make all this oleer to ub, wc must Cto«« «ajwrBd^i» «t uio UhU, ictoKi-
study diroaie oatitis by means of pn>p
aralions, Tbc vrbole derelopment and course arc quite niialogoua to
the coarse of rhronic inllamowtioo io the soft parts, but the harducu
•tid difficult solubility of bons giro rise to somewhat diffureat ciicum-
staocca.
In the coune of these leeture« vc hare repented time and time
that iuflammatory neoplasia is developed in an<l from the
tissue; that the dose oooQcctirc-tiesuc filaineiila, by rich in-
*10 CHRONIC IXFUMMAnON OF THE PEBIOSTEDSf. SOKE, ETC.
filtration of cells, ts imnöformcd into prlatinous or eren fluki intcp-
ocUuIar substance. Xow, bow sli»Il tliis be tmnsformcd into booc?
The cells embedtlecl in tlie stellatt; buiu-KxvrpuBclos porticipattt uo mon
in tlio ir.itamniHtor^ new formation than tbc stable cotmcctiTC-tlasae
oorpusL-les. Hurt? ulso, »a in moal lifi«ii^ of tli« bö<Iy, the inflanuni-
torj' nouplam iiifilttiites the connortive tisam'; niuncly, ihnt wliH'li
envelop« the Tessels in tbc Hsrcnian nnalN, hii<] In tlie medulla of the
bone. Still, tbc E))acc for tlic vxtcn«ve prcxluctioD of cells is limited,
and, if llie wanJering of tli« wlls went on very rnpidlr, the wsm!
would »oon be cntirclv ccniprcasL-d in »he bony canal ; if the ciiruU-
iioa be then arrested, the nutrition of the youn^ brood of coUa abo
ceases, and the neoessary residt is death of tbc affected portion of
bone (necrosis). Quite right, this may be the course ; superiieJal up»
crosis may thus combine with periofftitis ; ol (lits hereafter. Uaoallr,
bowerer, the cell infiltration in the Haversian canals is not »o rftpid u
to roni]ireiM tb« veftfteK The proceu Is chronic ; tbe bone gisdually
givcji way, the UavcrKtun canalfl become wider and wiilcr, tbe fin»
cortical etibstance of the bone becomes porotis, in the canals (wideaed
to merles) lies tbe brood of young cells, intcrepensed with grelntinotu
interccUtikr substance and numcmus vessels, an InttntUiat prol^feni'
tion of ^rantiiations. If you iinaj^ne the process ascoftiinuinir, iLc
bone diaaf^pears more and more, tbe entire inRltrated portion may be
ilisaolrcd, and the infliimmittory ncf^losm takes its pfatcc. If you
macerate aui-b a bone, at the seat ot discnsc you will £nd a loas of
aithstance, with rough porous walls, Ihat look as if gnawed off; in this
d<-r<>ct lies tbe neoplasia that has taken the pUo6 of the bone (Fi^.
G*;), Now, remember that so far the worxi pus ha« not been mm-
tioned ; still, of course, the inflnininatory neoplasia may siibscqueiilly
suppurate, ami, if we continue our aiipposilion that the process l>ogan
in the pcri'wtcum, you have a superficial cold »hsccsa lying on tho
bone; its wall» may be covered with granututiona.
If you have oarefuliy foUnwiMl mo thus fnr,yoti will linve remarked
alrenfly thiit throiiglioiiL tlie wliole proa»» tlie bone sulntance remains
entirely passive; it is entirely consumed, and wc mi^bt say, with a
certain amount of tnjtli, elirunic ostitis, or caries, is actually onir a
clironio iiiÜninniatioa of the conneclirc tissue in the bone, with con-
sumption of tlic latter. And according to my view this is perf«rtly
correct, «t lca«t for thu great majority of coscbl Still, how doe* this
consumption of bone take place ? Should not microficopieal examitu-
tion show whether tbc bonc-cclls are clmngcd or not during the pro-
cess? Remore with the fiircppa a particle of booe, as thin a slicct ns
po«jiible, from a carious spot, and look »t it tmder the microscope,
you will in many cases see ilacdgvsand surfiicc bitten Dut,u it were;
CARIES.
4U
Üie boDocorpusrles axe unrHangetl ; Uic- inU'rcvlhilsr subetsnce some-
wbat muru clumly tlinn usual, pt-rlmps, but uut much altrrrd ; & eoo-
tJoo of bone, t^cii froui iho riciuity of hucIi & carious spot, ahows
notliiiig difTcrent If you saw or cut uut a piece from a. otrious spot,
atotl abstract tkc chalk/ salts fron) the bone b; chromic add^niid theu
make sm.-tions through it and i^lear them with glycerine, ^-ou will haro
about the foUoii'iog picture (Fig. G7) ;
Vm.«-
^'
BmHod of« ptoci of cartons bonotwIntiiBtDW). BUcnttnlaaOiIlnineien.
These piccfs of bone arc often billvn out, ta it were, quitu n^ifu-
larly along their edges, the young seopUsJa grow-t into these dofecte,
their furthor increase poes hand in liaiid with the dissolution of the
bone ; tlie boncKrorpuscIes arc unehangrd, no destruction starts from
theoi, we occasioDflllv' see Ihem half destroyed at the edge of a piece
of the bone. WImt boc^ime» of thn celU ihnt were in tb(>m, ire ean
hardly eaj-; they can no loiigi'r U' reix>(7[iized among the numerou»
young cclb of the iuäammatoni' new fonuutioa ninong which tbvy
enter ; it is possible that, freed from Ihcir «age, iboy aid i» inercaslng
the cell-brood by suMIviding, poasibty they die ; at all event«, as far
OS may be jitdgnl by the change of form, they do not aid in diMolving
413 CHROXIO INFU.UXATIOK OF TBB PEIUOSTEl'U, IIOXE, XTC
tbe bone. Hui how the hone is diuolvisd rennins an unsolrcd riiJdk,
Livinjr, like (lend banc, nuir, to a certain extent, be dissolved bjr the
Inttfrvtiltiil bony granultition. 1V;i'ioiiKlj', wbcn tpeaking; u( opcratii)^
for pseiidiinlirusts by the iiisortinii of ivory pogs, I told you. If yon
will mncmlicr (p. 310), that the ivDi>' peg« became rough oa tbctr
8iir£acc, carious ; tlii^re tlio process is ju»t the sauie, and tlud ohbetrf
tioti is exciwdinf^y int<>restjng siitl important na a pr(K>r that tho bone
itself ttocTi not neceswirily liare any thing to do with its solution In
carit«, but may pla.y » peiftwlly pasajirc puri. Tu anticipat« tbe cbxi]ic
that I admit onA/thi« vftrielyof eonmimptioB of iKin^, whore thenboro
changes oct^ur ou tbu surfuri.', I miittl add that I have alrcadjr calli-d
attention to the fact that the irort- pegs introduccKl for pBeudartfaroeis
do not ahraifa beeomc roagh on the Kurfactf, bot might renum smoolh
and still lose subetance, as miiy be shomi by weigliing tliem Ijefiire
and after tbe operation. Tlie inorplK)iogi<-ul appear» mv» in tlierarious
bone, wbich li. V'olkmctnn rery aptly clwignat« tacvnar commtmä,
and whieli Iloanhip liret made kno\m, are now generally reocf^ised
as correct, althoußliditTeretit views were formerly held ref^tuililig tfacm,
wliicL yuu may liiid in the cellular pathology of T'tVe^ffK', and ia
Jfomter'ä alüiit, if the Riihjtwt interests you.
One point, however, wc must cxmsider. It would bo rery luifh
posable that the bone-substance, having its nutrition ufFcvted, would
begrin to break up anrl crumble into very fine pnrtielc*, or pOiWd«r;
this would be especially apt to occur if tliK bone liad preriousty tost
its or^nic »uhetanee. It rould even bcshown lliat this is Ihc primaty
step in idceration of the bone, or earie», and Ibme who regard destruo-
tiou of tissue a» tho primarj- step in ulcers r>f the »oft porlA, ami in-
(tammatnry new fonimlirai as tJio eeeond, will also hold tiiis view id
rtgosd to bon«. As 1 have already elated, my observations spwJt
wry decidedly ii;^iiiist the universality of this view of ulceration, and
what I did not find proven an rej^inls the soft pans, I cnnnot rousidor
tmc OS retards the bone«. But there is no doubt that portioos of
bone may enimble off, and, when there is supptinilive ostittK, ihcise
nnalt pitrlicles of hone may be found in the pus. 'Iliis would be a
nocrosjs of the lowest form ; such a deatli of the purtieles of titMiue
also oceiirs in the soft jKirl^ I>uth iu ueut4> and chrome inflammation ;
you will doubtless bear In mind that wc tiuvc spoken of this subject.
It cannot be constdcreil as a nilc In caries ; it is ouly seen oocasioiuüty
in caries with suppuration or caseous degeneration. Hero even larRe
portions of bone may become actually necrosed, and for tlds (.-ombi*
nation of caries and necrosis we have the curious name of caries
Thus far wc have tised the term caria as exactly synonymou« with
CARIES.
4It
ekroob) oelltts unci Milution of bone, nnii at present iliM ü v^*ry |g;cBfir>
&1Iy done ; but foniiorlv tb(.> nairiL' caries vpm oqI^ used Tor ulc«nition
accompanied bjr euppurntion, for opcii ulcc-rs of the bone. The inti-
mate connection bptwccn chronic inlUmiiiation nnij ulcctalion, vhirh
we prcriously studied in the soft part«, also exists brtvreon cluronio
Ofltitifl and raries. IF you drain? tn dctug^atc Ihn cliaracbr of iJie
iDflanunation more Bpecißcally, it uiny be done coni-enicnlly by certain
additiraia which j-ou alroady know from the chapter on u1<»ra. Up
io this pcnni we have only stuiliol SNperf!<-ia1 caries ; hereuncr wt^ shiill
come to centra] curies, wLicb holds the »amu relation to the su|)crlictul
tliat Ihr nbsce«« doctt to uti upon ulcor. In ih« sofl ]»ris I ahuvrcd
Tou the dcTcIopment of the process of ulceration in a fiiugous ulcer,
whem the producUrc character prcdofoinatcs. This lias its analog
in bone, in oaft/w jungosn (br caries sieea, Virefioie and I'oiicmann
mean carios with prolife-rating gnuiulalionH and dcstnietioTi of bone
vithoot suppuration), wbeic there is as yet no destruction of the
Inflammatory new formation, Imt wliprn intrmtitial f^raiiulation>ltmie
ha* grown nil ihrongh ihebone. 'Hiiii doe« not by any nuiin» alwaya
fwcur to tbe extent wc have ju5t supposed. If you buar in mind the
•tonic, torpid iilccr of the sofl part«, and remember how the neoplasia
rapidly breaks down into pus, uiidergtics caseous transformalion or
disint^^itcA, and Himply apply tlte aaine changes to Ixjiie, you will
readily uudontand llie case; tlua also gives caries another character;
there are very torpid, atonic forma of caries wliere the neopla.sin caoKB
bnt little dctitniction of bone, and then disintegrates or iindcrgncfl
«seous metamorphosis, and thus in the Uring orfpiDism there is a sort
of inacention of the diwawil Iwiie; tho sofl {larts in tli« bone «uppu-
mte; if this liappcu IfJ'orc the bone is dissolved, the portion of bono
that bns suppurated is necrosed. Ucrc, also, most of the fault of the
diBintegmtioii is duo to deftctont vascularity. But wu must look to
constitutional influences for the causes why wc have la one case fan*
ptua, or proliferating, iu another atonic caries.
In cloaing tlu*SG anatomical deseripüona, I will direct attention to
some derintioiis in the? details of atropliy of tb« bone, to wh!<'Ii R.
J'oi^Kinti luis recently called especial attention. He distiuf^imhes
as tNueiiiar o«titis a raricty where new canals with %'ewu>Is originate
bum the Haversian csnals ; these break through the lamellic iti nirious
diroctions, without any of the above lacunar defects bciufr fontied in
the bone, «Ithoitgh the final result is also atrophy and ponwity of tlin
bone. Vbtknumn also calls pou-ticutar attention to tlie form of atrophy
cf tbe bone, where the tamcllm of tlie »pongy sulistancc gradually
grow thinner and thinner, without our being able microscopically to
see how it happens. Tliig variety of atrophy (halitlaretie) occurs in
414 OBRÖ*nC INn.A»UATIOK OF THE rERIO^EtJlf. RONE. ETa
caripa, but is stiU more Irequent in osteoituiliiriA ; wc shall return to
this agmJD. I knov the htttcr fonn rcr^ well ; but I bftve not bcca
kbio to sulisfy rnysflf blxiut vascular ostitis a» described bj* H, Voilb-
tnanit.
Oimnic inilarnmatioii of the periosteum anil bon« is diirilj due to
CQUsliluüonal, dyscrasial diseoacB, and although injuries, blows, liills,
etc., majr be pxriting cau»e.s of th«*o diseases, llie ultimate cause must
lie ill the iiijuretl purt nr ihv »yslem at lar^c, otherw-i»e the process
would t«kc tb« course usual to traumntic infliitnmatioas and soon t«t^
miiiat«. If ail injury iii<bices iiutidious c-hronio indamniation, this
must be tluc eitliiT t« a pccuüor local or mnstitutiHOsl condition ; so
Car I bar« had no reason to abaudou lliis opinion.
Of the dj-sonisia altesdj koown to you, the scrofulous and s}*pb-
ilitic r?ipccial1j' prediH|inse to chronic perioslt^s and naljlia; among
acrofuloua cliildnru the fundus forms of cnriua are mowl frcquc-ut,
irhile amriUf^ adults the nttmic occurs oftoncr. True luben'los are
aUo foiuid in bune, but, &o fur as I kauir, uul la tL<> jwriostcuDi or the
cortical layer of the long bones.
But chronic periostitis also occurs frequently when none of the
above dyscrnaia are discoverable, and where wo ean recognize no
cause; in oUl people especially, perioetili» with caries aometimes
conies from rcry slight iujurics, aud runs its course io the most dis-
sgrcoablc torpid funn.
Tlie tiilhtmmatury neophiü'iB in the bone will greatly «ympathixc
if the geiicnd health fails ; in childrcu who have died of caries, you
will almost ulways find the atouie form, for, just pro\-iouB to death,
while the tuitritioti whs bad, the neoplasia also broke down ; the dis-
eased boue, even during life, was mat^eiated by suppuration and mni'-
tjfication. Pathological anatomists, who only see caries on the dia-
seeting< table, rarely know the fungous form acctirately, or consider it
the more- rJin> ; bul, wlien one often examines pieces of carious bone,
cut out during life, espcciaUy the iwtectcd joints of children, where
the proees» is going on actively, he learns to judge diöerenlly from
what he would in the anatomical museums, where maoeratcd bones,
fclmost excluaivcly, arc j)rw!Crvcd.
Allhdugh I hnve merely sjioketi of fungous and atonic cauies, you
still understand that I ha?c otdy depicted the extremes of the pro*
lifcraling and rapidly disintegrating new formation. Of ouune there
are many intermediate forms.
It is not tJie object of these lectures to rarefully delineate all the
shades uf this process, as will be dune in the clinic, but htTc the pic-
ture of disease« should bo drawn from typical cases, you should ac-
quire a mental mastery of the subject; bcuco I only lead you so ter
CARIES.
416
into the (Irtails of tbc procciui as is necessAij for uiKlfretandin^ its
anatomj.
Now you will venr' justly ask, llowr «hall we know wfMrthcT the
case, which we have only iliagn«j4eil with lIi« probe, b« of llio proUflei^
«ting or torfiid vanety ? Thu will hai-e an influence 0» ibo Ueat-
iDcnt, a» it has in case of uloers of tbc soft |wrt& And it ia int-
|xjrtAiit nut only for the tnaitinviit, but for lliv pruguoais; for pure
ti>rpid L-axii» oSvn far pocror chaocvs than tbc fusgoue fomi, because
it is far more apt to tux-ur in poor, badly-nouriBlied, and old |>cr30tia.
The distinction is not difficult. In llie more prollTeraUng fonna the
aweUin^ of tlic soft ports, pcriostcuui, and skiii, and ca|)ci.:ially of Uie
articuUr capaule when the cariw affocte the articular <>iids of the
bone; ia often considerable j all these parts feels opongy. If tltere Ix?
any openings in the tiltin, protift-nitiuj^ ft:ruiiitliitiona projcot fruui them,
and a mucoii», tougli, «viKivia-liko pu^^ «^4r>i>cK. If you caamiue with
til« probe, you do iiol come at once on bare bone, btit must push the
probe into tbc grauulatiooa, uFtcu to some depth, bcfoni entering the
rotten bone.
In the pure atonic form there is less swdUtig, the skin is tbio, red,
and often nndermlncd. The edges of the opening are sharji, iL<t if cut
out witb a [luuch ; ibere is a diächat^ of thin, aeroua, sometimes !«(}•
ly-onelling or »anious pus ; if you introdmv the probe, you eoiiic at
ooce on tlie bare, ruugh bune, from which the soft ^wrta have alri'Ady
been separated l^ suppumtion and muccmticHi. llicsc are the ex-
treme raaes of the series ; Ihcru are vnriotis in termed in to funns.
Taking all things into consideration, I tltink you will now have a
cxmect idea of c-ariea superbcialia.
Ixt iM mako a short rei-iew of what we know of chronic dia-
eases of the periosteum anil bone- We hare considered chronic os-
teoplastic perit-stitia (with foniialiou of neteopliyti-ö without suppun-
tion), suppurative periiwtitis alone, and combined with ostitis superfi-
oialia, «r carii-s. Hut ri«te<pplustir j>eriu«li(iü may combine with carles,
and this ramlnnation is cTcti frequent, i. e., osteophyte» form round a
ttriouB point in the bone. If you examine a scries of pn-parations
of cnrioua joints, ytm Gad the osteophytes starting frotii llie surface
of the bone, around the destroyed {mrtion ; the periostitis, which at
ODe place induced destruelioo of tbe bonei Cftusod formation of new
bone in tlie vicinity. You may very aptly compare tliis to an ulcer
with callous edges; thickening by nevr formation in tie prriphery,
dcetructiun in the centre. But wc do not have formation of osteo-
phyte*« at tltu ]>criphcry in atonic forms of caries, it only occur« in
those which, at least for » time, bore a prolifentJng cbamcter; just as
in tf^rpid, scrofulous ulcers you only Giid thickened edges, where t)>e akin
i6
410 CHRONIC IKFLAHMATION OF THE rERIOSTEDV, BOSS. KT&
had for a lonf; time been tliickcni^ byjdaslic Indltnttion, so lu Ute^
bone also wc bavc ihU combination of proHforalion and deatnictioo
which we havo so often met in the study of ioflammatioa.
LECTUBB XXXm.
Prinwrr Cantnl, Chnwk OMltU. or Cut«*.— fi7u)KoiiM>.-'0Midi Inlenu Oil«a|ili
ties, SnpvunlW», FuntioM. —AbKc» of Bone.— Com blnatlotM.—OaUU* »bk Cm-
»au9 Mauuncrphoiil«.— TutoiroIrA nf Itone.—DIc^oab «t Cwtw.— PUIocrtloo nt
Uk Boum iftAF ibalr PftnUI D<auuioeioii).— Conf «ntoa AbMtMM.— EUnloo^ ^
FTrTHKRTo we liave only irealed of chronic osUUa in Ro far as
dcperKl(.-nt un puriustitis, 'Vhis is almost always Iho cwsc iu the
low bone», for in them the cortical layer it not much disposed to b<y
oomt' printarily dideaaeil. The case is diSt^rent wilh tlie spongy booea
and Ixiny parts ; in ihcm a cbrrjnic iiinammation may arise indepen-
detitiy, juat aa in tlie medullary cavity of a boUow bone there may oo
riir ft ci rcumgcribed climnic osteomyelitia, so that t)w cortical subsUne»
may bi-coitie disciised from within. These cnKcs arc designated as
ottUU inlerna at caritt ccntraiU, The eymptoms of such a t^uouic
inflammation, occorring deep In the bone, ore in many eaaea very un*
decided. A dull, moderate pain, and a confler^tient slight impairment
of ftincüoD often form ttie only evmptoms. Swelling comes on later,
Hiid the disease may exi«t for month» before we ean form n twitaiii
diagnosis. But t*tii*ii we fincl »evere pain on pressure, and cedema of
the skin nnd tht- pcrioslvum participate« accondarily in the chroeic
infiammatlon, we shall fj^radually be led to the correct diagnoeis, the
more readily if the disease be oircumscribed, and perforation finallv
take» place, i^v that we may pass a probe tliixjugh the opening deep
into the bun<.-, and find exactly what is tlie »tat« of affairs. In muny
U18C8 periufitilis i» for « long time the r>hifif symptom of ostitis; tho
former may be au prominent tliiit it uppciirs to be the only disease,
till, from the long dumtion, and from losses of eulistancc froto within, or
lastly, perbiip«, even by dr/tauhment of smnll |necos of bone, atteotiao
U eulled to the fact that the continued suppuialion la due to '^seaae
deep in the bone. Tbo scquche of ostitis interna may bo forruatioo
of new bono, suppuration, caseous dogenenition ; rarely there is also ^
derdopmcnt of true tubercles in spong}- bonca. fl
Wlicn oatiti* interna osttoplaatka develops in the boUov bonca U
usually attacks the entire bone at the same time, and also OOcnmenccs i
slmultaneou'ily in several Ixmes. Tlie result of this disease may be tho fl
complete lilling of the medullary cavity, with a tolerably compact boDjr
8C).ER0SIS OF BONK
41T
.1
■■«.
mam, thealmoAt complete filling of IheHsTeniancuulAivitb Itony nib-
suincc, BDtl gL-ncrally «iso tbc br-
mnLion of bone oii tlm suHm». ^^' *■
Thus the cntiw» Ixinebecomcsrcry
beary sihI cli?i)B«r thati nDrmal.
Thin pmcefts is olfio tcroivd diffitt»
hypertrophy ofthi öon«, but more
jurnliy edfroiis oMiicm (con-
l^dcasin^r o«tilb, R, VM-iiian/i).
Bcsi<tes tbe bolloT bonea, otlicr
I of tbc «kdcloii are iil«o uo-
nonalljr attacked, c, g,, bonra of
Ibe foce aad pelm ; in such oaaes
Ibe bony deposits aie spongy,
puffed, BoduUr, »o that l)ie bone
Lpoqutrea & reaeuibUuce to ekiii af-
'feeted with dephantJuiiR ; indc<>-r!,
tbe discAsvs xrv ray nnnlogoiu
(LroDti&sis ofiKium, VireAmc).
The t'tlling up of tlie diploö be-
tween Dip outer snd inner tables
of tbe cnnia] bones with bony
subetonr« is such » ooouDon
ohange wilb advancing age, Umt
it can hiirdty be coasidenxl as
itliolofi-ioal, alUiougb il really
iK^longK under tbU bead.
Till* muse« of »cleroüi» of booe
OS B primary disensc btc cnlirriy
• «bscur«; in «omo pasm syphilis
any act as a cause, but the ossimi^
tfttioiui nocurrin^ in this div
rarely atlun such firmncas
I'M in «elenwis proper. The maU
t<kdr will rarclT be reoOf!lliz«>d with Sckni««] tiUi uid Mom ilw toracr «Iter
, . i.r , Frillt. tli-liilrr frooiAipMlniall ««t of 111«
UOty dunn^ UK, tKCauSC to Tbnna ruii'>kfsIa1AMlank«l^U*cth>g.
the touch the<« bones present
lii>lhing ntore tlian a certain increase of tbickncaa and a alight ine-
quality of surfimr.
Ottiti* interna ti^fpurativa rirctunsefipta usiuilly bea^in.i in a
bollun- lx>ne as osteomyelitJa. Tlie inflammsttoa gntdunlty extend'«
to the inner surhco of the coriicaJ substance, which is dissolved, aa
we bare already stated, and &na)Iy completely contumed at aoni«
27
«8 CHBONIO IKI'LABMATIOS OF TUE PERIOSTEÜ«, BOXE. ETC.
point, In sufh esses pus mar form qidto t^rly in the eet\tn> of the
inflammatoiy new formaticn], and flubscqiu-ntljr be cvaruatcd. It is
this disease that is especially termed bon« ahartn. The periosteum
doc» not remain uimReoted; it in thirkened and new bony d«po«iM
form ill tliJB CMV also fn>m ilie gurfaee of the Ixiiie, vrliii-h is oot nt
linit {icrfontcd but is irritated Irani witliiii. 'I1te hullotr bone is thus
enlarged exterually ftl tbc point where ihe «hscew forms in it, and
givos the impre'.isinn of tlip bone Itcing lier«? prve^ed apart and in-
flated. It i« diflit-tilt, indeed nftt'n iinpn»iible, to diMingiii»}i miHi a
bone^bneess frvui a cireumsc-ribed oBteopla»tio perioetitia, lieuoe «re
should not I» in ton great haste to operate. Tliig central rarie» may
be accompanicKl br partial nocrusis of certain portions of boiie on tlie
inner üiirfsi^ of the corticnl Mib^lunre, rnrniinff a caries nftrnttca
ctntrali*. L*Btly, we have llip worst cases, where chronic internal
and external enriea are an-ompaniiHl by necrosis and by suppumlive
or osteoplastic perinsUlis. All Iht^e develop in one «nd the sanie
bolLuw bone at tbe Bamc time; ubsuesses appear at different points;
whh the probe we sometimes toucb rotten bone, sometime« a seques-
trum; in one place we enter the inctlullary cavity of the bone, in
another only the Äiirfaw «pprara diM-iiH^I; the whoir- ixtnc i* tbirk-
ened, as is thft periosteum, and a little tJirii pus escapes frimi the
liKltiloiis opening 1'be maremtc^I preparation of such a l>one bus a
peculiar nppi'unmce; (.he surface is rovei-efl with rerj- porous osteo-
phytes; between these, here and there, we find oecrojed portions
which belong I« the surface of Ihe lH)ne; »oincopoiiin;relfitd into the
medullary CAVily ; if you »aw tliruujib these bones longitudinally, jou
find the medullary carJtv also partly filled »itb pomus Iwny aub-
etanoe; the cortirnl layer haa loM it« even tliicfen"«i, and it also is
ponius, so that it a only at some few points that it c^a be distin-
guished from the osteophyte deposits; in the original medullary
crivity wc find occasional round Iioles, and in some of these ueerosed
porltons of lione. 'Hiese txines am in biiHi n »latp that their recovery
caimot usually be es]>eeled, mid either their ext!r|>alion or amputup
tioii of the limb is nccessar)-.
In the itfiorl, spoitffi/ hnnfi the ease is somewhat different; in
tl)t?m, when there is prolifernting, inflainmntory neoplasia, solulinn of
the bone with sccoiidarj- snppiiralion comes on qnite rapidly. »hhou|^i
it is not an absolutely necessary restiU. There «re cJises of ostitis of
tho short spongy bones of the wrijit and ankle, and e«i»eeiaily in the
c|JJphyscs of ilie hollow bones, where, wilhoiil any dended swelling
(wliich it usually caused by the resulting: periostitis), the bone is en-
liivly dissolved by inlenHHinl grniiii!atin»s grx^iwing all through it,
without uny neccsoory scoompamment of the slightest trace of sup-
DESLOCAHOK OP IWNBS AFTEB PARTIAL DKSTRrCTION. 410
purutiOD {oalitix interna Jitnyoaa), The result of sucb a sulutioa of
bone in these, or in other joints, u that by muscular tractiou the booes
SI« dispLic^ ia tbe dimctiuu where tlic deslrui-tion is luoiti ftdvuuoed.
And from ibU defontiity w« may judge approsiiiuitAiy of the extent
n( the (lestnicUon. A short liiii<^ siixv, I «inpiiUteil a foot wbicti wu
ftu diMuTttxJ by BUch il dcslructiuti uf boiiu, u-illmtit nuy suppuration,
on ihi? inn«" ^id« of ihf uUw und cftlcAiieiw, thnt the inner bordor of
ibc foot wus greMly druwu up, jtiHl its iit well-in;Lrkc'd coiigemta! rltit>
bot, nod tbe patient wulked Tcry insecurely on the outer bonlfr of
tbe fool, A good-sized ulc«r bad also fonned on the outer edge,
which bad latu^rly entirely prevented walking. I saw n nimibir case
in the wrUl-jiiiin: A girl twenty years old bnd suffereii for a \ong
time from pain in tbe left wrist, nitbout swclÜng of tlic soft parts;
pressure on tlie wrist wiu I'm- [taitiful; gnidiinlly, wltliuiit any swcll-
ing or suppuiBtion, the bund became very niuefa abducted ; if lite pa-
tient were aiuesllielized, the baud could be returned to ita uonnal
position, and then it was found that part of the vrisX bud entirely di»-
appt^Ared. Tn the larger sjMmgy bones, as the calcaiicu;*, and in the
epipbyaes of the larger hulluvr bones, a oentnl cavity, or a bune-nhneess,
may form, and this may be necompaaied by • neerosix eeniralis. In
tbe great ntujurity of cascä, however, the ostitis is at'compatiied by a
purulent periostitis; Ibis ispartii.nlarly the ejtse in the small bone« of
tbe wrist and ankle; these are so small that, when the periosteum be-
oomes di«GU8iHl, tlu^ di»on«u ivadily exti-tidü Ui the entire Wine aiid its
atiiciilnr surface», und that ouuversely primary disease of the bone
quiokly «hows its cITect on the periosteum and articular »urfaeos, In
tbosa ouoa altio there is implication uf the sheaths of the tendons
■od of the skin, whieb Is perforated at various phtces by uh^i-ration
fiWD within outward. In the baud the radius and ulna as uell as lit«
articular end» of the inetat^arpal bones may also be impUeute<), aiwl in
tbe ibot tbe lowex ends of the tibia and Hbula, an well as the posterior
ends of tbe metatam^l bones. Tbe wrist and ankle joint» arc thus
swollen out of shape ; in many ]>lae«s thin put« eseape-s ^m the
fislulons openings, and the hones uf these joints are partly dissolved
and partly replaced by spongy Rmnulatioas, or else are entirely nr
partly nocrosed. It is hardly necessary to toll you that (he course
of this form of primary suppurative ostitis also, in regard to vital re-
laiioos, is jtisl as variable as that of rJimnic perioetitis, and titat Itere
also you see eases of a typical atonic, and others of a fungous
variety, while there are a rariety of crscs between these extremes
I must porticuWty riKnitiouone other fonn of chronic ostitis, vi^,
oHitU idilA caMOu» dejfeneratton o( the inllsmmatory net^laaia. You
ore already aet|uaiutcd with this variety of ohiunio inOamniation ; it
480 OHROKIC nfFLAÜllATION Of THK rF.RlOSTEfM, BONE. KTQ
Pm. V.
belongs geaerally to th»s utonio (onns, with alight vnscuUrizjilk)«. It
oixura chiefly In thn spongy hones, and readily combine« wilh pnrtial
iiRcrusis ; in the ohi>csy piilp which
lills the cavity in the bone then
are nhnost «Iwuys [Mirlious of dead
bone tliAt hove m>l l>e«>n dissolved.
Th« Tertehiv, the epiphyses of tlie
larger bollovr bonca, nud the aü-
caneuB, are the most frequent teat
of thi» oatitia interna oueOM.
Tliitt fonn is only recogiuxaUe in a
few cuäes during life; we gT«d-
uiilly furi^T? »t the diftgnoHM of o*
titis iiilerna, biit csu only detai^
mine ita special form in cases
where the half-fluid caseous pulp
in evaoiinlecl through an rzternal
0(H!nii)g. Lastly, we niu&t not
omit to mcntLOQ that iu rare ca»es,
nsuully in the vicinity of e-aseoua
deposits, true miiiarj/ tiAertiet,
email, at Bret gmy, Utt<;r cheesy
nodules, «ome in the sjiongy sub-
»t^ince of the (*piphy«e« iti the lui*
kle-boncs and >*ertehnr and induce
kolutioi) of the bone and ptu-tial
neoroei», A ilin^OBia of this true bone tuberculosis cannot be oei^
t;i:iily made duriug life, wo may only t-oiisider It a« probable wheie
(here is marked tul>erculo!»ia of the lungs or larynx.
For all forms of ostilits wliioh induce softcniojf of the booo-sub-
stanco, R. Vvlkmann einploya the designation rarefying oalUi».
rolDl of UUOOQi dpcecipmtlan Ui Ue ■plD*'
eoliima al i mui.
From the occaitional remarks tlint I have iiin<le cont-erning the
diaffnoeif of chronic periojttitis and ostitis, you will liuvc already »eoa
thill, afk'r they have last«d a certain time, their recognition is not
generally diflirult, but that it is not always possible to state the
variety and extent of any given case. Ilicre are two very iropoitaot
£nctors for the dia^osis in those cases that cannot be exanuned di-
rectly by the sound, viz., the ditplaemngnt of th» botif^, wliioh must
result, in many parts of the body at Icaat^ from tlicir partial solution,
mad /onnaticn of abanene«, which oft«a aeoompaoiea it,
DISLOCATION OF BOXES APTER TARTUL DESTRUCTION. 4SI
Carious deatractioD of tlie lugcr bollow bones rarely goes bo deep
to raiise a RoluUon of voiitinuity ; wlierc this migbl uttii>nri£e oo*
cur, it b often prvvciitcd by ostcupliytes ^rawing od tLc outtudc vrbile
tbo destnictioo g^o* oit wiUiin, so that the booe grou-s thicker at ihe
point of disease. I have oiUy seen odc case w-bere, from a perfectly
■tonic caries of the tibia of an old, decrepit jie-reon, tlie bone was at
ODC poial 9u far cuusuuieU tluit there vrere i^tire loss of couUuuilj
and spontaneous fracture; poM-mortent examination showed that
there was not a tiace of osteophytes. THie boue in Fig. 66 l» nlso
nearly calcn through. L*on))>lctc destruction of the substanou of tho
email hollow bones of the pitalangcs and metaotrpi is not so rare ; the
Bcmfutous L-«ries of these bones has from time iminemorisl been cuUed
J\rdartJirocfKe, or spina veiilOM, old uaiiiea that only mean caries in
the finget« cw toes, with spindle-sbaped enlargements. Should the
bones lie «^itirrlj cb'stn)yeil by the fungous proliferation and partial
necnnis of the snuill diapbyst-s, the fingers atn^hy and art- drawn
bftcfc b; (ho tendons so strongly that thcj cepreeeot miithspcd nidi-
en is of fingers.
Displaceinent of the spongy bones b £kr more frequent when Hh^'
are desti^oyed. I have already SjXikeu of this as occurring in the
wrist and ankle boncK, still, it oceurs Jar more extensively in other
bonea ; for ia»ta»ix-, if tbc head of the femur and upper inar;^n of the
acetabulum arc destroyed, tbc femur is gradually drawn up in pro-
portion to the amount of destniotion, and assume« tbc position that it
baa in upward dudooation of the hip. Similar dislocations occur in
the shoulder, elbow, and knee, tliuugh there they are less remaHcable.
About the most noticcublc are the dislocations in the spinal column
after carious destruction of the vencbnc ; if one or more vertebne be
destroyed by ostitis, tbc port €>f the s|nnal column lying nbtivo this
point has no firm support, and must sink ; but, since tlic arches of the
vertebne and spinous proeesses arc ror\.>ly di^^cjuied nt tito kiiuu- time,
only th^ aiilerior part nf the »pinal column siukii in, niid an anterior
currature resulle, and a iHiiisequent posterior projection, • so-called
J^)tf» 6a«, ihtis nnntcd after tlir Ki^liiih surgeon, -Percivat fott, who
first sociuately decicribed lliis disease. In L-very anatomicAl (^illeotJoii
you find prcparattons of tliif^, unfortunately, rather common iliscase.
The ooemreuce of such a bo«s is occasionally the solc^ but tolerably
certain, sign of caiies of tlie Tertebt«.
A second im|)ortani symptom of devtmctioa «f bone, or caries, is
the suppuratiuu which accompanies many or most cases. Th<> pus
ooUecIa around the dtseaaod bone ; a eold nbM^ess forms ; the pus does
not alK'sys remain at the point where it form», but simit^inea sinks
deeper, pariicuUrly when it has displaced Lhü puts from witfaia out*
ClIROMÜ OSTITIS.
4fiS
a niU>, Uiey *r« bad aigna; tbeir treatment, of vrhtoli hereafWr, u
! of tb*> iijust difKoult potiita in Mirgicul iheriijieiiticf: In 8pe»l:>ng
>r tbe ditikiiiff uf [lus, it i» inuwiit ttiMt. folluwing tbc I&HB uf grarity,
the pus sink« mcchunioolljr ; it will do so lucet icadilr whvrc thcra
is simply loose coiinec^tire tissue present, and no opposition ft>>>m
rascia, muscles, or bone. But I must call your atteiiUon to tin-
(act tliat this purely iu«cbaiiical picture b only partly correct; for
it iit pnrtly nn ul(M>rntive nippumtion tbttt progresses in n cortain di-
rection, uliirli is uiily slightly iiiflu^iicfd by thu pnrssun.' of the pus ;
the abaooBe foUr^-s as it doea tu t>Uicr cnncs ; if tbc pus irarbcs n
point under tbo akin of the thigh, perforation uBudJy results, nol from
tbe mecbaaical pressure of the pus, but from ulcerutiun from witiiin
otitirard, its in the ofK-ning' of ntlier äWcmm; »ucb u coiigrsiiuii tiU-
»ceM may but tmv aud a bulf to two yvura before opening :«pont«QC'
ously.
Wc come now to the etiology of oatUU and carift itUerita^ which
wc may treat very bricBy, as tbc chief (nctors act berc a» in rbruiiie
periostitis, or in chmnte infliitnmationa generally.
It is, on the wlioti*,' rare for injury U> induce ne*titis cbroiiiet ; but
Ulis may develop iu tht; funn of nu oHleoaiyeliUs in one of tbe liirgtT
hollow bone», from seven- concu9.'<inn nnil bruLiing, with <'xtmvii«ntioii
of blood in the tnedullarj' euirity; the samti thing may oecur &om
contusions of tb« Ikmics of the wrist or ankle. But it la more oom-
iitun for 6uch «uses to biduce aeute disease, such as acute |>erio<stitis,
If 3iup[njfiition take pbuie after eoctusion of the wrist or ankle, if tlie
cutjtage be deMroyeil and tlie .tuppuiatiou extend to the bune, we may
have fungous uestitia uf tbe small KpoiifT)' hones, and tbeir complete
deatroction. Kvuii benllhy, strung |K'*r&oiii; luay. fiviii protracted
trjumatic iiiäammiition of tlie joint, lieeome so anjcmic and cachectic
tliut the di»eA»e will nut go on to its normal terminiitioii, but lieoomes
ehronie.
Mnst frwjueiilJy «enifula «ml »yphilis are the eauses of clinmic in-
flammatjon of the bones; in sonifula, while the cbildn-n are fiit and
wcll-nourif^hed, the ^ngotiE forms predominate. In tiiin, hadly-nour-
ished, icrofulous children, on the cootnu-y,oKtitiK with easeous degen-
cration and oilier atnnio forms not uufrcquently develop ; boUi of the
latter Icod to partial neocoeis. The most frequent aeats of eerofulou»
ostili» and {Mmofttitis are tbe vertebne, articular epiphyses, phalange«,
«od mctdcnrpal bones; tbe jiiw-boaes and large boUow bonca arc
rarely ailcctod.
In syphilis, Ostitis and pcrioatllis osteoplsstiea are moat frequent
i» tbe tibia and cranium ; caries sicca fungoisa aUo occurs, some-
< primarily in the diplo6 of tbe skull, sometimes after perioetitis;
4S4 CHttOKIC IKFLAHUATION OK THE FERIOSTKCa. BOXE. BtC.
the stenivm, pnlaLitie pnxe»s, auil uasttl bonea, sre often affected; ne-
croaia oftea follon-s »yphiiiti« ««ric». Sotno recent «uthora, such u
R. Volimann, nepieseiit itypliiLis of tbe hune us somcthiu^ peculiar,
ander the name of oatUü gwmmoaa ; I acknowlodjiP that L-erialu oom-
binations «re particularlv froqiKTit, givinjr ris« lo t^-pioal pidurcscf
tbe disvuKv; but, snatamicaily, syphilis in tli« bone is nolhioj^ inoi«
than ostiti» atul pcrioHtitn, In mnny ca»es, eveu cm moat careful ei*
aroination, we arc uiiaUt; to S»d uiit local or p^cral cause for tlw
rxisilng caries, and I oonaidor it botU>r to ailmit tliis tfaaa to try with
all our might to dlKorcr some d^-Bcraata.
LECTURE XXXIV.
ProoM« of Cure In OuIm and CongMtlo» Abwxue«.— nti^o*!«.— Omural D«a)lb
Cbronlo liilUintnitlona or tlia Bona-^aoondsTy lormjihailo KntarKtwMiU.«
Trmtaani of Carlw and ConftMltoa AbMMM«.— ItMeotloiis Lii tb* Coailaul^.
Bhpoiie passing to the treatment of dironio pcrioetitis and ostitii,
ITC miist add a fow rcmarlts nbout tlie procfM of ruTv in oarics, and
about thfi proi/nosi*. Tlie first will vary somewhat with the actirity
of tlie procL'i», iia it doi-a in uIvlts of llie skin. Suj))»)»!!!); the prt^
cess of proliferation in the new formutioa to cL-asv, the intersiUial
granulation -tissue will gmdually Ghrink together, and be transfomied
into cicatricial tissue. Considered hixtologirally, this procexa oOQ^sta
of the rctro^rcsaion of the gelatinous ititeix-elluW Auhtitancc into finn,
filamcntaiy connective tiasuCt while the ridily-dnTcloped capillary
vessels are moslly oblitenited, atid the cells aoquirc t>u.' chanictcr of
conoective-liiisuc cells. If the caries was accompuntcd by 6uppura>
tion, tlie Ultcr gntdually oeaM«, and th« Sstuke dose. If part or the
bone Innl »Irvndy l>oc[i di*«lmytHl by tbe ostitis, and there waa dia-
plaeement, it does nut disappear, hut the loss uf bunc is 8U[)plled by a
retracted connective-üaftuc cicatrix, and the dislocated bones are united
in their false position by such a cicatrix ; this connective tiüsuc ^ncr-
ally oasißes «ubscqucntly. Tlie cicatrical union of I wo dislocated bonea,
as of two Yertcbrap, uhicli b»ve come into contact by the destruction of
a vcrtebm previously lying between them, also ossilieB, and thus
imiles the vertebne flrmly ; the actual substitution of bone for aojr
nroplasiii to such an ext/nit as to strulgliten tim spino again, or en-
tirely or partly to replace any other bone, never oooura in cnrica.
Shmdd an atonic uloer of the bon« heal, it may do so iu ooo of
two ways : cither any portion of bone that hts become nocroecd must
PROCESS OF CURE IS CkfUESL
495
dctAch«d nnd tlirowa off, thrn bjr a ricli devclopmcnt of vessels, &
rigorous new formation must form froin tbe vsiüa of tbc defect, and
»wlien Üiere bos bwn n large excavation or absoesa in Uie bone tho
entire cavilr niusl be filled witli granuliitionK before retnirery is pos-
itiblc — (or a pi.*rfect cure tbe»o granulnlionit must dcatrizc aad ossify,
■nd to a certain extent the torpid ulcer in tlie Imhic taust become pro-
liferaling— or else granulat ions arising from tiie bemltlij- bone beliind
the diseased, necrosed portioD dinolvo the luttcr ; ut the satoc time
the torpid process beoomos proliferating, nnd tliua leads to cicatriza-
H tion. The defects in bones, for example, in the centre of a bollow bone,
^ caimoi decrcuae bj ooiitraction, which ao mud) curtail« healing in tlie
toft part«, but niitst be entirely lilleJ up hj now tiasuc. This is the
point that so often prevent» rworerjf in caries, for the coiiatitiitiüiuil
cuoditions at the root of tbc torpid form of caries arc often ao serious
that it IB not only difficult t« orrcat tbo advance of tlio ulooration, but
is jOBt as difficult to induce active new formation in tbeseatof dts<>a.s(>.
If we aotunlly »uecccil in arresting the procea» of uloeratioii, llstulie
Dot unfrequcutlj remain and continue for years, ornever heal. Never-
theless, whim the disease remains stationary, the tistulie in ttin bone
rarely do nnidi hann. If you have a chance to examine sucli ßatube
anatomiL-ully in macerated bone», you will find that the bok-s IvodtDg
into the bone are lined by an unusually thick, scleroaed layer of bone,
B^juft like old fistulic of the soft parts, vrliosc walla conaisi of a ban)
^roicatricial subetancc. We have still to speak of cite pro<vsa of aura of
^Pohtonie cold abaoessea in certain diseases; usually, if not o]wned,
these do not heal till the bonenliseaae ia on the way to reeoveij.
Then, if tbc cavity of the alincess be lined with vigoroua granulations,
&« is mrcly the case, the wnlls inny unite immediately ; but more fre-
quently, when such an abscv«a ceases to iocireaae, it ta first contraoted
by siirinkage of ita inner walla, and ts tbu» pfraduoUy closed. For
this to occur it is retpiisit« that the process of destruction should
have ceastxl on the tnnor vraÜ, aad that the tissue should be suf-
ficiently vnHciilar. If a cold abscess do not open, but remain ftubcu*
lanviiu!!, while the lione-discaac recovers, most frequently a largo psrt
of the puB, whose oells diftinlegmte into fine moloculea, is absorbed,
while tbc inner walb of the abscess change to a cicatricial tissiM^
which, in the ahapeof a fibrous sac, contains the puriform fluids. Such
pu»«aai often remain in this stage for years ; unfortunately, complete
reubsorption, or afaaorption to auch an extent aa to leave only a cheesy
pulp, is much rsrc-r than might be desired, and than is usually sup-
posed.
In the yroffnmit of a oa«e of caries, wo have first to ounsider sepa-
^ntety the bte aniüLing' the disesscd bone, and the state of the geii>
42C CBROKIC lyFLAllUATlOK OF TIi£ I'EBinSTEl'V, BONE, ETC
eral kealth mduoed by long HuppiirnUon of th« bone and soft putt*
Hegtattiiig tit« f»te of tht- purt dittvased we have alreadjr said enough,
having on the cnic hami described the ]>roceSi8 of desUuction and its
results oa the parts around, atkd on the other the mode of the poestbla
cure, nprf I sliall «mlj a<]d llie mniark that, iii mrieii of tbe vertebne,
as we »my midily set;, the spina] tiiediilki inair Im' eiKlaugercd, bj
participation iu tbv Guppuratiou, or by being so bc»t, by ibc indinn-
tio« of llii^ vurtL'bnf, that its function U dt^tin^rod ; thiiit wc tniiyliave
paraljBis of the lower extrfmiticji, of the bluddur, or of tho n.*ctuni,
from curies of the spine Pniclically, this is rarer than ought hsve'
been eijjocted a priori, because tlio ttpinal medulla is eouiideraWy
protected bj the hard dura mater, an<l bears rjuitc an amount of giad*
ual cun'alure wititgut impaimicul of its function. The stato of thu
gerit'ral health, the gmde and varictj^ of tbe fobrite reaetion, arc tit
general prngnostic »ignificance. Chronic disease» of tbe bone larcly
b(^n willi fever; indeed, iu uiuuy uiMS, u8]x.-eiaUy whco those u no
local tTcatmenl^ iin<l tlio «inseciitive nbsce»K i« «llovred to open »poiv.
tancoualr, the puttt'ut iisuullv cscapea fexer Bllogutber. But this jier-
fcctly afebrile; course dues not contiuuc ; if llic patient baa rcnuiocd
free from fever previous to the opening of the abeoesa, after this
there is n^iiall^' hwtic fever, which is gRiiiTBllv a remittent fever
wiih »tcep curre», i, v., low morning and high evcntug temperature
The earlier large cold ubscrca&cs arc opened tbe sooner the afebrile
passes into a febrile stale, and not unfreqiwntlj* there is an intens«,
exhausting, eontiiiued reniitteiit fever; the cbronie ulceration then
often be(-i>iiios an acute inflammation, wilii grOut teiideitcy to disin-
tegration of the diseased tissue; af^er the tJiin, floceulcnt, hut nnl
badljr-uiieliJng piiD i» evitctintci), tliere !s occasiouidlj sauiuua sup*
puration, which amy be only teroixiniry. In such case« pyoania may
bo the winding-up of the whole di*ense.
It is dlfHcidt to BtAte thu caust^ of tliis change of course after open-
ing nf a cold abscejts, why the chrouie inSntnmation should so quicUy
ohungi) to an acute form. The eommmi supposition is, that tho
entruuce of air excites severe inllatnmatioa in the walls of the large
abeoesa cavity, which were alrfady dinpoeed to disintegrate, »ml that
the oxygen of the air is the especial eause of the deeoutpoAition. This
view may be correct rn uinny ca«et, but it is not the air itself or tfaa
oxygen that is injuriuua, but tlic organic- germs contained in the air
are tbe excitant« of the decora posi tion ; tboy find a partteulnrly
favorable soil for their development in the enclosed blood-wami space.
Nei-ertheleo» cases occur where the RHppiimtion, though pnifiise, re-
niuiiits iKrnign, does not become eunioua, and uotwilliBtaitding there is
high fever ; even is cwtc« where the pus ha< been c»iicuated without
PROGNOSIS OF CJÜUES.
4n
^Ihe entmicc of »ir into ihe cavity, and the opetiiiig liaji bwn closed at
ODoe, bigli fcvwr muy iJso occur. Ucncc wc must mtt bide from oui^
ßolvL'stlipfapt Ihal there are other inRuenres acting h<'re n-hicli wt-do
not perceive. I tliink tliat tlie nimple puDcltire mid the cbmigc in the
tension of the remclA of the walls of the itiiwx-sa may indue« iJie mrute
inflammtiti/m M^tli Its tendency to decomposition of the vt«|)s of Üie
nbuviw and of tlu) diseased bone. The ptw^ibility of the chrome
piT>c«ss becoming acute in this way justifie» the pmgnnsis thai «»pen«
ing of the «bsccas incrcMCs the daagvr. We mmy here add that the
genenil health is first decidedly affected by the «iippuration; cane«
Emigoea, whether running its course without üui>pumtJoti or with only
a slig-hl amouut, Js couet«<|ueatly Ivsa daugerous to life than caries
atonies, witb great tendency to Kuppumlion ind decomposition. This
pro^oslic! [x>int i» »1m baaed on goixl grounds, for, as we have pre-
vioualy stated, ]>rt>lifeniting' inflanmuiton- new formations ntore fre-
(juenlly occur under oompurativoly &v<oniblc cunBtitutionalcoodition9.
If tbe fungous proliferations break down quickly, if the Ruppuration
brcomes more profu&e and tbinnej-, it is a bad eign, a tiign that the
general health hau also beeotne impaired.
Tlie strength is used up partly by the prodoetion of pus, partly by
the fertT, iitid i» only partly replaced because reahBorptiun dors not
go on properly from the stomach, digMtioo is not good; this reacts
again an tlie local disease, and tlius the genc^ral and local slnte are
most inlimatety connected. The smaller the carious spot, tlie leMt
dangerous it ia for the general health; still there are certain localilics
where it is more dangerous than clsewliere; thua suppuration of the
vertebne, with large rongetition abeccMe», i» verj- dangerous, while
caries of the phalanges, even if ecrerml be altavkcd, has little effect
on the genpmt health ; then^ l« great diflerenee in ibe danger to life
acconliiig to the joint and diaphyscs allMcttfrd ; caries of the hip, knee,
or aukic, is far more dangerous tlian in the !<hotildcr, elbf^w, or wri^t.
Of this we shall speak more pnnicuWIy when treating of disenees of
the joint«.
Tbe age ia also of great prognostic importance in caries — tlic
yotnger the patient the better hope of reeorery; the older he is, (he
leu lio]>e : in caries coming after the fiftieth year, whether a sequent
of periostitis or primarily ns ostitis, llie progooais aa to recovery is
venr- doubtful, insignificant as the local diseftse may be at Grel ; I do
ni* remember ever to have s*en CJiric* in okl peiiüfiuR »n fr«i«ently as
at Zurich. I^BStly, the prognoüs depends greatly on the constitutional
disease to which the caries is due. Relatively, sypbilitic enrie« i» the
most favorable, because we can treat sypbilis the most sucoessfully.
Iti well-ooiirishcd children »croiiilouH caries also is rarely dnngeroas to
486 CSROKIC INFLAUUATION OF THB PF.RIOCTEUU, BOXS, ETC.
Iiri*,RAt)ic scrofula <lüa)>pears ftpontniieousl/, or after tlie use of proper
rcmedira. UuL oarics in atxoptiic scrofulous ciiiUrea is dangerous be-
cause Bucti chiUlrcQ cftstlj die of cxbauAtioo. Tlie profj^nosU id cuk*
is most unfuvonible where there is alretuJj-prunuuncvtl tubonmlotis; it
very rarely mxivrrn; the pulmooan' disease generali/ ad vatiocs rnpidlr
aiid Houte miUary tuberculosis develops iu tlio serous racrabraaes, and
Koouer or latnr tcTrninntes life.
The patient, dying slowly from chronic suppuratioD, gradualUy
gn\n tQorc and more cmaciiitcd, palv, aud very aiuetnic, at last
oedooia of the lower axtreinilie» comes on^ he cat« Icaa, and finally,
after yenn of sutfcTing-, ho dies of inansmits, often very slowly; loni»
timßs he sinks to rest quietly; somctiioos stru^lca for dnya irith
death. Formerly it was generally supposed tluit dvuth in these ease*
was solely duR to gradual exhaustion ; but more careful exatatnationa
have shown that the exhaustion and impoverishment of the blood
often bar« TOry palpable cau5«L For in th««e eases wo often find the
livor, spleen, and kidneys, in a state of fatty or amyloid degeuerauon
{Sjfoitttoae, 0. We^), u vuriety of degeneration wbiob consists in the
deposit in the substance of tlio organ, from the smaller arteric», of a
peculiar material eliaraeterizcd by it« lardaceuus con&isttince, and by
its reaction; on addition of iodine and sulphuric acid, tt cxilors partly
dccp-rcddiHh brown, partly dirty-browu violet, with a play of color*
into green and p:j.lc red. Concerning the nature of this materia) there
are t-anmia views, which yoii will find more detailed in the patho
logical anatomies. I shall only tell you here that tbe above rcactno
with iodine and sulphuric acid is similar to that of dioleslerine, and
tliat consequently Heinrich MtrJxl oon Sem^ach believed that the
fatty substance owed ita reaction to the large amount of Choles-
terine it contaitvcd. Others Üiought that thia material was allied to
amylum, and hence Tirehvie, who held this view, called it amyloid,
Kithne subsequently ahoived that both of these views were untenable
The so-calted amyloid is a peculiar substance, plnse^y allied to albu-
men ; it diETeni from albumen porliculnrly by its insolubility in acids
containing- |)C|»>in. From the mode of ita occurrence this material ia
very interesting and notewortliy ; it and fibrin« aro tbe only orgatuo
bodies we know that pHss in fluid form through the veasds, and oat*
side of these coagulate fuinly in the living body, without the vital
power of cells appearing necessary-,
The satumiion of the livec, spleen, and kidneys, as well as of the
walls of the intestinal njtcrics and of the lymphatic glands, with Cat,
must naturally bare great iuBucnoe on the fonnatinD of the blood, aod
finally prevent it entirely ; thus, in most of these eases death is caused
by disorganization of the blood. Extensive chronic suppuratiooa
TREATMENT OF CHRONIC PBRlOStlTIS.
4S0
tiy predispose to fiitty ctegviienitjons ; lieiic«i in pKtienta witH
extcaaive oarica vre sliould cuvfull^' attvnd to this point, though fre-
quently we cannot «rcrt it. Besidca tuberculosis and imyloid dcgva-
eniion, wbkli unforLuiiatctj not uafrequently combine, these poor
patients nrv occnsioDally uIkd cndanKcrcd by the commoo forma of
and chronic diffuse nophritiE, or morbus Brightii.
I will also mention that, in chronio inflammation of the periosteum
and boDC, the proximal lympliatir g^lantls oflen participate in the dis-
eafio. As in acute inflammations the lymphatic glands are often
infiltrated and excited to acute inflammation by nuteriftl coming to
them from llie point of disease, so io cbroDic inHammation» the same
thinfi^ oocut« and from tho same c«um. Tlic lymphatic fflonds swell
slowly, painlessly, but often enormouitly in th« course of months and
years; the tissue of their frame-work thickens, some lymphatic rca-
soU arc obliterated, while others increase in sixe ; rarely it goes be-
yond this hypejplaatic swelling; occasionally there are small abteeasea
and pcwnt» of oaseoua degeacnition.
^P Nov, after having examined chronio periostttu and ostitis from all
side», it is time to think of the treatment. In so doing, after Iiaving
spoken of thoiie disease» in their most i-arici extent and combination,
we must again begin n-ith simple chronic periostitis. The treatment
should be at oucc ^Bcnil and local; in all coses where dyscnaiat
causes «r« erident, thoy should be chiefly treated, and on this point I
refer you to what was said in the general consideration of these dys-
onsia^ in the chapter on chronic inflammation. Therefore in this place
we shall chiefly consider local rcmedic«. Ke^t of the diseased part is
the first and most general nile in the treatment of chronic inflamma-
tion of the bone; for moromcat, accidental blows, falls, etc^ may
change what would have been a mild, not injurious course, to an acute
and dnogerouB one ; hence, in most cases of disease of the bone« of
the lower extremities lying quiel is of the first necessity, in the upper
extremities carrying the arm in a sUng. This rest is particularly im-
portant in diseosea of the bone near the joints ; under such eircum-
staoces rest is often opontaneously resorted to because motion is pain-
ful. Some forms of fistulous caries boooine so quiet and painless,
when suppuration externally begin«, that motion has no effect on tlw
diseased bone, and in such cases moderate motion may be allowed.
Elevation of titc diseased port is a good adjuvant to tlic treatment,
for it avoids venous congestion. This mechanical aid to the escape
of the blood must not be undervalued.
When the first aymptoma of chronic periostitis and oetitia bc|^.
430 CmtONIG TXFI^MMATION OP THE PBRIOSTBClt, BONB, BTa
tTx.^ttacnt should aim at inducing reaolulion. For tbis purpoftc, power-
ful Kill iphlo^Htic rcmt^dtes nre of little uae. Thi' ajiplii^«tion of
leeches or cups, the tntfrrnal admnitittniLioii of jMirg»tiv<-», the nppl»-
cstioQ of bladder« of ii*, seem t»i mr tni\y U-iifücial iti «cut« exfc-w
bations of dironio iaBamrantion ; lli^r nntion is bIwajt« very t«inpo-
nirv, utid ihv Piii])1üj'iiii.-iit of local bloodletting and purgstires nmT
rvcn prose iDJurious if often repealed. The repeated applicaiioa of
lecchc« and cups ]>roves locally irrilan^ and may Rnttllj- ntalce the pa-
tient ansmic, and a eontinuaiice of laxatives exbausta his strength ;
hence we should employ these mn«lics spaiingly, reserving them for
Ihe acute exacerbations. Recently I^nnrc/i Iiu9 very urgtutly reeo»-
mended the continued application of hladdem of ice in chronic iiK
flainmation. In cases areoinpanied by great pain, I luve seen rcr^
guoit cScct from this treaimcnt ; in other cases I sec no true indio-
tion for their use.
Most frequently, at the very commeucement of ehronie infiainiiia-
tion of tho bone, the rcsorbcut and milder dorivatirc renu^diea are
proper: officinal tinoture of iodine, ointment of iodide of potiuli,
inereiirial ointment wenltened by ihf? addition of lani, nierciirisl plas*
ter, ointments made willi couceiitmlcd eolutioii of nitrate of Btlrcr,
hydropathic dressings and mild compression-bandages. With thcss
reraediea, and proper oonstitutional treatment, we make our first at-
tack on the diseases in question, if ihey are just eomroencing, and
oci'naioually we succeed in arre^ling them at an enrly stage. In the
early stages of serous and moderetoly-plnstie infiltration and BÜghl
macular eeiasi«, tlic rt-lmgresslve ciiaiigtrs either occur without leav-
ing u trace of morbid cliuiige, or perhaps leave n modenile fomintion
of oetoophyte«. In thin »lagi», the treaimenl of ityphiliiie diseases of
the bone b^ actire aotisyphiliilc remedies is the most sooccaafiiL
If the process progrcsacts und the caries runs it« course wilhoni
suppuration, ue may continue with the above remedies, and in suit-
able cases, in otherwwc rigoroua persons, may combine with the
above, derivatives to the skin, euch as fontanelle», the hot-iron, etc.
If the signs of aujtpuration begin, and abseessea form, yon may do»j-
tlnue the abnorbeiit reine<lies for a time, in the hope of even yet in-
ducing reabsorption; it i» true, thii« will not Riiceeed in moat iwies,
but the (jtiertion will «mon arise : Shall wo open the abscess, or wait
for it to oi»on f On thi« point I give you the following genenl rule:
J/ the nhnccM comet from a bone on ichich fw» ojirratton is impouthle
or Widairahie (as the vertebrrp, Bncnim, pelvis, rib«, knee-joini, rte,),
do not meddle teith it, but be thankful fw every day thai it remains
closed, and wtilt quietly till it opens, for thus there will be pclatircljr
the least danger. When I have departed frosi this principle, T bsvo
TBEATMEK-T 07 CHttOSIC TERrosmm
431
mlwnyt rcgtelted iL I saw, witli i^reat pleasure, that Pi^noyr;^ said
almost cxiictlj the Biuae tbinff. Ksperivnce bos Sufficientljr ebowa
^hat nono of our opt^nitions, aiming nt imiutinf; the slowspontitncotu
opening of these abscesses, prove aa little irritxtin^ ua tbe slow per-
foratinn of tho skin irova within by ulccnition. Vurioua mctliod» faaro
been proposed for opening large cold nbsoes&ef, corresponding to tlie
theorjps in regard to them. For a time it was lliwught tliat ihc pus
must esca|}e slowly, in order to prevent inHainmation of the absccsa-
wnlla. To accomplish thia, setoos were introduced, and the piu
allowed to tri«1ile from the pnint« of opening. Then it was claimed
that, hcsjden this alow escape of inaiter, the ekin should \w perforated
slowly. For tliia purpose, a oauatio was applied to the thinnest spot
of tlie ahfleesa, aod a slough made, wliicli gradually became deLiiched,
wbcrcu|>»n the pu« slowly eacaped. Subsequently it was supposed
thai we «hoiiM carefully aroid the f>ntrance of air, M this was tlie
dangeoju» {Kiint ; iio R trocar was introduced, a portion of the pus was
evacuated nod the opcnin;; acc^uratcly closed, or the soinilled subou-
tancous puncture, according to Abtmethy, was made, i. e., the slcin
otrer the abec»w was lifted up, and a narrow-hladed knil« was passed
under it into the abscess, a larpi- purt of the ptis was evacuated; then
tbe knife was quickly withdrawn, and the skin allowed to go back
into Ua original poaition, so that tlie puncture in tlie skin did not
OOmmiinieatr directly with that in the a-bscess-aac» but the latter was
covered by the akin ; the cul-aneous opening was carefully dosed.
Subsequently great importance was attached to pladng the walls of
the abscess in such a cuiiditiou that the fornititioii of pus should oease;
it was thought tbat this could be done by tnjceting solutions of iodine
after the pus was ovxcualod; this method was especially popular in
France. Recently a French surceoa {Cha$aainiiac) has returned
with great enthusiasm to the old sctons ; but, instoad of these, ho
chose line tubes of caoutchouc with perforated walls, so that the escape
of the pus wa» greatly facilitated (Drainage, page 160). Uster, an
Englirib surgeoi), particularly urges that in opening these absoeaaos
the iostruroeat« and dressings should be prefioualy disinfeeted with
carbolic acid, and also tliat the enlranoe of air should be carefully
avoided ; hia proooeding, like all previous ones, has enthuaiutic advo-
catea. It is not ejuty to decide on th« value of all these methods ;
but, wbcn such a number of remedies and mcihoila are recommended,
yoa may nlmoftt always decide that the disease in question is very
difficidt to cure, and that none of the remedies are ntitcd for all casesi
Let OS briefly criticise the above plans of trentmeat. A single e\-aciK
ation of the pua, do it as we may {we regard free openings of con-
gest it« absoosscs as universally abandoned), has at first a tolerable
19
432 CintONIC I}fFL;il[l(ATION OF THR rERIOSTEOM, BOKE, ETC.
result, if doiMJ slowly and carefully, wfaether with Ute trocar or 8ub-
outaneouftly with the knife, with or without LiM^t oarbolio-B«id
treatment. If the opening is nicely ckwed and lieuls up, ttiere in usu-
ally no fever, but llie absoeas fills again very quickly ; an abaceas thai
probably toolc ten month!) to form, may fill again tn ten days. Tbia
is also punctared ; the oppiiitifi agnin eXotn ; the |HiLii-Dt grows fcver-
i«ti ; tlir pus again ooUfcta rnpidly. A thinl, and pt-rbaps a fuurtb or
fiftbf puncture i« made, always in a Dew »pot ; tlit: patient grows more
fevemh, the absoess is hotter and more painful ; Uie pntieiit looks
languid and suffering. Now the points of punelure cease to bcal, the
preriou» ones open again, there ig a continual e»^pe of lualtcr, and
occnsionally, in apite of all our care, air entera, especially when the
wallH of the ahseesn are rigid and do not collapse. Now tWre ia a
fistula, thu fever is continued, and the subsequent course ia xaott un-
iiTorablc, a^ wp ricHoribed it abcTC. So far as my experience goes,
tlie course i« not much cJiangt^d if tite puncture be followed by injeo>
tJon of iodine. There in not much difference if you make the opening
wiÜt a seton, with drainiLgc-lubcfi, or by cauterization. 1 have seeo
notJitng from any of these methods that in the least approximated the
c-IainiH of their proposers.
It is true this unforiuuafe oouree niay be run if you do ootbing to
the abi>cr«s but leavi> it to itself and nwait ita opraiing; but then all
progreases more mildly and slowly, and fever eomea on later. Reoor-
ericB take place under all these mode» of trealnicnt, but I think tbore
are more recovcrie*, nnd certainly frwer deal])« from pyiemia, under
the *>xpectflnt treatment, "iam eatislied that where recovery has fol-
lowed injnctJona of iodine, drainage, etc., iL would also have occurred
bad the course of the disease not been interrupted; we cannot accept
the nKM^rtion that a cose would ha^e nin its ooume tJius and ao, if this
and that bad not Iweti done. Summing up my own experiences, I
can assure you that, of wry many cases of large oongcstivc »bscceses
along the spinal colunui, nrtißeially openod, I know very few that mo
a favorable course; the others were only hastened to theirend. Qenec
I »gain repeat the previous assertion, t^at these atMccssce, espeaaUy
congestive abscesses from caries of the vertebra?, are a noli me tangert.
In such esses it ia indeed frequently very difficult to wait ; in private
praetire, cBp«^i»lly, the pattenis heeome impatient ; the sur;geon is urged
to do something, it is cast up to him that he does not trj- any thio^;
tlie public firmly beliere» that, if the pus was only out, reeoveij' muat
follow. Tlie surgeon also at length becomes wearj-; it is trying
to look on from week to week as the abscess increases; all local
and oonstitutionul remedies are exhausted, and finally the 8Ut;geon
departs Crom his priiidplcs and makes an opcaing ; at first all goe«
TREATMENT OF BOKÄ'
4SS
weU, but Ui!s duci not oontimie ; you already knon- the stilMcqiient
counip,
Tito case is sowcwliat difiercnt wbca wo have to deal yviüx »mall
«tAnv-Mu originating in diseBse nf bonts of' the tairemttiea ; tti siippu-
iBtions connected with the larger joint», we alco villinglj jxmtpoiie
«peniog ; we shall speak of Ihia iiorcaftcr, under diicuM» of the joints.
]n «-old abscesw?8 fmm iho dinpiiy^f« delay i> not of muoh nvnil ; ht-rc
I nither oonsidur an varly opening as proffer, except in »yphiliiic
^ummala; in these cases there may be rcabsorpt ion, e%'cn after there is
cvidimt flurtiiatioi), and in inarkcdiy tiiberciiloti8ordebUi(at«^por«ODS,
in them no operstire interfeience i» iadicat«d, and opening the ah&c(>M
would ooly induce profuse suppuration, without doing any gnnil. In
the other cases 1 am in faror of opening the ahewss freely, to obtain
a rJear view nf t]ie variety and extent of the disease; under these
circiiinatanoes the reaction is insigtiiricant, frequently there is no
fever, often there is modcntto fe^'er for a short time. Let us suppoae
a chronic periostitis with caries superficialis of the diapbysis of a
hoDow bone: un abscess lias funned and been opened ; the woimd is
at first drc8«cd with charpic, and wc then wait to «ee what appear-
ance the Kurfa«! of the ulcer will assume. Tlie local treatment should
be mcxlilied according as the ulcer is proliferating or accompanied by
breaking down of tissue, and I should only be repeating, wer« I to
refer again to the proper remedies. The treaimciit may be aided by
local baths, wliich we may render slightly irritant by the addition of
potash or Uooturc of iodine. Wei compresses, cataplasms, cliarjiie-
nrnds wet with various fluid», scn'c us drcseingii. llie mbscqueot
course will show more and more to what extent tlie bone^scase d»
peods on tbe general health. If the patient be a weakly, tuberculous
indiridual, all loeal remedies aro in rain ; if the general health be
good, you may even reoort to energetic local treatment. If the ulcer
does not improve under milder i-cmedies you may apply the liol iron ;
should this be followed by formntion of strong, healtby granulaliona,
it is a favorable slgii, even if there he necrosis of the carious piMtion of
bone. Id other cases wc abandon all idea of induciiiff bcniing, and cut
out the entire afiiyrted part. For this purpose there are various forms of
cutting forceps and saws ; I prefer detaching the diseased l)one with
Bcmpcrs, gouges, and hamnKT, to all otbcr methods. If the ulcer of
the bone has been cleanly cut out, and the general health be tolerably
good, it is to be hoped thut the wound of the bone msde in tbe opetv
tinn will heal normally by bcnlthy granulation and suppuration, as
other wounda of bone do. %ould the caries affect a small bone, it
may be proper simply to extirpate tt, to arrest tbe process at ouccl
If the case be ooo of ostitis inl«rna, caries oentcalis i^ a hollow bone.
434 CHROKIC IMFLAHMaTION OF TtTE PERIOiniBCrM, BOSR, KTC
or of « Urge, »pongy hone, sucb as the oWnnm ; if »e?ere pain Mtd
other prcnoiulj-iiiciitioiicül symptoms of l)on(.*^bsoefts graduaUjra|^
pear, it mny become jwopt-r to rlitsel out the Iwoe, or open the t»riiy
oT the boiiK and let out ttic [nis: bittloDlyiulTiBelliisopciraüoa vfaeti
)^}U arc eure of your liingiiosis, for it ta ao al%ht injury to a patiout
to have X healthy metluiUry cavity opemcd. V'ory acuK> osKwmyeUlis,
with iu often dnngemus reoults, may arise from nntimely intcrHerenoi!^ ]
while « similar operation on a dineased bono ia not usually rery mii-
ou*. In ntber coses ynu will await the Rpnntaneoua opcninfi; of the
abscess through the Ix^iie; then you may ii»e a prol)e,anil jixlge accu-
rately of the slate of nfbirs. The obetnclca to tlie hualiu^ of such
oxcamtions in the bone hnve l>ccn prcnoitsly muntloncd ; aliould tliv
proecs« n.>tnain statiuimry for a bm^ titne, it may be best tc enhu]ge
the opcninjf in thtr brniR, expose tlic abscosa, am] rcmoro its walk ;
this will be the tnure necessary if there ar« any stuaJl occrosed par-
tions of bone in tlin abatwss-wiTity wliieh prerent its heating ; thatis,
if thr: casr^ ho one of r»rii'g necrottcn. litit all thi>.se mai)ipi]lal)oas
are only itxlicoted if lb« funeral bealtli b« good ; if tJiere be »A-
vnnred tuberrti1os!<t or marasmus, nmi the diüeas« will neoesiaiilj
pmre fal»), no surgi-on would wish lo do an openition which cnii only
prore successful ivhcu the local changes in the livw vrouod of ÜMt
bone go on normally. These operationa, part of which, at least, may
be c1as9c;d anmng the partial raeriiona in the continuity, hs?e loit
their cruel atnl ierriblo appearance since the introduction of chloro-
form, by whose aid the patients eAoape feeling the chisj!!, bnmraer,
and saw.
In thoee coacs where the caries is so exlensjre as to affect ibe
whole thiclcnoAs of n long Imne, we mi^ht think of nawin^ out the ett-
tjrp diseased part, Tlii» (."WÄe is very nire, au<l such oiierations are of
extreuifly doubtful benefit, Wc might, it is true, saw out a piece from
the middle of the fiWIs, radius, or ulna, &otn the metacarpal or met»
lantal bones, without greatly Impairing the function of ttie rslrrimitT;
but, should wo do the same for the buTncrua, femur, or liliLa, nml re«
eoverr take place, the funolion of the extremity would, n! mudt, only
be partially restored by aid of an apparatus ; io the lower extiemitv
an nrliScial leg imuld be of more u»e than a le^ tliat had lost a oon-
sidembie portion from the contiiiiiily of the bune. It has boeo
thought that the periosteum, detached from llie bono iK-fi^re it is
sawed, and left in tlie woimd, wouhl fbnn new booe; but after opera*
lions for earios Ihi» refreneration of booe ia very »canty, so tliat we
cannot count much on it. Moreover, caries is the rarest indicatino for
these total resections in the continuity.
Lastly, in regard to those eases which are on tlie whole rare, where
TSBATKBKT OF BON-E ABSCSSSSS.
4SB
ft hollow bone b diaeaM<l Uiroughout will) periotUtts, external uid
iatenuU Okric», purliul iulvrnul and czlenuJ uecroau, tberc cuu uuly
b« a qutiKLltiii uf txiirpatioH of the entire Öoiw, or aii)]Mil4itiuit ul' tli*;
afluctcd limbi Cam-s of c^xrirpation of Uiu viiUrc ulon or ntlius w>
cukmally tum out well ; cxtirpstioDS of tbv lirtst tnvtucurpal boac ure
often siiooeaiifuL I alao know of a cas« where the irhote hurocru«
ms retnotrerl, leNviug Iwliiiid the tbickeiied periosteum ; Init the |)i^
tieai died u Eew moulba aftvr the u|>enitiuii fjoiii eonie iutcnial diif
MM, morbiM llrif^htii, if I mistftke not, «o thai no decision could be
nmde about the uttefuliie»« or the exlrentiljr ; iu 8i>it« of the alueiioe
of thr hutiicms, the liuud oiight have bceii uf «c-rvicc, which of itttctf
would have i>o«a a fprcat guin to th« pnliunt. Cnrics of tho short,
spongj' boiiH«, luid uf tbe artioulur upipliyitoe, in so intimately con-
nsotod witli diacaitcs of tbo jointa Lbat nc sbuJl discuss it berca&er.
Tlie stAtc of general tnantamiiä that finallv occurs from didoascs
of the boo«, vritli extetisivu suppuralioti, is to be treated on general
priiicjfdea. We should try to prcTcnt ita occurrence, or at leaatward
it off to the utmost. It is the pbyuciaii^s duly to preserve life us
lonj^ui pouible. It is also his duty, evea ia a patieut aluio^l eer-
tainly dying, to ^ivo btin every thing Utat csu keep up hi» strength.
Nouriflbiog, ti^Dit, »tretigtlieoiog diet is to be given from the time
tl»e first symptoms uf emaciation show the Jailure of nuuitioii; lulor
it is of no tise. Iu ohildreu and young persona tit« iiiexjjcrieiiced
ph>'Btciaii may readily bo decotvod as to the BtrcDglh, and yim will
lierrafter see lbat |)stiei)tE in n very bud tttate, emaeiated to a tikole-
tnn, and cjiccssivdy anannic, pick up noodcrfiilly and unexpectedly
on amfiulatioa of tlie diseased liwb, which si-cmed to he ootittimiing
tlieir life; of ooutse benefit eould rarely result from resection under
audi circumstances. How far it is safe to carry the principle of pre*
serlug the limb by sawing out the diseased portion of boue osa
only be judged of in individual casea, and then only upproxinutcly.
LECTURE XXXV.
lf«cro«1«.^B(lolO)ir.— AuBComleal CondltlMU In Total snd Pntlal HmtokIi.— flymp-
toBis sad Dia^Mti. — Trostaiciit.— SsquMlNiooi?.
OKiTTLKHBar : Wc have nlrcndy frequently apokcD of " necrosis,"
and you know that by this tocm we Ricun gangren« of tlic booe,
death of a bun<.>, or psrt of a bone. I have also told you that tlie dead
porttOD of bone is called a M^ttettnun, Vou also know tliat necroaU
496 CHROKIC IKFLAMMaTION OP TOE rBRIOSTBCM. BOXB. ETa
majr result «ither from an aout« proccfts, or ucoompany the prorcM of
ulceration as *' caries necrotioa,"
An in death of aay piirt, neuution of dreitlatioD*it also tbe iin-
roc^alc cause of necrosi», while ccssiition of iicn'ous actiTity doea
Qot induce it, although a disturbance t>( nutrition, an atntpliv nf the
bone, ifl occtasioiially sc-uii iti |Mirulyzo(l parts. Necrosis mav be due
to Tsriaus caunes; we Rball bricflv ^oup tiicra It^tlter:
1. TVatanatic i/ißuertces. Among tli«fte are aeveru concussions aud
injury of the t>on(>ii, rven without (external wounds. The ooime i» u
follow»: Ae a rrault i)f lUe al>ov« ittjuriiftt there are «xtravasatiuna
in the medulla of the bone, also iuto thu spanf|:j bones, perhaps also
in the compaH bony substance, and occasionally under tbc periosteuio.
If these ruptun.>s of the vi>as(<l)( bu ko ()xteuBiTc that th<^<ir results
cannot be muorcd by collatrrul circulation, whicli ia of ditÜtmlt en-
iabliftbineut i» boue, part of ttie bone will no longer contain any
blood; this will dit>, mid, nccording to rirrumstniKrt'K, we may have
oentrAJ, KU]>frrridHl, or t'ltal necrvHtio (the latter occurs most mulUy in
the strudl bones). The |)ortion of dead bone remaiiifi in the ni^niAm
as s foreign body, but still cuiitiniitu in rontinuity with the healthy
bone ; the solution of the sequestrum, by liquefaction of tbe Iwne-
0i]bsi&ncc in the honler of the living ti.'sue, has been alroiidy ex-
plained (page 195). Another mode of injury is exposure of the sva*
face of the bone, or turning through a bone, by whioh tbu aawed siu^
face bccumcs the surface «f the Ixine; in complicated fracluroa 8
piece of hone may be so denuded of soft parts, and thus robbed of
its ctpcnilation, tlmt it bi?i!<)nic«t necrosed. We liavo also explained
why the exposed bune or suwe<l surface docs not altva^'S become ne-
crosed, but that the bone may, like tbc soft partf^. immediately pro-
duce gninuhtttouB. Xovcrlheless, after tbc above injuries, supor&oiai
or partial necrosis is common entJUgh, either bp(?ause exLenairo clota
form i» the ends of tbe injured Tesaela of the bont>, or because the
rcBScl« are comprcsMKi and »upptirato on account of the acuto suppu-
ration in ihc Hflveretiiii etinals.
2. ^-Ici^ perio*titU, otttUts, and oatfomi/eiitü, arc Tory rrcquent
causes of occasionally cxlensivo and especially of total uecrottia of
the hollow bones. In suppuration of the p^frioHtettm the sup]>ly of
Uood to the bone, by reasela passing tiiroiigh the periosteum, is cut
off, and the suppuratioR ia propogatvd through the Havcniao canals
to the mcdtillary cavity ; if th« latter also suppurates, ncerosU is in-
evitable, and will extend us tar as the inflamniation did. Tbn same
rcsalts will occur in primary acute o3titi.s and osicomyelitis with se»
oudary periostitis.
'i. Chronic attilis and perioatitis may combine with uocrosis, for,
ASATOiTT OF mSCBOSlS,
m
H ton
Pbor.
DC
jont as in Ac ucutc proocsncs, suppuralioiit diasKc of tlic inflHmnia-
tory new forro>tion to detritus or coseoue mAtter, exiendd into the
lo, atid BO impaim itc oirculatiun tlmt purt of the bone is no hmger
Duunsbcd anil must necrose; atoaic foniis of rarien induce necrosis
ore readily tbun the fungoos forma, as baa already been »tul^d.
The necrosis that is supposed to occur after thrombosis or embo-
ism of tlie cliief trunk of tlie nuirietit urtKiy of a bone appt-nnt to
be of more thvorc1it.-3d than pructic«! imporUinc'C. Tliia ruicty of ao>
croais has hairily been proved by di««eetioiis on man ; it 18, moreover,
very improlMibk', bemuse the arterial supply, iu full•^TO^«'Q hones,
comes from so many sources that stoppintf ouc oi the many afferent
bnuidiM dues not sudtoe to completely urreHt the cireulation in any
idcnblc portion of bone. Although the collateral circulation in
le caiuiot, from mechanical causes, be greatly facililated by dilata-
ion of tbe vessels, and lienco in capillary stnsjs there is always clangor
of p.-irtia] necroMS, a.i already stated, still llie conneeLiini, arrange
meiil, and regular diatributiou of the cupillarie», e\'L-n in the firm cor-
tical substance, arc suob that when tbe affiux is interrupted from one
source it may ea&ily irom« fn)iii anotlier. In 1>one tlieni are no defined
Cftpillnry tict-works and cupillury fn^>u{iaaA in the nliin, but all th« ca]>-
arie« ar« intimately connected in nil direction«, tis in the miiätles.
Tbe experiment of iiisorting- a peg into ibe furanien nutritium in
up|)er part of the tJbia of rabbits lias been tried, and it lias been
followH by necrosis around the peg. 1 have made this experiment
Slid obtnineil the same result by inserting the peg at any other part
of tlic Innr, nnd hence I believe that this ex peri mental ly-iiiduced ni>
crosis depeixlft only on the variety of the injurj' to the bone.
It will be proper now \o t^Ludy more uceiinitely tbe anatomical
tne of necrosis, especially of that coming after acute periostitis
osteomyelitis. I bavo already told you, on various occosiona,
'■when treating of the healing of fracture* and of chronic ostitis and
periostitis, titat tlie vicinity of such collections of pus is almost al-
ways affected in such a vfuy that osteophytes form on aud id the
bone; their development ix greatly intlueaeed by the periosteum, and
also by iJie siuTounditig [>arl«t (where tliey form after fm<;turcs),
Wliilo Aolid healing ia due to this new formatioa of bone after frao-
tan?s, in chronic ostitis and perioBtitix it is mmre an aecidental prod-
uct of irritation, which subsequently has no further significanoe.
The same thing is tnte in su|teritcial mxTO'iis. When, from new de-
jXMition of ost«>ophytC8 around the se<iupstrum, the bone becomes
■n dense around the point of disease, whether this be exfoliation
of one of the cranial bones, or a scqui-atrum from a aaweil »iirface,
it boa no furtlter practical tmportaace. It 'u different in complicated
^
^MO]
«3B ODROKIC TNFLAllMATIOM OF THE PEniOSTEITlI, BOKB. ETC
Amcturcs: when the brokco voda or noulylooso £rag^coui of bow
beoome necrosM, the formaliun üf ii«w buoe ia the vicinity may tuA
odIv induce future fimiDPas in the bone, but the soqueitruu miiy be
eiitireiy enclosnd by th« new bo»e,a[Kl it may be oeoeesary to rvmuve
it by operation. But this formation of nev bone in most imporUuit M
in U>UU necrosis of entire diapbyses; it is intended to repUca tlx 1
bono wliich dies. This very important proocsa, which üt ao wondec*
fully ftc<omptt«hcd by Xaturo, we imist now study more ourcfuily.
Let us ttuppoKtf an acute (otiil periostitis und uatcomyi'litis with n»
orosiB of the diaphysis of tho tibia. The cittirc pcrinetcuni and me-
dulla have suppuratod ; within the bone the pus falls to dc-tritu», or
actually putrefies ; the ptis firom the periost«uni has perforated the
ekin nt various points, the drcuiation in the diaphyats baa ceaaed ; tl»^
entire diuph^-sis is a aequestruin. A longitudinal «Mtioo give«
following appcaranoe (b'ig. 71} :
'•>'- cr^^^^ -~ ilS
DI«((Mior loUlcccTMliof IhadUpbj^liefaliallciw hoam.
a, the sequestered Tione; A J, its upp«r and lower extremities; c<^'
puA aurronnding the scqueslnim ; d d, where it Una perforated cxUxf
nally. The darkest layer, e «, is the wall of a la^^ absee)t»«Bvjty,
which con^isl-t of tisHue (connective or tendinous tissue, or even of
muHctc), infiltrated with plastic matter, and on ite inner mirfBcc, which
lies next the Bequestrum, like any absoMs-eavity, it hiut n (i^nalatioo-
layer, which constanlly produees new pus. I will mention ut once m
tiiat tbia view, its in acute puritntitia, difTcrs rn>m tlint of other but- H
geons and nnatomiittx, hec-RtiBc they »tipposo the tcndimnu portion
of tlie periosteuiiii is tiflud, like a vusiele, from tlte bone by the pua;
this is incorrect, because the t-endinous portion of tbo pcriosteom Is
not sufficiently elsxtic to be quiokly elevated like an epidsm^ reaii^s^
and because Utis elevation would fait to occur at those pointa whors
there Li no periosteum, i. c, where tendons are attache«! to tlte bone;
but the latter is not the case. The inflammation and suppunUioD
rAOHMBNT OF THE SKQÜESTRÜlf.
480
begin partly in llic surrucc of tlie bone, |mrtly in Uie sotier jmrta of
the perkwtcum, in its outer Injcr« ; the tcndiuuus portion parttcipntea
bat little ; indeed, it is mostly dcscroyöcL lit proof of thi» I have wry
derided minlOTnioRl eviderK-ea. Thn anatninista and surg«ii» who
believe in ilic rkvtition (if tliv jieriociteum conoidcr tJie aiiaded layer,
« «, W infiltrated, tliic-lccned perioBteutn ; this ia only canditioniklly
true: it niikv hspj)«i) l!mt piirt of tlie pericwteung dues not suppurate
and enters into the eompoaition of this Iiiyit ; iiowtn'iT, olbcr udja(%nt
part« may also be £0 indumtc<l In' plnati« iniüJtnttion as to fomi n firm
abseess membrane, as is ofleti seen in abscessL»« of tlic soft purta,
MHioerer maintains the exolusivo power of the pcnnateum to produce
booe will, on tbeoretica) grouuds, regard tbis layer, e « (where bone
Is subsequently fonned), as thickened perio&teuin. liut, in the forma-
tk» of cmltus, nftt-r fmclures, we liavc already seen that bone in COD-
eidcrable quantity may under ««Ttaiii circumstances be produced in
CPtber «oft pari-s lyin-r near I lie Ixiiie, mid hence we are tiot obliged to
demand periosteum tu this thickeitc-d layc-r of the ubsc'cas.
But wo arc ^in^ oQ too rapidly. Lei us return to our exunple»
Thei pus-cavity around tbc eequeblrum cannot close till tbu latter is
out of it ; but ihis remains attached at both ends. You already know
iHnv thedcta^'liinent i» effected: at b &, in Uio c4ge-8of tlu> living bone,
tbere is an interstitial proliferatioD of gmnulations, by which a ali^t
amount of bone is consumed, so that at last tbe osseous suhstance is
entirety replaced by soft granulatiuna at tbetse ends ; this completes the
detadmient of the sequestrum (see page 1!)5) ; the granulatioDB form-
ing here break down somewhat, soften to pus, and then the sequca-
tnim lies loose in a pus-carity, which in lilled willi pToliferaling granu-
lations. In the thick hollow boncä this detachment of tliv sequestrum
requires a lon^ litiii>, uHimlly fievern] month», Honietiines oit-r a yetir;
up to this time the pus lius escaped from tbc places where it had pei^
forated tbc »kin ; if, during this tinw, you introduce a prob« through
tbeopenitigK, you may usually feelUiasioootb surCaceof Uie diaphysis.
Butv during this proucKS of deUrhRWnt of the aeqiKstrum, something
elae is generally going on iu the immediate Tidnity, to nbicb wc shall
now turn our attention. In Uio thickened layer of the pus-cavity, e e,
new osseous ti*snp has formed regularly around the seqiicBtnim longi-
tudinally; this o^tificativin liaa al»o continued to the part where (lie
tliickerted layer again joins the periosteum of the i>|>jphyida and the
cajMule of the joint, so that the hon»capsutc is intimately connected
with the cptpliysis a1x>ve and below. The longer the sequratruni
remains in the cavity, the mow the honv envcifvpe increases in thick-
ness; in time it becomes very tbkjc; iu the course of ymre, if tbe
sequestrum does not ouioe out, it may be orer half an incb tbick; st
UO CHRONIC DIFU-UUATION OF TH£ FERIOSTKDX, BONK, ETC.
tint, it ooiisists of purtnis bone, but nubac-quciiUj- is more ccnDpttCt ud
■trofigor. A rcfpilttr cut liu been formet around the sequcstmni,
just like w« sliuuld initke of plastur of Farut if we wish to moald an
object ; tliis cast, bowcvor, hü« several opening, laspcciallr wbcra the
pus escapes} tlicir closure is prevented by the conelAtit tlow of pu&
The ^x>ve piutura (Fig. 71) baa ao-w oban^d to the following
(Fig. 7») :
VM.nL
Dlai;niii of tuul oMfMb of tbc diaphr*li ufi hollo» lKii>».i>ltli «dtoebad Mqii«ann na
new boar neapUd».
The scquVBtrvm a la detached Bud bathed io pus, which is »ccrctod
from the gmtiuliitions'abovc meiitioiied; d d^ tbe fibtul^e li'uding tulo
tbc pus■l^arilJ■ (they have received the name cloaca) ; eeii tbe bon/
envelope derived froni the ossificstiou of tbe thickened abaceas-wall*
the su-ealled bony rcecptnele. This tliiekeiiing now progreasc* ttgtt-
larly, if the irritAtiou eaused by the sequestrum coatinacs. Let ua
now suppo«c that the ecqucitrum escapes fiom its case (as happeus
oocasioiuilly— of tbJs later), tbeii, altbough all the bone of tbe diaphy-
W\g. IS, >nar raiDDTal of Ui« («qtintinini.
sis i« losty there is no disturbsooe of function, for tbe aewl^-farnied
boiu' envelope üupplies the pinro of the bone that baa Ixrcti loot,
Xow, what happen«? Will tbe CAvity in wbiob tltc sequestrum
44S CHROXIO IKFLAUHATlüN OF THE PEEIOeTECH. BONE. ETa
ff che indiv-iduol afTcctod bo coostitutiotiaUji' diseased, or booomce so
from tlie cootiaued euppuiatioa aoooiupMyiog cbe proocaa. lii Uiese
luDg-oontiuued ftup])urationH from bone, albuminuria not iiufrequi>DÜ/
develops, althougli or niÜiRr mild furtn. I do not knuvr wbctlipr lliu
may in timi.' apuataucuiisly dUuppcar after tbe cavity io the bom has
liealod ; it would be iiiU'rcsUng und of prognostio importaooe to ooUeot
obaervationsoiithispoint. After rmnoral of the setjuestnim, the thick»
eoinff of the osecous envelope ccasea, and the ptoooas of ossiKcation
establififae« itsvlf in the I'&vity üUed wilii ^mnulations. What I have
juat dcRionstmtcd to you in diagrams, you here sec in thcMe beautiful
prcpumtioti!} fron] the anatomical and &ur^c&l oolloclioo of Sliridu
Vou now knniv the ordinary normal course of a tteorodt«, I muttt
nest introtluce you to some deviations from this normal rounu:. Vou
will TcniL-mber that, when speakinf^ of acute periostitis, I tuld you that
occRStonolly the opiphyscal oartiloj^ aim ossi&cd (where tbcjT Mill
cxist«i:l, that is, in youiif^ ]iem»i»). VPIien thta takes place stBiuJta-
Roously in ihr uppt-r uml tower ends (ii very r»ro case), of oourse iJie
soquoFtnim will be detached, and diJtacheil very oariy, so early liiat
no bone can Imre yet formed io the pus-cavity, or, if it liux, it must
still be very weak. If the bone be now oxtracted, thero b nothioy
yet formed to replaoe it,tiordoes any thing foraa,betiau«etlie irrilatiaa
which gives rise to iha production of bone is absent, this cauBC of irri-
tattoQ being t1ii:«H|U(>«truTn, na long tia it remains oa a. foreigti body
in the bone; hence, under tbcsc circumatAnccs, if tlto se<)ueatrum be
extracted yorly, the extremity b(>comes boDeleaa and unservioeable.
When the epiphysis eartUage Huppurates at one end, e. g., the loner
end, tho Bcc]ucstruni rcmuiiu firmly »ttnc-hed above, und the break-
ing down of the bone muiit go on »lowly as in other coses ; It T>%y,
however, ltai^]en,a8 I saw in one cuMi in tha th]gli,that the lower end,
PM.fl.
NMWtU of tha lon-er bUf «4 Ihf iUiphj>(li at the famDr, «rllh <l«tMlUn«nt ot tlM apl^lu>c«l
catUlice. and porfonUan of Uh ilcla.
DETACmiENT OF THE 81QUKSTRÜM.
443
loose in the cpiph/sifl cartilage, pcnue» stmngly against Hie skin from
wiihin apd (jjadually peribiatca it, so tJi»l it »ppeats extcnwiUy; Üic
lower epiphysis of lUe femur u'lut mt the Rartw time drawu up by ihe
nmscles, so tliat tbc ap|)enniiire was m» follows (see Ftg. 78).
Tht se<iue9tmin. subsequently n:i»ovcd, hud Um following form
^Fig.77):
^K rtan.
1%t tKMtr ennoud from Ftc. n.
The fonnatton of bane wm strong enough to ainy the bodj ; siib-
Kqueiitly. under eblorofonu, the knee was str&ighteaoil, »lul |n:rfc«t
lecovcrv r<>*iilt*>d. I saw a perft^otlj- similar case aSrcling tli(? Iniver
end of the humen>8. In both cases, as is iisuilI in nci-rr«)» ucar ihc
jointa, the joiot hud suffered wv«relj, and became quite stiff. Still,
even witliout cnrly (lL-t-i(;hiiiciit of tho »cfjuestriitn from sufloiiiiijf of
tbe epiphyseal cartilages, under einnimiitanccs whii^h wo do not accu-
itelj know, the formation of bone may be veiy feeble, bo that, after
'Hhe dotoohment, the new bone is not 6rm nt some point, but ia quite
flexible, whereby we have n jHteinWUirosis of the new boiief I have
ecca two cases of this kind : one of these I curr-il completely by occa-
BJOoally driWng ivory plugs into the weak part of the newly-formed
booe, thm constantly stimulating the bone to new production ; the
object was attained in tlie course of eight ntantli», and tlie patient,
thoD twelve yean old, dow wollu like a hcoJlhy {wrsoni
Fm.'S.
444 CHBOSIO IKIXA«»ATIOK OF THR rERroSTEtf«. BONE. BTG
.Partial Tueroti« of tfao iUapbysü ia more frcqtwnt than tbe abort
complete necrosis ; this m»j' either affect ihe entire thickoeas, or only
half the circumfeieoce, according to the extent of the osteomyelttisUMl
periustitis. You tnay readiljr apply what Ims been saici to theae far
tial nAcmi»!«. Hr>re ia an ejiample : suppose a pe-riostJtii of part of
the diaph/sis of one f^niir nnd sti)i«equent nectouU } tlie circuBtttaooa
niiky ussuine the following shap« (scv FigB« 78 and 79) : a, eequefr
truin ; Ö d, its borders ; e f, the pns-oarity ; dy the perforation out
ward ; e ^, the thic^eoüd ossifying trail of tlw pua*oavity.
A few months later (Fig, 79) ; <B| detached aequv«trum, which is to
F». ft.
Dt^na o( nc- IS lo 111« Uur iusm, w KU (bnutloo cf aatr Ikd«.
be removed; « e, ncwiy-fonned bone-tissue as substitute for the ]Hcoe
of bone that is being tost ; of miirse, tbe newly-fnoned bone coren
the aequestnim anteriorly, but, u» in Pigs. 71, 72, mekI 73, must bo left
out to expose to view the sequestrum. •
Ft« «X
nj. n,«Rarf«naf«]«rib«Mq«ralr«ia
The dianges thzit tre hare now beeome noquaint«d witit may atao
be applied to iHcrwh in ßai and apon^j/ efwH baitea; but at the aame
DETACHMEKr OF THE SBQirESTBlTI.
44S
time we must remark that in necrosis uf Uio^ bone« tlic new format
tion is ranch Jess, often entirely wanting, bccaii»; Ihc inflammation
bcre is porticiiläriy of coustitutiotuil ori^ii, niul titiicv occasionally
deviates from the uonnal course; as a nile, the inflammatory neo-
plasia in Dcorosis of the spongy bones sooa aasumea the ulcerative
eharacter, and then tlio formatioti of new bone is but alight; monv
Bbver, acute, ooo-ttaumatic perioatitia is something very rare in spongy
^^ Extenaire neeroais may even oociir after originally pure oMifying
periostitis and ofttiti% in case t)ie newly-fonncd ossiAc deposit is re-
absorbed, suppumtra and deoompoiH'S nt the point of its attachment
to tliedJscneod boo«; this KrncluiJIy afTccts the nutntioitof the bone;
i( often poutiuuea to live for a long time in the medullar}- cavity, or
rather leads u half exietence bctweea Imng and dying ; this variety
of periostitis and necrosis occtire cepecidly in the maxillan- bonce
after chronic poisoning by phosphoruua fumes, a disease peculiar to
worfceja in match -(actoriea. I cannot enter more minutely into this
phosphorous periostitis and necrosis, which has many noteworthy
peeuliarities, beeaiise it would be necessary' to load you witJi loo
many detaib, whtdi would now confuse you. If you bear in mind
the abo%'c-dcscTib«l course of necrosis in the hollow bones, you will
have the opportunity of Icnming in tlic clinic all the deviations that
may oäcur in any case, from peculiar circumstance«, for nccroeis is a
relatively fn^uent disraso of the bones.
X cannot leave the anatomy of necrosis and the rcgy>neration of
accompanying it, without mentioning an exoellent French
rorkcr who has spent many yean in the study of the osteoplaatjc
power of the periosteum, and has nobly carried forward the previous
works of 7Vt*Ja, Flmitvim, B. JTf.iuf, A. Wat^nrr, and other», on this
subject: I mean Offür, who, with untiring zeal, has pursued this stody
eiperimentally and clinically, and has closed it up for a long time ; I
have repeated part of his cx^ieriment«, and can only confinn the idea
that Dnder certain rJrcumstuuoea, iu young animals, prcserrauon of
the periosteum decidedly favor« th« reproduction of bone. In the
ooitrse of these lectures I have already stated my opinion regarding
tlic osteoplastic power nf human perioeteum, cspocially as coinjnred
with other soft parts surrounding the bones, and hitherto 1 have found
views ocHifinncd by every new eiperienoe.
Wo t»w pass to the aj/mptom» and diafffioti* of necrosis. Dis-
I of the boiw is called necrosis from the time it becomes c^-idcnt
• a part or the whole of a bone is dead, tilt the sctjucetrum is re-
446 cnSONIC tNFUmiATtOM Of THE rERIOSTGOSI. BO.VE, ETC.
moTi-d; tbc subssquent healing of ttic ravitj in the booe Is nemlij'i
siniplo developinent of bcalthy f^niiiations with suppuration^ wUeb
msT, it is true, assume an ulcerative dianckn-. Now, tbe qnattjan
arises, Huw diall wc know thai a put is dcctoshI? This majr be
very simplr> in %nme c-niif*; fvpcoinllj whcfO the Qe«KMecl boa« tt
eiiHMted, tli:it is, in »11 msrs wlieri' TiecimaB foUowB UDcarenng oS the
bone; the ilcad bone looks quite whlto, but io sonie places, it W
coJTiPs binckish, like other dried, necrosed partA. Gaiigrcac of tbe
bone, as far as rej^rda the hone>»ubstnnep, maj remain u diy gia-
grvni^ ; the sntt parte in t)ir bone, the vouuls, connrctirc tiaatw, and
metUilIn, may, however, lik« other sou part#, be attacked bj dry or
moi»t ßanj^^np ; pcrfL-ct di^npss occurs in no«t eases where tbo ben«
is iinc'irrrrd, exposed to the air; Ijriicc this super6cial Deccomil
mrolj- a proct;« of decomposition, seldom aecompaniod bj bad sneUi.
In doeplv-situatod necruas, as in that of a wliole diapb\iits or of ft
ttavred nr fmetured »urfaoe, which is embeddAd in nnSl partsi, iJiure ii
iifluully dci'oinponition of tbe medulla ; tbe unrll from a larj^ «•
tmetet! sequealram is oncasionaily very ponotratinjy. ITiia dcentn-
poislnj^ ttieiliil1:trr Mibstanve is dan^eroiu ss long as no line of
dcniarniti»n haii formed, while ttio lympbatic vceseb of tbe ricinitjr
are still open; when tlie prolifemtion of tissue has occurred in tbo
borders of the bnne next the healthy ports, tlie inSammalor^r neopla-
sia rnmij» a wall thrwigrli which reahwirption does i>ot rcndily fioc»i.
Uon- are wc to reeoj^iiize a deeply-»! tau ted sequostntm? Tbüi ran
only he e««etlr done by llie proln?. Through the oponitig from whirii
the piis flow» vre pass u probe, as large n one us possible, with which
i\-e feel the surface of the sequestrum, wJiidi is usually smoolli and
firm, more rarely roujrh and soft. Wo attempt to elide the pni»
along it, to dptrnniiie the length of ihc »equf slrum ; we al«i press lb«
probe finiily agninftt the BCqnestr\im, to find ^vhetlier it he mot-able,
detached, or whether it be'atill firm; as you will underatand, this !•
im]xrrlant in relation to the question wliethur we may n» yet nltirinrpt
extraction of the sequestrum. A further aid to diapiio^ia is the iu'
ereafwd thickness of the extremity ; we feel the extensive new for-
mation of bone ; thick yellow, often muoous, pus Sows from the
openings; the bone »» not especially aea^ilivc to presattm; nor Is
oareful probing usually painful, although the pitlicnl often dreads it,
becauM; some surgeons do it with «niieeessory violonee, but without
nay result. Tlic patient is free from fever.
From thc4C points you n-ill readily diagnoao many cases of ne-
Croiiis ; as long ns there »re no external openings, the diagDOBisof oen-
triil necrosis of a bone Is liable to error. Ome» is almott the only
thing for which necrosis can be mistukon; the mode of origin and
FATB OP THE SS<ttTB6TRGll.
447
the lorality «id prcatly in the disrintrtion, for nc^nwrg ownira more
Crequeittl^ mi a rt±sult of aouU; intluitinialitHi In tltc hollow bonptt
(Jkmur, tilia, Ajmren«), caries usuilly iwcumnif more slowly in
tpoiiXy boucs; liowerer, the objocüre symptoms are alao diOcreot:
in ouriM there i» biit little formatioa of new bone «boat tlit> ulocr,
often niOTL* i-nn Ix- felt; in necronis this is extensive: in raricit llir pu»
i» thin, had, serous; m uccrosts it is t)iii-k, ofWn grmd, fri.-quciitly mu-
oous : in csrie« we pes» ttio probe ioto rotten bono, and probing U
usually «jwiio painful ; in necrosis ihc pn)lw gcDcrslly strikes on the
GnB«r<|uestnim Atitl is not often paiafuL From this conijmriiton of
the Byniptoma, which result from the dUT^rvui natures of tho iwn dii^
, you must arknowlMlge the poestbility of a dis^osis; in many
, indeed, it is very easy and ümple. In other cases, the anatom-
tial conditions Bn> mon> difficiilt to UDdprstand ; when ne<<r«isis and
csriet occur together, nil the symptoms, eict-pt feeling the BfC|UL-8trum
m probing, nie in £a^-or of caries. In central carica of the hollow
boneflf roormous thickening of the bone occurs in exccptional casM,
at the nmc time the inner wall »f tlie boneK^vily msy feel very firm
ftnd hard, like a srqticiitnim ; these cases mar ^Iyc rise to error : on
opening the cavity, no sequestrum is found, ha had been espeeted ; it
is pnsKible that in these rare ea«?« the M^uestnim may have been reiy
small aihl may bare been absorbed ; of this morv bL-reaftcr. But these
exceptinnal rases dn not disprOTo the rule ; faeiice you may, U> a f^reat
extent, eoniid« in the above comparatitre disgnoua.
Now, a few words about the fate of the sequestrum. Do you
nean to say tbe dead bone cannot be reabsorbed ? Have I not told
you fnwjuently thnt dead b»iiie may he dissnh-erl and oonsumed bj- the
granulations? Hunee we should expL-ct that tbir elimination of the
sequestrum would not require any ai<l. From my observations. I hare
nn dmtbt that small sequ<«tra may bo oomplctoly consumed by prolif-
erating gronuiatitMis ; ;nanulat)oos that are being destroyed or under-
]P)äng cheesy degeneration have no power of dis»oIHng bone; wc
bave alm«ly statetl, when s[H-i>king of caries, that partial ncvruais oc-
ours so wadily in atnnie suppimitive or caseous ostiti», just beeaufte
the inOaiiimalory neoplasia, wliieb so (|uickly breaks down again, does
not dit>«oIvc the boac, but leaves tt tobe macerated la tlic body. But
the rcobMrption of the so(|uestrum has its limits: first, of eontse, it
ceases where the bone is uncovered, for here the gnmulatioos have no
cSect; it also ceases as soon lut tliey secrete pus on tlieir surface;
henoa n sequestrum, re-iutting from acute periostitis, is t»nt uauallj
ahaofbed at the point where the periosteum suppurates and wluTe pus
forms liuriiij; the nliole process, because it does not ooroe in cootact
with t}»e f^milations; but at «11 points where the sequestrum inuat
448 CHRONIC IHFLAMMAnoS OP TEE PBRIöSTBCM, BÖ.VE. ETC.
be looseDcd, rcabfiorption conimvoccs from Ute intentitiül grouulstiofr-
nuases forming on th<> bono ; lastly, tttcr the scquustntm t& tltjUiclicd,
if these gronulaUons also pn)fluc-c pus, rcubsorptioo cc-asca Iicre aUo,
and the sequeotrum bathed in pue ceases to decrease; th<; granula-
tions of the piift«avity, growing from all sides totmrd tbe acqnestnuD,
in tlie ootirse of time un<]nrgn chemirail ctiangn; tliej beoouie very
ffclutinous, raucouts mu) often undergo (»iiy tleg^aemiioa.
Rut the »oqucHtnim muni, ünnlly oome out. (.^n tt do bo un-
aided? This duM occur; vrheucu the puw'or that puslics it out? Let
us suppose B o-Dlnd oocrosi»; a ecqucfttrum becomus detached frocn
all sides; then, for the reasons shove mentioned, it is conaidenibly
smaller than thq eavit}* in whit-b it lies ; the piece oC bone i« now
quite loose ; granulatioos grow toiranl it from all sides except from
the one where the pus-f^rity npena externally ; here there is oo re-
gistnni« ; if the njtening Ix; lar^p; enough, the ooiisljiiitly-increaKing
gruriiiliilicins ptmli oiil llie Hetjuestruni. But for this to occur tbcre
must be ovrtaia mcchunical conditions wbiah arc rarely fuldUcd ; aoiaD
socjucstra are often thrown off spontaneously; lai^ ones, wbksh can-
not pass the eiistinpr oiM!iiiii|^», must be removed artificially.
The treattiient of necrosis at first coosist« Hinply in )(oe{Hng tlie
fistulie clean. Chemical solution of the sequestrum is not to bs
thought oC If you were daily to pour muriatic acid into tlie fistutoua
opcninfT, it vrould affect tJie newly-furmeii osseous tissue as murh ns,
or more than, it would the «pqueatmm, which would be »ery unfortu-
nate, as it must replace the lutter Hvn(.<e tfie viwAanieal reutoval
o/tA* Mquestrwn is the only thing Wft ; this ahot4d not be tOtttnpltd
btfor« compiete detaehnteHt. This is a ver>- imporUinb rule : first, Im-
eouso the dead bone can rarely be »awed out without removing a good
deal of the healtJiy and of tlie newlyformecl bone, both of which are
bad ; and, scL-oudly, bccauoc the now bone is rarely finn cnoi^ before
the SLMjnomnim is dclaehed. Hon>, agsiii, we meet n wonderful pK^
vision of Nature : the sequestrum is not gooerally drlaclied till Üt»
new foimatioQ of bone is strong enough to replaon the U^t portion of
bone. This hene6cv>nt provision should not be brought to naught bjr
meddlesome interferenrp, Tliere are only a few ftpec]]il exrepLiotu U>
the iil>ove rule, es|K^?i»lly in neoniins from phosphorus, which is not
ft pure aecroaia, but is often ooraluned with caries ; but of tbia we
ghall treat more imrtieiil»r1y in special surgery and in the elinie.
] have already told you that we niay sometimes tell by the probe
whether a sequestrum ts dela>ehcd ; but this is not alway« »o; it maj
be so shut in by grantilalions that it cannot be felt to move. It i»
always hard to decide on the mobility of a large sequcstnim ; and tbe
curved shape of the bone (as of the lower jaw) may greatly iuterfero
SEQCBBTBOTOinr.
(40
witti the decision. In sn^h douStful «uos the duration of the ])ro-
cos», «»d ihe thicknms of Ihi? bonjr case, are important aid» in deter-
mining «lir-tiier tli« Siequestrum bn dctarbcd or not. hfost tiet)u<>sln
•re usuall; dctdcbod in «ifht or tco month« ; ia ■ year even an
mtiTC necrotic diaplijsiii uaually lies as ■ loose Be<^upstruin in the
nunly-foftn*<l bonj- caw\ Thesp »re approximate dct^^rniinations,
which may of CMime hiive cxce|>tion». If tlie formation of hone lie
fttiU w««lc, and iierertbelewi tlic siMjupstnini be aInMidy detached, it
IB vreW to po(it|ione the ettraction in Ihe hiiimrnis, tibia, and (eniur,
so that tbr formation of bone mav be fimicr, provided the genera]
health does not auffcr. Should alburmouria bcf^D, the extractioo
should be haKt«D(<d.
Extrai-rtion of the aequestrum, eapecinlly irlien it r(X|uirea prelim!-
□ary e n Urge« m^ Tit of the cloaca (fistutw leading' into the boay cat«),
ia called the operation for ntrroniM or Kqwitrotmny. This operatioo
ina^ be rmy simple. If one of the oponinga of the bony case be
tolerably lar^re, and the Buquestnim small, wc may paas a good pair
of forceps thrf'Uifh the opening and try to sei2e and remove the »«•
questriim. If, as in carieJt necrotic», there be no formatioD of new
bon«, n-e enlarge the BMuIous o)>ening throiigl) the M>ft |>arts with
a knife, and remove the necrosed piece of bono. But, if the oponinga
be small and the sequestrum Urge, a portion of the bony ease must
bo removed, both for the purpose of introducing inslnmicnta for ex-
tmctiuo and for removing the oequeetrum. Iti rare caaee, it is luffi-
üent to enlarge one opening witli trepdin, ehhel, and hiunraer. I
uaudly do the opeTati<in aa l<>]lon-8 : With a etmit knife T make au in>
cision through the soft parts down to the bony caac, &om one fistulous
opening to an ndjiii>>nt one; then, with a handled acraper, a rtrjjoo-
fon'um, I draw the thlckeneil soft parts from the rough surface of the
bony case, tm as to expose it to a certain extent. Tliia expoM^d por-
tion should now be removed, to matce an opening through which the
sequeatnim may be rernoTed. Por this purpose we may iise saws of
varimiA kind)« — the osteotome, the panel-saw, etc.; of late, I atwajrv
employ chisel niul hammer; Ihe woric is labofioi», use wliat inatri^
menta we wOL The portion of the bony esse removed aboutd be as
small as poaaiblc, so as t/i interfere tlic less with its Rrmncss. Whoa
the case is opeoed^the sequestrum is exposed; we attempt its remoTftl
by elevators or with strong foreeps ; this also is wimctimes very trouble-
some. Wlien the rnnorol Is acrom|>lished, the indication is fullitlod.
It, cootrary to expectation, t-he sfrquestnim be found not detached,
Wfl should aroid forcing it out, hut n-ait a few weeks or mnnlhit, till
we are satlsfi»! of its detachment. After the opemtion, tlio snppit-
rstiii^ OBTity in the bone is to be kept clean ; the patient should kwp
450 CHBOÜIÜ INFLAMMATION OF THE IT.RIOSTEITlf, BOKE, BfO.
faia bed for Mine time ; moitt fistuUc soon oonsc dischoc^ixig, but H «
•till KOmo time before the Bequestrum-cavity is (UIbU with osufyiog
gTHnulntioiis. liVe canaot do much to luutco this, attd the fiatvla,
wbtcb suuiftintes remain a long while, usualljr cause so little truuUc
that we are not often called oa to do any note operations for ibem.
OccH8iou»lly, liowever, too large a» («[>eniiig reniiün» for a long tin«,
its walls become sclcnxwxl and cease to Kisnulatc ; here we applj the
treatment for atonic alcors of the bone. In tboee old caae», tl» hot
iron to Uie cat-ity in the bone, and ehiselling out the traok of thti &*■
tula, i» the oiilj treatment from which I have ever seoD any beoie&tk
Many «tsea of tlie«»e bonc-fislul« are inourabUx
Th(> full value of Hei(ii(?«itrototny ha.i only been appreciated for the
past ten yeais ; it first becaine coininoD afier the iatroductioo of
oblorafonn, for it La n tcrrifj-in^ openttion. Tbia diiaeUiog, aawin^r,
ami hammering on the bonea, are horribk* fur a lookcron, and tite more
50 as the operation niajr last aome time; oniintlatiou is a triCk' in cm»
poriaon. Formerly amputations were froi)UoaUy porfonnutl toe toUl
noerosUi, a tiling that no aurgeun would do now. HenoBt in old
museums, you find the most lx»miful prepatationa <rf extensive n<^
omais; now these are ran^ly found, Iiecauso almost all sequestm are 1
removed at the proper time. I.4X!aIly tbe operation is quite extettanr^^H
but the febrile reaction a usimtly itlighl. Severe as tbe inflamniato*/^
s^nnptoina und fuver might be, if you were to <re«t 11 lioallhy l>ODe to
the same way, the efTcet on the l>otiv cftKC of tJie sequnatrum ia but
slight. From my own experience, I do not know of a case whei«, aftex
•uoh ao opentioQ, even where the entire bony cue wa» ojivned in totel
neeroaia of the tibia, that tiimod out badly, and I am aatisfied that
Hie opemtiori for necrosis is uuu of the moat mccemful of operatiooa,
and that by it many lives arc saved, surli as were fonocrly lost (naa
amputation, from constitutional disoasosdue to continued «uppurntion
from tlic bone, or from &tty de^ieneratiun of internal urgaita, morbus
Brightii, and iubcreulosio.
LECTURE XXXVl.
AFPKKVIX TO CItAPTRK XVI.
Mwliitls^^naWmir.— BympmtM---Eüolpgy-— TfciimmiL— OUeaBMilxh.— Hj
pliy kod Atrophj of BuDu.
SacAitU and Oeltontalaoia. — Wc must still tixx^ on two const
tutiooal disc«««.-«, which arc chiefly maoifested in certain ebangee
the bone, namely, »ufteii iiig. Tliey are eall(H) rarhitia and osteom»*^
ladai Their offsets in clionging iIh; form of the bone are mueh alike.
BACHtriS.
4fft
bot their luture« differ somewlmt, llwy c«uiiot bo exactW clas&ed
tmoiig the ohrunic ttiflamiiuitioits, ulÜKMi^h nearest related to this
prooeu.
Let us bcgio frith rachitis, Tho name comrs from i^X'Ci t)>c bnck-
hoEH.', and properly sif^lties infltimmatjnn of the spine ; bat the vort«-
hnc rarely aufTer much in rnohilbt ; hence tJie uri^ii of the iiuine is
not Ton' ck-^ir; subsequeiitlj it waa often vullad " Kiigliäh distw«.-,"
because it wui partimlarly vr<>ll known \o Kn^liitli writers, snd |mbn*
ly also w«s e^f^iallv fn^ueiit in Eagknil.
The ceneDce of the dinciifc consist« in deficient deposit of chalkjr
'■*]tA in tl>e growiti;; bone, and reninHcable Ihicknees of the epiphyseal
oartiUges. You will iüresdjr cw-'e tliat this disease is peculiar to child-
bond; it is a disease of thn dovrlopnirnt nf bnne, which however
usually affects so many bon«s, lltal it must be regarded, nut ns u local,
but as a eonstitutioual disease, which you may reckon among the
dyacnAKB already tnnwn to you. We often lind nuliitic syiuptoms
in Kcofiitoi» children, and some phjsiciaas reg«rd the iliscaso a« oue
«ynptom of «rrnfula ; but this is not quit« eorrect, for in many tar-
tjiitlo chiMreii we fii»d no tiace of scrofnla ; moiem-er, the racliilic pr»
«eM bis liltlu aiiatoniioiil connection with tliv fonns of i>ciioslitiB and
OCtStis that we have studied in Mrnfulous ehildren, for it never leads
to Buppuratjon. Accurding to i^ircAott, in rachitic bones thir boue-
täaene is hislolo^cnlly (bcinod, except that the Ixmo^iartila^- Itaa no
chalkr salts ; thu bune-ti&sue dewlofts reji^arly, but the chalky salts
are not th-positi-d, or at least only in »canty amounts. The result of
this tnuBt nuturally be decreased tirmnees of ilte boues ; consequently
Ihev bend, especiaUy those that bear the wi-ifjrht of tlie hudy. >\'1i(m«
the Itonea are very aoft, muscular nonliaction also a4"Ut on them so aa
to induce curvaturr. 'I'heai- curraturvs »tv most cutiimou In the lower
üties ; the femur bends anteriorly and inwardly, the bones of
leg bend »nterioTly and outwardly or inward. The thorax ia
compressL'd laterally so tlial the steniuu pmjevts alurply, and tlie re-
sult is the so-eallcd chic)cen-)^*Aiit {ptetta ^irinatwn). In liijj^ grades
of rachitis there are also distorlions of the pelvis, s(^al column, and
upper extremities. In such ebiltlrcn Ibc ocei[>ut long eemiuiis soft
and oompreasible, and tlentilion ts rJelayed. Sometimes the eoftoess
of the occiput is the anle symptom of radiitis, so that this has even
been legsnled as inde)>eRdcnt of the gi»winil rachitic disturiMOce.
Aooofdtng to Virchovt, the distortion of the upper extremities de-
pends mcAtly on ii numlier of small ctirvHturca (infractions) of the
entire boue, or of parts of the corlical layer. Complete fracture«
rarely oceuc; if titey do, the bone is again united (irmly by callus,
under tho ordinnr%- treatment
4S9 oBROfnc ixFLAiniAnoK of the pekiostbuh, bone, rra
Rachitis naiues other cliAiigeo in the bone besides tfaete defonid*
tics, itamely, thickening uf the epipliyw» aud of tbc point of union b^
twecn the oostol cftrtiUg«« and the bony ribe. Tho thickening of the
epiphysis may be so great, at the lower «od of tlie radius, for iustiuce,
&at, above the wrist, at the point just above the epiphyseal cartila^,
ttiere is a aeoond depte&sion iu the akiu; tliitt appeanuiu« uf thi- }uint
ha» ;pven rise to the term *' double-jointed ;" tbc nodular tbielcRDin^
OQ the anterior L*iirU vt iim Vibs arc oft«» very retnarkmble, «iid, a«
they lie reji^ilarly tinik^r mie anotber, tliey have been called Uic " n-
chitia rose-garland.*' If these changes in the bone bare taken place,
there ia no beaitation in diagnowng nwhitis ; before tbey have become
evident, the diuguoitis is doubttu). It is true, tliere are »otnc pn>-
dromaJ symptoinii : vomelous «[^tite, pot4)cllri disitviiniktion to
staodinj^ and wulkiiig; but thMO syniptonis are always too nudecided
to permit any dcGnile coneluMon. Tiic disease most frequently bo-
^ns in tho second year, and attacks trell-nourishcd or even f&X chil-
dren; indigestion and inoUnation to (^onstifmtlini oocur uccasionally,
but Tiut always. We know little of the exciting causes of raefaitis ;
here iu Germauy it is utiuut equally frequent iu ull cUases of »ociety ;
horoditiiry inflnt-npc may ht*ve aome efftwl ; we may suspect, but can-
not proTeadisttirbsnce iu theeoinjiosilionof tliebtcxxl, in UiciiSMinila-
tioii of nuLritnent, In regard to tbo course of the disease^ under
proper trcatineat it often subsides quickly ; that is, the syroptoms of
dJstürlion uf the bono ciki»c, or rather, do not increate ; the (äiildrenf
who had «vrused to walk, ugrnin dewru to do so. As Ute norma]
growth of the bone goes on, tho distortions become leas peroeptible,
antl often disappear entirely; lids may be reiidity utkdentood bom
the nature of the growth of the b(me. Before the bones again soqnue
tlicir uonnut coiiatätenoe, at tlie end of tho ruchitio prooeM« tbere is
usually an abiionnnlly rich deposit of bone, bo that in ecrtaiD stages
the nicliil-ie bono» are alwiormaUy hard and lirro ; that is, in a sclerosed
sbite. Ihtrcly, ruuhitia \asls till the skeleton has attained its grow^
and thcftp cascs furnish the P3tce«»ive dixtortions anil dtitlncaHona that
are usually prasented as types of this disease. In every patlicJogical
■natomica] (»lleetinii yon £nd examples of sut^ rachiUe skeletons
Rachitic children are rarely brought to the doeUw beftm> i;itber
the parents notice th« tliiok limbs or distortion, or until, as the i
expresses it, " tliey are olT their legs,** i. o-, tbey oo loogei wish
stütd or walk, as they formerly did; the diseanc is so comsion aad i
well known Itnit often it needs no surgeon for its reoc^poition. At i
rule, (rtatmtnt has only one indicntit^ii, that is, to remore the diathe«"
sis; hence it is chioHy medical, and especially dictelio. Itf^^arding
the latter, the patient shotUd avoid too free use of bread, potat
BACniTlS, OSTEOMALAt'U.
453
rnnsh, and flatulent r<>getiiblc8 ; lie eliuuld freelj ctmsame miUc, eggs,
meat, and gtxtd white brL-nd, tuid should take strengthnning hatha of
malt, herbs, etc, Inleruallj vre should prescribe «Hl-liier oU, irou,
and similar slrongthenlng and tonic remedies. We might think
of giving preparations of lime, hut thej' are so iodtgeatiUe, ami are
so (juickly excreted hy Lhe unuv, that tli^'v <lo no goud : they burc al-
most been ibrown aside ; it is po(taihle,alHo,thnt Rtchttis i« e«iu^ntinlly
a dUease of dige-stioti, in which the prcjmnitiuns of lime are, fmin
some unknovrii cauM, nut nb»orlKK). Frequently the parcnta ask for
splints to remove the eun-alurpg, or, at lett«t, prewut their incrvtaw ;
tbcjf will also uak you wheiher the diildren should he urged to walk,
or itemiitled to lie BtilL On this point it iti br»t ui let i-hildn*n have
their own way : if thoy do not wish to go, do not urge it ; if thoy lie
still more tlian Ihey nin about, they should be kopt in Ui« i>}Mm air us
much ax pOMihle ; taking chililn-n from a damp dty diin;ll!tig to the
country often suffice* for tlie eur« of rtu'hiti». Splint boots and eimi-
lar &p|ttirHtiiBes, that loiul tlie fiH>t, eliotild only be applied In caaes of
cxoesive curraturt-, where tiic position of the feet mecbamcally int«^
ferea with walking ; thie stato of atfiiirs is rare, hence the indication
for suoh orthopedic Bpparalus is limited.
\Vhen the raehitis hi\a disnpppornd, such amount of curvature may
remain in rare cases ua to retjutre some Utiatniuot ; in the great ma-
jority of cuiües tbia i» unnoce&sary, sinee, aa already Mated, the rur-
Tatiuvfl »iHjnlaiKtuiiily «liwpj»ciir with lhe growth of lhe »ki'lflon.
Only in the leg rur\-nturL-a sunit.-timcs remain, ho that the foot i» ilts-
twted, and only its iuuor or outer border nau tw plamfi it» the floKir;
if this remuiuK for yi>ara at the same jwint, an attempt sliould 1x- made
at stniiglileiiing. Tliis may be done in two waya. We aiui-sthetisc
the child, and oorefiilly fractun.' the bone subeutaneoutily ; hare the
leg lieW straight, apjily a pUatM^bandage, and treat the injure »» a
Mmplc fraeture; rerovery usually take» place readily. In some cases,
however, after the tafhitis has run its «lurse, the bone is so very firm
that this bmikingdoi« not aucoeecl. Tlten anbeutaneouR osteotomy,
according to 2f.vo'i iMn^ubeek (p. 210),ishidii'ate(l. The remits of
thia Operation, which I hwve had to make four time», have ao far l>een
veri' satjÄfsctorj' ; in i«ie of ihese eaaes the Hkin-wound healed by
finit intention, and the suluetjuent tn.-iitnient wse that of simple frac-
ture The o|ieralion will always remain a rare one, bccauac these Cx-
oeasire rachitic dtstartions are tlienisclvee rare.
Now,a few words about o«t«omalaeia^ booe-Miftening, Kar' Hox^.
The disease only ooeurs in adults, and is also charaoteriied by distor-
4« OORONIC rXFLAUllATlÜX Of THE PKRIOSTEL"«, BONEL ZTC
tion of tlie bone»; but liero there is «n nctunl resbsoiptiou at existing
bone, ai)d in this purely niiatuiaicul cunsiiifniti'jD Uiu di«ciucU rvlal«!
to ostitis aiid owi-ifiH, difft-rL'nt as tliej «re <;lii)t4»IIy. In the boUow
bones tliu iiu^lullti gnultnüly itssiimtrs tho prcpcMiilLTaacc, while the
cortical 8ubat4mcc bvcomua tliiuiii:r und thinner, and conaequcally tlin
bones WMkcr and mora fli^xiblc, u»l fiaallr tUeK may bu L-uui]>letf!
absorption of thr boiu.-, so tliat little is left besides the pprioBteiiin,
wliich partitripatcs raxuly, and tlien but little, in Ute discmw, »cniity
oateophyt^s groiriag from it. The spongy lioDefl aJao j^rotr wenkcr,
the t«bi-> utie tlitnner, and become k) i»oft. thai thqr «liriiik. The tn^
dullu u|ipeära reddish und gL-Uliuuiis, but docs iKit, as in fungous
cnric«, consist solely of granulntioos, it contains muoh fat. Beoceyou
may, uith ^une eorreetnees, desi^ate osteomalacia as (nngnUK, fatty
Dstcoiiiyrlitis. Tlie noture of the reabaorptäon of bone is not exactly
OB it is in tlio on)ii>a.ry foniia o' caries; the romains of tlic Ikmic do
not UBunliy have the ühiirplv-gniiwed edges j the bony traboouUe gf**i-
uallygrow thinner niid tbiiiner,biit usually retain their smooth sutfiuie
{haiitteri^/ifr boiK-atr^^by wf H. Volkruami) ; thy Inst remains of
Üie «mall bony phil«^« nnd traljecul«? npe veij* pllnhle, wft, auil coo-
tain litde lime. In osteumiilacia, lactic acid li»ft btrru found in the
mctlulla of the hoUow bones, so that it is iu the lu^^best degree prob-
able that the bone \& dissolved by it. The lime pafisiug into lln> blood
19 often excreted in large amo'juta thniugh the urine as oxalate of lime.
So muoli for the unattnny.
Contxtiiing ihp ctiolofQT of the disease we kiiuw but little ; osteo-
rnaliu-i» ig purticuhirly fre(|iietit in some purti« of Eurup<L>, artd nmonj^
wuiiieii ; it uttueks the lutter more purtictilaily while in th*; pwrrpervl
condition; oi?CAMt>naiIy it i* pri'c^tled by druwing pains and soreness
on nioviiij!', wbieii eoiuiiuie through tlit^ disease. The disturliocM
occur ehiclly, priiimrily, c\-cn »niely, in the p<>U-i«, whicb assumes m
[locuÜar, latemlly-cPinpressed form, of wliicb you will hear tnorc tn
obstetrics. This is fulloned by cunrature of the spine ami lower ex-
tramitiea, with muscular contrartinns, Tbo disease may pause, and
CKacerlmtc with a netr pregnancy, etc SUglit grade« aod locsUacd
fonus of usteoinalactu, as that of the pelvis, not unfrequeatly recover
SpontAnenusly ; if the diseasi^ be of a high grade, general marastuus
occurs, luid the jwtieut <be». The treutmcut is the aumc ws in rachitis,
but th(> hiipeü of KuceeKi« tire less.
Tiie l^l»e^ of l"c-al o:tteiinialiu:i» or usleoponisis, which often ncrom-
p«Dy curies, nrc mwre interesting to us tliau the above-described gen-
eral osteomalacia, i will rehit« you a ease that will at once oxphiin
what t mean : A woman, nWut forty years old, was brought to the
hospitid for oxtoosiTC caries of tbc kne«-joiat ; she was ozccaaiTcslj
HYPERTBOPHT XSO ATROPHT Of BONE.
455
mantsmic, and <)Ie<t tlie foDowin^r day. On autopsy wu ftiund com-
plct« fatty dvgL-ncmtion of the liTcr,»{>lci:n, and kidneys ; in ibe knee
tha «mdylos of lliu fomur and Libia vrcrc extensively destroyed by the
carious proce». I san-ed uS tlie loner end of tJie femur to remove
the preparation, and found that it waa Tcry much tbiclieiKHl ; tliu cor-
ttcal layer measured et^tvely half a line; the medulla wnn rcddeoed,
and resembled tbnt in asteonialacia ; the thinninf^ jextcndod upward
to tbc triKhanter. I exAmiite«! the tiUa of the di»L>a»f<l hy-, ihr femur
of the healthy one, and the pelvi«, attd found them oil perfectly normal ;
that is, only tlie feiinir of the Oisea««! leg- was ueteomalscic. In the
same vray I oncv fuuiid tli<r lower ludf of ihc Itbin affected with osteo-
malaciit, in caries of the aitklc. There wa« appureiitly the Baute tliiuf;
in a child that hud tliu lifu<l of one femur removed for caries of the
hip'joinL I assisted in thLs operation ; »a I was on the point of Uf^*
iog the thi^ and rotating it outward to aid the operator^ tfao thij^b
broke through the middle, rif^ht in my hands ; a pinKter-luiiidiigo via»
applied, and the fracture rwrorerc*! ; the child w«s «>tn|ilfiely restored.
In otlier cases, howercr, after fntclurcs of bones with ostcomalada, in
tlie so-called fra^Iitas ossium, pseudartltraces arc apt to romain.
I will aUo mcnttoQ htfptrtrofyhif and iUrOf^y of bouo, which, how-
ever, hare more anatomical than clinical interest.
Aiiutomi(»lly we may ciJI any Iwnc hypcrtro|iUic which is enlarged
in length or thickui.-Ȋ. TUt^reare very few eases where aiugle hollow
boaea, aa one femur or one tibia, are exfywaire in lenf^, and give
rise to inequaUty of llie extremities ; for this excessive growth I ac-
cKpt the uaiDc '* hypertrophy of bone;," or, better. " (liant-frrowth "
(" riesemnicliK ") ; still, to giit' this term to every ihickeiiing or scle-
lons noidd b« of tu pmctical \-alue, although aualumically correct,
because these conditions of the hone may dcpcud on vviry different
morbid procioflfte>i, partly active, partly comjileted. Even more indefi-
nite ia the term atroj>/iy of the bone ; occasionally, a carious, osteo-
malacia], or a half-destroyed bone, etc., ia thus designated. This is of
nopmctioal value; we do not mean to deny that there maybe atrophy
of the bone without a true morlitd process. Senile atrophy, as of
alveolar process of tlie jaw, is a htriking example of this. Here the
term atrophy of bone mny l>e retained ; in most other cases it would
be bvtt«r to naate tlie juooesa tltat has ittduoed the atrophy.
CHAPTER XViL
CSROyiC lyFLAMMATIOX OF THE J'OiyTS.
LECTURE XXXVII.
Q«iuinü Rottiarlu en llui DlftinTokhins CbtruUnjrtiM of tl» CfaitT Fonni. — A. fw-
gunt and Stip;>iintlve ArtlouUr laflKUmuUona (Tumor JLlbua), Spaptoea^ XaUo-
ctjr, Curie» Siiwa, Supiiurntion, Atocuo t'aruu, — Etiulo^. — Cvanoaui Pngaotii.
Ix more tlinn half the cases of climnic iiinHiiimatioo of llie joints,
tbe synovial iiKMubrane is the part first affectoi] ; tbis affccliuii mar
be aocompaiiiec] by more or I«m «ecrction of fluid, and this lluid niajr
be purely serous or purulent. Chronic serous synovitis (hj/dropt
articidortim chranicua), unices from some extomal oauae, ia no mom
apt to Hoootne pumloDl spiuvilis than ig chronic artJcular rheumatism.
But othiT forms of ehronic inflammation of tbe jointa may be aooom*
ptiiiieil by Riipimraiioii from tli« litst, or elite may be oliar^otorised by
the formation of numerous grunutitlianü. llie tvo i'hief gntups of
cliroTiic nrtirular iiitljiniitintion are ctiaraoterixed by tbe cxHidition of
tbe synovial luetnbritiie even nioro tban by tlic quality of tht; fluid
coDtfttncd in the joint; when the secretion i» purely serous^ tb& syno-
vial mombnuic is sontuvrhat tbifkeuud, it is true ; tbe tuft« are en-
largiii), niid their apieea aro anmewbat more vascular than nonttal,
still tbcsc ohau^^ are never ao extensive as U> grvuÜy lajurc the
membrane ; but in, the other vfirioty nf cfaronio inflnininution the meto-
brane cbaiigeä greatly, »nil is ^nuliiuUy transformed into a s}iongj
(fou^us) mass uf graimlations, which often, but not alvraya, produeea
puH, opens oulwiinlLy (fistula, cuhl uliscesH), eanses distortioD of tti«
enrlilagcs and bonea, and may thus induce peripbccal cartoa of tliQ
epiphysia, Thi» latter j^roup, which has several subvarietien, we atiaS
term funffouim\A »upiiunitiw inßammation» o/ the Joint«; they fonn
the great majority of all articuliir inflaramationa^ and lienoe will oeoi^y
our attention fur some time.
TUUOB ALBUS.
4S7
A. TOE fUNtitiirS AKU SUPI'UUATIVE ARTIÜULAB JNFLAHUATIOKS.
(TCMOB ALBUS].
Tumor «Ibua (wbite swelling) is an old dadoo vrliicli waa formerly
apjiUed to aloHkst all swellinj^ of the joints tbat run tlii^ir i.-ourx'*u-itk-
aut redneu of the itkiii ; now it has bee» agreed noly to give this luim«*
tv the affection we ure ubout to duü>cnbe, whicH is niso, with mom; or
les» oorrecto«»«, term«! arrofaioug inflammation of tM Joint ; but of
thix latLT.
The disease ta vcxy frequent in childhnodf particiilnrlj in tlic liip
and hoc« joints; it usually begins Tery insidiousW, more rarely auh-
aoutely. If the kne<yjnint be nfiecle«), the parentt uRunllv first nnttoe
a s%hi dra^in^ or timpiug' uf the Inme \Kg ; llif child, eitlu-r volun-
t&rily or nn «questioning, complniiis of pnin »ft^r wnlltinff tioii»! di«-
tuiee, und on pressure uver tht* joint ; about llic koüu ilself ihu laity
can »ce uothiug out of the way. On comparing both kiiccs, the sur-
geon will find, even quite e^rly in the dieca«-, that tlic two fuiTöW»
which normally run alongside of the patella, when the limb is ex-
tend<xl, and give the knee-joint it« ahapelineflo, have either diHiip])citreid
on tbt; ndecteU side ur at leaat «re ahullower ihiui uu the oouiid sidu ;
except this there iit nothing ohx'n'abli-. The htndetnnce to walking is
so sliglit that children go about with a s1i|j:tit limp fur nionth)!, and
oompUio so little that it Is aomc time before the parcut« feet obliged
to oonstilt a surgeon ; they oftcii delay doing this till, after oonlinned
exertioo, the limb has begun tu pain and swell more. The swelling,
nrhidi was at firet scarcely pen?eptihle, is now quite erideiil ; the
knee-joint appears erenly round and quite senaitive to pressure. If
we suppose that no treatment he instituted, but the diat>ai«i> left to
itself ita course is about as follows: The patient oünlinui^ to limp
around for a few months, but finally the lime coim.'s when ho canaot
walk ; he is obliged to lie down most of Ibe tiint', beeause the joint is
BO peinfUl ; gradually it liccomea more and more angular, especially
alkr caeh subacute exacerbation. Now, certain parts of the joiul, at
the inner or outer side, or in the hollow of the kuiee, become more
painful ; th«r« is evident fluetuation at some one of these points ; tlie
skin grows red, and finally suppurafea from within outward, oud is
perforated after a few months ; a thin pus, mixed with fihrimjux dieesy
flocculi, escapes. Now the pain decreases, th« cvndiliim improres;'
but this improvement does not last long; a new abaccss soon forms,
and so it goes on. Meantime, perhaps two or three yesra have
eln|»sed, tho genera! Iieiilth of the patient has suffered; the child,
which was prcriously stroug and hcnlthy, is now pale and tliin ; the
opODing of the abscesses Is not unfivqucntly accompanied or followed
by ferer ; this fever exncerbates as eaoh new ^Moeaa develops ; this
t&B
CBRONIC rNPLAKKATIOK OF THE JOINTS.
exlmustA ÜK patient; he Insrs his appetJte, digestion ü imp^retl,
ilüiiThosa comee on, and the emadatiou b iiicrctuied (rom week lo
ne«k. Kvßii üt thiR p«>riod the disease iraj sponlaneousljr HiibMde,
HlÜiougli this nir«)j happens; more frequently it proves &tal, from
tfav oxhaudtioa caiued Irr tt>c sup|}unitioa and cotittaucd bcctic (over.
Should reouverjr Uike place, it i» announccKl \>y dty-rvaso of the «up-
puralion, retraction of the Ratolouii upiminj^ im^MviTPiDent of tli«
jfcncr&l bi^nllb, iacrposcd appetite, etc ; finally, tbc fistulas boftl, the
joitit rcmHiiis anguhir or distorted in eome way, the pain ceasea, and
the patient earapca with bis life and a stilT leg; this lennination uf
chronio Buppunitiou of the joint in anc/tffioei» (iitiff>j<mjt) is the tnoet
faTorabl« that can occur when the diaoa«« kn«be«n «evcre; the ancby-
loHiR may be complete or iuiperf<»!l, i. e,, the joint may he perfectly
atiff or slightly tnorable; the whole proceiH! may hntc lasted frutn
two to foar years, Amoo^ the local symptoms I must add that, from
long disuse of the limb, the musrics biive beconio muiih atruphled
from fatty degenentlion and cicatricial cocitrarrtioii, the Inder <xx.iirring
especially in tliu vicinity of long^uppumting «bsccwce. The capaule
of the joint nUo, whieh wa» mtich infiltmtiLvl and swollen, as well
as the surrounding ligaments, is ooiitnicted, particularly on t)ie side
toward which tlic joint was bent; hence in tlic kiirc-joint this ooti-
tntction would be greatest toward the hollow of the knee.
Tilts short description may aerve you for a genenil type uf the
dixcaac in question, and of its iniporiance; to rnublc you to under^
«tand the various forui* in which it may appear, it »ccms advisable to
firet give you n eleur descriptioii of the aitutomica] changes in th«M
discasM of the joint. Wi- hare the opportunity of observing tlie rlif>
fereat slagca of these changes in oxscctcd joint«, in ajnputatrd limbs,
and OD the dead body. I hare paid so imioh nttnntion to this mibjeel,
that from my iiidividiiiU obsenration» I can give you a very accurate
account of the aitatomicul cliiuiges. llieae are much alike in ail eases,
and, froiii wliiit you already know about chronic inllnmiiiutio»8'>r other
part», you will Hnlicip»te that tlicre is iu reality only a varinttuD uf the
old Eitory of serous and pluatic infiltration with various grades of ts»-
culurixalir>n, of pro life rati on, and destniction, etc.
Let us first with the naked eye study tht-so joints in varioin stsgeB
of the disease. Let us suppose the oomnion e»t>e of the aSection b^
ginning n-ith chrome synovitis; we first find swelling and nxlncea of
the «ynoi-ial membrane \ it has already undergone sonie change in tho
lalernl portions of the. joint, in tlic foltht, and neighboring saoH ; its
tufta arc puffisd up, very little elongated, but very «oft atid sueeiileut;
the whole [uembraae is more readily distinguished frtmi the firrn lisstlM
of lite oi4Wu]e, tuid may be detached with greater facility than normal-
TiniOB ALBVS.
4S»
I7. At tliia time tbe «ynovi« is mrelj increiwed, bat is oloudj, otctod
R«em1iJt>« muRCvpug. Tbeiie chanp« in llie »j-iiuvial memliranogTaäu-
bIIv incTL-riAe; it bcootnoatliicktr, niL>rf a-dcmatous, softer, rcilder; tfie
tufts g^w to thick pods, ond id places reecmlJc Epon^v ^^TSDuJatioRfl.
The Burfaw nf thu cnrlili!)]^ kisc« its blue lustre, thoiif^h it 19 not yet
Tisibly diseased ; but tlie svtiovial outgrovrth» begin tn grow over tbe
oarttlages from ibe aides, and to push tn lietween tlie two ajj«««iit
surfnrea of (^rtiluge; Dusajitinie the eapsule nf the joint in nUo thi<^-
ened, »nil ha» acquireil an ecetily, fiitiy uppejininct-, and i» very ccdemn-
tous; this swelling Aud teduinA grndimlly extend to the subcutancoaa
tiMue, and to the sicin. Fmm thi* point, tho chtuig«« iu tlie cnrfilng«
oliiiD most uf our nlleiitiun. The synovial proUieratlon», iu Ih« shape
of rrd ffnnulnr masset^ advance gradually over the entire surface of
the cartilage, and cover it completely, lying over it tike a veil (E^ff. 81) ;
Pi*, si.
/
Dtapm
Tlcnl.
ef m Mtdnii or a ki!i««-]ahit fth« Intcraniciiliir «antbum Iut* hr«o I*n oat. Hit ir-
mral ^ r. Tpintir ; it, (Ibtn; it. tongmu «piorUI mnatmnn ernvlna; loin the «rttltc. U/lt
•rra Ecnw* Into tl» b<)»; at t an IwUtcd pralUesUoni ot Ui* (nuivlall««* IniD lb>
bn« <m (h* boidM' IMwevD boDcanil carUlBse.
if wc attempt tn remore thia veil, we find that in (tome plnepp it i»
studied quite firmly by prooexses enCeriug tlio cartiUg«*, juKt a» tlio
iDOto of an ivyrine cling to oimI insert tbcinsclrfs into tbe wall
a^Inst which it grows (as is also the case in pannus of the ^ohica) ;
tbeec roots not only elongnte, tbey epraad out, and gnulually cat up
the mrtibige, which, when the covering of fungous pmlifications is re-
moved, appear Kret rough here and there, then }>erfora1cd. And finally
dJMpprar ntlogetber; then the fungoux ]iroliflention extends into the
bone, and cxininietioes to consume this ; the result is fungous caries, ss
400
CHBOSrc INFLAniATIOX OF THE JOINTS.
we bnre nlrcndy lenrned; ks a result of tiie (changes firom uhronio
inflaRimttttoti, the Hone is destmyed in (lie maoner belbre rlesrribml,
und berc voii h«TC llie whole ooutm and th« Telation of fuiij^oua in-
flaiDiRaiiun of tho juint to (wHeR. Tlie mnrbiil (iruces« odrsnt^ot un-
equaUj; one condyic ufii joint miiy be almüHtDotisuincd while ncothrr
partly proaervi?» its cartilagiaous surfooe. The otbcr port« of Lhe »y-
Dovinl merahnuie may also proliferate outwanHy towsiti the capsul«;
capsule, siihc-eliular tissup, and »kin, arc tranerorniei) at otic place or
unollior inter fuiigoua ^niiiuUtious, with or witltout suppuration, aod
thiu we hftvc CKtemiil openinf^ii, and fiatula;, which eJther coniiuunionte
dirertly with tlit.* joint, or with a »ynm-ial sac-
Hrrtt let UR atop a niomRiit to notice what nuy be soon with thr
miomaortpp at the nffepted part; on this point I can give you Isast
thn-t in new. The normal «ynovini membrane conRixts of lo*«e ivxi-
nectiii'« tissue with moilpral«!^ rich capillary net-work, whicb forms
©oinplicnted foldit in the tuft»; on titc «urfac« of tht' incmbraac tfiere
is a üiinplß layer uf endüthelium, (TompoHiHl of Hut polygonal celts, just
as there is on most sertnia mcmbmnes. The tissue of the membrane
is j^iulually peraieatcd willi cells, becomes softer, loeea its Gnu, 6ljroiia
character, niid th« vessels dilute and increase decidedly. The flu«
dotbeliu») is destroyed in limited layers of flat stales; it» plare Uaup
plied by small, round, ncwly-fomicd cells, which soon unite witii the
coostantlT-dege aerating tissue of tlic synovial inenit>rano, and CCMC
to be distinpiishable as separate layers. Through the progress of iJie
plastic infiltration the synonal membrane gradually Ioats its fonner
structure ; the ootineotive tissue, filled with innumerable new oclls,
gntduiilly benonies liomngeneous, and ^ra the consLantlr-incressiitg
rasculiirizutiun the tisane IiisUjIoj^k'ally exactly resembles thatof ^rmn-
ulations. In these spongy grnnulnliocu small white nodules form
here aud there; these am i^uiiiotiines like mucous tissue (p. 03), some-
times they arc composed chiefiy of pus-cells and even giant-ceHs;,
Anatomically there Is no objection to calling these »odules "tuber-
cles" (iCieter), but wo then run the risk of regarding them as the
expressios of the infertiona disease now known as ** tuberculows.*'
Similar «langes take place on ilie surfiioe of the CArlihi^", part icularljr
at the point« where it is cfwered by tlie fungous gmniilatHHis. The
osrtilage-oells begin to divide up rapidly, while the hyaline int*>reel-
lular substance melts, and is dissolved (Fig. 83) ; if from sncb n
changed, perforated cartilage you cut a superficial piece parallel to
the eurface, around tlie defect you nlwayH find numerous cnrtila^e-
ocUs comincucing to proliferate, and of course there is at the same
time atrophy of the c«rtilagc-tissue. At the point« where tbe cartt-
Is^ is thus transformed to a non-vascular voUular tissue, it melt« in
TÜUOK ALBCB.
4«1
wttli Ute fiu)>erJBCCot •yDOTisl prolifcretionx ; tbc biHcr sinks loops of
V(!«s«l8 into it, und the bettor the n«op]s^ is oourished \>y this
mesns, the idoi« tapidly it consumes the entire cartilage. From llub
dattcHption you see that the coutm- of Uie diasohitiun of cnrtils)^ is
about the ssme ox in the mse of bone, but vLth this importnot dif-
no K.
2^1=:?^
]>rf«twiatIon of ibi etrtlten !n fi3ii|c»o> inAainnuillan af ih^ Joint, a, GrannlalloMlMMaii
Ut« «Btvw«, BM^invd 8U dlKmMra ; «Am O. Vtlir.
ftrenoe, tlmt tho ovtilage-«eUs therosdvea ■otnclj' assist in disanlvin^
llie inlerceUulftr rabsbocc, while the booe-oellt n-nuiin iiixctivir, and
•beorption result» solely rroui proliferation of the cvlU in tbc Uavcmaa
«Lnals. But I intiKt lion^ ulate tiint i» cnrtilngi* there *n> also ocoa-
biodaUv appuaranp(?9 nhich »how th«t sometimes the eartilag'e'^eUs
do not take much active part, i. e., participate little in the o(/ll-pnilifrra-
tioo, so that there may also be & tnorL- passive absorption of the enr-
tllage^tilMtanoR from prolifcmtion of the synorial nieinl)nin& The
bistologioaJ chan|^ in the arti<-ular capsule and li^nients eonsi^t to
MKNU ud plactio infiltmtiaii which only attain a high gtade at «-rtain
pohit«, hut generally only inducM; connective-tiiwue neoplaake, whloh
to the naked cy« resemble fatty thickeniuj^ Sine«; CoAn/iam*a
ohscrvations haTC shown that a grvat part of the cells (otind in in-
flamed tissues are nanOeriiig wliile Mh^Kl^'Orpiisi'les, it seemcKl tluubtp
fill what part the cells of the stable tissues have in tbc iadammatory
new fonnations. Although this question may not b« answered for
B time HS regards the soft tissue, the sew disoot-eries csum* no
dunge in tlie above «bservaüons, regarding tlie proliforaliou of cartl*
lagc-ceUs by dirision. It is actually nocesSAtj to prore the latter
OT«r again by apoeiid new observations, becauw t1if> Riiprising new
facts regarding the funner are so Imposing, that one can scarcely
believe bis eyes.
4«Z
CHEIOXIC KFLAÜMATIOK OF THB JOINia
Now that jou hnve s geiienil view of tlie «natomica] cbaogea in
fiiDgoiu inflamniAtitMi of tho joitits, wc n»y go more tniautolr iato
the v»ri(Hi8 modiAoattMis ; in to doing wo nhnll atari horn the nborp-
desoribed oöurse. 3o br I hare represeoted the course of the dis-
ease aa it occurs when ori|fii>ating in Üie synovial nieinlimut?, but
thore are also oth«r fltartinj^^points for tho diiWMc ; th«rc mar be a
ccotnü, or more rarely a puriplieral, oiu-itm in thu spongy ^iph/sfs of
a hollow Ixitic, or in one of tlic spon^- bonus nf the wrist or uilde,
and HUB may perforat« from williin outwardly tlirougli tb« cariiUg«,
and thus asRit<! «ynoritia. It hIbo happens that, sometimeR, aloD|r witfa
the fiingmi.s prolifemlion of the synorial membrane, Uiere ia an inde-
pendent prulifi.-rratioii iiuilur th« curiilagi.*, in the boundary lictwecn it
and Ihr botie (Fig. SI, (f), which Bub«oqucntly unitus with thnt firmi
aboTi', so that the cartilag« lim partly movable between the two
granular layers. Thin ocrurs quite frequently, cnpedally in the hip,
elbow, and ankles. Tho oartiUge is so loosened by this primary oati-
tiii of the ends of the bone or mjh-ehondral earies, that it may be r^
moved apparently intAct from the subjacent, raseular, soft hocic. It
has already been mentioned that inflammntiOQ of ft joint may be in-
duced by aeiite periostitis and osteomyelitis ; the in flam mat ion thon
extends from the periosteum lo the capsule of the joint^nnd ihencc to
tiie synorial membmnc; tho anatomical changes arc aa above de-
seribed. When nn nctito traumatic inflammation of a joint or an
idiopathic aout« suppuratiTS synovitis pames into the ohronie Slage^
Plg:8S.
T?*'^"-;;
■^7^/
Hab<h<ni<ln>l cf>ri<>« of tb«utnfal«K. Perfontllco of U« iirotilurallticEmiiikUiai Ini« Om
Julni: luiitiilfleil Iwraiiy dbia*lFr>; a.tmntii^: A,Biupbtton«i «, nonsd bM^ «Wl
tbe anme anatomical vliaiigus go on a« in fungoua inQammntioo.
Chronic pcriostltii in tho vicinity of the joint may also cause iullain-
malign of the joint, G^xäally when it indue«« ccid abeceeaes} as may
TCUOn ALBUS.
449
also ohiouic gmiiulnr pro!iri.>nlion« in the »psule, iciaalns of ueg-
looted sprains of tbc jtHiiL
The oxl«rniil ap]>oantnco estp^ciallr if greatly iaßucnccü bj titc
extent to wiiich the parts imnKKliatcly around the joint parlicipate iii
tlie ii)fl»iiii:iatioii; if the capsulo participate very activclj-, ihe joint
hccutnca n-gulnrly thiik and roun^. Tliid uiiliirgcmciit uf the joint
is also considcnililr increiispH hj" the formjilion of osteophyte*, whioh
form on the arlieular surfneea; tht-se will he the larger, the more the
aii»ule and periustt^um nf the articular surfaces have been impliailed,
and the more proUfentitig and productire tbo disease gencnlly;
wliile from the joint Uie condyles and sesamoid bones are tlectroyed,
from u'ilhoiit new bone iü fLinneti as desmhed to you uudtT caries.
Caries of the joint ha* an old name, whi<.-h is etill occasionatly used,
it is artkroraüd ^ tliis word is cumbitied with the name of the different
joints, and thus wc speak of ^oartlirocace, coxarlhrocaee, oniai^
tbrocace, etc M»^ ^»rote a book about diseases of the joint, and
gare it iIm^ fearful name ** artbroeacolofi^e," whieh it i» not vrorth
jour whilu to remember ; T only nuMitlon it as a curioAtly ; it ori^nated
at n limciv'lR-n tlie sttidy of L^yc-diMrüscs nlso eonfeistcd almost exclu-
sively in lenmin^r by heart the most frightful Greek names. The ex-
tent t« whieh the muscW 8uß«r in tumor albus is important. In tbe
vicinity of che Jnflained joint, and often aome distance from it, the
contraetilc tubstance in tli« primitivo filameoU gradually diMppeais,
ustudty after precedent fatly degonenttion, und tlic alTected limb
atro(jliies more and more, in some patients mure tbau in otbL-rs; the
thimicr it become«, the oioro striking grows the enlargement of tho
joitit^ wliich oflfm is not realty very decided wlion you compare its
inpasuremeDt with that of the^ouiid one You will occasionally Itear
and read of tlic puffing up and ealurgement of the tu-tieulur ends of
tbc bones in tumor albus; this ia a false expression; in caries of the
joint lb» bones never swell; when they appear swollen, the swelling
is due to tho tbickeiiing of tbc sod parts or to formation of »«teo-
(Ayte*.
A further dißerenoc in the oourse of disease« of the joinu lies in
the greater or less tendency to supjmnition ; altscesscs and fistulic are
by tw mea&s ooocssory scquelcc of fungous inAaminations of the
joints, tliey are rather aceideota. You already know iliat earic» fun-
gosa Dot unfrcquentJy runs its countc without suppmiitiuu. The fiitt-
gcais Articular inilamnmtioos are often Aocompaiüed by canes sicca; tiic
affeetion msf go on fur yenrs without the formation of abscesses, ce*
piM^ally in adults otherwise healthy ; tlierc may be cxtensire de8troi>
tion of the cartihiges and bouos, witli tho consecutive dislocatioos aV
rftady mentioocd under eaiics, without a drop of pus. If, in such a
31
4$1
CUROXIC ISFLAHMATIOS OF TUB JOISTS.
tsasa of M>«Alleit carles siccn, joii examine the jin^nulatiotu id iha
pint and boiir, you will fiiiJ tlicu fintier than uauni, aud orcastuoaUy
of almost cHitilHgiiiouH coiisUtoiiee, liko jrranulalicuiK Ibnl arv «bout
to atropby or cicatnzo; iiulcmJ, tlii*v do (jvitly xlrupliy, but tiie pt»
liferation often f:ocs on again, aod tbc bouv is dratrovL-d; the pro>
cess is thus analogous tocirrhosis. Bene« eiippunilion is hy ito nuwnii
a nieasure for tlie ex1«naion of tlte proceas in the bone ; nn tUa etwif
trnry, tlic iiioru luxurioiiH tlie proliffrntion of the granulations, the
more extensive Üi^ destnictirtn. 'I'he ilUlocatioa of the bon^ the
defunnily of ihe joint., is thu most itnjiortunl racaniire nf the exlciit of
the changes in the; bones und lipnuix^^ts ; if in a case of di»cas«l kiico
ih« log begin» to rofcite outwardly, and iImj tiijia to titovv backwanl,
there is (tertoinly deslruolion of part of iIil* boiK», and of a larg« part
of the ligaments of the joint. In many cuaes fungous inöniiunatioa
of the jmnt is icoonipaniod hy suppuratiou ; the pua is produoed
cither by llie (j^nulnUons, or elu> rorma on the surfaee of the sjik>
vial iiXL' n'hich is not nuieh (Üsi'jtsed ; soiitelimcs In the mmc no
Ibcnii« a »ubaeutc a^-navitia, while another part of the sac roramioa
intact, and still another la completely degenerated ; the knee anJ el-
bow jointa are rsprrinlly liable to these cireumacribe«! sepiarat« ilia>
«ftAea of individual synovial sacH, which only comintintoat« wilh the
«ivity of the joint by small opening«. Thc«o suppuratioas are uau-
ally uccunipatiied by unite exarorbatiuns of pain an<l fever, eapeciaHy
when the abace.ss opcna extenmlly, ami s>-noviaI saca, which have pro
vioiisly part icipe ted little in tliu inllaiuiu4tLion, ouddeiily brfvmc
ftculely or aubacutely diaeaaocl. An early profuse suppuration of a
joint is sometimt^s an evidence of the previoaisly «^iV/Af degeneration
of the »yituvini niembmne, as most png is given out by serous mem-
braiiea in the «tagu of ptinilent catarrh. The piis fnim the aynovial
grauulatiana is usually of slight amount, and of serous or inuc!aua non*
8iftt«ace. Ttie syniptoma may bn diflbrent^ if, aa ofleii liappcns,
there be also suppuration in the cellular tirtsue around the joint, and
periarticular «Asw*.«:* (whidi, indm^d, may occur without diM>BAo at
tho joints) acconijisny Üie fungous inltHmiiinlion of the joints. All
of theAe Ruppuration» arc important, from tho (act. that they imptur tbo
gencnil health, jwirtly by tliu loss of juices, pÄrtly by tlie fever.
Lnatly, we must give »»me attention to the rital eoodilion of ilio
infiaminatory neoplasia. The vitality, the luxuriance of groutli, and
the future fate of the ehronia inllannnatory nevr fonnationa, gruatly do*
peril], aH you already l<n<iM-,oii the general consiiluliniml cnmlition of
(he patient; in fad, this la «o to such an extent that frtiin the viljal
condition of the local ittTcc-tion we may often make a d<HMSlon wt to
the general health of the patient Funguna inflammulioD of the }oint
TÜVOtt ALDI'S.
4«5
with mrics eiccs, and s disposition to cicatricial contraotioo ot llie
new foniiatifm, uauallv o<?ciirs in persons otherwtKe healthy, and in
these rase» it i» oftFU diflücult to find any caiisp for th« rliroiiirily of
the (li»ea»r, ichich »a« mkI to Iwve l»een first iiHlu<fd liy cold, fii-
tipto, or injury of sunn? »ort. Wc aUo find the mo« Iiurariant,
vpcngy gmiiulntioriH »ntl serivlinn of muoo-pus in tolemtdy )H?altliy,
or nt k'asi wcll-iKfurished pcrsonn, in fnt, Bcrofulous childmi, aino as
thr rhronin oonlinnation of ttn ncxtic nrticular inftamtmition in per-
sons pro\-iouä1y beallhy, who have become niiffimic from the long sup-
pimtion. Great tendency of the neoplaAia to lircak down into ptw,
or to niolöculur distiit<-gration, ia usually a eign of bad outntiou;
ve find thin, badly-flinelliiif^ pus in larj^ amount^ with excessive ul-
oeratJon of the »kin, nnrt tintuloxia opening», that look as if cut out
villi • i>unc]i, in tht; articular intlainmatioi), with or iritbout caries,
of ohi (aiohvi'tio jxitienL*, in I kuUv -nourished tuliorculous subjects and
acroTuluus rhildrt-n. Here wc may liure the same course of aSatni as
in torpid curies; the niKtplasm i» very short lived, it breaks down al-
most as soon as fonned ; and along wilh the caries we have neenwis,
ftx in the small bones of the n rist, more rarely in the epiphyses, »Im
OaseouB degeueratJoo of the ncoplniuii.
:9
>^»
Atonfr nWrktloe of lb« ewrtUac« fr«» '•"* kiMW.Wnt of b rtilM : 'hp («rtlticnN«l!a. wtiTri «nlf
ERilUt'Tat« »llittiUy, iiudvrgii (Bltf dnvnanuua. «nil lb«}, wtUi (be Uitvrc«llulU eubaUnMi
fMkdown V(r7 rapltHj. UacnlDM IW dUnutnn.
We could distinctly separate this atonie form of chronio suppuni-
tire inBumroation of the joint from the fim^us variety, but avoid
dnin^ so : finrt, lliat we may not disturb the general description ; tieo-
ondly, becuuse thi« foriii aim:) often bof^in» as a lyjMcal fungous syoo-
Titia, and sul»equentlv piu^es into the torpid form as the nutritive
state of the patient det-lines. We find it chmfly nn autopy, and
sbmild allof>t'thcr mistake the earlier slofTes if ire did not study tbe
rtiowiHi in rcBe<^1ed and amputated joints. ] «hall not eonlintu* the
asatctnieal details, whieh mig^it be eajiied much further, butwliatfaas
already been sairl will sufllee to explain to you any ^rcn case.
About the oaiMM of chronic fuagous articuhtr inSsmmation tliore
466
CHROSIC INFLAMMATION OF THE J01K7&
is little to BBj beyond what you alreuily know. The scrofulous diotb-
csis especially prcdispoeea to it; acut«, epoDtancous, or traumalte
(whetlier from wounds, coiituaioiifl, or sprains) inSanunstious of iIm
joint occasionally become trliroiiic. ScrofuliMis chil(lf«ii, three jremn
old nitd upward, un; uspccially incUticd to thc&v juiiit-disciiJMis ; • fall
or twisting of the jolul often proves »a exciting cuti«\ Cuiss oooor
wlicro vre can £ud no local or general oius« for the disease. la Switp
zcrlaßd I bavc very often accn atonic fomia of fung^ru» purulcot tU'
flammatioiiB of the joint ia old pcopl«, irherc no cuus« for tlteiik could
be disoox'ercd.
The course of this discusu ia Tcry Tariod, bat it is always ofaronio,
Ia«tiiiß for monthn, usuully for years; ofteu interrupted by pauMA
and improrement, tlitm aguia exneerbating. 'l*be disease may halt,
and recover at any stage ; in Uic first stages tbi» recovery may bo poi*
foct, that U, tbe joint may remain entirely movable ; or it may be itn-
perfect, tliat ü, more or less stilTuess of tlie joint is lefL Befove tbs
carliliige bax oomincneed to proliferatv, or has ita under sitrfiice d»
turbcd by any neoplastic tissue growing from tlio bone, there ia ■
possibility of tolerably good motioo being rratorcd — which, howeinef:,
may be impaired by ciralrieiul contraction of the fungous synovial
menilirune, and vt llie infi]tniL<td [ifpi.n)enla,aa well as by Becon<lnry
contractions of the mu«ok'9. If tlic curtilage be partly or ootirely
dustrDjtx), und oaries has occurred gradually or with the onset of the
disease, it may recover with anchylosis, the cartilage is not restnre<I ;
the granulations of tlio adjucciit surfacea of cartilage gradually unite,
and often firm adhesions form, which may B\-en ossify, \\'heth«r tlie
disease goes on so far or thn dtntructiou of the joint continues to
progress, dejMiQds greatly on the oonslituiiofi of the patient; treatment
may be of great benefit, if begun *>arly. Tbe oxli?nl to which tbe
muscles sympathisu varies greatly; according lo uiy experience, the
highest grade of muscular atrophy occurs in those cases where there
ia no suppuration of the joints but caries sicca, and where the jointr
diseost^ seems to proceed from ostilts.
Now for a short diacuwiion of certain symptoms. Each fomi of tbis
disease may run its course with more or le^ pain ; the cause of tbis
I am ininble to explain ; there arc eases where the bone is extvnsivdy
destroyed, without any pain, others where it Is very severe; tbe acute
exacerbations with development of new abscesses ar« always rntbor
painful — on probing the listuliB we sometimeH Snd bone, at oilier
times not; whether we feel it or not, depends on whether it is covered
with graauIatiüDS or ties cx[K>sed ; the same is true of frictioD ; crep-
itation is only valuable as a sign of carles of the articular extremi-
ties, when it exists ; if it fail in the later stages, it is no proof that
TREATUBNT.
4«r
bo bone is not diseased. The d«formi^, ilie displaocmeol of tbe
Jar euifaccs, patbolngical or spontanoQUS luxatiomi, are tbe only
'evidence at »II certain of ihc «Mlonl irf Ihe dwilnictkiu of the bone;
bere yre can only be deceived when tlic capsule luis ruptured carlj,
and tlie hcnc) of tlic ttoiir? is ftctualljr liixHtL>d ; ii niru crkc, wtiidi has,
howei't-T, boon M'trnin tlichip, andmigbt p»s»il)ly ocmtr in lbcahouIdcr>
Jn rcpu^ to judging of the anatomical condition of tbe joint, tittle can
hv üililed to what has alrondy b(?(!n fiaii), hut we hn\'e some as^islanee
icom tlic etiology and duration of the complaint. ProfiiHc suppumtion
tlie joint is always a isi^ that part of tlic »^iiovial tneinhraiio
'Iiaa not yet been destroyed, or that there are large ablceHes near iJie
joint; tbe secretion from fungous granulations U less abimdaMt, serous
or mucou». We hare no certain ciHdcnccs of the extent to which tlic
cartilag4 is destroyed. To add any thing about the diapnotU and
jmgno»i$ would only be to repeat what has already been said, from
wbich you have all the data for forming your jiidpmpjit. Fi-om my
^Own experience, I think I may say that slight swelitng of iho joint,
rith greitt pain and early niusculur «trophy in amemio children, but
»ith little or no siippiinition, indiutles jirimni^' ilisease of the boite,
f*i>d lenders the prognosis vcrj- bod. A good iiutritiii'O condition is
tbe most imiiorLant point fur a favorable prognosis, xiliieb would not
pbe Teiy greatly afl'i:>cted eveii by early and extensive suppuration.
LECTURE XXXVIII.
1 0^ Tumor Albui.— OporsUona.— BwMtloa «T ibo JotaU.— Critklta« oa tfa«
Optrattoiu on (ho Dlffarent oln».
Now let US ta\iK np tlic «jbject of trentment. As in all <4iroinio
aflammations, this iiiii»t be both general and Ineal, and the general
treatmcot should be the mure prominent, the more cliroiiic «ud insiil-
ioQS the disease ; it is nnnocessary for us to waste word» over this
OOOBtitutional treatmeal, which will depend on the peculiarities of
each case; you already know iis outlines. Regarding the local treat-
ment and its reaulta, we may B»y, to general terms, that it is the more
effective the ninm acute the stage ; aa a rule, it is not dilTieult to
rdieve subacute ex«ccrt»tiofi8,or subacute eonmiencements of ihe dis-
ease. In tlicse caeca we deriro great bcoc&t from the already ofi-
mentioned remedies; strong salve of nitntc of silver ( 5 j to 3 j of
lard), painting wilb tincture of iodine, f)>'ing blisters, vet compresses,
gentle oompreBsioi) with adhesive planter ; lliis should be acoompaaicd
408
CHRONIC INFLAMIUTIOS OF THE J0IXT8.
by nbsolute rest of the j<iint, wfaicli in tbo lower extxemitie« can uolj
be «ttaiitpcl by continued cnRÜncmcnt to hf(\. If tfae courseof tlw
dUcsan is entirely chronic, and doGS not improve after a tiial of reft,
aiul «lie Miiiedie« «hove nientioned, I kunw of no belU'r crvftUnent
tbaii t/ie maintenance of continued mwierate prannire on the itirotlen
limb by mtan» of a frm bamlatjf, tu<Ji at a fikuttr-aplint^ Khich 0t
the same time Icetp» tl>e Joint perj'tetty quiet in a tuitalde jtotUion.
With Riicli a dressing vre may [Kmiit tlii^ jntient to f^ aiu^iit, if il
does ttut iiaiii Uim ; in &o douig, liu umy me 11 cane tir eruli:Iir3, iic>
ixmliii;; to the n'mkiicu» of llic afltcLetl limb. Shotdd tlie pativDt
ne«:il baths at the same iJint.', l^ip- bandif^ may bo divided longitu-
dinally, and be removed before the liath oiid rtrpliwicd eubscquctitly.
This treutDiOTit has the advantage tbat tbe palicDt vse» tbe miudea
of the extifinity »jniewhnt nt leasl^ and consequoiitly Iboy do nol
entirely utropliy; we aru uut to think that sliffu«» of the joint unst
nece*Rarily rosuU from wcarinf» tlie plaster-splint fop a Ictigtli of time;
wc not uufrcquently litid the opi>osite, tliat is, that a limb which WM
Tory slightly mavabtc before the applicatinn of the dre«aing' ia ntoi«
so afterward ; tliia ia because Die swelliiiK- of the synovial raumlffiuie
often nubside» iintlcp Ihe banda^nL Before applying the phuter^res»-
iog' wc may rub the limb with mercurial uiiitnicut, or apply mCTCmia]
plaster, or cren nib in the niliBto-of'silrer ointment In all dtrtmit
cases of fungous inflammation of the joint, I cannot sufGciently roeocii»
mend to yon the pla»te-r-sp]iiit ; ibis trejitinput apivar* very iiieflWent,
jet it is more ttseful tliaii all Uie otlicr renic-Llies Uiat ne have for
0Otiabfl.ting this diseaiie. I can asjnirc you that, sine« following iIub
treatment perse verinply, my cases nrtt Iwis frequctitly eutnpliailed
nith suppuration nii<l listnhe. Evtu whtm there is evident 11u>'tuatioa
JOU may apply the drcswng; it is true yon will rarely oec tbe abacess
reabsorbed, still, when it opens (ipoiitaTi(<uusly under the bamloge, ox
the patient will readily notice ti-nm the mointentng of the dressing,
this will take ]>la(;e more ({uiotly, propiiiuuüly, and juinlcKsly, tliau
under any other plnn of treiittnent. When fistulre hare formed, vre
may still use the plaster^pllnt, i*inij>1r slitting it up and putting in new
wwdilinj; ; il should bo removed daily and the sores dn-sswl, tben re-
applied; nt the same time the constitutional treatment bImuUI be
persevered in. If Ihr» limb lie very painful, and llicrc are any fistu-
Ife present, wc should use splints with opcninga. In this way [ have
occosjoonlly preserved a ffood, useful )iosition in joints moderately
movable, where the pniguosis was at Gist very bad, and have indeed
been frcqueutty most agreeably surprised at the results of this treat-
Uent. Exlcusion must bo uiideriftkcn very carefully in joint« that
are suppurating or much diseased in any way, and, if oven daring
TREATUENT.
*69
aaiMtbc&ia tliere sliould be rcMstanoc, complete «xtensicn kIiouU
iiei-er bc' made at one sitting, but it i^lioitk] only \>e wirrii-J to ftir a«
any bc tlune witliuitt gmM furcc. lu kiK-v uiitl liip disciiscs I um*,
rith great benefit, tbc extension by wcij^bt« whicli bas bc-cii no otivH
'lecoititiiL'iidri], niid <.xx?aäiunal]y tbus |m'[>»ni patii^iils, L'&peciälly cbiU
dmi, for tlic applii-uliuii of th« plaslar-baiidage. f'oli:iniiiin deserves
nnitiy tbaiiks fur hiscuurg rtic rL-cummuiitbitiuii of tbis plui uf treat-
ment, wiiJcb bc culls tlie " Dislrncijonsmcthoiie." He attAches great
importaiiM- tu Uil* fact tbat tbc extonsioii ivtluct's to u rDiiiitnuiii the
ptcBBUnt of Üie articular ttiirfucva on cacli otbcr, tJiat ta <jtuse<) bv 'lie
tension of the musvlcs and contraction of tbc U^ments. I'bu tiiuJe
of applying Ük* extensioti la so very important for the pniclic«! ii80 of
^■Uiia metboil, tbat I in\iAl patrliL-uIarlv rcconiinuiKl yuu 1o ^rc your
^^BVciul attention to its mccbaaical application in tbc clinic.
^Bi Feieevcmnre on your pdirt ant] u>n tbut of tlic patient is abaolutdjr
necCMTy, for tbc cure of cbrouic inflammations of ibo joints ; rppre-
sent to tbe p«tit^(,at tbc out&ot, tbat ibi» is a ilisr^ise of at Ic-ast sev-
eral niontha^, poiaibjy of some years* duration, an<l tbat the (In-ȟtig
I is not to bc left off till tlie limb ia fte« from pnln, mid strong eriaugb
lo walk on, whether aiuliun be lost or nut. Utj^nliiig ould nbsccsscs,
I repciit the a<lricc only to open Ibcin, whon yoii propf)*c lo follow
ihem at some time by an operation ; if tliia cannot bu done-, or you do
not intend to ilo it, leave the opening to Nature, even if it slioiild re-
quire year».
So fjir, I Ka\-e briefly giv-ün ymi my maxims rt^ianlinjr th« trcnt-
ment of fuii^rous inflammation of tbc joint, but I must not ncj^lt^'t lo
call your attention to tbc fact that other surgeons bare diffcnmt views
oo tbe subject, liiere are atill advocates of tbe strong classical anti*
pblogistic tivatmeut, who, even in chronic iudammations of tbc joints,
from lime to time apply leeches or wet cups, put on compresses witb
Iead>wut/(r, an«! give cathartic« ; Inter tbey use cataplasms, and finally
tnoxfe and the hoi inm. If tbe disease oniitiniies lo advance, if fis-
tube hure formed here und there, if tbc pnticul has become rery
aiumtie, tfaey consider amputation indicated, especially wbon there is
crepitation in the jc»nt. This was tbe old belief; tbe results were gen«
eralty imfaviirablc or favorable, as wc may choose to constdiT Ihcnt;
tbftl iss they were the Utter so £ar as r^ards tbe fiivorable course of
tl«! amputation, whii'b wag made, sooner or later, under such cmruro-
atancca. Even now it astottishcs tnc to see bow often amputations of
tbc tbiffh oie iiuide for tumor albua of the knee, in many hospitals; it
is not Rsyinjj* muoli lo mention that, in my own ho^ilal service, I
have rarely found tbi^b-amputations iodicalcd for caries of the knee ;
appeared to me very remariable thai, during tbc seven years
419
CHROSIO IXyXJlSUIATION OF TUK iÜIXTS.
I was asÜBtant in tho surgical dinio at the Univonh^ nf B(>rlin, there
wrrc only Iwo amputations of tlin ilugh for cnrii-s of tlic koiv, vliilv
formerly, iu the rejK>rte of the 6iiiaUest hospitals, eorcml «iich wn{)ii-
tntlCNia were reported every year. I am muob iooUned to nifer tlie
more fiivonible rewult«, tliu rarer Jniliuittons for amputation, to tbe
treutiiicnt of tlic disease by tlu? ploster-buiidsj^ wliicli was diicfly ift-
1roduoi.vl and pi*rsist«titly i-arri«! owt by J'on jAtngettbtrk ; and I otn
£nnly convinced tbat, by it, a large number of liinljä luivc been
]>ie«crTe<l in a relatively good condition, vrbich, in fonocr times, would
«wrtainly havts b(^n nniputated. I would «at nwomroeoil the ulwtno
tion of blood in chronic disoaso of the joint»; it con only prove beoa-
fid&I in subacute cxaocrbatjons, and in tliese very cues wo bavc
bettor rcmodics, wliich are not at ibc some time injurious; for it is
dTtaiiily improper to abstract blcHxl uiice, or even ofteiiT, from pa-
licnla who are inclined to unseniia by tbcir diacasc ttsclf. In some
case« of ftidutcut« attacks in chronic inllaiuuiatiwi of tlte joint», cold
IB an c!t<?«llcnt application; in »iich ca»P:a 1 now use ice with pxxl ro-
Bulta; but I cannot say tbüt cold would be parlicidorly bencficäal in
cues tbat nin tlicir «ours*; witbouL outward s^-mptonts u( iaflamma-
tion; and it is no slight affair to treat a )mticnt with iee for yon,
keeping him in tlie same poüilion in bed with a bladder of ice on bia
knee, which, at any rate, does nut give liini inucii jiain. Kxottirfh
claims very favorable result* fo*" peraevering treatment with iee. Now
I must speak of the fmrtisleiit a/)/)tieation of heat, which may be ao-
oomplisbcd by the careful application of cataplasms, comprcsaes wet
with warm water, or even the continued u«« of worm batb» for weeks.
Tliia treatment may be indieated when tlie course of iJie disease is ex*
occdingly torpid, when bad-looking fistulous ulcers, deGcieot rsscularity
of the granulations, or bad, tliin secretion, seems to indicate a tnodct-
ate irritntion of some kind. However, when high temperatun!« are
applied, they should not act tnn long, or tlicir effect will be lost, and
there will \m complete rvlaxuliou of ibe parts, instead of tbc Quuou
that it was proposed to excite.
From tlie almvc description of the benefits« of treatment^ you may
see tliat in fungous LutlammiLtiuiia of tl)C joint» tbe rusults are gcnet^
ally gooil, if we leave out of consideration lite groster or less nÜS-
ness of the Joint ivhich rcmainit; tbis is (uirlicularly the caae If tbe
patient ia trentwl early. Still, eomc cases are not cured, ia spite of
the most carefnl Ui'ittinent; this is partly due to the auatomictil ouo-
dilinn of the joint, partly to tlin general health of the patient. F<«
anabimical reaaons, diseaaeof the joint« of tlie bands or feet ia the
most imfftvorable ; from the many small bones and joints affecled, th«
progress is usually cxccsaiTely tedious ; tbe disease may begin quiU)
trejtmest.
471
Sc at one of tli« small joints of t]iP hand or frx)t, inaj- rpmsin
statioR»rjr at this ptnot fnr a time, then 8j»vad to tbr^ next tvro, again
bait a while, or ercn recede ; but a new joint is ultackcJ ; siippura-
tltm be^ns first in onp pUice, tlien in another, the patient grows
amemie and wenk, Ite iH C(m<lemiieil to iiiarlion for years, anti finally
longs to hu\x> the aRiMrtcd liiab niiiputatt><], so thnt lie may ooce again
feet well, after his year« of suffering. In other «wies a serofiiJot» or
tuherciilm« cachexia gniiiiially iiiiluces amemin, iniJIigeHtioii, fatty do
gfticrntion of the internal (»rj^^nfi, tubereulosis of the lang^, etc., so
that from llio general health of the psiicnt we must gire up all hopes
of a etire. If, uniler such cirrumatancea, we leave the disease toitMl^
tlie patients die »fter yvnn of sufferiug; the md comes the sooner the
larger the joint affected (knee, hip), and the greater the number aimul-
taneoQsly affectetl, aa is apt to be the case in scrofula and tubereulo&iit.
Untier such rimimxtanees ne may reanrt to two modes of treatment:
1. Oirc ui» the linili to^ave the life, that i^ amputate ^ 3. Give up the
attempt to cure the joint-affcetion, eiit out the diHensed end« of bono,
so as lo sare both life and limb, that is, rrffct the joint.
Comparing these two remrdiea thcrirctieally, there can be no doubt
that resection is preferable to amputation, nnd in principle thia is e«s
tainlv tnie; modem surgery is justly proud of the institution of re-
section of joints. Nevertheless, irertain dreumfttance» «lay eomhino
to reikdcr amputation preferable in any given cste ; chief among ihes«
Is the slate of the patietit's geneml health. After resection of the
joint vre have left a large woimd willi two siwed edge» of bone,
which will certainly oonliniio to euppumte fir weclcs, possibly foe
munlbs ; there may 1h_> supiniration of the subcutaneous tissue, uf the
sheaths of the trn<loD.s, and suppuratirc periostitis and necrosis of thft
sawed edges, tilings which patients may live throngh, hut which al-
ways require time and strength. If, tlien, in badly-nourished, cachec-
tic person», lo«» of strength should indicate opcratire intcjfcrence,
amputattMi vt often a more certain remedy for saving life than rcsoo-
„tion. The surgeon should always think more of saving the life than
limb. "We have also to answer the question, Oin tlie patieut
rc«ertion, with its scquelie? It ts dil&cult to give a grncml ao-
' to this (juesti'in ; ex-v« in individual caaex a decinion may be diffi-
cult; we must determine whether tlie patient is emaciated, ann^mic,
and (k'bilitated, »imply by the drain on his system, or tf there be mora
serious lesions of internal organs ; iu the latter easo amputation would
be preferable, if, indeed, any ojieraiion would be servioeable. Of
coiireo we do not operate on atrophic children with disease of several
johtls, eohl nbseesaes, diarrhoML, aphthie, ete,, or on persoos with
tuberculous CAvities in the lungs, or with indumted, fatty liver and
472
CHROKIC INFLABlJdATrON OF THE JOINTS.
iiptcea, or on old mnniKniii; iaiUriduals; we cjiiiQot give uiy aid to
8iicli {uitient«. Hiit a titiU lunrr impt>rliiiit ((ue.Hiuu is, AVliicli opcm-
tiuu ix less (luif^rous tu üfu ? Wu ciiiiiKJt (prc a yencrtU bhsivlt to
this qucstioo ; wo mu«t scpuntoly coiL$iU«r tbc joints conccraiag
whicli (tie questian uf n.*.<>ccti(>n arisi.-s. Tn «trios of thp s/ttmfilcr-jiMDt
ros(!ctioii ia Iciks daii^rmus t!tiiii ilisaiticulation nf llie ami at tlie
stiouliler-jotut ; tli« eaiu« tn true of the hij^joint ; bij>-jüiiiit aiaputa-
tions are anitui^ tlio most diiiigerous in siirgery, while in ytiun^ ftulv
jet'ts r«S(M;liuii is iioL »u very ruUl. Hemi: we arc uut tu ihiiik of
c-xortit'ulntiun at llin shuultk-r ur hip cni ucrauut of corks; lii-rc the
only question is, Is titc general Itcnlth of tlic patient 8ucl) tliat it%
sliould l«t tJic fliBease run itd cnurj^e, or Khali we amst it by resection ?
Ill tlie most ftivorelilc cuaes of apuiitjiticous ctire then; will be aticliy
losi» in a bud positiuu ; if rccvriTy takes pkoc aAcr rcscctioQ, the
f>xtruniity rciTuiiiis mui'iiijltiut ihc shoulder or hip joint. Thi.>8C duuicev
8]K:ik strongly for rt'scctioii, csiK-cJBÜy at thn sUoulder-joiut ; hereira
might dcf'itie on resection c|uit<; early, even in order to get the patient
about soon nnd in good order. !{<.'■ section of the hip i» open to one
gr&vo objection : wo cauiiot rt-äoct tlio aoctabuluui, whtcli is usually
disoasril at tho same time, nr we can ouly do so imperfectly ; lience,
when the juint la inudi Uiuuuaßü, tbu resection is imperfect; alif^btcr
gmdcH of tlie nifi^cti«!« miiy i-roii rcroror without ojH'mtMin,
In the elhowjomt Vtiu stale uf alTnin» is more fin'omUe, [X'rliaps the
most farorsblL-; the rcseclion of ibis jiunt is uot uiuro dangcroue thnn
amputation of the nrm ; but, in favorable cftsos, after resection, quit«
a u«'ful joint is left, whtlo aflur spuntuiicouit recovcrv thero Is. pen-
cmlly anchylosis ; iu tlicrsc cases the choice is caaier: wc prefer n>
eection of the clbow-joinf, not becauae ti«: operation must be douc to
save liHn, for cniies of this joint is only dangnrous from long duration,
but because, while the danger is rclalivety slight, it oflers good ch:ine«s
of motion, and in uuy other case there is usually aochytosis ; indeed,
the ouchylosed joint has even been sawL>d out in order to obtain a
movable fiilsc joint, L'nfortuuately, mopH recent observations on tlw
motility of amis wiili rcscctfd joinLi have shown that the false joints
fonned after operation beeome more relaxed in the course of jcor», so
that finally the operated extremity does not remain as useful us was
formerly tvupitoseil. The case is very different with tlm km-t-Jotnt-
here rc&cction is quite tt dangerous opcntioo, being on a ]Mr with
high amputations of the thigh; aft«r resoction of the knee we only
obtain aneliylosis, wliich is also the result of sixintaneouit recovery.
Now, as this openitioii if, quite daugi-rous, and as it f^ives no better
rcsuhs ihHn non-operative tn-atmcnt, in ea«e the diswise is arrested, it
sliould only be done to save life, and, ercu iu this respeet, it is of
TREATMEST.
478
doubtful advantage. I have larcly tlccJiIed on an ojiention fur cnriea
of til« knee-joint, cither for iini))ulatiuii or insertion ; wc can only pro-
pose Hinpuintinn when nil Irentint-nt is iniMvs», nnd the patient ii
failing rapidlj-, or wlion it tx an oM person in whom extensive cuHm
of tie joint wi>uld be vcrj unliki^lT to li«il.
Tbo above nrc my personal opinions, irhicb conttantljr bocotno
more 6xed, as I see more »ur;li kiiee<liM!Bses rcco^in- spontaneously.
T liffve typen ia»uy cliildrvn iltu uf coxiti», aod cDnscqucotly am rotbci
in favor of r\i8<>otioti of tbc liip, in »piti> of tlic want of Buc<x-e& of my
own c^icT^Lioim ; iHp only duallis I Lavo seen from caries of the knee
have been in old, marasmic prrsonn and tliosc with tubeicIcA and ex-
tensive caviliL-s in the lungs, while tlivr have beeu rare in cliilürcn;
in all of these cnscR <ipr>niti(m voiilil have been u»cU->s. Hfv« }'ou
have my belk-fubout Optoral iuns of rarieit of the- kut-v. Other »urgeona
have diflcicnt opinions ; in England, especially, tlie operation le bo
popular that it is very often porfonncd. I believe ttiat many German
su[;geons ahare my vicwb on this subject, othem arc more undecided,
as tbey view tliia ojierntion more favorably from havin^^ ttccn a few
c>siiful rcscolions of the knee-joint.
Now we come lo tJie teriityoitit ; liens rwtection luunlly conNial» In
Oic removal of nil tbo bones, and sawing oBT thu lower surfan-ä of tjio
radius, ))erha)>6 al^o ihos« of the o«sa metacarpi. I have pcrfonncd
this operation tievenil tiuiei*, occasionally with brilliaut rf«tilt8, tlie band
becoming piTfectly movable and tlu; fiugcra useful ; two of the pa-
ticols wrrc seamAtrrEscs and were able to rcaumc lbt:ir occupation,
tlio third and fourth unfortunately lost pattenv« ; after the opemlion,
when the wound bad eloped exrept two fistulie, and the [luiu lind
oeued, tbey stojiped in_'»tniciit ; there were still eonie curious s|xits
in th« inet*<!ar|>al bones wliicb sliould have been cxlirputL-tl, whi'u llie
result would certainly have been »8 good as it wa» in tlic previous
case«. I should liavc liked to rt-sect tbo hand more frequently, but
90vcr«l tunca linve submitted to the patient's special request to am-
puUite the fow^arm. It tnuat seem straiigo that a patient does not
readily oonscot, when the surgeon pioposcs, by a lolembly »afo ojierm-
tioii, sodi as rescrctioa pf the wrist, to preserve the hand ; 1 always
fell obliged to snv that it would be neveral months before tlie wound
healed, so that the patients should not exi>ect too mucb ; tlicy replied
that it was too long a ( ime, they bad not used the hand for (our, five,
and eight years, and it always J>ained III«« ; lliey were tired of treat-
ment, and had floindf^l to low» Üie hand, so tliey would not again un-
dertake a long foursc of treatment. 1 Iiavc told y<m this tliat you
may soo what obstacles the surgeon runs against when be bcmectly
tries to Aa the beat. All the caces of caries of tlic wrist are by no
474
CmtOXIC IXFLAMMAnOK OF THE JOKTR
mciins suited for rvscctton ; wc nci-cc decide on an. opcraUim bofcra
there « extensive doBlructJon of tiic boiiw, sUtiougli we kootr tlut
caries of ttie wrLst very ranrly spontaacously rccovera witli moraUe
joint. Caries of the wrist is not frrqucnt u» compared witb that of
tjie kneo and hip, and is pfirtiriilnriy rare in children, being moro fre-
quent in adults. Tli« cutuv of tlif diDimilly of rf.>corer^' is psirtly due
to loco] conditions wbicli wc have prcriously described. IScaMk» tbi«,
titere are about the hand so ma.ny tendon«, most of whos« sheatlis ptr*
tiäpnte in th« disease ; the Sngers ate stiffly extended, the melacaifUil
bones, ntdius, and iilnn, are hIm) freqiicnUy disetuted, tliough tliey nur
bo oiily affected with periostitis. Thu other boH parts about llic
hand, es|iociulIy the Kkiii, nro p«rfomtcd by iiumorous fwtulip, orenm
extensively destroyod, bo that the most farnrabic oUcumstaooea tx
resoction do not exist. Hence, wbci'o csten&iye c-arics of the liaod il
aoconipatiied by eunaiderahle degeneratJon of the neigbboritij^ put«)
amjiiitatioTi of the lbtv«nn will ju»dy assume it« old portion. Ex-
traction of single nietnrarpnl bones, or simply sawing off the mdius, li
rarely suflicietit; I hare, indeed, smn caavs where the diacaso wu
limited to one or two metAearpu! bones ; lliese Had l>ocorae neooeedl,
and the disease terminated at that point ; the patient was sent to me
for amputation of the tumd^ and vius tuuch pleased when, ofli'-r l'xmo-
ination, L told him that amputation was not nceessar)'. Hut tlMM
case« are rare ; usually the diaease advance«, and is not arreatcd hy
the e.\lirpation of the bones wtiieli are ohiefly diseuaed. I thiuk that,
on thewhnle, total r(>se<ftioiioftli« wrist is atill too little cmplorcd; ao-
oonling to my experience, it is worthy of th« greatest attcmtioii frooa
Hur^Mins. Tliis operation, HS well as u similar otHi on the foot, of which
wc shftll epCAk shortly, is well 6up|>orted by a reasooinff that has been
falsely applied to resections in peneraJ; L c., if reaectioD doe« not
arrent the local discaetp, we may .still aniptilat«. In resections of tlio
liand and foot ttiis ia tme, and they are rarely followed by pytcmia,
but the caM! in not th« «ame with the sltoulder, hip, elbow, and krKVi
If these opemtjons arc unsuccessful, if suppunition be exhaualiiig, or
pytetnia occur, wc can hope little from amputation or cxarticulation.
Lftslly, wc como to the ankle-joint, comprising the joints of the taraos
as well us the tihiu-tarsal artieulatiotL The eircumatanoes here xetj
eloacly resemble those for the wrist; although caries of sin^e bones,
as the nut unfrcqucnt caries neorotica of the calcnncus, will spo&lsn*-
oiuly recover with time, ewperially in children, just as scrofulous carl«!
of tlie Rngem, toes, »letatamal and inetarurpiil bone» do, ev<^^ in ynruojt
adului, caries of the joints of the foot rarely recover spontaneously,
and in old persuns hardly ev»rdoso. Consequently, in these caiea
openition will frequently be indicated at some stage of tlie dlseaaey
TREATMENT.
■tJfi
and on superficial observation we might tbiok Ikiit rcecclion and ox*
tjqidtion of bone sthotiM be very romiDOtilj' reeurteJ lo ; but, prnoH-
ciJIv, tltcre are two obji-ctions to tli«; extensive tvsort to these
opt-ratiott» in cnricsof the foot: 1, llic experience that, aJ'tttrcktiipa-
tio« of ociv bono, llie disens« often attacks anoltier, bdiI contieq^uetitly
perfect recovery doi?a not result. Ä. The tact lliat th« foot must
alwaja retain (luiTiricnt ttnitnee» for the patient to walk; ao, vrhilc wc
«n«jr remove the cuneiform bniic», the ecnphoid »ml cuboid, or even*
kb« agtntfrwlus or cali'sucus, if we rumoru both tbu latter bones, and
[Xrhaps also »aw off the arLiculatinjt surfaces of thr tibia, wc sboutd
bjiTo A rather usclesa foot, which voiild be worec than a good stump.
The cicntrieeH oceurring nt th» place whence tlic bone wa« extirpated
coattact greatly after a time, and even if noroc Itone form in tlib cica-
trix, still jt is uot re^^enorntcd as after necrosis, but the foot contracts
grently at the point from which the bone Is «bw^tit, and thus become»
distorted und uaek-ss. TTicse are decided objections; morcorcr, a
good stump, such as is left by ChoparC» or J*iroffoff"'a operation, is
often juBt as good or even better for walking than a weak, deformed
foot, And it require« several mnnths to get the latter into shape,
iqrhile tbe foniier may be obtaiiieil in six to eiglit wcekfi. In one case,
I removed nil tliree cuneiform bonex, and tlie os eubald, with good
results ; in other eases, in boys, I hare removed the aalragalus ; then
ibe tibiii artiruliitetl with the calcaneus, tbe new jr)int rcmatned mova-
ble, and the patient did not even limp; eiich results are rery encour^
aging for this operation. Another time I wished to remove the cal-
caoeous alone for mries, but unespeoledly foimd tlic lower port of the
Ds(ni)irnlus affected, and bad to rvniovc it also; tlie result was miser-
able: the young boy lay »x inonllu) in l)ie wanl, and even then did
□ot recover, »o I amputated at the lower part of the Icg^ and tbe
wound bealed by first intcn(ir>n ; a few weeks later, the iiatient ]cCt
the hospital well, with a gocxl wooden leg, glad to be rid of his sore
foot. Tlie ii-ery favorable results of IHroijaff'a amptitution make a
Btjoog opposition to resection of l)>e ankle-joint, and I think that
expcrienco will soon Rpeak more strongly than now against loo great
eo^lloynieot of exscctlon, and for »nipulations tlirough the foot.
BcaDotions of joints, which have excited bo much conlruvexsy tbo
last twenty year«, at first appeared so brilliant from the fiivorable
remits in certain joint«, saeh as the elbow and shoulder, that Ihey
were «ometlnics too much resorted to ; this is the fate af all inventions
of the liumnn mind, ^^'e uro only now gradually coming to certain
tndicstions for these operations; of eoiir«e statisties tuid first to be
collected, and it was soon found that resection was of varied value in
dilTerent joints. Although I am not prepared to say that the question
419
CUnONlC LSTLAMMATIOS OF TUE JOISTS.
13 C7CQ nov settled, still I belici*« I bare gircn jou a mrrfvl ^*mi
of the preseut ivx^iticm of Rffnin.
I cannot n>rrait) fmm mHkiii)^ one observation »t tlie rlusutf lb
vtiiiptcr. lu til» Cantoa ZOrich patients wbo had buLti FUccenfdlT
treatctl for ninir)', lir rL>s(M.>Lion or stnpiitntion, ofl(>n r<.'tuni«d, nJ,
sad to »ay, mimj' of tliciu wh«, after Buffering for years, bad ln*u j»
foctly etired, and had left tlie bnitpittl quite Mmng, came back «(Wr*
je*r or two willi enries of otlirr bonea, or with tubereles of the liogi,
aiid often (lied there. I liave bcfii unable to gmilier iinv extesiire
statistics oa to the final turmiualions of bone and joint disease, hA
fear tliat ihey will prove niitcli more uufarornble than we gwienjl»
incline to believe.
LECTURE XXXIX.
Jl— Chrouio Serou» Srnoiiti*.— llTdror» Artlcmlorum CImiil««; Aiulooir,
U>at, TrMtmonl.— App«Ti<Ux : Ciironl« I>n)pitci ot tk« Shculi* of tL« T«
Bfuovlal UcmlH ot iL« Joint« «ud SuImuuugoiw Muwu Dun«.
Ä— CHBOMIC SEUOUS STSOVmS— KT DROPS ABTtCCLOHOM OIUBlin-
Cl'^— IIY1IKAETHKU9.
Thb ehronic diteasns of tb(< joints llint we have now to ileAnil»
are mucli inore rare tlian fungous synovitis And its result«, irlii^b w*
liiive already deseiibed; taken allojirether, they an) senroeljr bo ftf>^J
qiient as tlic former, niid, «s a lx»ly, they form a decided ooatiast t^H
suppurating intlanitnatiuna of the jtnnt«, for they never spunliLncoualy "
BupiMiriite, they only do »o when tR'tod on by repealed irriiiilion«,
juries, cte, M'c sEall commence wiili tbe iQost simple of the«« fo
■witli chronic serous synovitis, or hydrnps articulonim cbnjaieus^ i
hydrartbriis. The (Hhciisp consists in a morbid, &lowIy-itK!re*lsti
colleetinn of ratber thin synovia ; tlie synovial membrane eltangos
very liMle, it gradiiully bei-onies noinevrbat thicker and firmer, UiOj
conneetivc liflsuc inen^asos, but without any marked inerense of vt
cularity ; tbe tufts elongate, «nd, allliou^h tbe vereis fonn into Ic
at their npire^t, the siibstuticc n^tnios the firmness of eoanective lifltmc
while from pliutic and serous infiltrntion it grows soft and roscni
gmnuhitioiis in fun^nai synovitis. In serous synovitis this does
(X'fur; tbe entire pal!i<>h>p«d ehanges of tissue are very sllj^bt, i-vetij
when tbe diseuae has lasted o lonj^ while, Some aurftvona wiab
consider these dropsies of tlie joints, as well as similar disvftses of I
mucous liursa*, as not In-longing to the cbronic inflammations, bat
oottsütutitig' peculiar diseases. Tliis does not aocin to mc justifiable«]
CmtOKIC SEROUS STXOTITIS.
4V7
Vo ono will dispute Ui»t chrnaic catsnhs of the muoous mi>nDbrancs,
"frith a tenfleiwy to hrppTwwrelion, are to be pUbshI ninoiig llie chronic
influiiinntiong; diiDuir rlrapsy of tlic M-nnrkl mombniQe is pertcvtly
•OkUiguua tochrootc ciiturrh of tlie iiiucouti iiirmhraaeH.
Chnnuc dropsy of tlic joints is often the remnins ofttn octili' nrtio-
llbr dropsy, <»tu((xl hy uontusioiis, ott-liiog cold, etr., m lias already
been dcombcd ; but in many «wcs, also, Ihc disc-»«; is climnit; from
tlto etvl, and rein.'iin8 so. HydmrtliniH is most rooimoD in young
iDf!!!, and occurs most fretumnlly in the kDi.t>-jüiat ; il oftpn oodipr on
both sii W ; it is vory rare in the shoulder, btp, or ellmw ; I Iiat« never
atxti a pun> onso of »1 in the othor joints. AVlien the <Utit'«i?c is well
ath'anmJ it ii rciultly rcoogiiim'd, and oven the Inily know il as
** dropsy of the joint.** The joint ts .tniicli swulk'n, fiitctuatcs all
OTcr; in the knee w« have also the motion of the putelln ; it is liiltnl
up hy Ihc fhiid, and may bo readily pre»^xl n^in into tin? intt^rcon-
dyli>i<l fiin&i, iM^-asionally mth a perorplibV sound. \s the tiiirfucvs
of the joint iin' uiiittMl by lirm tjj^nicntjs (iii the knee b>- the laleral
and crurial Ii;»ntnentii), whi<<li arc not »n ca»ily stretched, the fluid
PoIleetB ehielty in thi* inufiHw Imrs.'*' adjuceiit lo iIm* joint, iind on ihis
■ceount we may <iftcB diujfnose the sweltin}; as nynovilis by simple
inspeetion, especially in Ibc kne<vjoini, where the bursas under the
tendons of the OKlensim at botb sides of the patella, ami in the
popliteal s|nce, anr greatly di»teiiilei1 by tlic fluid; while, ou the
other band, io re;cidiu- snetliii]; of the c»|KHiIe, the enhuffemcnt is
n^f^larly rouniL Sunieliincs, also, patients with this disease (!an
ntoTe their joints quite freely nod without pain; tbey can often walk
quite a distance, ami oceasionallr have so little intoavcnienco tliat
they di> not ask advire of the physician ; cren csamination of the
joint by palimtiun is |Mi.i»les8. Where tlic drojNiy of t)ie Joint Is
cons idc-n hie. great exertion reudtly euuM's rutij;iie of the limb, lis wdl
as pain and inorca^'d cxniUtion ; however, after resting u while, tJiis
pus«& off, and generally the inconvenience is verf slif^hu
The prognosis is j^ood in ho 6tr as tlicsc dropsie« of the joint lead
to notliing further; the fluid may increase enormously, but ihnt is all;
Uiile^LK ihore (»<• some overstraining or iiijur\, the «Üsense remains the
same. A» rcffanl« reooverj-, il»e |>mgnoeis is roost favornhle in tlmao
caAcs wbcre the diüeaae remains after an acut« or subacute commenoe-
mcnt; in tbcs« cases, a« « nde, eomplote recovery takes place by
reabaorption, altbougli it may be slow. On the oiIht hand, those
oaaea wbcre tlic iliscasc is chronic in it« commcn^-mcnl iiutl couno
»ery obstinate, and are often ettremoly difficult to cure.
Tlie treatment consists in the spplicatiou of the remedies already
lescriboil, which are to be pcraevcfingly used whik the joint is kept
vmm
478
CDItOMC rarLAMMATlOX OP THE JOINTS.
at perfect n»l. viz., tincture of iodiDC, flj'ing bliAteis, mnä oooipra»-
■ion. The latter is the most oflectivc remedy, but it must be &troaf
and coQtinueil (tbroeil compression, accordiog to I'oUrmaim) • vre m^y
»p]>I^ firm dreasiiiga vritli moist or clMtio bandages; tlie palicul must
lie still during the treatment ; if there should be any wdciu» of tlia
Ivg*, it will do no bsmi, but, if the tot4 grow blui; nud ould, the bond-
age must be remorcd. If thv jjativatu will not submit to thin ti«at-
ntent, we mny let (hem weur u Urf^ mcrcuiial plaster, wtlli a anuj^lj^
iittlnj;- knee-cap of leather with elustie in&ertions, which prevents loo
much nKition of the joint, and gives tlte limb more liraitM»» and se-
curity iu walkings, If all tbid Ireatiiieiil dues uo good after months
Of years, or if the improvcinent has only been temporary, we may still
resort to simple tapping, or to tapping, followed by injoetion of iodine.
Usually simple tappinjf doers little ^noiL You pass a Üne tnicar into
tlie joint alongside of the patella, allow the fluid to flow out slowljTp
and close tb<! camila n little before it has all escajied, so that no air
miiy enter tlie joint, then ctufer llie woiiud witli adliesive plaster;
now ])ajiit tlio joint with tincture of iodiuc und cnrelop it willi wet
baudagt'» or n colloflial bttndage, and in üom« cases jeu mnv attain a
care ; there will be a rapid collection of serum and some pain in tfae
joint ; this new fluid may be completely alMorbeiL If tliis ojieratton
has done no good, if the Suid eollccts again to the »ame »mount, and
lenmins unchanged, you may make the tapping followed by injection
of iodine. This oper.ition is not free from danger; you jK-rform it as
follow«: First tap the joint carefully, as nbcn'e directed, then KlI n
weH'ttinile svringe with a mixtum of olTieiEiiiI tincture of iodine and
distilled water iu equal jwirts, or, if yuii wisb to be very careful, one
part of tincture of iodine to two uf water ; after seeing that tlicrc is
so sir li'ft in llie syringe, you may inject from one to two ounces of
this mixture, aixrordlag to the amount of previous distention of the
joint ; keep the fluid iu the joint throe to five minut«», nceording to
th« pain induced, then let it escape slowly; now carefully close the
wound, and make compression, as above dcscrilicd. A new aeute
serous exuiJatton always results ; tJii;) remaioa stationary alxmt eight
days, and is then slowly absorbed, and T«eorery usually follows. OC
course, under such treatment, as after simple tupping, the pntiont
must remain altsohitely yniet, for liiere is always inflammation, and
perfect re^t l* th« first reriiiircmcnt in iuHamod joints. It is uot quit«
evident why it hnppens that, when linclure of iodine comes in ooataot
with a serous membrane which was disposed to excessive secretion,
even for a short time, it should have such an influencv in altering and
arresting the secretion ; formerly it vras thought that after these in-
jections, wliicli were adranta^^usly used in many cbroaio dropaics
CBROXIC SBBOCS STHOVTTIEl
♦ra
terous membranes, ibere wm adbenre inOammalion, » uaion ot
tlic iiurfiioo» of lUe t>erDU& sac, and itg consequent olilitcmtiori ; thj^is
1>y aa moiia ilic cumt, »I least nfter Utc Bucoessful mjectloiiti oi iodine
in hjtlrope urticuli ; if au(.'li uilhvsiüiu occurred berv, tLc joiot vri>uld
become stifT. Wliat roally occurs io as fttllows: The iodine is de-
pciftitcd ill the aurfuoe of thi- mcmbranv and in ttic vndothcliiitn \ it
rcii'aiQs boro for rooDtbs, at Icact, and hy ita presence appears to pre-
vmt furtber secretion. At first tbere is atrong fluxion Krith seroaa
exudation (afut<* serou» svnovilis), but tbc wnim is a^in absorbed
hy ibe »till-dieti:n<l<.-<l vi^üselis and nuhflcquently tlie nicmbmne »brinks
to th« normal volume l>y cnndcMiiiatioR «f tbe eonoective tiwue, which
iul>M.>()uently n-niains more denae. So we may consider tbe pnx.'e8s
of cure aa analogous to the aimilar proceu in Die tunJcA Ta^inaUs
propria tostis, in tb« cure of >iydropele of tbe ttinio« ra^nalifi, or
vstprrupture ; after injections of iodine in hydrocele, there has been
an opponmiitjr of inalting^ many examinations, from which tlic course
of the cure appears to be as nbow 9tatc<l ; the »brinkaj^* of the scrooa
membnmc, with ticw fonnation of cmMhiHium, »ccnis to meto bo tbe
final cause of tbe arrest of the Bccrrtion,
Iodine injcctiona in bydrartbnis ore made by few surgcona ; I bare
Men them made three times, aiid bare madu two, alwayB witb good
ivsult; but tliia is not alway» tbe caie; then tbcy must be repeated,
but 1 warn you against repeatiug Lbcm too soon : you ftbould at all
ct-ent« first gJlovr tbe actitc stage after the operation to aubsidc
OaaoK have also uceiured where severe iiiAammntti>n8 of tlie joint have
reeullcd after tbcBc iotbnc injections, whicli have been most used in
liVance because they arc a French invention (of Itoinet and Vrlpt/iu) ;
aa so often happens in Iraiimatii! articular intlammationa, the acuta
terous synovitis became purulent; in favorable cases there was re-
cover^' with anchylosis, In aom« cases amptitAtion wns necessary, in
other cases the patients died of pysmia. These imfurtuaatc termioa-
tions of an operatimi done for a disease, which is obstinat« it is tme^
but not dangerous to life, have justly rendered injection of iodine into
the joint« tmpopiilnr; it is always dangerous to the joint and to life,
and honce should be done as rarely as possible.
The diagnant of hydrartbrua is usually simpte, and the diseaao
3way8 very different from chronic fungous punjent synovitis ; bow-
ever, T would caution you that, in the commencement of tumor albus,
also, there ia occ-asionally a slight amount of serous exudation, and
even fluctuation, in the joint, so thai at first tbe diagnosis cannot alwaya
lie enactlv m.i'le ; but ol»eervation for a few week» suffices to diow the
natureof tbe tiisease, and, moreover, hydrops arliculorum occurs chiefly
in young adults, white tumor albus is most frequent in children.
82
480
CUBOHIC INFLAMMATION OF TUB J01NT&
APPENDIX.
CBROmO DItOPSIES OF THS SRUTBS OP THK TKNDOITS. MCC0D8 BTläÄ"
AND STNOIiTAL DERMAS.
WKflhall now nny gom(ttli ing ofltie ciironicdrojteiesof tfaeslMnUlu
of the teiiduQA. The diacAsc cüosUts in »a abnonnal increase of the
sjnovia, secreted trota the &bcatb of the tendoo, for facüitatiog tbe
tnotinn of tlm t^-'nilon, and in abiiomiKl diHtt^ntioii of the smc. The
Blieallis of the tcndoiis of the haad arc most fre<[uctiUy Affected,
There is a giaduaJ formstiou of a swdUng in the boUmr of the hand
Slid lower end of the volnr Htd« of the forearm ; and we may distiDctljr
fuel t}io passage of n llu!d in the »heAth of a tendon from the voIa
matius (o the foreunn, undia- the ligainciitum ctupi volnn; aod back
again. The fingen nre generally flexed and csnnnot be fiilly extended;
the movementg of the hand and fingers are »omt^what limitod ; there
ia not neoessanly itny pain, and the patients do not ususUjr apply to
a surgeon till the dise&ee has attsincd a hi^ grade.
Another form of thia diseasn ia partial hernial ectaaU. of the aheath
of the tendon, with dropay. On the slieath there forma a sao4ike pro-
trusion, alx>ut the size of a pigeon's egg, containing an aboormal
amount of synovia of the slieatli.
Dltfiani of IAb ordiiuir lUtgtlcn. a. ImJoa ; A *b«4lb f4 His t»doo «Ml ara^kal iMraU
pTOlniBlun npiittd ; e. »kin.
In ordinary surgical ]nngaagc this is called a gaaffiion irbea it
comes on tlie back of the hand. It is of far more frerjuent occurretkce
than dropsy of the whole sheath of the tvadon, but it only comes at
certain places. Ganglia are most common on the doml surface of tb»
wrist, where they arise hota the sheaths uf the cxtvnsor tciidons ; they
arc more rare on the Tolar surface of the biii«i and hifthcr up the forth
ann, rarer still on the foot, vbere I bare found them most frequently
on the sheaths of the peroneal tendons. These ganglia usually oon-
tain a thick, mucous, iitreous-looking jelly. "Hic contents of previous»
ly-desoribed extensive exudations in the sheaths of the tcodcnu may
a\&o oonsist of clear jelly ; but frequently there are also innumerable
white bodies, like melon^eeds, which are not organized, but usoally
constat of pure amorphous fibrinc. TIjcsc bodie« may b« preieat in
TREATMENT OF OAKOUOX.
»udh numb«-« thit uo fluid can be ei-ncuati-J od puncturing these
BUS. SoraoUmcn wc can dispose tbesn fibrinc-kcnicls beforcband,
firom ibeir giving rise to * strong friction-sound, sucb u occurs in
subonjto iitfliiiiimulion of tbr> shpAlli nf tlie teiidonü.
In the trcatntent, vte miisl, iibove all, bear in mind tbat we sboutd
aroid any operation tb&t might induce suppiuatir« infl&mmatioQ o(
the flbeath of tbo tcudoEi, and might disable f^r a long time or potuilily
OftUSe a stiff hand in a patient who bad b<^cn but little inoonvenienced
by hiä ganglion. Keiaedies, such as meivurjr nud todiiK', which so
stimulate rcabsorption in cases of acut« or sulmmite inflammation, are
of little uxe bore. Th« simplest aiid their most frequent ojMnition h
rupture of the ganglion. If, ua is customarjr, the ganglion he on the
dorsal florfaco of the hand, ve take the flexod band of the patient bo-
(on us, pbioe the two thumbs close together on the gangUon, and
make strong pressure; tliis somctimes ruptures the sac, Üio fluid is
«ffused intjj the subcutaneous ti»suc, and theo readily reabsorbed.
When this method succeeds readily, there is not niiioh objection to
it, except that it does not always cause a radical cure, llic small
subcutaocous opcoiog of the sac sooo closely the Suid expects again,
and Uiu disuaso ountinucs as before. If wu cnnnot rupture the eac
with tlie tbumbs, it has been recommended to do 90 with a quick blow
by a bruud hammer; althougli this succeeds novr and then, I would
not reonmroend it to you, for if unskilfully done it may cniise a seven
oontuxiun, whose const^'pieiices we cannot always master. Wlien the
MIC is loo tbic-k to rupture with the finger, I employ sttiKittantoua di»-
eiaton ; 1 pass a narrow, short, curve-pointed knife (ßi^enbtu^^a
ivnotome) borizontally into the sac, nnd with tlie point of the knife
make numerous incisions on the inner wall of the sac, 1 them draw the
knife slowly out, meantime prcasing tl>o fluid out of the sac. I then
at onoe apply a compress, envelop the band and forearm iu a wet
bandage, to prcront any cxtenairo rnntion^ and have the fomarm oar^
ried in a aling four or Bve days. Then the liondage is removed, the
smaU opening li healed, and the ganglion does not usually return, aa
it is apt to do after .simple evacuation. The entire hernial sao haa
oft«o been entirely removed, sometimes sucoe«sfuIly witboot sub»&>
quent inflsmmiition, but at other liinox with suppumdon of tJtc sboath
or loss of motion of the (iiigvr, so thnt I do itot recommend this pro-
ceeding to you.
The treatment of extensive dropsies of the slicaths of tendons in
the palm of tho hand and forearm is much morv difficult, since, fiir
various reasons, Bubculaneous discieion is not available hero, and r&>
aorbeuts are of little use; the only thing left is to try other methods,
which often at least induce some suppuration. Take into connderm-
CHBOXIC OITLAlUanON or THE J0LVT8.
ticMi then whctlwT it he really necessary to do nnjr Uiitig- »even,
the dbturltuiiDc be not so dvcid«! ms tu grvutly intcrfcn: with tbe |w-
ticDt'e buKiiKisg, jrtiij hud bctttT Jearv tiling« alone. But^ if somottiini^
must be done, jour choice w «Imost limiled to two metlwds, viz. : ma
eztmsire incisinn nnd |>ii[K*tion, with subarniiient injection nf iodine.
Wbea you make the punction, which I prefer to inpision, you should
choose n trncnr of niediiini ivize, as tlie fibrinous iKMlies will not escape
tliruiiglt n rt'ry fiue oiiu. V'uii will uftcii have trouble in evai'uatin^
Uicm crcn tbroiigh n ]»rgo cnDula; then y>>u will CacUitAto the (^peta-
tion by injeetiog tepid wator thruiigh thi^ cäintla frotu tiiui? t«i time, so
that the iDcrcsscd amount of 6uid will aid the escape of the olippety
fibrinc-kemelB, As already moalioiked, the quuutity «Tsouated iaoElen
large. I oace took one and a half lumblerful from a t«ndon-äao. Aft«r
all has been reinored, fill a syringe with an ounce of a mixture of
equal part« of water aud tinctuit: of itxliiic, or a corrcspuoding quan-
tity of solution of io^U^(^ and io<ltde of potassium, and inject it slowly.
Let it miidin in the sue one lo two niinulut, and then esrapc slowly.
Now rciQuve the canula, coircr the wound wtUi a sraoU cxNopn-as, bind
1^ tiie hand und forearm carefully, and put it on a splint. The patieDt
■bould stay in bed serei^l days. Tbe operation is followed by a con-
ndenible Kwcllinj;, due to collection of fluid us a reauU of B«ute in-
flammtLtion of the serous sac. If the tension become decided, w«
should remove the drcfising«, carefully close the puncture with pltutcr,
then ftaint the swelling with atruiig lincUtrc of iodine. In tlie aiorv
favorable coftc«, the swclliug will then grndiutlly »iibsidv, become leaa
pBioful.and in tbe eourso of twotothrw weeks ilisaf^ear mitimly. In
Daany other case», however, tJiere will be some, even 1/ very temporary,
suppuration, wliioh luar be eht^cked and subdued with ice. In the wontt
cases there may bo extensiv« suppuration of the sheath with neeroms
of the l«ndun, nnd its results. Of course, opening the whole sac nat»
urally induce» suppuration.
On this oceniuon I must affaln repeat that there may be hernial
prulrusiouit from the ca])«ule of the ji^int, ju.it as frum the sheaths of
the tendons, which may become dropsical without the dropsy cxt«*nd-
iag to the outiiw aynoviul membrane. Tluf fibres of tfav capsule sep*.
rate, aod the synorial membrane passes between them into the sub-
cntanoous tissue in form of tlic iingcr of a glove. Altli»uj^h »ui-h
fommtioiut of round, pedunculated, long, wreatb-like, and oiher shapes
may develop from any joint, they are chiefly met in tbe knee, hand,
and elbow ; in ilie taiter I have often seen these isolated dropsies of
iMniiaii of the synovial eac onrnmuninating with the joint} they Ore
ftooompani(^<l by «li^fht stiffness of ilie joint.
I urgeoUy wain you against operation qd theae gattglia of
«ANOLU or THE JOINI^ ^gg
tlie joints ; this opcmtloo may be followed by BUppunitimi of the
joint.
Cartilaginoug bodie«, enchondronmtü, 6ometin>e8 evca oMtfyin^,
occur in tbe tuft» of the sheatb of i\to leiidoaa. Liponu {L, arbore»-
fte.«.
liMt^
1^.
* r
d —
d u e
¥ ,
BtrnW pralnialrai' «( itir >pii.(int in<!nihrane or lAe knrr-Jolot pualcriiirii iiflet W. Srvlmrl.
J.a.M.Minli)iciiibnui»ui: ft. H. bl»»: rtf. H.rauir&airailDii; f , 11 |>l«]Urli^//.>T-
aoTBlbamlik.— An. <Bp«nl«fl[ kpte-J»liil;cir, BTgiuUrartivniUB;//. «itiotU lienU.
e«n5 otJ. MuUtr) baa also been seen io tbe villj. Tbe tuiuon sboutd
only be removed when tliey cause decitJod incouveoienoe.
B»re wo «ball also epcak of ftsuilie and obroiue dropsiea of tbe
SubeuUitieows n>uco(t» bur».r. If vav of ibetw burs» be opened by a
smultancous skin-wound, we aOca bare protracicd suppuration from
tiie aae, which is not dangerous, it is tnw, although there mny be an
exteosion of the auppuntiun tn tbe subculaneous wllul^ tiuue,
which, from it» duratioi], may prove rerr amiovin);; m'pii «ft*T ibe
grcat^T part of the wound is healnl, a fine opening mmains; through
tbicaprobe may be passed into tbe sac; a moderate quantity nf serum
il daily eracuated througli tliis fistula of the mucous bursfe. We may
tOmetimeft liea! tbea** fistuln? hy cautematinn with nitrate of silver and
eomprvRstott by mlliwive plusterj but in some cas^L tliey are very olh
i9l
OHKOXIC IKrLAMUATIOil OF THZ JOINT&
stiiinie. Theo you mty attempt, hy injecting tinctiu« oS iodine, to
excite A more intense suppuration of the inner well of tin* hoc, mai
thtu cAuac it I« Atrophy or boooiiu> ndhcrcnt ; but « quicker way i« to
introduce a blunt^puiiitcd kiiifu ihruugli tlio tistttU urn) »lit up tlio
Hav and suprrjac^nt skin, so na to oxpoec tJic whole iiitcHor ; granula-
tioDB will gradually spring up, and tbe wound will fmnlly 1ic»L I di>-
ddedly prefer this metbod.
Z}roi»ic» of th« sitltctitaneoun mticous buncB ace [lerfertly analch
gous to tlie abure-describcd tlropAiea of tbe ofaeatlu ^^t leitdonfl, l*e^
haps tlioy niny occniiionnlly be nias^d 1>y premure or blovra, but la
many chsvs it U impossible to fmd any «xdtiug cause. Allbougfa
dropsical may ooi'ur in any of thti uoastuit, or oocoKioiiikUy in newly
formed subcutane« u» mucous bnrs«!, lliey «re pjirtimiUrly fnÄjuont in
the bursa pitepat^l Iuris, wliiclt, aeocirtling to Zin/iart, often oonsists
of two or ihre« mucous bursK, Ij'iog over ciicli otlicr, aomctiioca ea*
tirely closed, at others eunituunicating with each other. Dropay of
the buma pnepat^llitriH is very easy to reoognijee, for llie lumor, which
uttaina abuut tlic size of a amall applo, a very evidently situated oa
the palclla, and ciiuninntioa plainly »hows thiit tlic sac containing the
fluid doe& not communii.'aU; wiili Uio knM^•jotnt. 1^118 diM'UKe often
begins acutely or aubacutely ; the fluid coUrct« rapitlly, tlie »welling
is painful, tlie skin over it is ivd, and tlic patient cannot walk welL
Tilts l^enninalion» are various; there is often entire reabsorjition of the
fluid, uud a return to the noniinl stale ; hi otlicr cases the reiil>!M)rp-
tJon is partial, the acub^ nyniptvin» aub^ide, and the atate graduiiily
becomes chronic; Kuptun> of the sac ia one of the rarer tenninttiom;
tbis may be siibcutancoiis ; the fluid is emptied Into the subcutaneous
cellular tissue, and iudiic-KS diffuse inllummatioii. Itupture of both uo
and skin is the rarest result ; the diaeaac then nins the course of a
punctured or incised wound of the bun^a, of which we hare already
spoken.
The fonn of the di«o*ae which is chronic from the start i« more
frt^quent thiin the acute. It begins slowly, witliout pain, and is more
frequent in old than in young pcrBona. In England this chronic
drop*y of th« bursa pncpatcliaris u called *■ housemaid'« knee ; *" there
it is said to oceur purliculurly among the servant- women who have to
scrub tlic atairs on their kncca. But it aeems to me very doubtful
whether this has any effect on the occurrence of tbe diacase, for it has
been shown by many anntomistä that in a kneeling positton iJie
weight of tlie body docs not come on the patella, but on tlie uondylea
of the tibia. To bring the anlorior »urface of the patella dd Ha
ground, it would be necessary to lie almost on the belly.
The conlent« of these dropsical sac» are much less tODadoos tluut
HOÜSEMAlD-a KNKB.
486
of sbcatbs of the Icndons ; Intt aot uiifivqiicotljr tbcsc sacs aiso
liX>ot«ta fibriooiu bodicft, vrhioli, on palpation, give a &ictioD-eouiKi,
like Ütat m&dc by Btan:b-rae«l v;hvD rultbed bei wceo the fingers. In
tbe coune of time tJie sac itself ü Itiickcnod, the more >o the older
tbe disease.
Only tbe «ciitc cdacs come under the nitrgeonV notioe. They
Bboidd be treat«<l us follu'n-s: Fii«t of all, ibe patient iihould hv kepi
quiet; then paint the ewolliuff freely with tincture of iodine. Under
this treatment the dropsy generally subsides rapidly; any remaining
fluid you may attempt to remove by compression with adhesive plas-
ter or baadages ; or yi.>u may from the first employ ootnprcfl^ion with
wet bandage«, or envelop the knee in wet onmpressea; mercurial
salre and mercurial planter are also of good ««rrice.
CbrODtc dropsy of the bunui pnvputcllariB usually causes bo little
inooDTenienee that it is generally of long standing before it comes to
tbe «urgpon's nolioe. Most persons scarcely have their mot'einenta
Impaired by th«.- disease ; other« Mty timt they lire »ootier than fur-
mo'ly in tbe nffrctcd limb. The alFeoUou ia usuully limitvd to one
Bide, but may attack Ixiiti. ll i* genemliy very «liHieult to cure chronie
dropsy of the bursa prwpatvllaris by tbe remedies above mentioaed.
Tlie trouble nwy be removed by c^cnttioo. lapping is no more k
tttdical cure here than in other dropsips, as new fluid ooUeeta ; fop ta[k
|dng to prove eflimeiuiis it «houUl h^ ff»lIowe»l by inject ion of tineture
frf iodine This b free from danger, if the patient subsequently keeps
quiet ; the result is generally a radioal cure. Another treatment is
fitting up tbe eac, which is followed by ita 8up)Minitioa. If the sac
be very thick, it is justiSsblc to extirpate itcntin-lj, which, however,
should be done very carefully to avoid injuring tbe adjacent capsule
of the joint. R. Votkmann has reeonunended a plan of treatment
which T hare often einploy«! with good results, i. e,, forced oompre*
sion; a ncll-piuldit), holloM- itpUiit of tin or wood is applied to the
back of the kne<e, und the knee is dmwn as firmly as poanblc ftg«izist
it by means of flaimel tuuidagi?«; this compression, which usually
cause» cnlems of the foot, and sometime« severe pain, should bo con-
tinued sereral days. Rcabstjrptt'm result«, in two or three daya, in
mall bygromata; in six or eight days, in large old ones. I have seen
Tet7 good result« fmm this plan, not only in hygroma prtepalellare,
but oIm io dropsy of the knee ; in dropsy of tbe sheaths of the ten*
dons it nvely does any good.
4M
CHROKIC INFLAMMATIO.V OF THE JOINTSL
LECTURE Xt.
C. ChKituc Klwuuutie IiilluuiijuLiixi of the JoisU.— Jüthritla DflbRnus.— IfaloB
Coxc Sunili-.^AuBCaujy, Diffurvnt Foruia, Syoiplom*, Diafsoaii, ProfBOib,
Tnutniutil.— Ap|ieudix : Fureigii üudiua in the JoJnU : I. Fibrinn* &(&«■;
a CHKONIC SiUrOHATIC IXFLAMMATIon OF TnR JOIMTS-CHBUNIO
ABTICULAK KUEUMATIBM-AETUÄITK SECHK— RIlF.imATIC OOOT—
iBTUBITia DEFOEMASS-MALIM SESIUJ COXE.
Yov will be fiighteiieH at Uii» cruvrd of nonua, wtiii;h all rofür to
the same anatomical morbid changeit, and ^ou will rif^liüj' a«k, WHif
so manj name» for tbe asm« Uting'? ^NIiimi a iliiu>nu) ha« roocirecl so
snany dcttigtuiltotis, it is often a sign that its nature is not ccrrectlj
undcrstod, or that there have b<:«o rahous views r«gaidillg it ftt dif-
forvnt time»; but tlii« i& nut the cbsg her?, for the prooeas has always
bccii rcgwdrd in the sotUR wbt, and all observers fully agree in Oieir
deci^ous. It >nll be boat to commeuce nitJi tbe anatomy. Tbc dts-
Rfi<tn cbicflj afTtTots tltft airtilBff<>, H«<>ondArily the synoriiü metnbrvtMl
a,ho, as well aa the periosteum ntid bone ; in mo»t com« tbe cartilage
is primurily sttiickvd. The cliiuifc«^» that vre 6iid in (bo cutilage are
M follows : In some places it becomes nodular, theo rough oo tbo
aur&oe, may be pulled into I'llamenta, and, when ih«; disease ia tar ad-
▼anoe<l, tt is alloj^tlier absi-ul in places, learing tbe buue cxpoaod
quit« smooth and polished. If you emnine the cartilage that is brokea
up intii filfiineiitx, yon will find ere» iiiicroccopically that the interzel-
lular subnt&ucc, wliicli ahuuld be bomogeQcoua, is filmncntaTy. Voa
also find that the citrtilagc-oavitio» are cn1arj;:ed and contain cellfi,
«bkb are dividing up ; but tboio colb are not eo small or slighlly
developed as is cii&tomanr la fx^ll-fonnationa oocumng in inilatnma*
tioua; tlicy are well formed, and sontctimes, from a »oiuewbat tbick-
ened nitimbrane, arc reragoixafale as new «.'artila^e-cells ; the changes
progress very slowly, and the newly-funned cells go CD to a rather
btgbcr grade of biatolo^cul develuptnetit tbaa in tbe aboveHlescribed
fonnii of innAnininlicin (Fig. >i7); tli(> iiitercellubir subvbtnoe does not
soften, as in iiilbuiiiuutioDs gt-nerally, Iwt breaks up into filamentaj
thia i.1 a cbjiruotcrisijo pcoulinnty of the disease, but there are also
Tsrious othem. The rough cartilage do«s nol resist the friction of thfr
artii-utar surfaces, but is gradually rubbed through, and ia worn down
to the boue.
Immediately under the cartilage there is always a layer, cren if it
be very tbin, of compact buny substance; lying next to this are äie
ARTOItnc; DRPORHAKS.
48lr
•pongy Rods of tbo opipbjs«« ; after the cuHiugo is dosbojcd the
CricCioQ affects tbia lajer, and, as & result of the meclianica] irritation,
aevr hoay aubataDce ia foimed in thU layer; under tbc point of irrito-
tkm the oHKlulla of the spongy subetnitc-e ossiliea to a alight extent.
Hie adjaoent bono« are gTsdually ground off by tbo motions in the
na.eT.
or tba frtOtLt* In tfUfttti äeHmUfi»; a. %Uj 4f3«MnUua «f It« c«tU^«-
telb. )U;;tiUeil no dUnnen, after Ö.NUHr.
joint, but, at the friction constantly causes the formation of new bone,
the part ground off usually rcinaii»; firm and smooth, as the bard-
eoing always precede« the atrophy buai frietian ; hcnoc, if tbe joint
remain movable, a conaidorablo portion of tbe bone may be wiim vS,
and tbe defeetivc articuliir surbce of the bone may still remain graooth.
Ill the liip, Uiese ^ruuiid fturfar;es are at lite upp^^r »luiiiue of the head
of the femur, and iu the acetabulum; in tbc knee, tbvy arc ou the
condyle«, etc In the«e changes the nock of the femur mnr be coh-
ered with osteopbytee in some place«, while induration govs on at the
amooth surfar<:&. The neck of the fcraur may l)c surTOUiidm] by osloo-
^hytes, and thus acquire a oharacterifitio shape. This will sometimes
468
CBKONIC QtfLÄiOlAXlOH OF IHK JOINTSL
ocproe up Id very peculiar forms ; in one pUoe, fttropbj', In Rnother,
funoatitm of bone, in Uie mihiv caoc, iilongsidc of cncli otber tn Ott
sum« bone. The diseaao riol uiifroquoutly bc-fpii8 u nodular proliim-
tiou of cartilage, uid eods vritb atrophr of cartllKg«:'. I thiuk you are
already acquainted with this combination of atrophy and acvc forma-
tion in chronic inäamroatory processes; oitlj call to mind caries, th«
type of ulccradve prooeuefi; tiiere we also »aw deetruolioD going oa
at the ulcvralLiI 8in&oe| and extensive new Cortuatlons around it.
The uboro cliang«« in tU« cartilag« and bone are nocompanied by
Bome in the synovial membnine, wbioli, however, do not differ niidl
from tboso in clirooic dmpsy of the joint ; tlus oontaim a sliglitly-in-
creased amount of synovia, wbkli is cloudy, thin, artd mts<»d tritli th*
ground-down [lartioles of cartilage. The DiL-oibrane itacjlf is tUck-
ened, slightly vaAciilar, the elongated tuAs alone hare more nisoulat
loops in their «picea. Ports about the joint may participate in tba lo-
flammatinn — {leriüstetim, tendons, and musoleis. The*« occasidDaOj
ossify ver)' sluvrly,8o Umt the cuds of tbeboviesarcufleiK.'Overed with
bony maiBos; thia bony prulifcrotiou is »»motimcs vcryvxtcuairc The
form of these o&teophytcs is very different from those with which ve
are already actpiainted ; they are flat aud roundish, not ehiiped like
pointed stukirtites, but look like a Quid which hod been pourud ool
and Mtflcned while Howing; moreorer, they are not no porous nj other
osteupliytes, but nil tlic luyera are of more ooiupact bony sabstanue.
From tliese pcnulinritics, which you will nt onoc notic« on seeing a
series of prerpa,rat tons, th<- appearance of this variety of articular difr
ease is even exteriorly so charsoteristio that, on seeing a maeermted
preparation of the bones, you would at once recognise the disease
without knowing any thing of the special oaae.
In tliia disease the tu^.w formation of bone probably taken Rocii a
peculiar form, first, because the proccsjs of development is so slow;
secondly, because here the ossification is not preceded by any apodal
Taaoularity, as in oateophytca forming during the union of fractures
in caries, ncci'otii», ostitis, eta ; if a tissue be ve-ry vascular wht*o it
oesiiie^s a porous bony subAlEincc must be fonned, for the nwre fcntlB
there are the more holes lliorc will be in thct bones. But in arthritis
dvfonnuns the ub^ificHtioii is not preceded by any con»idemble new
fismmtion of vessels, tlic ttissucs onüfy mostly just as they arc ; perio9>
tcum, tendons, even th« cap«ule, liguracnt«, and muscles, and all this
goes on very slowly; this is why th« bone furniod is firmer. Sometimea
also in the vicinity of the hone in the mitist of the subserous cellular
tissue dctuched point« of bone form, which for a long time remain
isolated round pieees ; subsequently they may perhaps unite witli the
other bony masses; then they look as if glued on, and from the farm
POLTilRTICULAR CHRONIC lUlEL'MATIäU.
180
of Uie bon^ groi>rth we may olleti tell tho course of iU formatioa.
TbeM periarticular bony foroiationa may caiup entire dialocatiotL of
tLe jouit iiad force it into «u abnurma!, haU-lusatud pusitiou ; they
Fi>i.M.
Fl». 8».
FUlH.
■ät:-^
VWk. tt uid KL o^lioiih'trt Id «r-
IbriU« dafUnuiB r(i;. M. Ina--
*t sihI of U>* liilaiorui. illmlii-
Mc4 : a.Mi«apb] im ;a.«iD<Ki[l>-
PIk. dt, csriuni' Flbon-jifliii,
fbncijii» Inlljtmaiiillini ut
lhi> Jnlnt*, >U)iteU1«'lik«
(Mi«i>h]n<^, Olmlnlifccd.
FlK< tn, iH miia-
attm. I 4 ftud
».Min nie. aa
^HH^ ercn rrndt^r it catinrty imno^-ablc Somcttrocs those osseous
^RwbMione grov iiito the joint, Icx>Bcn from tltcir attacluueut«, aud
beotnne loose bodies in the joint ; of which we shatl s^jeak heTeafter.
lastly, chmnir dropsy may a<X'oinpiuiy this aScction ahio, and you
may reaUily uiitk-rätidid that, ^m all thes« concurring oircuciat«,iicea,
the joint may become »o deforme«! as justly to desan'e the uane
"arlliritis deformans.*' But, I again repeat, that all tlie«e pathologt
Cftl cbnugva never ]ctid to suppumtioa
We now crutK.' u> tlu- diiiir»! appcoratiM of this poeuHar disoaee.
According to my experiünce, I should distinguish thre« forms of tba
dtaeaac : one, which is usually polyarticular and accompanied by ooo-
trndinn of the muscles; a second, which oomes in one joint in young
ami mi<ldli>sgf<d persons ; and n third, which only occurs in c^ age,
1. Potyarikttiar ehrauie rhcitmati^in (arthrite sMie, rbcuiiiati»-
nus nndosns, theumatic gout) altacVs young or middle-aged persons ;
it is mor« fr^juent in wonwn than in mt-n, and in poor than in ridii
people; bftdly-nourishcd, atucmio persons arc especially liable to it;
490
CHROmC INFLASniATIOS OF THE JOINTS.
it may onginatc tn acute nrtioular rbeuiniLlictm or in a gonortliGBa] ht
äAmmnIton of the joint ; after the tennination of tlic acut« or tub-
aoutw dJM'Jise of llie ji>ii)t«,s[i0Hes»,paiii, and swelling^, rettnaiii insoiDi
of tiio juiot«, moet fmcgucntly in tlio knees. Bat tbv cUsesao may be
cltroaio from tho etn-rt, vnth modcnitc, iinRlf^dy pains in tbe joint«,
At 6ret the patiwitK u»u Uieir Utnbtt wry well ; but in the course of
months and years tbe mobJlitjr graduall; dccn-asea ; after cxertioa aul
cat<'hin^ cold, subacute dropsies of the jwnt come on, a part of tbe flutl
m»y be renbsnrbed ; but tbe joint always retnain& somewhat stiffer afW
everj esBccrtuilion, sonietintrs also it is ciilar^ecL In Üio momiug,
wh«o tlte patient risoa, tbe limbs are so alilT as to be scaFwly mor-
able, though, afler a feir efforts, be gets along belter fur tlie rmitC
the day, but towani evening Uie joint agnin Ixvoinr^* painful. Now t .
ncn* symptom gradually arises ; tbe muscles atroj)by, tbe legs beooo»
thimier, and ar« fixed in a fluxed position ; the atrapbyin^ muscfcf
bare gteat inclination to eontnct, «rliicb is eonstanily brored by tbe
abnormal position of tbo joint. Meantime, tie geneml Itealtli ui litt
patient remains perfect; bis appetite and digestion arc good; hs
grows (at, and only hiia fever wbe» tbere is au eaiic^rbatiou of tbt
jotnb- trouble. IW joint is not very painful oa pressure; if it bi
movable, we may f'^'i and hear frietinn ami grating crninda. Tliie go«
on for years. Finally, tlie patic^ils emaciate greatly, tlie joint« bfr
«ome dernrrae{l and sttjf, or, as the laity say, "nil drawn up;" tf tbe
disease be in tbe hi|M or knees, tb«y are bed-ridden, but with proper
core may livn for years; tbe knee, hip, wrist, ankle, and ahooldtr
joint«, arc most rreipiently attacked.
Ä. Arthritia dtfortnan* is almost always monarticular, rarely it
attacks simitar joints on both sides; it occur« tn persons ut)iL>rwiso
beullby and strong ; I have seen it somcwlmt ii;ure frequcnlly in mea
than in women. This form received it« name from the (act that in it
tbe periarticular periosteal fontuition of bono and the ground surfaces
booomo »o extensive tliiit the joint is deformed. I have seen tbe dif
€Me oaca m tbe hip, in both knees of tbe same perwui, once in tb«
foot ami elbow, aiid ttrice in the shoulder. Usually there is tm> auip-
able cause ; in sonic rases it was prcix<deil by luxations or epcains.
These joint» are generally painle««, »tiff, dropaical, and often oontam
loose bfvny bodic«, and the synovial mombrono may be corcrud with
fatty tufts.
8. MtUutn coxoB »enUo. If the disease attack old |>cople, il b
oaually somewhat milder than the bad forms of obrooio rheumatism.
TkM bip is tbe chief seat of the diseaKe, hence t]ie name ** ranlum
onxn senile,** but it abto cume-t in tbe shoulder, kuccB, and ellxiws, but
Mpeoially in tlie finger» und great toes of old people. Its couuDeoo^
lULÜM COr£ SENILE.
191
ment is nsiMlIy chronio, tliere is littte pa!n, but much stiffiicss; more
nrttly the iniliAl stngc i» a«it«; ul fint, tbc patieot« oftca coiuiiluo
only of »tiffno*», e»j>eciully in tin.- momingf ; afUT tlie joint ha» l*een
oscJ, it grows more niomble, the friction is oftrrn so markcit tlial the
patient calls tbc pbjsidan's sttontioo to it. Att«cks with svT«rc pain
and slight fever are mast common where the fingers arr the cliii'f se«t
of the disease ; in the course of years the tiiigier-jotiilft arc inucli do-
formed. Tli^ir««! toe is dialocatcd outwardly, and the bony deposits
on Uie bead nf liie ßrst metataninl bone becvme vm' prominent. If
tlie diM-iL»« drY<.-lr>|i in tlie hip, the patients limp slightly ; in old per-
sona the booy deposits arc gt-ncmllr iosiirnificant ; hut the thigh is
grsdually shortened, Gram tlic w<.>ariu^ down of ibe hesd of the femur
»od the acetabulum ; the muscles «trophy, the hip gradually grows
stiff; but this may oot take placn lor yoiim. Tlie di»emw: is much
more frequent in men than in women, and thin people arc most liable
to it It LH mri'ly acfompaniod by diRpafte of other organs, partiou*
larly the intemnl one», but the nfTeclion is not unfrcquently found in
persons predisposed to ehalky deponit» and abnormal osöificatioos ;
rigidity of the iirleries, ossilicalidn of the ribs and intervertebral car-
tilages, and anterior spinal ligaments, arc often present in patients suf-
ftring from malum senil«,
The fiia'jtiottM is easy; after the abo« dMcription you would not
readily mistake the disease. If the sflection nltacJc a riogle joint in
■ young person, we may at first be doubtful if it is a case of fungous
inflammation or uf arthritis dnformaiis; but, after further observation,
tbc dingoosta will be easy. In the later stages it might alw I)« mis-
taken for fuTtgoua inflanunatioi], with caries sicca, where we also find
atrophy of the museles and fnfltjon in the joint, and which also runs
> rery chronic cniirse in young and otherwise healthy subjects; but in
caries sicca there are ne^-er sudi extenstre de^xisif» nmimd llie joint,
U ia arthritis deformans, and, tvtxa when of long dinntion, the latter
diows no tendency to «uppiinition. When the chronic rheumatic
ardeular inflammation occur« on boUt sides, or attat^a sercral joints
at onco, and is aceompanio<l by the reflex contmetton of tbc muscles
due to irritation of the si'noi'ial membniiie, the disease? cnimot be mlv
faken. Rheomatismus nodosus is often confounded with gout, (»ecause
tlie effect of the two disense« on the hands and feet is somewhat simi-
lar. But gout is so chaiactcrized by its specilic attacks, and by the
excretion of uric acid, that it should be regarded a.s a diflerent disease;
we hare already spoken about this.
The prognmiia of pntj-artieiilnr rheumatiKm in very iMd as regards
rcctnery; when it attacks old |>er80iis, I conBider it entirely incurable.
In yottog patients, hy very careful, persistent treatment, tbc dtseaae
403
cHRoyic raPLAiutAnoN OP THB jotxm
muy tuoinetimcfl bo arrestee! at s certain point, and sliglit improTcmera
be «ttnined ; but even chin is very difficulty only a lew cases are rnlir^
]y cuntl. These unfavorable result)« am äiw lo th« anatomical prod-
uots of Ulis lüscoac ; the wom-dowo Garliliifi;^ nod bone are not r^
jriaccJ, the bony ficpo*it« iiro not rpabßoi'b<^d, they are too firm aod
fiolid; the nutrition uf tin« muKclpH fnilü to be exdted by the natunl
motion of the limlut, fur they tav almost too weak to put in actioatbe
stiff Utnba. Mlien you lia\-e euoh a patient to treat, unn yuut«eif witb
patience, and be not KnrpriM?«] if ha consults fint one then aDoUier
pliysiciitn, und finally all the ijuni-ks about, and buitly blnnics yoa fa
the origin and extent of his disease.
Of course, e\-en these patients must be treated; the surgeon cnonot
pdcV out the ruratJe oases, the inrurnble and dying also hare eloinu
for bi» aid, »nil vhere vre cannot aid wc tdionld at least tty to alleviate
and mitij^te the disease. Chronic rhfttnuatic infhunmation of ibe
joint», by its shnidtaneoui^ ut-ciiTrence »t dilTerent {luintft, filmw« thai
it is not due to a local injury*, octhiff on a special joint, Init frt-qucnUy
at leapt to a constitutional cause; the enigniAtical rhoumatto dlatbecif
IB often blamüd for the tendency' tu inHammalion of the serous mvnh
bnincfs and exudations in the joinlc nnd muscles, hence we eniplr^
aiitirh'.-uinntio remedies. The persistent cmplt^ymont of iodide ofpo^
ash, of Colchicum and aennite, of diaphoretics an<] diuretics, is reo-
ommenderl, aIthDug:h little benefit Iikb been olwerved from than ; hot
there is notlung else that i« better, at least nothing to act apecially C*
the rheumatism. Beaiiles these remedies, and tho»r called for Iff
special peculiarities of the case, warm baths arc highly recommended,
particiilatly the indifferent thermnl halhs: Wildbad in '^^''tlrtembcrft,
Wildbad-Gaatein, Baden in Ztlrieh, Baden-Baden, Teplitz, Ragaz in
St. Gnllen; besides ihese, »alt-haths may be given, e^pecia]ly where
tbete is cmnimencS ng muscular atrophy. Special attention should bo
paid to the climat« of these watering-places, for all of these patients
are very sensitive to ctdd, damp weather. Hot Kul]>hur fprings should
be tried Tcry carefully, and given up nt once if a eubnctite attack occur
after their use. If the patient live in n climate where the winter is
cold and damp, he should be sent to winter in Italy, but, for fear of
possible cold wciither, idioiild only go to places like Nice, Naples, Pa-
Icnno, etc., where the htniflea arc well built I>iimp dwellings sLoold
be most carefully shunned. The patient should keep warm, always
wear wool next the body, and the afTecled jointa should bo wrapped
in flannel "Water-cures arc much recommended, and show »ome suc-
cessful eures; when sensibly used by physicians, and not simply by
proprietors of the establishments, they are certainly appropriate, and
often prove peculiarly advantngcous by hnrdcaing llie patient, and
TREATMENT OP TOLTARTICCLaR HHRCMATISH.
403
ring liiiii lees suscc|)lil)le to external inäuence», ospecinlljr to
CAtcIiiiig cold; moreover, diiiiking quuittitiea of water, and the vrmp-
piug u|> after the Imthü, have a diuretic and diaphomtic effect ; bcärlea,
this mode of trotinetit liaa tlie advantage that pati«ut8 will follow it
Out ronJiHcntinusIy and ii^^rseveringly, wWi\c tlK^J■ Ronn tire of tnking
mpdiciiii-« ; us i* vA^ kixiwn, h^'dTT>iiuthi4 »ooti IxMroni» enrnpturvd with
tJio sjrstvm, and arc vcrjr »utisfitctorjr patient« even where the treat-
ment is iitisuoo««Kful. Hence, if the patient be not too much debili-
tated, and have no disinclination to the treatment (im sometimes
hup[K-ns), it fihoulil bo tried, but should l»e (.-(lutiiiued at least a year
^mto l>c of nnj rcid bcucBl. Hussian ^-aporhaths have aho been succces-
^Mil in oomo cases, as have also pine-needle baths, i« badlj>QourUhed
^^OBtlentji the disease has also bcnn cured hy end-tiver oil, (|uiiiiiie, and
^Kon. For totml treatment we may rub in various things — the friction
^M doubtlcM the moat important part of tlie application ; jou may use
iodiniMnntineiit, simple grea«e, voktile liniment, ute. Strrxig dcriva-
tJTc remedies an; of no ubc, and citm tincture of iodine is only bcQ»
6cial iu subacute attacks, in which cases blisters may also be tried
Be careful about applying powerful irritanta to the joint ; in ehrnnie,
torpid caaea douehca may pmvc Tory cffieacinus ; even bot or steam
doucliM and local Bulpliur-tMths hare proved beneßciiil in MmeoMc«;
but in other case» even the mildest shower-bath, from a foot high,
proves too iiritatiog; we catuiot olwaya prophesy the efloct, the
patient «hoidil try it carefully under llie »tipervitiion of tlie Rurgcon ;
as soon AS pain is excited, the douche should be stopped, and, after a
period of reat, ha tiied with new precautioni; ; if the pains oome on
•■giun, and JDcreaae, the douches hod beat be given up.
I Sbotild the limbs be kept at re<it or moved ? For rarious reasons
perfect rest is not desirable : lirnl, l»eoau»e the }oint would beoouio
stiff, often ta a vety luitavorable |>o»itiun ; secondly, because absolute
rest still more increase« the atrophy of the muselca. Moderate nvotion,
both passive and active, avoiding tlx? excitation of pain or fatigue,
sboald be made ; the patient may mnkc die paKtive motions with hia
own haudts or with the very ingenious machine invented by B^nMt
for this purpose. Lastly, we must add something about rauseular
•trophy. We attempt to strengthen the muscles by friction, clee-
tricity, and regulated movcmeuts both active and passive ; bcrc cura-
tire gymnastics «ometimes prove beneficial. But, to be of benefit,
may of these methods of treatment must be followed perscreniig'ljr.
From tiiis therapeutical review you sec we are not poor in reme-
dies that may prove serviceable in elironic rheumatism, but all these
modes of treatment are expensive and oAen unattainable by poor
patient«, oud, as this cluss ure peculiarly liable to the disease, tbey
iH
CBBONIC IKFIAUUATIÜN OF TBE JOIKTSl
are very onhappilj situated in regatd to it Since dry, warm air, good
nourülbtnctit, prntnH.ioii from «etching cold, and baths, are aeldoa
to be fouiid ill ttie dwvlliiigit uf tliu puor, and ntncc t]i(»r arv b1>
solute nm>4^MtJ«« fiir iW tr«itm#nt, the presoription of crpcnsir*
mcdioiiiea is a ptire wast«; of itioncj. Still, I again repeat, the soons
thL-Kc patients comv under trcBtmciil, the mare recent thr dtsnaae, thr
more yon may expect from treatmeat. You may sonietiioes arrest
tlic diapa«'. If the malady he already far advanced, its arresi is tnon
difficult, and a «un- is rarely to bo exjierted, I l>elit've tliat on«
cases of maliua ooxie senile are iocuruble ; still, even there the abort
remediea fonn the rnitonul treiilmcnt. Artliriti« deformans moinu>
lintilaris ifl iuciirabia If tlic Joint be tnucb dcfunncd, yoo may resect
it or amputate the limlx
APPENDIX.
IXHMB BODItt Df TIIE JOINTS OTOBSS AimCÜI.ieB0).
ßr tiicse ioote bodUa in the joint«, vo mean mo«« or less fine
bodies, formUty in a joiut. "We exclude foreign bodies ente-ring the
joint from witbrMil, siicli aa needle^ bullet^ etc, or dL-lacbcd pieco
of bone, lyini; loode in the joint. There arc two rarieties of loose
bodies : 1. Small, oval tKwiie«, «»enibling inelon-secds or irrogtilar in
shape, which tisuully form in iiirge ntunbcni, and on microscopico] ex*
arainatioii are found to consist of librjae. These fonn in joints willi
chronic dropsy, and an; üc[)UHilii from the qualitatively aikd quanttta-
tirely abnormal sjTiovia, just a» the analogous bodies arc in drojiay
of tlu- ülieath of the teadons ; blood-clote may also possibly »erre a«
u source of otiptn of Buch bodiea. This form of loose bodies ncvra
requires any o])eratioi> ; it i» Hinply an accidental ncmmpanimcnl of
hydrops arliculonun chronicus. Oocasionully wc nay predict their
presence from finding *oft friction when palpatinp; the joint ; this doe«
not change the treatment uf cliruuic articular dropsy, and only com-
plicAtes it in that it renders more difficult the c\-vntua] rcductk» of
the joint to \\s normal size.
j. Tl»e Dtber variety of articular bodies ia of cartilaginous firm-
ness, generally conttiining hone-nuclei, sometimes adherent, at others
quite loose iu the joint. The form is quite varied, being sometimM
verj- odd The nnnic "joint mouse" (Gelenkmaus) may hai-e arisen
from some accidental shape, n>semb1ing a nious<^-. Tlicsc bodies arc
always rounded, but seldom regularly oval or round, being usually Dod*
ular or warty ; their abapo ia that of the osteopfaytos in arthritis defcr
LOOSE BUDI£S IK TUK JOIKTS.
4W
j:-^i»
'''JfionMOpleBlly til?;' conaisC of ■ ihin ooveiiog of true Glameit-
twy or hyaline ciirtilat^, which, from the centre, ceeiAea, or stjinetiiiice
only culäfiv». Ax these curtilugm an' mcwtl^ orf^ttized, th«?^ cantiut
be i^wdnl as depoaita from the sj-uovia ; but, even if found quit«
frac« tbry tnuat fonnerlr lAve
bMQ cc>noected witk and have ^i"- ^
formed in living tiuu«, and sub-
sequenlly heoome detuclicd.
Tbe actual procc» i* as ((>]•
lows: Tbese bodies are mostly
fMt«opliyt(», vrbich luLvc on-
land the joint from without ;
rarrfy tlicy (vna in tJie apices
of lh(r synovial tufta, E^'en
nommlly thcro are aofaetimM
Ckrtilagp-ot^lts in the tufts ;
these may prolifcraie. and
thus in the tuft w« (tliould
liBve a <!artiluf^nu(>l«U3t, u
oartilag^tuiiior, nii (riicrhuii-
(Iroma, vrhich Mihsvquciitl}' o»-
eifics from tho ceiitTf, For a
time this lumor remains at*
tiiohod U) the tuft, hut finally
it break.« off nod then liea
loovf in the joint. Hut by far
the niu»t fn\itii.-Dt funii uf tlicrsu
orticiiLtr Ikmücs i» from the fot^
DiBliim of vesirrtiig ciirtilafL-s
^osteufihytcs ) in the ca^nlc
of the joint immodtatcly un-
der the synovial mrnibmne,
whicti may enter the joint and tiimlly tear Ioom: and become tree It
ia prubiiblu tluit,when once deta^lied and lying froe in the joint, thciio
bodies do not grow any more ; although it is not impoAsililc llml ihey
might derive thtiir nutriniPDt frotu Uie synovia. Tlie devetojniient uf
loose bodies is always accompanied by some dropsy of the joint ; per-
haps tlic iHtter is oecaxionally the primary disoaso. Ixios« bodios
occur almost exclusively in the Icnee-jotnt, and only iu aduU pslientst
they arc very rare, pcrbnpa the nircst of articular discuses There is
an undoubted eunnc-L-tiun hutwotii Iho funiuitiou of artieiihir L^orti-
bifCCA, artluitis defonnsns, and hydnulhrus^ These diBeases urc of the
s;iiue cl*aft, and from s possibly congenital or dcrdopod gcnerul diatli
J3
Ualtlpl« anlculu txnU», alUr tT uutlMnv
498
OBBOXIC niFLiUHAnOK OF TBE J0DI1&.
esa tbcy form n contrast to the fungous and fuagous-euppurstiT«
articular iaflammationi.
The sjrinptoms ivKidi m»y be üo»ip(1«iw(1 u cliaracttfristU! of tli«
existence oC free bodtca id the joiat arc as roUowB : The patient hu
tvng bad ntoJcrate dro(>s_r of th» knoc-jomt, and, while vralking, awl-
(i«iüjr has a seven; paiti, which prevents his walking for the time b^
tog; the knee atitndü iKtween Dexion and extension, und o&nDot be
moved till it bius hvcn rubb«d iu a cvrtaio vr»y, Tbia »jroiptom t> due
to the loofiv body being caii^ht K'tweco the boot» funniiig tbo joint,
between tbc BetDilunar cartilages, »r in ooeof theej-nmial sacs. Bui,
evcu before tbis, tbcac patients usually oomplaia for weeks or tnootiu
of weakness or slight pain in tbu knee, and, aa ainndv stated, exami-
nation uill gfnpralljr show a sliglit amount of drops/ thera From
tbc peculiar mode of oooutrence and subsidence of the pain, the pa-
tients themselves often suspect that there is a morable body in their
kncp-joint; nut unfrL-quently ther cuii feel it distinctly, atid c*ti,tnr
certain motions of the joint, m-nder it perceptible to tbc 8Uif[oon. la
other cases the surgeon docs not fee) the bo<ly till after soreral ex-
aminations, and oan move it urouad in various directioDs; it aA«n
cli^ppeurs again, and it may be several days or weeks beforo it agaie
oomcs in a pc>»i(ion where it can be felt llicse Aviiiptoms ooly bo-
come very evident when the body i^ dutacb«d. While eIUI adherent,
or, if too large to be caught as aboro mentioned, it caus(!S little or dm
difhculty.
Hence, although the ineonveslcnoes of a loose body and of a mod-
enitf dropsy uf tlie knecfjoint are not always gnst, and do not
incruiuc spontaneously, or go on to suppurative iiiQammatioD, and
only hare occaeiooal subaeutc inflammatioo, vrith serous effusion after
Home exciting cause, still, in other cases, the pain from the squeitäng,
and Llic anxiety about being constantly liable to it, arc; so great lluU
many patient« iinperutirely demand aid.
The attempt to Sx these bodies by adhesive inl1ammatij*n, induced
either by a compressive bauJttge. tincture uf iodine, or bUiitera, has
had little success. The opention consists in the extraction of the
fiH-cign body ; it is done as follows ; The loose body is pressed tJg'htly
under the skin, at one side of the joint; the skin over it is then
preesed strongly upward, and put «tdl more on the stretcb ; then out
throi^b the skin and capsule down on to tbe body, and let tit« latter
^ring out, or lift it out with an elevator (perhaps an eai^poon, aa
Foak ha« done); insbmtly uKisc the wound with the finjfer, oxtHnd
tbe leg, let the skin return to its nnrmat position, 6o that the cut in
it lies lower than in the capsule, and the two wounds do not oomtnu*
nicale directly; the skin-wound is now to be closed with sutures and
akchtlosis.
MY
plastcn, »nd tlie limb extended oq a splial; a pUBter«pUnt would bo
very suitable b«re ; one mi^ht b<^ made with a larg« opening &nd
ftpplie«! even bt^rnr« the operation. According to tbe Kjrmptoius of
, inflBinmstion that arise, Uic tivutineiit for trsuiiittUc inflain (nations of
10 joint la to be iiutitutcd. In former times, these openUons were
^xery unfortunate; thpy wlto not unfrequently followt^ bjr «.-vfre
inflammationH of the joint, and ocaiaionalljr the surgeon had to con-
pvtulate himself if he saved thv patient's life b^ omputfttin^ at the
thigh. The modes of operation nere often chaiigcil ; finally, tJiat
«bove described, which is the simplest, carried llie day. Foct per-
£6nDod this operation five times, always with succeos. The symptoms
of Inflammation vorc imtignifirnnt, and the patients eould usually
letuin to their occupation in a few weeks. If a loose body causes no
inoonrciuenoc, wo may apply a kncc<ap to limit tbc dropsy, and give
the joint a certain amount of firmness, so that there shall not be too
much motion ; tliis often gives the patient great rest
LBCTÜBE XLI.
Ji^flM», VmnOiea, Amtomj, DkfaMJ«, Tr«*tnMnl ; Ontdatl FoTO*d Sct«Mfa>B ;
^^ OpcniMlu with Um Knifh.
^B AXCUTLOfiSa.
^y Toe already know that by anchylosis we mean a stifr joint, but I
^f must add that (Jiis desl^uiliini is onlinarily utied only wlien the acute
^r Or chronic proocss which causes tlic sliffnoiw fif iho joint haa c«a9/-d ;
lliat is, whtm the limitation or total loss of mobilEty of tlie joint is Ihe
only morbid symptom present. For instancx-, if, diiring nri inflamma*
tion of the knee or hip. a stronf^ly-flexed position of thelimb be caused
by involuntary continuous contraction of the muacles, and the joiot
cannot l»e extended on acootmt of the pwn, although it should be me-
obam<^Iy possible, we do not coll it anchylosis of tbe joint« but artic-
ular inflammation with coiitnietion of lh<» mutu'les.
^^ The causes why a joint uinnot be eztcndwl, after tlie siilMidenoe
^Bof tbe acute inHammation, arc partly mochaoioal hindcrances either in
the JOTTit or exterior to it, or in parts aptually belonging to the joinL
& muscle Bhurt<.>nod by atrophy and shrinking, a Htrongly-conlracted
cicatrix of the skin, cspircially when on the flexor side of the limb,
mav greatly impair the normal mobility of tbe joint; such cases arc
not meant when ire speak briefly of anchylosis, they are termed inui-
cular or cicatricial contractioa Should wc term these t-arielics of
498
CHRONIC INFLAHUAtlON OP TITK JOINTS.
limitation of motion nncliylos«», it is well to (listi»j^i»li tbem u
Atii^liyloBC» froni cxtuniiU «usus, uiichjloais spuria, etc Now, we bnrc
left those caaes of stiffnesa of tlio joints whicb an? ciiiisctl lij- pulb-
ological cluiuge» of parts arluullj' perUiiiing to tlie juint; tiiKler this
heiul vre have tite following oaseft:
1. CietiLncial iLdlicsion» bctw«ca luljaoent surfaoes of the joint
itaulf ; tlws« may diffor greatly iu rarioty and extent; they form aftrr
cure of fundus articulBr inflammatiomi, by adbesion of tlm |< '
Btiog-granidatiiig: surfaces ; btnngliko adhesions arc tliua fom>' .
tlio!^ between the cootul oud pulmonary pleura, or i-1su thurv an
thick extcusive ndhesiotis of the nirfaoes; along with this state ihe
cartik|i^c may be partly pn;SL-rvä(I, or it, togetJier with part of tLi; boac,
may be destruyt-d. GvnoniUy, tlicw adhoslotui, like other ciaitnee«,
arc Ennned of connectiTe tissue; in othurcase», CMpcuially when the
joint remains pt-rfisutly quiet, this oicatncial tissun D&sifida, and the
two tu'tiadar surfaces are unit«! by bony bridf^, or e]ae the entim
aur&oe« are cotnplett-ly «ulilcivd togt-llivr (Figs. 92-94).
rn. M.
Bud-Ilk« aiUicatoiii) Id ■ nwacird elbow Jalnl tfttto an adall. »tmvM utWAl«!*«.
2. Further impediments to mobility are «initrtcial fthnnltagefl of
tliB articular capsule, of the accüaeory ligam^nta, and evea of the
semilunar cartilageH, which may aliMi be entirely ilestroytHL Tlinse
änatricial contractions occur injt only at plwces wberc fistiilw have
formed, but oIbo when theri> ha» }>ci;a no luppuraÜDn, for nny tissue
tluit bax long been inltllnital, and so more or less suftoned, suImc-
quently shrinks somi;, ofttTr the pmcesH hiu run its ooursc;
3. A not insigniüciknt intpcdimcnt to mobility, and one which is
the causu of it« ocauional noii-rec-urreuce after extt.>n&ive fundus
iuflammations of the jointH, lie^ in the adheekm of the walk of the
«ynorial sacs about ibc joint, which Qormally sboukl )[lide over eadi
otlier. To reader this cluar to you, I must touch on the normal oen-
ditious of the lar^r joints in motion. Tlie capsule of the joint is
AKATOMY OF THE JOTNTft
4M
i
»
nerer bo elMtic as to »dapt itaeU by ifais mcaas akno to ftU pooitioiu
of UiR joint ir^-ou inu(;;iue a iiunic-niR l^itig on the thorax, then &t
tlie UiwvT part of the joial the
oapeulo would fwivo to be
firmly drnwti Infjcth^r, »bovf
it wuiild liarn to be greatly
atrotcbed ; if yoa imagine tb«
arm raised as hi^h aapoasibl«,
tbe upper pan. of the capsule
would bare to be strongly
drawn togcUier, aud tbe lower
stretched; tbe articular cap-
Mile would liave to be aa eU»*
tie a» rubber; tbi» is aot tbe
case: oDcbaDgiog theuxlnnnc!
positions of tbe joint, it con-
tracts little or not at all; it
folds up in LvrtAJti directions;
if the poaitio» of the joint o<«j.k.i« ck.WcUl rfh^b» cf Uio *rtcikr «e^
diiuv«», tbe fold »«.ootl« o^^ ?r'KAi.''^.^:;^"'SLS'Ä'rÄÄJ
snd on the opposite side which •"■t*i : i*euim MatwiilM, i
was prerioosl^ smooth another
fold farms in the capsule You
lere ooe perpendicular sections
tbe shoulder-joint, pamllel
to tlie ant^-Hor auHiu?« uf tbe
bod/ (socn fnmi tlic front, af-
tor IfrtiU) in an elevated posi-
tion (Pig- 95), hanging by the-
side (Pig. Dfi).
If tbe synovial raenibrani*
lO diseased, the joint usu-
alty reinuiiiH in a i^rtaiti posi-
Una, the humerus ix fj^enemlly
depressed, (l>e lower |»rl of
tiie aynorial sac (Fig. 96, a)
amy snppiimt<^, «brink, and
beoome adberent ; theo, ctrun
the joint ncro othcrwise
bi^althy, it would be (mpoisi-
tile to raise the arm, because |o^^,.,„,„ „,0,,^^^ fc„„ t^ir™. »mouo
the capsulcat the lower jmrt («-•o«italii »b««! n.h.r.iiiM,
of tbo joint could not uafold. Aacbjioses may thus result while
m M.
m
'side (I
Hpbeoomi
»aUyn-
600
chrontc inflamuatiox or the jodtts.
tbe cartilage remains intact; tho at^cretlon nf sjnank ocas», u
tbe oourte of years tbe oartilag:« ma/ degenerate into connertJv« tit-
nun (as in old, immoTabl« luxatinns), ar ma^ e<^n ossify, anil tbe
ancliylosis will thus bcooine more immonible. 8tiuilar circDmstaoces
cxiat in sjtoosl all tbu joiiits; you will find tbe beat ivproscotationi
FU.K.
ri». t*.
v:-S-
..--5 -
^^
■ 'T-
^iTv*
^fM
-ir.
■minw (V mi «11001.1) uujcuNT. itti nu» rm nunrr.
n^ Ot. Die tfni» Mdm lb«*«. «1 0. Wig. 96. tb« ctpiula bldod brh». at ■.
of tliesc in Henle^s utmtoniy. B, VoVtmann bad previously described
tliis variety of ancbylosis, widcb occur« oBpedally ofteu in ^ojung
prrsons after subacute ouxttis without suppuration, but wilb great
tension of the musciea, as "cartilaginous anchyloeia.'' The oame is
well rhosen, in so far as in tbem the cartilage long remains intact.
1. A furlber mccljanical obstruction may lie id the bony deposita
wliitrli runii in the joint on the articular aurTaocs of tlie bones impli-
cated ; for instance, if tlio fossil !<igmoidcft, anterior or posterior of tbe
lower enil of the liuincnis, fill up wiUi noiv]yfonne<l boue, in.'itbrn' the
processus corotioidcus nor anconeus of the ulna can enter it, and in tJio
fonnor c&^e the arm ounnot be fully llexcd, in the Utter it canrK>t bo
^Uy extended This biaderaoce is most common in arthritiB de-
formana ; it is rare in fungous inflnmniations of tba joint (Fig. 88).
5. Lastly, aa a result of carieft of the oada of tlie b^inei, there may
he Kuch loss of substance tliat the epiphyses will stand ol>lir|ui>Iy to
euch other and i-annot be brought into pOMtioQ again, becaiiw their
surfaces arc too much changed, and do not fit ou each otlter iD tho
abnormal poüitiün (püUiologioid luxntion), or cannot be moved st alL
Examine Fip. 93 ii)i;nia; na a »cfjucnct; of the dcsUiiclion of tbe
InK^hlca humcrif llic ulna is so dniwn toward tlio humerus that, even
if some motion were posEible, complete flexion could not take plaoe,
because the pjfpcessus coronoideus slrikrs on the bumenu anteriorly,
OS tlto fobSA Hgnioidea ia abseaL la uariea of the kne« alto tJic tibia
mACJKOKIS OP ASCHTLOSIB.
Ml
ly be half dislocated outwardly and poetciiorij, so that tlie surfsoca
which bdong together no longvr lie id apposition, and in the «bnomul
position there is no motion al all, or only a »light amount,
Destdes those cause» of immobility irliich lie more or Ic« in Uio
joint, therr maj* be «xt^Mnal fmr%, especial);' th*> «bove-mcntiorrcd
muiMriibiranitnictions, axwell usciuitriceii wltitrli miiy bL>eomp adherent
to llic inuaclcs, tendons, or bones, and thus materially aid in fixing
the jennt in n false poeition.
Generally, the dtaffnoaU of anchylosis is not difficult ; but it may
gt be easy to deoidn which of tlie above^nvenlioned factora &)ioulcl Iw
led toe the deficiency or entire abaenoo of motion. When the
■ttffiiess ifl eompletc, we readily aiippose thai thi>n! it bony ancbyloiis,
but ibia is not always the case; very short, stron;;; adhesions, espe-
cially if very broad, must aUo cause abM>lute immobility. The longer
such an anchylosis ramains entirely immovable, the greater the prob-
ability that there is bony anchylosis ; eren wheii the joint is pmpor-
tionately little diaeaBcd^and tlie greater part of the articular cartiluge
is normal, if the joint has remained at rest many years (perhaps only
as a result of shrinkage of the capttul«), complete bony auohylosb will
often form gradually; for even a healthy joint will Gnally become
ftochyloerd if kept immov-iblo for years; motion is nn absolute no-
oawlty for the continued health of the synovial membrane and fjirti-
läge ; you may eren conclude this to be the case from the fiict lliitt all
Ibo articulations which are subject to Utile or no molion {as the bitci^
verlebral, pch-ic, and st»'nin!), hare a very sliglitlydeveloped »ynoviiil
membrane, and arc very deficient in cartilage, MTicii the motion of
tbe joint ceases, the secretion of a useful synovia is arrested, the ay-
□ovial membrane booomes dry, toii^b, the cartilage becomes filamen-
tary, and the rutirc beautiful apparatus finally rbanges to a dcatricial
conncclivo tissue whidi may ossify; then the function of Ibc joint
oeasea. We have made these statemeots for the purpose of calling
attention to the poanbility of deciding, from the duration of an im-
movable nn^'hyloeta, about its firmnet«. But if the anchylosis be mor-
able, even if very i«lightly, the Äjnovial membrane in rarely destroyed ;
part of the curtilage also is usually preserved in such Ciises. We iiuty
be greatly dcccircd as to the mobility or immobility of anchylosis, if
we lesTC o«t of oonsideration the tension ^f the muscles; frequently,
we do not fully compreheml the amount of this mechanical htnderanee,
till we arrest the mnseular contractility by anaattheeia, which must
be pushed to the point of total relaxation of the muscles.
Now, what is to be don« for these anchyloses ? Cam we render the
atiff jniiit movable again ? In most cases Uiis question can be an-
lowered affirmatircly. Out we permanently preserv« this mobility and
&oa
VBRONIC IKFLAMWATION OF THB JOISTS.
reetore Iho normnl ftini>tion even spproximAtely t Dnfartunitoly, Hüb
is ratcly possible. \V\ml »hnll tbcii be dot>e V Whni, then, » the aso
of treatmeat ? This Uil«r question » Kometimm a just one, but w
not usually Ki. We have already said that, in inflainmatituiB of tho
joint«, the iimbs UHunlly assume an nbaurnial pooitjoii, a itoeitiini in
wliick tUuy are very uu»crviccsblc ; a lo^ Wnt at right «nglcs at lite
knee is a useless, unnüoos&ar)- bunleii, hen«* eucIi limbs were fnnnerly
nmputsted, an th« patient could go about bettor witJt a good wofMlen
leg than with twi> crutches. An arm entirely exteiided at th«* olbow,
ur only xliff-Utly flexed, ia also n very ineonvonient member, and rrry
unsuitabk- furst-izing nn<] lioldiiig nbjtrlx, etc. By simply brin^ug
tits aochyloscd limb into a position trhcre it t> relatively most tiaefal,
aa the knee into (lie extcndoil position, the arm to a liaihx an^r, we
may do the patient much good ; hvoc-e, these opeiBtior» of stnuglit-
ening or bending aochyloeca arc vciy satisfactory, AndiyloMe in an
incottvcnicnt puaitJoa were Tery frequent for a time ; they are btmxsinfr
rarer, and will disappear entirely aa soon aa unireraal nttcntioa is paid
to the principli; we urffe of pludiig the joint in the bcsi positioa for
ancltylosis, when n-o arc trcatiug ncube or chronic inflammntions. No
fltirgeon of modem times will hare occasion to operate on auehyloem
for tlie iinpmvemcnt of position, in a patient that he biinself rn^au^d
for inlliimmatton of the joint. But there nr« still many easoa that
have to betreiiloil in the country under mui^t itiiTuvomble ctmimstntioea,
where wigular ancbyltms of ttiu knee or lii]t result«, so that cxtenaon
of nnnhyloais is still among tbe bolcrahly froqunnt oporatioaa.
Attempts to straiiflilcu deformed and alifl' limbs are qiiile old.
Even in the surgical writings of physicians of the middle ages we find
illustTiilion» and descriptions of macfaiiteB conslnirted for this pur-
posp, for the method of relieving the deformities by slow eclenalon
with mjtHiinery ift the older. A large number of appataius for the
var><ju.^ joints hare been constrooted, by whu»e ahI the cxtcusion and
flexion nf the extremities may be induced by the action of n »crew.
Now these instrunientH are cliiefir employed in ca»es where it is
thoTigtit thül. while &ifnight<:'niiig (lie joint, we may retain its mo-
bility ; hut A» ihew »se» Hre very rare, and as they also may be really
impruXTvl by mpid extension, these machines are much less used. la
oontnulistindion t» slow extcnaion of uDchyloses, we have the rapid,
forcible cxtcnwon, whirb i« falsely t(*rmcd tri^emcnt ß^ni, Befor«
ßblorofbrm was known and employed in these oasi?«, this oprrstioB
was, on many acoounte, objcctioiiahle. It was very painful, and not
free from danger ; it required a great deal of power in tbe forcible ex-
tension of anchyloüs for breaking and tearing them up ; thi<i wai dne
not only to the abstrucUoDs in the joint, but also very grmtly to the
EXTENSION OP AKCEIYLOSIÄ
M»
muscliM, wbich oontrnuttMl Atrouf^l/ as suou us tbc paio bqDcan. Ueau(*j
before trying to CKU'nd ih« «nchylosos, it tnw oft«i Moeusrj to di-
ride thctenduos of tlw letise muNcles; tbis cumplicated Ibe operntiun.
Moreover, the nftcr-trcatmcni was not correctly undoratooci : llic ex-
tended limb was boun<l (o a splint^ or bold firralj by machinery ; the
coii!tequ(>nce8 were Kerere inSamni&tion and great nwcllinf^ ; the
meUKxJ did not become popular. Bouvifr and J}i^efthach were oJ*
Diost the only od«« vrbo oocMiODoUjr rmortcd to it; otbcr surgcoiui
pvefcrred to coastder the«e patient« «s incunbl«, or to send them to
orthD|)cdisls for gradiul extirnskin, or, if the paticnts wrre poor, to
amputate tlic limb, so that llicy might haw a wooden leg to go about
on more Beeurely. So the matter stood till B. von Lan^enbeek m 1846
made the 6rst attempt to eilend an andiylcsed knep-}oint while tbn
patient waa aiuMthetized. TIüh showed tlieinterestinf^Euctlhiit iiiider
anicethesia tbe oontnicte<L muscles beeomo perfectly relaxed and pli*
able, and may be stretohvfl like iudia-ni))l>er ; this rei)()«T«l tenotomy
Bod myotomy unuccrasaty- in this operation. As anaesthesia rendered
tlie operation painless, it eoutd be done more slowly and carefully,
and with the aid of the hands alone. The results vere so very favor-
able that this Riethnd. which in its new fonn srarwiy deserved any
longer the rather brutal name of " brisement forc4," soon became um-
vei-HiI, and now ii. has, perhnp«, too mticti di»plneed cxtenMnn by in-
Strumcnia and weights^ The method of tlie operation, tJie indtLVtiona,
tbe precautions to be obfierved,andtbeafWr-treutincnt,wen*gra<lualty
■o perCeoted by B. von Lanffenbeek that this operation may be re-
garded as one of the safest and simplest in surgery. To prerent
your being inUled by the name " Imsemeni fore*," and forming too
horriltle an idea of the operation, 1 will deseribc fnr you tlie ejcten-
eioii of a Icnt-e l)eiit at right snglee. At first the jKitienc Vws o\\ his
bftck, and is ;^dunlly au«8thetixed so deeply that all tlie muscles are
felftxed, and no reflex morement» oecur. When this state has been
ranched, the patient is turned on his belly; one assistnnt holds ill«
head, another places his arm under the breast of the patient to fucili-
tat« respiration ; the pulse and hreitthing are csrefiilly watched, for
the operatiMi must be intemipted at once if dangerous symptoms fol-
low the deep aiifeslhcsiii. The patient, lying on his lace, is to he
drawn toward the lower end of the oporatinp-taWe tilt the knee
comes to the edge of the table, which shotiM he covered by a lirmly-
stufled horse-bairmshton. Now an nssiataat with both hantis presses
as strongly as posiibi« on the thigh ; the operator stands at the outer
Bide of the h.^ft (anchylo.sed) knee, places his left hand in the popliteal
space, BO as to depre^a the iJtiglt, and the right on the posterior
surboe of the leg, corrr«pondi»g to the posterior surface of the con-
504
CHRONIC nrpLAMMATIOM OP THE JOINTSl
djrles of the tibiti, t>utt is, dose above the calf, »nd witli bU li^
hand tie makes downward piwure oa the leg. If ttui anchylorä be
sUU recent, uiid itol too linn, the leg will gnuluslly girc wmy villi a
perceptible »oft crackling and tearing, and will be straiglileoed hj
üegree&. Should extensiun not be made so readilj, tJio openitor
places hia hnml lower on the leg, about the calf or close below U;
but then be sbould not us« to much force as he could above, becauie
he might readily fracture the tibia just belov the condyle«, edpecially
if tlie bones were a little anft ; the force should here act more in tlie
way of tntctioii or extension. If wc <lo not succeed even by this la<l
meanx, we idiouid attempt to mpture the ndheitions by »trong ficxion ;
we eeüc the leg from the front and try to Ilex it by slow, regular pes-
urc; by thin means the ndhcsionii somctimcB rupture marc readily
than by movements toward extension; after a few of the adheftiOM
liuvo been torn, extension ia genenlly easy. All painful t-wisting
and wrenching ift decidedly injurious, and very rarely does any good.
When we have made a« nuch cxtenAtoo us we consider prudent for
one operation, or, if the leg lie fully extended, we tum the pntient on
the btick A)]^in, let the usistaiita press down tJie (high by means of
Hutiir's bandages, extend the leg by the foot, and from the foot to
within an inch of the perinnmm apply a stout plnster-of-Paris ijroesing,
inserting iliick Inyent nf wadding at the knee and at tlie ends of tlio
bandage (below and above, where then* is most ptessuie). Bul^ad
the piaster doe« not always harden before the patient reeoger» fron
Ills anivstfaeeja, we bind s welKpadded liollovr sj^lint to the flexor aide
of the limb, to prvvcut the knee contrndln;; afniin ; this hollow splint
Is to be rcmnvc<l after three or four hours; hy Hint time the plaster*
dressing is hard enough to resist the contracting musdcs. The ptla
that ihr |utlicnt sulTcrs nfler rreorcnng from his anirsthcsia is not al-
ways severe, often it is remarkably slight in proportion to the fore«
employed. The foot sometimes becomes w<lematous, if it baa not
been properly bandaged; but if this hoa been done, or is dm» inn
mediately after the operation, there is no further trouble. Should the
pain ho very severe directly «f'cr the operation, we nay apply a l^ad*
der of ice over the pJastcr^buiidaj^c, and f^vc u quarter of a grain of
morphia. After eight or ten days wo may allow the patient to grat-
ify his H ish cif getting up with the bandage on, and going alxMit oo
crutches, or with sticks. AfUT eight or twelve weeks the nacliyloais
haa healed in it« new position. Meanwhile, the patient haa thrown
aside his crutches, and goes about with a stick, perhaps even witlt*
out any support, his knee being stiff, hut straij^ht ; then the bandage
may be removed, and the patient rcgartled as cured.
In the above case we have supposed that an operation ntcceeded
EXTBHSION OP AKCHTLOSEa
M»
ia stniig{it«ning tbe knee. But tins is not alwajrs th« cue ; frs-
quently At the fintt opcrntion wc dare tint go bo fur without risking
serious coitM-'qiieiices. What cirouiaKt^tiires can prevent unr complet-
ing the oprmtioa at one sitting? Tltcsc »re cliicfl^r extensive cica-
trices of the »Inn, whifh d<Mii&nd rcrygr«at pre«iiiti<nw ; cicatrice» in
tbß hollow of tho knee arc especially tiitficult to deal «-ilb, ana must
be extended gradually; ttiey would bn torn if we tried to Ibrce the
extension. Occaaiooalljr, also, tbe cicatrice« Surround large rewcU
and nen'es, whose sheaths may have participated in the previous ut
ernUion, ami tearing ihese parts would be a vorj^ serious, pcrLaps
fatal complicntioiL Breaking up of any cicstrix niuj be followed by
suppuration, or even moitifieation ; hence wo should nftrer stretch
CMHtrices of the skin to the extreme point to rupture them. Har-
in; reached the point irhere the ci<»trice8 are very tense, we idioulü
stop, apply the dressing, and repeat the operation in four to »ix
week«, and so on till we aocomplish our object
A further drcumstanee re^juiring attention ia the faulty position
of tlie tibia, that may have resulted from can« of the knee, capocüUy
its inciinatiuu to luxation backward; it is alwa^-s difficult, sometimes
impossible, to corrrct this position of the knee, but we surceed best
by making tbe extension very gradually; under such circumstance»,
forced extension would induce luxation badcward' — ^ then iwrfect
st47iiglitcning would be impossible.
\'ou must not expect that the knee will again acquire its beautiful
oonniil shape, even if it be quite straight; this never occurs, but, aa
we are not called on to go about wittT naked knees, as the lligblanden
do, the shape does not make so much difference, if the knee l)e r>nly
straight and firm enough to walk on. Altliou^ jointB with tumor
albus may be brought into the most nervieeable position at almost any
time, even when there are li&tulie prescol, and should be placed in a
closed bandage or knee<!ap, still, the period when tiirtuUe hnre Just
clased, and the ctaitrices are fresh, dense, and tender, is most unhror-
able for the extension, for then rupture of the cutaneous cicatrices
and new suppuration will be moat liable to occur.
What has here been said in regard to atraigbtoning the knoe-joiut
may apply equally to the hip ami ankle. Anchyloses of the shoulder
and elbow hare a totally different functional significance, in them the
problem is to restore mobility, and this cannot be obtained by break-
big' up the ancltytoais and applying a plastcT'bandagc.
If, on straightening a knee, where there hare been few adhe-
sions, and the joint is tolerably healthy, we wish to obtain mobility,
of course we should not apply tbe plaster-bandage after the operation,
or, at least, should not leave it on long, but we should apply instru-
fiO<l
CHRONIC rSFLAUlJATIOy OP TAB JOISTS.
meots bjr which motion mar be mnde «omr time sftcr the extenswn 1 1
this motion should first be tried under anirsthv«!*, niid mlMusiucntljj
rejietited tUily without the uneKtheU«. I shall not deny tluit va
occur where a tolerablß amount of motion may be ohtalaBLl id tuna
Vrt^Y; but ihey are nre, auil ihov are either cases where stillDew
has remained »(tor (ractotv» tliro«if;ii tlit> jnint, or aftvr iaflannoBtiOM .
of very »liort duntJon ; 1 could almost belirre titat^ iu some of
cases, mobility would have been restored simply by düJy ww, hrvw T\
haTB no very brilliatit nntidpntione uliout the rvsiilt« of eIniigliUmtiig '
andiyloees goucrally. But tlie mere fact, that we may outr almiMt
entirely otbsr anchyloeis Irom the list of indications for ainputstion, i
is a very grent triumph over fnrmer eiirf^err ; but this does not bar]
the way for further improvement! of the new method, or fur the at'
tmiument of bptt<;r reeult^
Oases occur where the mechanical omditions in the jcHtit ar» of
such a nature that th« end« of the buiR-a cauoot be t>rou}^lit irilo any
different position. I have already pvcii you the eibnw-jnini ah an
example ; e. g., tlie case is one of arthritis deformans, the fiiosie at]
tlie lower end of the humeniB above the trochlea are tilled with
Dewly-formed bone; here it ia impo^ble to move the ulna forwardor
backwarti ; in arthritis defonnuDS similar ctrcumstancee occur to otbtfj
joints, henPG the consequent aneliylose» eaimol be reodered movsU^j
any more than they can aAcr true arthrilia, therefore both
are ustitilly contmindi^ationn to extension of the aacfayloda. I.ABtIr, ]
aH ftbovf stated, the adhesions of the ends of tbe booea may l>e bii(kv,j
there may be anchylosis oraea; H will rarely he possible, indeed. «>x<x7t :
where there are »imply a few oeaeous handK, to break «orJi niictiykmn;
in most of these eases the anchybMis will stand firm. What em be
done in siieh ease* ? There are (wo ways of altering the pcwiticm of
such joints: by bending tim bt>ne above or bf^low the anebyloaBd
joint, or by sawinj^ out a piece from the Joint or &fim the boiWi, Id
regard to tbe first, some surgetmB would shnig their «huuhltTs if it
were prnponed as a melliod ; still, this bending or even fracture of the
bone has often been done unintentionally, and has generally turned
out welt. Several tiroes in extending anchyloais of the knee-joint,
nnoe in the hip-jnint, without intending it, I made a parlinl or com-
plete fracture of tlic bone j the joint remained as before, but abovv
the knee and below the hip tbe bone bent »o as lo compentttt« forlhv
angle at whiuh the joint was nnchylosed, nud straightening was pni^
tically aoGomplisbod, although not by rupture of tbe wtohylosis* lo
all these cases I appUeil ihe plHsier^bandage; tbe «mrBe was jttst tf»]
siitne as in simple subcutaneous frsctures, the pain was even kos
than after breaking up anchylosea, and Uie result waa periiootly sattf-
OPERATIONS FOR JJ«C[ITL0SE8l
601
[ cannot »ee vhy we should ruJKct tliü operatioa »r suhsti-
Utiing' u fracture of tlie btnic for an unsuccessful attempt al MnighV-
cuiuji; ih«.' anchylosis, bikI I shouUl mucli prefer it to any ie«cctioo of
tbe ktice or hip, wbera it «in be done eauly, uitboMt great force or
liiml jerks; I even bclirr.'> that w« shoulil alwtiyn trv to substitute
fraeturo of the femur, if it can be eatily hrokcn, for n;MMtioiift o( ibo
knee at leaxt, no matter how Uiey «re <Joue ; iu uthor juiuls resucliiHi
is of <'ouratT to Ik." juvfi^rrett for various rcusous.
Ttiffo am Uiro- nivthodi of rcsci-ting bony anchylosis : 1, Jt/iva
Sarton"'» (pubÜBhud in 1825) ; in anguUir anchyluHts of the knee,
after diTidnifr the soft parts, dnee above the joint, you saw out froni
the f«inur u triaugitlar piece, whose base ia upward, aud whose aof^lt-
pointinjf dou'nward must rompeniuite the angin of th« aiicliylu«i« (wb
tnigbt rIsii mw this pit-re out of tlie uiicbyloiwd joint itst^lf); then
the limb id stmif^btentid, the joint is untouchc-d, the distortion is
plawil ill llii- thipb, M it i* iifU'r fnu'ture of the booe. This operation
has be«^!) dniii- frL-quvully with gocKl result» in auchyloseci of the bip
and kncf>.
"i. We mayn)^«a«ci^ura>M!i7Ms ostoofomy tbroii|^htheanchy1o«cd
joint nfier 3i. «on I/ongtnbefk'B method; tliin o]i<>rattori, wliieb wo
found to lie virry useful in fnicturefl thnt h«d iiuitrd ciblii]u<:ly and io
rachitis (page SIO}, lia« hitherto be^;o little used in bony «ncbjlosis,
hen«* we oiin give no opinio» of it. Oroa» has enip)oyi*d a moditied
jnn nf it with ffrcJil bt;nclit ; lit- bores obliquely ihrnu^rb the anchy-
sb in many plac«», and div-idv» th« adhesions with line cLi^s.
3. Total Teaeetion of tfit joint. I have abeady stated my opinio»
alwut tlic Alhiiijutibilily of rrüivtinn for andiylosis of the hip and
knovjointA, und wotild rej^rd it a» utiimum renu<Uiim and void«
in the olhow-joim tbo ]i«ispi>ft ia mther l>fttlcr; hfn* by re-
I KCtioD we may clmngv the undiyktst^ joint into a inovabh* faW» one,
wbicb is occoj^ioniilly quite useful, {/' aU tuntt vut wdt, hut this is the
'>int on which all de|>eiii]t^ and wtiieb wt* oannot always master.
Iio wfHild risk liiB life for a stiff oHxiw ? Mumiver, in resection»
for anchylosis of the clt>nw, the result« have not always bee» rerj-
bnlliant, eith«r as regards mobilitj or lifo, althot^h aome oaseA seemed
tor a limo rer^* succeMtful. So wc should not bo too free with these
ctii'H.t.
la the shoulder, thd eircumstanoc« are very peculiar : experience
tcsche« thai pfr«ou« witli stiff »bouldets can, by constant use, make
their sboiiMer- blades so movable that the stiffness of the shoulder
causes comparatively little inoon\-cniencc ; in such a caso it would be
foUy to operate.
PsticntA with caries of the wrist are usiudly so glail, when, after
608 CHBONIC INFLAMHATIüN OF THE JOINTS.
years of suffering, the disease at len^h recovers, that they do not
complain of their stiff hand ; nevertheless, successful resections of an-
chylosed wrists have been recently made by Rote; it is true, the final
results of these operations are not yet fully known. In the foot there
would be no question about resection for ancbylosia in a bad position ;
usually defect of the ankle-bones is the chief cause of deformities of
the foot after inflammation of the joint It will depend on the indi-
vidual case whether the foot is useful, whether a correction uf posi-
tion be possible, or if a good stump be preferable.
CHAPTER XVIIL
DEFOBMIT/KS CAUSED BT DJ8BÄSBS OF THE NERVES, XUS-
OLES, TE.VDOyS, FASCIA AJfD LIQAMESTS, Ä2fD
ClVATlilCIAL CONTRACTIOXS.
LECTURE XLII.
A, DaArmhie* dio to Muncutor uu] ^*tIl'o^■ AtTectivnt : L tfiueuW CootniMtaM
mumJ bf DI»CM«of the MuaculurSubsUincc; II. MiuculirContnciiiMia ft()nlDi»•
n<«• of tbt Mcrrei ; III. UuBFulor Canmalioa» from Fault]' Posiliaaa. — B. !>»•
formltl«* <tu« to Dlapwn of Üic \.\pttaaa», Fud*, ssd Teadona : I. Alraphj' of
LlguncDU, l^Mcb», BDd TcDdotu; 11. Rclnxition ot WgKutina.—C. DriMmitiM
doAloCleMriwi.— TrMttnani; 8trEtohiiiK b/ Mnrhitici?.— Extcnainn during An-
«»Cli«su. — CoinpteMton. — Te notomy and MrotoiDT.— DivUion of FmoIs ind Ar-
ck'ulu LignmiiiU.— OfiDBucloa.— Elwtldqr.— Ardflslal Uuioloa.— SupporUng Ap-
Gbktlbmen : From wh»t has already Wen toI<l yo«, jo« know
tliat (ifformiliPB of the limbs may bi* causmi liy disirasoa of the bout'»
aiuj joint», and that Uii; muscles and 1i^;anicDtd have much to do with
the ciODtiniuiK.'e uf these ilefurmilice ; but lliei« are also other causes
for ftuoli (lefoniiitiHs ; as prinmry muscular oontractioiis without di»-
iww of the joint», etc.
We »pualc of contraction when a muscle mitintaiDS a rt^^ar. oon-
Untied ooDtraetion, as if tetimio. Contraction tran reiilly only take
place in muitolrs, a» iti n phy&iolugrical sense tliey alone contract on
irritation. But usage (;i\fs the tcmi a wiilcr meaning. Wc speak of
contraetiong of tendons and f&sd», meaning that the&e parts are
shortened or shrunken, and have mostly or entirely lost their ela»-
tidty. We have already used the woni coiilractiou in this general
sense, and »hall do so again. It i.t cx04>^dingK* rare fo«* tlie faai-iin,
tendons, and ligaments, to l>e |>riinanly diticaxod, idtlioiigh this does
happetL Rflaxatlon of the Itj^nmcnt« ntuy exist as a primary alTec-
tion, from atrophy of their fibrw, or oioro IVcqut^ntly from weakn^tM
of fonnation they may be unable to resist tbe burden tliey hare to
filO DETÜRIUTIES CAUSED BT DISEASKS OF TIFT. KFRITES, ETC
bear. In the same way muaolcs maj-, from btrtli, be loo short, uul
beiiotf wirhout epcoial aids may ool be ituraiftlly diaU-iuiblc ; dofono-
ity mny tlius be indut^ed uithout ther« bein^ any iriw ronUm(4ion.
You already know Iiow the iiiU!«i.-le!t »re 8yiu|intlietical]y sOrct«] in
diseases of the joints. From tbcsv few reoiorks you »c<: thai tbr^r
various cause» of defiuanity inuai bo projwHy imugv^d. I will try lo
make tliis arningi'iiieDi, remarking, bovrever, that bun* wt* onl^ detSse
to ubtaia g«ncra] |K>iat8 of view. Vou will hatrr fiprt^inl instruction
OH thU subject, in topographical pathology and surgery, and in thr
oltuia
.*. DEFOEMITIES DITE TO AFrECTIOKS OP TlIZ Ml'SCOJ» ÄKP NBBVBS.
I. JUtucular contraction dv« to diMtitea of the naudes, Hon-
we should firat speak of acut« paiufUl tnflanimatkm of tba mnscln.
Ydu may rcniRiobcj- that we huvc alrcaily i-piikrn <■( tbis, atKl that I
told you that acut« ioflammulioQ of muscle often leads to suppuraüon
(page 2T4). I will relate h tj']>irnl caae of tliis kind : A young girl
waa brought to the |)olycUiiic in Herein. vrlioM left foot na» in the iio-
sition of a tj'pcal pcK cquinu«; that is, the foot was fully exteudnl
(flexed in llie »Datoinind souse) ; this state liiid enmc on a few Any*
prcWouKly, with ncc^sive pain in the cdf of the leg; the akin
appeared uL^iiuiigeJ, but was painful to the touch ; fluctuatioo wu
evident; I made nn incioion, nnd let out a larf;e quantity of tnatler;
a few (hiys 'ster, the f<x>t had its normal position, ond the recon-ry
was couip]titc. Ill« in tl animation doea not i»eoee&aHly begin in the
niust-'lp itself to indut!« contraction in it, but inftatpmatioo, and ecpe>
cially »uppurntioii in the hnmediatc vicinity of the musch-s. in tbrir
abeittlic, the muscular substance being often secoudarily affected, may
also induee cotitnicticMi. For iustanee, il is very common, in aeut«
siit>punitiuus in the neck, fur t]ic stenio-clcido- mastoid to contract,
and for the head to be inclined to the ii0ectcd aide In tbc sane way,
the thigh is often Hoxod in aeuto initummiitioii of tlic psoas muscle,
and ill peripBoitis (fn^uently the two cannoi bo distinguished). And
we might partly, at least, plnce under this Itcad tbo«c contractions
developing during acute articular inflanimations. From the oodema-
tou» swrlliug accompanying every suppurative synovitis, wc see that
tiic 9oft parts in the vicinity of tlie joiikts are al»o itnpliraled, and thi«
infiammation, which is acute, if not very intense, may give rise to
cx>Qtrttclioi], But there may be sotne other explaiuitions, aa bas
nlmifly been nieiit iuiicd. Drawing up a limb that pain» us is often
an instinctive momKuvrc, a sort of reflex action of the seupHble iicrres
oij the motor ucrves. Il seems to mo thai the relatiuus of aculc ta\»
cular inflammation to museular contraction are not by any idciuib fully
MÜSCÜLAB COHTRACTIONS DUE TO DIREAFE OF KERVE8. «n
explained. While the cases ndducrd speak fnr the combituition nf
ibesc two proc«Bse«, I tnaj tell jou tkst I bare repeatedly seen hrgt*
metastatic inustnilar abecvsscs. Fnr instance, a sbort time eince, ou
autopsy, I founil one in the p^ooui m»i»cle, withniit any contraction,
indeed, without tbc patient havinf^ manifested any potn duriug life.
As idiopathic diseases, clironic i»fi«minÄtk>nR of nuiHcle!* are very
rare, nor do they necessarily induce contraction; iiideo«), this is not
generally their effect. Vlrc/ioK considers fatty dcfrcncration, and con-
aequently molecular disintegration of the contractile substance, simple
atrophy, as an inflammatory prooeas ; it is not always aceompaaied
by ooatni«tion, but only by simple atrtipliy and progTessire decreaae
<rf itrenfrth. Wp cannot consider this state as inflammation, for we
das» iiilUmmatioi) witli neoplastic formation. MHiere there iainflam-
mutory ni;« formation In muscle (nnd this i» pnrticidarly the case when
the intlnmraAtion extends from other tissues to the muscle), not only
is atrophy of the eoatracljle substance a frequent result, but there is
also usually interstitial cicatricial atrophy ; cicntridal coanectire tissue
takes tl»e place of tbc muscle ; tb« latt«r ia actually metamorphoeed
t,to connective tissue. This process nauses the drawing together by
rihe atrophy and induces the contmrtion, although in the strict physio
logical sense we should not call this ««ntractioQ ; but, in practioe, tiieae
conditions are not always to be distin^uislicd. In the lnst>ment]ott«d
olaaa of muscular contractions, there are veiy many cases; almost all
those where in chronic articular inflanmintioos the muscles ^aduolly
become permanently shortened. If there be absolutely firm ancby-
losia, and motion be entirely lost, the muscle finally atrophies to a
iVOBnectiTe-tissnc string ; thia does not occur very frequently, for osu-
Uj the mnsde retains some actioo, eren if it be but slight.
n. JVuteu^r contractions cauaext by primartf diuatt of th« ner-
v<nit ayttem. We roust here make two clasaes:
1. Primary muaeular eontraction» as n result of continued irrita-
tion of certain tierres; this state is most analogous to the tetanic ooo'
traction induced by the electric current; the irritation may belocntcd
in the nerve, spinal medulla, or brnin. Contraetton of the arm may
be induced by neuritis of the median nerre, indiKvil perhaps by irrita-
tion from a foreijEn body, as a piece of glass, by inflamraat inn of the
root of the nerre or of the spinal medulla at a point oorreepooding to
the root of the nerre, or by a circumscribed encephalitis. The cases
of limited contiactinns as a result of diseases of the nerves are not
nt. These contractions may slao be of reflex origin ; for tastaDoe,
DJ maes are known where ulcers of the cervix uteri have induced
itraetlnn of the musclea of the thigh.
2. Seeondary mw^cwAir contraetion«, olao called antogonittic con-
»i
512 DETORVniCS CAVSKD BT DISCISES OF Tffl KERTRa; ITa
tiaptions; tlieir primary cause is a parnljstt. For inttanoe: Kipfxiw
the exteiisots of the hand Iw pamljzecl »Rer ctivisicm of the nUal
nerre ; tlie hand c«n no lon^fcr be «Icratcd, »or ciui it bo lield in tbc
medium puifiLion, for At ever}- cfftul of tlie will on the hand tlie flesMS
nlonc act, aod Lhcsc ooun acquire sucb a continued effect oo the pcni-
tioa of tlio liaad that the Intt«r temaios flexed. The [taraljiic dub-
foot alao belongs under this head ; suppoge the peroneal and ext«n«or
mii»cle9 of the foot perotyzcd, theo the foot will be kept oxtcnded,
aod iuniMi somewbat iaward by the ^aatrocnctnius^ Scxar oohuiiubIb,
tIbUN poeticus, etc, and this abnormnl puKitioo iocieaM» in propor I
tioo as the putient trii.>8 to inor«^ the foot, for the will acta only on
tb<! healthy muscles. Still another example : if the &cial rtenrc be
paralyzed on one side, the angle of the mouth on the oppoAile »dt is
drawn up by the action of the zygomatic muscles of that sidu; vhon
the fitcc IB quiet, tliis it) little noticed; (hiring active play of Uu; fiMturDa
this forms a j^rimaoe, as only one side of the face is much tnoretl, llie
other remaining at rest. iOontraetJoiis ivsulting from pareljsii or
pari^üin of thr: antagonistic muscles are never very strong; they mih
ally offer little oppoeition to pasaii-e motion, and frequoDtly may bo
thus dingnoA^d at the first examination.
in. A further c«i].te of ahortcniug of muscles, and even of shrink-
age und atrophy, is the continued approximntion of the points uf ta-
flertion. This is the cause of some curvatures of the spine, espcaaOy
of tUeliilernlcunaturen (scolioses). Suppo««n child to aocuatoni Itfidf
to slaixliug most- on one foot (a ver^- frequeut habtt), or whca writing
to lean far over the tabic with the right side, to always lie oa tbo
«)imc udc in b(>d, and alwa^is to simp bent up, in short, in various em-
ploymeiits alwaya to assume tJic some oblique position : soon rartala
muscles will remain almost constantly in a state of moderate ahortm-
ing; if a yielding suftiie)<8 of the vertebne favor* this lateral curta-
ture of the spine, the shortened muscles MOn prevent the pwrfret
»Irai^hteuhig of the »pine eveti durin;; rest, i will not assert tiiat all
scolioses result in this wn}-, hut that this is oft<.>n the course appous
pretty certain from the concluitiouaof all ubscnren. In many casoi
coii(^-iiital club-foot aUo probably comes in the Ran>r war; if, while la
the iicoriis, thi? child's font lies in such a pc«ition that during its moi«-
ments the extensors are brought Into action hut little, and the foot is
permRnontly (Icxed and bent inward, the gaAtrornemius, whose points
of insertion are permanently approximntcd, is Itanlly «rcr fully ile-
velopeil and extended; it is formed too short at first, und when ihr
child is horn cannot be stretched beyond a certain extent. Tluais
one explanation of the intrauterine occurroDce of this doforuatT;
others suppose that cluI>foot result« ham a true oontnetioD due to
COKTBiCTION OP THE PAUfAB PASOIA.
M3
intTft'ul^riiie inflammAtioiu of the Bpiiul medulla, or brain ; stiU othon
tbinic that a faulty development of tlie aiikle-lton««, «tpMUUr of the
wticuliir siitThccs, i» tbo priimuv difficultj. hiiportunt facts may be
ftdvanoxyl in tavor of nil thcs« iri«w«, so that the qu^^tion about tl>e
tlevelopmeüt of oongtmital club-foot cannot by any meaos be con-
udared settled. The apprositDation of the points of insertion of a
muaole induce« increaM of an already-ojüstin^ defoimity mon ht>
qiwntly than it doet the ori^nal disessp. TIiuk it ia nntbinf^ u»
oominou, wbeii club-foot has oticc begun, (or the libiulis posticus
mwcte, and eren for the aatious and Sexora of the toes, to contract
gtadually, and lliits artiially to dnw tlic foot into a vlub-shap<>. Aiid,
irhoi (Jefbrmity früm discue of the joint» bia once bcfrnn, the approi-
imatioii of tt>e pointa of inscrtioa of the muscle conaiderably aids in
inoreasing the muscular contraction and the defonni^.
S. DEFOBUmES BESULTtKQ FROM DISBiJBBS OF TBS UO&UBNTS,
FA6CLE, AMI TBNDOSS.
I. Shrinka^ of the lif^mcnt«, l^^nHonft, and fasciir, is a rcry fre-
quent CÄUse of deformity, and L'specially iwnes to incn^ase oxistitig
deformities, and render them permanent. Chronic inflammation of
the synotHal membraao of the joint, oit^nding to the capsule and
fRipporting ligamenta, is the most (roquent catne of thig shrinkage.
But continued malpoaition of the part« niny fp^ually induce ahorteo-
ing and shnnkaitc, the same is true of the fuedir ; it iz here only no-
ccaaary to menlioD club-foot; in congenital club-foot then* is a primärer
shorteDtng, the fasda phmtiitia is formed too abort, but this slioTtening
may ooote oa sptxind-inly, ae the club-foM iH-comca more dereJoped.
If from inflammatioa of the hip-joint the thigh remains flexed for
month« or yean, the fascia lata abrinks to such an extent that it
may be felt as a oOfd running from the anterior superior crest of the
ilium, which sometimefl cnnnot be rxtooded even while the patient is
UHsathei ized, but niu«t be cut ihrough befor« the thigh can be
stnighlened. I'hc aboTc nhort^nini^ are nil eecomiary, Injt tbore ore
also primary idiopathic ehnnkagct of fascine, nmong which e<m(r<T(^ion
o^ the palmar fairia is ihe be«t known; it uccuni most frinjiicntly in
elderly people (rarely before the fortieth year), and begins by one
6ager assunuog a flexed position, and io the «xnirs« of years the others
do the same thing ; finally the hollow of the hand is drawn together,
and cannot be ilusieiidrd ; \hc. skin hangs in folds ; the tendons are not
»ffected; tbe seat of the contraction ia the faaoia immediaioly under
the tendons. Continued friction, or frequently-repeated pressure, is
reganled as the cause of oontmctura palmaria; tJits disease is said to bo
particularly frcoucat in persons who work mtKih with hamiuer, axe,
BU DEFORMITIES CAUHKD BT DHEASJES OF THE NERVE*, BTtt
etc., which must be held with the whole hnnd, itlso !n tliose (rboMtl
or sUnip lettore all day {B. von IiQnyenbtfk). In llie c«8M that 1
have B^cn, ihis contrsctiira palmaris seemed to be a «j-mptom oTchrnnic
rheumatism. In many persons wilb this dtneaae no cause, or mnner-
tion with otber dü««ae, ia discoverable.
II. Jieiaxation of Uffoment* — espedally of Biipportinff lij^ampiiM
of the joint — may alM> caus« 4l«fbrmities, jxtrticiiWljr in thi> lower ex-
tixMnilicA, whtnh hear the weight of the hotiy. Tlie causes of auch
rclaxationa are aliji^ht anomalies of formation ; (oo feeble d«veIopineat
of tlicse part«. Tlw result* of «uoh reUxntioiis manifest itienudfat
particularly ut the time when the growth is most rigorous, and the
tiiitXs of the bfjnc aftsumc the fiiuü form, that is, in young pcrvoo*
■bout the age of puberty. At tliis period the soHzalk'd knuekling nf
the ßaot is most frMiuicnt. The defonnitics reaultttig frum this nuse
•re bandy-leg' (curvature of the leg with the concavity iuvrar^ fftnv
varum) and baker's leg, or knoclc-lcnee (curvature of the \eg witli At
concavity outward, fffnu valgum) ; the latter «re more Drqneat than
the former. Genu varum depend» (csrept when due to bending in-
trard of t1ie femur) on relaxation of the cTt^^mil lateral li^ment of
the Icnee and sbiinkage of the internal lateral ligament ; genu VMlgum,
on relaxation of the internal latera] ligameat and ahrinkage of the
external HgAment, with «eoondary eontroetion of the biecp» fcmoris.
Some siu-getins and anatomists refer these dtyfiunnilies also to priraarr
anomalies of development of the onndylcs of the femur and titna.
Tiicso anomalies of form in the articular sur&cc« undoubtedly develop
aeuondarily in these deformilies. J^^planua b also referred to relax-
atinn of the ligaments; in this the normal curvature of llii? itmrr bor
der uf the foot disappears, tlie scaphoid and first cuneiform Irouea sink
down ; the sole of the foot thus become« flat ; hone« the naoie JIat-
foot f secondarily, there may be oontractiou of the pen>tii>al mu^elM
and great daogea in the articular aurßicee of the ankle-I>oi)c« ; here
ako the latter are regarded by some aiirgeons as the ptimarx* affn^
tion.
a. DEFOKUtTIES CjLIISED BT CIOATRICBS.
"Wo have already apoken frequently of the oontjaction of eira-
trices ; it results firom the inflammntory new fonoatioa in the wound
gradually giving ofi* water, oa the original gelatinous formation bv
deigrees atrophies to dry oonnective Ussue, and oootraet« like any body
that is drying up. Tlie larger the surface of the cicatrix, tiic »trongor
will be the contraetion in all idroctiooa; all wounds witli cxteneive
lo« of akin will be followed by cxtensiTe cicatricial contraction, and,
M this is generally grcateet after bums, cicatricea from tlii» cause arc
TREATMENT OF COIITIUCnOSa
»9
1|#illy tlie oDcs that cooLnict moat. Of cuurae it depends gmttly m
the poüitüui of the cicatrix whether it thai] produc« injiirioiiA result^
(lelunnititfji ur (liHtortiunK, CiOBtrtoes uii tli« flvxur hide of the Joini,
ffbcD tlicjr cxtcud fjir luug:itudinally, may pruvunt Ml usUuuion of tltc
limb. Extensive dCfttricee io the nc^rk indu«; distortion and fixstioT)
of tba h(.->d to the injured side ; tlioe« uu the cliouk may distort th«
mouth or lower eyelid ; on tJie tnck of the hand or foot, or about tlie
fitigur-joiiile, tiKiy mar rend«! Ute finget imtDOvublu, or p«rtiully so.
Hul cicalrioes of the deeper jwtrtit, as t)f the muscles aiirl tendons,
nuy, uf course, ubo c»utte ücfonuititn ; as neoroeis rc&dily follows iu*
jwry of K tenduu, aod cicatricial ti<siic nphicvs the tendon, euch a
part us a finger, when injured, becomea crogked and stiB,
Althouf^h, in wlutt has jiut been said, we hare spoken ohicfly of
tlie etiology of uffumiitiuti, still the diagnosüi is included there ;. and
it is unacocssary to pursue this point further. Of course the prQg-
»09i4 depends entirely on the poasibtlity of removiug the causes, and
the treatment also varies j^really with tlic latter.
To reaiovc coutraeüäiiH, the moot natural thing is to »Iretcb tlie
port« ; wc may try this by bavinft the cuntrocted limb Etrulclied a fevr
times daily. But thi& so-called manipulation, xvhich is very elBca-
cioos, requires much strength and patience ; henne it seemn better to
make this exteusion by the reigulor action of a mscliinu. The l-x-
''ieudiu^ mackinee now uaed depend on the oombijied uulion of the
screw and cog-wheel, a meobani&m that has been employed in Burgical
instruments from the most aiicit-nt liniL'» ; the maeliiue» may be vari-
ouxIt coualrueted, but muat b« light, firm, and well padded ; they
■l>ouId never press too hard, and lie made to n>t»iti miy jKuiition ; such
tnndiinea arc most readily made for the knee and elbow ; in the hIiouI-
der and hip it is difficult to fix the scapula aud pclria. Kxtcnaion
mny be made imdcr amesthotica, to haslet) tin- progre^ ; but theo
avoid using tx» much force, and esfwcialty bear in mind that cii^n
tricially-oontracted muAcles are leaa distensible than normal ones, and
«sn only be stretcbed gradually. Meohaoioal extension can scaroelj
be applied to those muMnilar oontractiooA depending on neuroses, or,
most, it CiUi only be u»etl aa un adjui-aut; the chief treatiiMint must
'Vc directed to the ncrrou« aflection that has caused the muscular
oontnetioa Not uufrequently these coutnctions entirely disappear
under chlorofunn, espocially when of a rcflcK ohomcter, in the ssmo
way that they subside spontaneously in acute articular iDflamcnationB,
as Booa as the patient is narcotized; the flexed knee, forinhtanoe,
siay tlten be extended without the least force According to Jiemat,
518 DEFORXiTlES CAUSED BT DISEASES OF THE NKRVB8, BTC
many contraction« disappciir inKln* th« us« of the conatAnt cumeoi of
electricity ; m many c^xceltrnt men arc now engnged sbidTÖtg tbe
constant mrrent, it is to be hoped that the mystery^ vfatcb h*s itntit
InteU' stiroii<)pd this «iibjeot, may disapfM'ar beftore c1e«r criiicwm.
Truitjitent bj upptintiis {ortAop^y) is particularly used in oontno-
tion« of ligamunt« and fasciox Contractions &om cic«triooB majbe
improved, but rarely initin>ly cured, by stretching tlic oicatrix ; a tnoro
potent remedy hero is continued prensure, made by odhcaire pbstor,
baadagee, or cooipreBses, applied to euit cadi case. Tbo «trophy of
the dcstrix, wliicb oecunt sponlaneousiy, in the coarse of years w tauA
promoted by tliiit treatment, retention is oombtned witli cocnpf««-
sioii in the treatment of rinj^bapcd oicatricia) csootmctions of canals,
»»«ullcd stri(!turf.-i(, «uofa as occur chiefly in the urelhr» and neftciphagus,
byt!ie introdut;tiou ofeLastio sound« (ealled bougieb because tliey w«w
formetly made of wax) of gradually-increasing thiekncee.
The ortiinpedie traitment previously mentioned doe« not always
auccecd, or itt least is often very slow, bonce even in the middle ag«
tlie tendons of the contracted mu&clc« or the muscles themseJros were
divided; thi« operation i« called "tenotomy," or " myotomy ;" the
fonner is far the more frequent. Formerly th« uporatkin vras done by
simply incising the skin down to the tendon, ihcti div-iding the latler,
and letting the wound beal by Kuppuration ; the rcsulia were not trsj
brilliant: ttio suppuration was sometimes very extensit'e, tliick cleft-
tri(!es fonnpd, which could only be slowly stretched. This <>iK-ratioö
wne first made really Acrncrnbic by Strome^ert wbo taught i» to
divide tendons mbcutanenualy, a method whtufa J}i^eniach intro-
duced extensively into prat^ice, and which is dow exotosively osed.
1 ehall lirst describe this operalion briefly before pAsaing to ita rceiilta
I^t us take, an an illustration, tenotomy of the t4?ndo Aoliillis, which
is the most froquenU For this operation you may best employ -^cq^üi*
bacfi'e tenotome, a slightlycurrcd, |>ointe(l, narrow knife. The pa>
ticDt lies on tho belly, an assistant hold« hix leg tint)ly at the calf;
with your left hand you sdze the club-fout ; with p>ur right hand
introduce the knife, flatwise, by tho side of the tendon under the skin,
and over the tendon, till you have pa&scd bcyontl Die t<>ndon, without,
howorer, perforating tlie ttkiti n second time ; now turn the edgr o(
the knife toward tlie tendon and divide the latter— when fwt doing ymi
nil! hear a craekling sound; as tho division is completed, you will
feel with the left hand that the foot is more movable ; you now mn-
fully draw out tho knife. Only the point of entrance of the knife is
visible estcmaJly, the tendon has been diviiied subcDianeoufily. This
method of subcutan cons tenotomtf J¥om mthovt itaearti Is easier for
l>eginncTB, because iu it tbcro is no danger of dividing the skin mots
TEXOTüMT.
61T
ry. Tenotomy ffom vithin outteard is mo» cicgtat
nnd bettiT stiited for some cases. Tlie foot is iiM as above, anil Uie
knife in ciituirJ tlie same way, l>ut it i& tiieu passed under die tendon
und tbe euttioj! cd]^ tum^ toward the tendon; the tbutnbof tfae
ri^rlit liaoi) should V» jdaood over the pcwnt of tbe knife to feci it and
pmvcDt paasing; it ihrougli the skin ; we then preää vu Ute knife ond
dtuvr it from within outTrard llurouffh the tcodoa ; being careful oot to
let it out throufrh tho skin wlicu the jerk occurs that accompanies the
completion of the dJvi:iioii. This method srema more difficult than it
is, but, like any openitit^ii, it requires practice on tbe <:adiiver. \N'heD
the tenotomy is complctc^l, iJicr« is usually but little bleeding from
til« punctUT«, tboogli soniettm«! tJiere tmy be oouaidttnible, as iu some
pcTBons a tolerably lar^ braacb of the posterior tibial artory runs
ftlongiside of the tomlon, and is di%ided with it. If the bleeding be
slight, a piece nf iohthyoenlla-plaster may l>e plaoed>orer the puncture,
and rtfcidcred tinner by oollndium ; if thn hicmorrhage ))c raiNv proAjoe,
the puncture should tn* covered Mith a small coiupre»«, and the foot
bandagud as hi^^h as tlie ealf ; the bleeding then eeiuie«. Thi» ibvssiug
^ould be replaced by plaster after twenty-four hours. I'he healing
ifl almost always by first iatcntioa ; tbo puncture is clo&cd in three or
firar daya But there maybe suppuration; then the wounded part
gniws n*i, SM'oIlen, ttenüitive; blood mixed with pu« flowH from tlio
wouitd, an abaosts often lunas oti the oppuslte aide; thia must be
opened, and, althouf^h tbi» sttppiirntinn is not danftiemiis to life, it
may oonCinuu two ur three weeks, and much impair the resulu of the
operation, fur it is n loug time bcrorc the resulting thick cicatrix is
suited for extension. Immediately after the tenotomy, at the point
of dirisioo you may feel a hollow, as tbe inusclc contracUi after
dirisinn of the tendon ; tids hollow diaa|)peai9 in the cour^M: of
twenty-four hours, and for a few days it is creit rephuxd by a swoll*
Slug; the latter gradually subsides, and in fourteen days at most, after
nonnally- healed tenotomy, the tendon a|ipears perfectly restored.
The course of this hcobng ha» been rarcfuUy etudir-d exi)eriinentally ;
formerly it was supposed there was something very peculiar about it;
Iharc often made lltcac experiments on animal», and find tiiut healing
takes place aa it usually does, and cnoat resemhlen that pmcefis in
oervc« and Imies. When the tendon is dividH, an<l the muscle eoo-
tracta, there would be an empty s|uu-e at tlie point of dii-inion if the
external atiiKMiphenc pressure did uul atonec press the surrounding cel-
lular tissue into the apace betwt^en the cods of tJie tendon; the Sp«oo
Is tliu» <illti<l up; as in any wound, tills tituue i.s inliltrated with plaa-
IJc rnaLter and scrum, and becnmi>s very vaaeubtr ; the cellular tissue
around the ends of the teikdon i« metamorphosetl ia the same way, and
6ia DKFOttlUTlBS CACSBD BY DISEA8BS OF THE NEBTES, ETC.
Km. vr.
tltc Inlter are sunoundccl Mm) iiiiitct] b_v Uieiiifliunmator^ new formatioo
derelDpi.-(l fruiu tho adjiKvnt ccIIuIbt liasut^, jitst n» tliu fragoioUa
of boiic MC by tl»c cxtcmnl callus (which, however, liore praMtt
bfitceen the ends of the toodom also; ai> iii(«n»l
L-allua cannoi. develop in tcadoos, as they have 00
lu-jdulUry cavity). In this siftge (about the lourtK
day), the picture is sotnpvrhnt us iu Fig. &7.
Tliis provinioiial uuiu« «ooii becomes Gnn, as ike
iiillHininatorjr new fomatioa iit metatnOrpboAed 14
connoclive ii«eue; moantiiiK], soino neojilnsti^ t'oAM
bas developed in the stumps of the ttiiidoti, wliicli
combines with the inbernwdiatß subatooca Tka
entire ttewlj-'fonaed intermediate muss gradaalljr
ooutnurtft sironglj, beooiues very firm, so tlial it a»
auiues exacUjr tliu ulinnicter of tendinous tissue; the
tendon ia thus cntiixJj rcgcoeratcd. It is tTue ihi»
dovs not idways go on as npidly n* we liave hav
dceoribcd, but (as also uccun in fractures) U not
unfrequciilly interfered with by a la^^ oxtnvaea-
tion ot blood tietwcen the ends of the tendon ; tht»
is enclosed by Lhe inftainniatorv now formation, bi*-
Domcs only partially ur^iiizcd, but must bo motttlj
reabeorbed bi-for« Üiuru ran bt- complete ref^efa*
'^aiSmliF^.TiIi'ton.^ tioa of the tendon. Extensive extraraaatiooaofWooil
dra, oa ii.tf loarth may Inlerfere with tho regular course of healing,
not only by their faix and the time required for their
nbsorptioii, but uy ouetisioiiuUy putn'fying nnd suppurating. The oper-
ation aud courve of bcoling' in myotomy are alwut tlio aaioe as bare
juai been dcswiU'd.
Yiiu hiLve just liesjtt that iho tendon is entirely ro^ui-mtMl, and
the cicatricial iTilcrmcdiate substauoo contracts Bttoti){ly, thai is, it
sborteua, «ad you will Justly wonder why, kuowinj; tbc«« facta, lie
opemtiou is »till done, as tJie tendon is not thereby niueh f^longateii
To ihin I hiiAwer lIikL tei)otoiiiy of iltself is of no use, or, at least, does
little gv'tfi, but that the tvndinoua ciciitrix iniiy be muttb more modily
strelclierl thitn the tendon of tho eoiitraetod mtuelo or tlie musol« it>
self; leiiotoniy only proves useful from tbe orlbojx.'dic afleMiestmaol;
it ^j^reatly aids the cure, a.nc\ often it alone rcii<lt-i-s It possible» wlus
the oontmcted muscles, fosciie, or ligaments, resist all efforts at extctt-
sion. Uence we should not awwt complete dontrioial oontroctJuit of
the divided tendon, but niiisl stretch tJjc young cicatrix ; the nrtiifipo-
die treatment may bcj^o '<>" or twolvo days after division of tho teii-
liun la club-foot, either by extension, manipulations, ajid appajntus, at
TEXOTOMT.
«19
by sttmlgtitening the &K>t and »iipWinjp *■ piMter drossin^. Faponiblo
result« vecrv first rciKJvnMl poe&iblc bj «vbeutanetnu tenotomy ; tJbcD
tbu bolEiijT poc» uii rii|iii)ly, STid a (listoiisiltle cdostrix farms ; if the
w-ouimI suppurates a loDg tJuie, aud th« skin is bIso afTeetctl, ttip brittle
doatrix probablr inaj not become diEtcOfiibl« for six or vi^lit weeks,
fiir Boooer it might tear and bc^giu to suppurate again. Of oouree
every club-foot, especially of tlie loxrer gnules, docs not require tenot>
oray ; but it is just as certain that in bigli ^idi» of this drfonnity
tonoloray farors the cute. From what ha« been said, you wiU sc«
that the indicatioiDi fur teuotumy are oftea the same as those fCH*
orthopedic treatment ; this is not absolutely the case ; llie iodioUioos
for tenotomy arc üoioctiiaes more liiuilcd, sometinics more jr^neral.
We maj/ diridfi any tense tendon aubcutjineou».ly ; hut whether this
will do aoy good is anotlier question. We ouinut heru speak of all
possible coses, but I will mention tbc tendons most frequently divided :
in the nock, tho two p«mioiis of tho storuo-eleido-uiastoid muscle, st
their insertions on the elnvicle aitd sternum ; tenolomy is rarity dooe
io the ami ; I warn you «gainst this operation in the fingers and toes;
ali tatdoit* teith fiiUy-devHoped »Jteatfu are unauUed for t^iot^my ;
from anatomical reason», llmt you may readily perceive, healing' would
not occur so simply as in tendons sinrounded by loose cellular tissue ;
thet« is usually suppuratioQ, frequently with bad results, or else the
ends of the tendon remain ununited. In the thiji^h, after coxitis, the
roiitrncte<i addtK-tor muscle niuy l>e divided at its point of ori^rin, if
it« coiitriictioa cannot be overcome duriitg umuathesiu ; the same is
true of the hiccps femoris, 8eniit«ndinoBu« and somimembianoBus,
which are to be divided close to their points of insertion into the
fihala and tibia. In the foot, the tciidu Achillis is most frcfjuently
divided, as are also occasionally tho tendons of the anterior and poste-
rior tibial and peroneal muscles, although it seems to me thai this
injure« the subsequent mobility of tho foot. In strai^bteninfr anctiy-
loMS, tetwtomy was formerly very often resorted to ; Init tat- this pur-
pose It may be eiitirely dispensed with. In anehylosia of the knee-
joint, fur instnnce, if Uic nlxive-Dni»e<l niuftdes be not united lo a cic-
atrix, they muy bo grailualty strctche<l diirinj; aniHitlioaia, that ü, if
th«r he still uiuscles and »ut strings of pure connective titwiie, a« is
rarely the c»se. I shall not here speak of tenotomy of the oi-ular
muscJce, tlie operation of strabismus, as this is treated of io ophthal-
mology. Sometime«, nlw», we may Ik* obtiffed to diride tenduns in
nntnifonislic con tactions, for the puqjose of remleriii^ the i-oiitnirted
mu-rles inaelive for a timp,Hnd subsequently elon|pitin}ftlieirleii<lons
by extension, to give the parotic antagonist mon: play and less work ;
tile latter are then apposed by no forae, or, at least, by u weaker uuu,
5fl0 DEFORUITIBS CAUSED BT DISSASB8 OF THE NERVES, irTG
80 thtit equilibrium is nstorod. Of ooune, this is onljr to be dooe
fur inuades wboH aDUtgooistfl arc not entirely pckr&lyztMl, but aaiy
p«ruiic; in perfent pnmlyBiii., t(.-nutotiiy uf the oontrat'lMl mux-lot
iirould have no efleot. The rc\-ivtl)-iiif action uf tenotomy is oocmjuo-
iilly epokcn of; it t» to the &bove casi^B thtit this expr««sion refen-,
iiidetKl, in antagooiHtc contraotioinB the action of teaotomv is mmdc-
tiroes astoniahiDg.
Tbc subcutnncou» divition of/ateict if not much doue; tiiK uonl*
of the fatMUB lata, wlilcli form wheii the thigh 18 kept flexed, arc oftpit
dividod with beacGt, its it is difGcult to Bttvtrh tbem ; tiic fascia plati-
taria may alfio lie occuaioaallT divided with bcac&t, when it ia tease,
in club-foot. Diriainn of lltc foacia fails in (he cases whvr« we ought
use It \iith iDost 1)«nclit, that ia. in rontmction of the psbnar fascia.
From Du}ntytren*s dttscnjition of the rvaults of this operation, iu sjuie
of the warning of my former preoeptor, I waa ooee led into p«»-
foniiiiig it ; but it was (ijllowe<l by Huch extensive aupptmtiun tltal I
was gWI when this finalljr oeased. In spite uf all orthupedio aflo^
treatment, the hand finally remaiiicxl m it had been ; some alight im*
proveinent M>on disappeared again, and I believe tliat this aSeetioa,
in its higlier crmdca at leii8t, i» iiicurabla
Division o/iiffainenU is nire ; but in elub-foot I hare oAen divido
the small Ugsmcntä of the ankle-bones, if they were tenae ; and, hi
apite of the fact that I must crrtaioly have frequenOy t^iened the
BUiall joiritiS Aubcut&neoiisly in so di>iu^, I never mw otty biul rtMulia.
B.VOH /^ny^ftAec^'intnyiuoetldixaitioitof the external lateral ligumeni
of l)ii> knee in genu valgum; in thic tlie k»ee<joini is alvrays t«nipo-
mrily opciicrd. l^is operation is only {noper in the hif^hcet grade of
the aifeution, but grcutly aids the treatment; I had not prenoualy
Been it, or even thought much about it, fearing tliat ii might be fol-
lowed by BUppuratioD of the knee-jiMnt ; a few yoari ünce, in one
case, 1 did tbc operation on both knees of a young man who bad tx-
ecsaive genu valgum ; the wound heated without any inflamioatioa of
tbc ln)eE>-j<)iQl, and the ortlinprdic LrcalitienI was very quickly ooih
eluded. The patient went out of the bovpital with his itgt perfectly
straight. On the wbole, ttie npemtion is rarely indicated. So £ar as
I know, no other ligauienta «re divide«].
It yvaa uRtnml to tbiuk of dividing ountracting cicatHcoa alao, so
ns to Kiretoh the »ew cicatrix ; but would it not bo wiser not to lot
the cicatridal ountnoiion come to such a point as to impair fum-ltun t
Would it nut be best, ercn during the healing of a large wountl— «■
the bend of the elbow, for itistsnee — to keep the arm extewlM, «o
that il should not be contracted by tlie cicatrix f The idea is a good
one; but the result rarely correapouds to sucli a tedious treatroont.
aOlTRICES FROU DUBXa
B81
fi the first plaoe, such wouncia, in which there «an be ao cicfttriciiU
oontniction, hpnl wiih great difficulty, nnd,Trhe(i Uiey «re GiikII^ bralod
and the limb m sot (rvc, cuntrHction DrvMlbL'k-sfl occurs. I well re-
mctobcr n chiltl with such a wound in the bead of the elbow, from a
burn, which, as assistant tu the Berlin olinio, 1 had to drees daily. Hie
arm waa kept extended CMi a splint, atid took six months to lieuJ ;
Snail/, tlie child was discharged, with tb« ann perfectly moral)!« and
the wound healed, and I waa very proud of the eure. Two mouths
Ut«r I saw th« child, with the cieatrix entirely coDlracted ; the arm
was at an acute &nf(le, and almost immovable. Subscqucntiy I lost
sight of tfao patient, and d» not know what was the final n>«ult; but
loleariy saw that I hod worried layeielf and the ohild for monthn in
vaio. Several similar cases have radically ourod me of tlie idea tliat
w« can, in suoli cases, do much by orthopedic treatmeot during the
cieatriBitioii of the wound. I advise you tn let the wound« ImhI aa
tbey will; large wound», from hums in cliildrcn, will even thus give
you enough trouble, as they alnuy« heal with difficulty, and readily
assume an uleerative eharnoier. In tlie course of moatha, often not
for ycani, as its vessels are nUitentted and its tissue beooniea more
^^Uke sulM'iitaiioous tittsue, iltc cicatrix Idm^b its rigidity, becomes ipore
^kistensihle, tougher, more elastie; benec, with time, mobility in-
^^reases, in case it has be«n iiiijMtired by the cicatrix. You hare al-
ready bet-n told how you amy aid ibis Bt(T>|>hy of the cicatrix by com-
pression and distention. WTicti the cicatrix has finally been reduced
to the smallest sixe, you may occasionally, with advantage, oxoise
the whole or part of it, at interrals, always being oarcfu! to obtain
hc«liiig by tlie firnt iiitentiofi, M (hat, in plaee of the thick, »carcely-
disteiuiblc dciitriciai utring, you may have a tine linear cutaneon«
cicatrix, whiah may be stretched more readily than the old cicatrix;
but if you bare suppuratioo und gafung of the wound after these
operations, ttie result is very dinibl ftil (iu, under the saiiH! oircuni-
»tanccsi, in tenotomy) ; there again forms a broad, jfranutating, slowly-
healing nound, and a cicatrix as brond, long, and firm as the previous
one. Hettee you can only advantageously excise contracted, string-
like, thin cicatrice«. In removing complete, bmad ci<iitrices, such aa
occur in the n«^k after bums, exoiaion i» not enough ; a pcrrlion of
distensible akin from the vieinity must be made to grow in the place
of the cicatrix. Tliis may be done by sliding a pit-ce of neighboring
skin, or by tTsnsplanting a flap of sidn, nocording to the rules of plas-
tic surgery, which t shall not enter into here.
We have now to speak of the treatment of distortions due to an-
tagoaistic muscular contractions \ I have already told you that tenot-
omy may be useful io these coses also, but it is only an adjuvant to
S22 ß&FOftUinES CAV6GD UV DISEASES UF THE NERVBB, ETC
the trcutincnt; tbe e6»ential point is the roDonl of th* pmniTom,
Till; cumbiUt}' of llicse ooQUiictionii, and of tbe (leformiu«« thvy cftUM-,
will (liqicnti uu what vre cau do tor tlie |«ralysi5. Here upois the
wide field of ueuropathology, u-jtb which jou will booome bettet ao-
i|ti«iDt«d in tlic UKTturt« ou iiH!clk.-iiii.', «uJ in ibt? uwdical cltaic There
are matij case« where you would st ihc outset ^vc up ao^ trcaUneiit (J
tbe panlysis; iu tunorft of the brain, a|>o(]leües, ohronio eaoephalitM,
tmumatic iiijurir« of tbc spinal niiKluIIa, extensive injuries of nerves,
etc, trviitiiieiit will do little good. Other raae« of spinal diaea«« with
parcsia of tbo lower limb», CttpCciaUy hi i.<liildrcn,iK>ia<:tiuieA jnvt •
rdntiTely good ppognoai». On the one hand, tpe*tincnt vitb cod-liver
oil and iron, malt or iwlt baths, and t»p«n'inUy time, may act very ad-
vantagx^uiiiy in remurinf^ the chaugcs in the spinal medulla, of which
we ui 1 fort lit Mit ely know but little ; on the other hand, irritaliooa may
be applied to the muscles then)sel\*ea, that may reriviiy tbem; we
tnay expect relief in tliose oases especially where there is oo oumpktt
paralysis vj panipleK)i>i but unly p»r««ig of certain groupB of nnwclM
Hcn.1 two L-xti.>niH] rviiuiliL'» are lie most useful: I. ifytitntutic trtat-
meiU; Z. J^hetricUy, llie former eonsiaUi iu awakeniug the aluinber>
tng, slightly -developed controotilo power by concentrating tlie will ou
the puretio muscle«. CeTteiu niovemeats »ro made regularly at cer-
tain time»; iht» may l>e well doue by tlie "Swedi»h movenient-^ure **
that has been tvcvutly inlruduuud: this ooaasta tn rcquirittf; (Ik
patient to make movement« tvith certain muttelo«, whil« Uic gyomasl
offeis a Blight op|x>Hitiüii. For ins tu uw, I huld your arm extended ;
you now bond it, wldlc 1 oppose tbe laoTcmtnit by gentle preBsuie*, n(
course» the proper movomciits muet be det«nnin«d for each indiridual
case. Of late, this method of gymnastics has become quite itopuhir,
and proved useful ; evidently it, like all gymnastics, is uselcaa in oaof
plct« paralyaifc
Our BocoQd remedy is electricity; of lute great advances have bevu
made in it« use. The appamtus employed bus been greatly simplified,
reodexod inora transportable, smd no adjusted tbat tbe current eau be
strengthened or weukuued at ^vill. Moreover, the methods iu wbiob elec-
tri<»^ is applied aie greatly improved ; formerly one or several groups
of muscles of a limb were electrified, by applying tbe poles first ud
one place then another; now we understand ejei?tnfying the individual
muscles ; the Fn'iich pliysioian ThicA^nne ih liouiogne baa done great
service ta this matter. The poiutttat which tbe pole or poles should be
applied to tndmv contnietiorwi in the different muscles were first fbuad
eiiipin<?al]y by Ihchtnue ; subsequifutly RfmaJt disoovored that, as a
rule, it was at the point where the largest iDotof nerve cutered ^e
muscle. Of late, ZUm««e*i has been moat euooessftU in electro-lbera-
CONTRACTED STOSCLEa
SM
']>eutic3; hü book \a cbantctcnzcd bj practical utiÜtjr and scientiRo
iiDportnnce, and aborc all hy its Irustwörthin««^ Tlie treahnent is
ao c'arri<Ml out that usually one or two Hitting^ arc bad doily, during
which fir^l one, thim another, muscle is niethodirally clectrifictl ; this
may he oontinued half or three-<]uart«rB of an how, but not too long,
I^br fear of d<?strnying the weak nerroun actiiHty by too great irrila-
ion. Much liarm mi^lit be doue by excessive electriiatioa; a pfaysi-
ana ■thmild always ooiiduct the trvJitment, nnd gire very posttir« d>-
jrectionH about the duratioD of the sitting, aod strength of tbü current.
Jsually we veiy soon hoc bov much the muaclcs contract to the eico
rical irritation when they p<vhaps cannot bo moved spontaneously ;
^e should nut give up even if we do not obtain any twitchings at the
Bt sitting; oocssionalty theao only appear after a time, when the
'electricity haa had some eSect.
Of late, Sarweü has sucoenKfuI ly employed a very ingeoiouH RU>tb-
od for removing contractiiHis; Itc makes oontinued tniclion in the
direction in which tli« muE«lc« fail to act | for tnstaacc, in club-foot, a
stout india-rabbcr band is fastened to tlic out«r border of the foot,
and the inner side of the tibia cloae bolow the knee; this act« contin-
uously 0« ao " artificial muscle." l^tis seems to me rational, and it
should t>e tri«l extensively. I have used this method in several oases,
with very quick renult ; Lütke han also stated recently that be bad
attained good result« by this treatment.
In paresis, movement oi a few muscles occorionntly miffieee to en-
able the patient to walk, if a certain finnnesa whicli tlie musdes &il to
supply ia given to the limb by some sort of a splint. These splints
are not always to be regarded as a last resort, but they may aid tlie
treatment by enabling the patient to walk alone with the aid of sticks.
But the movements of walking, made by the paretic musrlea, have an
excellent gymnastic effect; although artificially wpported, the patient
in thiü way use^i his muscle», while, if he were oootinualty lying or sit^
tJng, the muscles would remain entirely Inactive, and atrophy more
mure.
Gymikftstics, eloetricity, artificial muscles, and splint apparatuses,
Combined with proper internal treatment, especially suitable water-
curCi m»y do a great deal for these patients; attd, although many
of them arc iaeurable, some arc oorable, and others may be greatly
npfored.
CUAPTER m.
VARICES Ayj) ANEURlSMik
LECTURE XLIII.
Variem: Vtriona Fortn*. Ckiiica, Ttrtou« LouUtle« vlun tlie; oocwr.— TOignii Ji —
T«iD-«t«n«a.— Traunioni.— JtumiBM/lnftuDiua^nofArtcTiM.— AtMnTunaCfa-
(oldcuiD.— 'Atbrrcnii*.~y*rlam Form« of AiMiirLun. — Tkair GubscquefU ClumcM.
— *jTBpti«n», RcxiilM. EilnliBj-, "DiiKiMwU.— 7Wo*w«U -■ CoiopKuioa, Ij^iÜbk,
Injaodota of Liquor Ffirl, EiHrpuion.
Bt varicc« wc mean dutcDtions of vein« ; Üi««e mftjr h&Te vArioui
rorniB., and ugiia.I]y alTcct both the diiimetcr aud length at the v«ium4.
Slongatitm i» onlv poBsible when the resai>l beod« Utcnlly, nnd take»
a tortuous course^ nti niflo occurs in inflammation nf thr smaller vcsecli.
1h Bnme nasM lh<> «^lon^ration is \ees marked, and the diameter oC ÜHr
caimi is not n'gulsr, but tbi; vessel li dist«.'ii<led in n cptndle or sadt-
like sbnpe at diffia^nt poiutB, especially wbcre tlic tnltree sn. Moot
£req\icnlly the large veins of the eubcutaocous cellular tJMue are thw
affmted ; Bometimea cbiL>Öy the deep muscular VL'ius, oftjea both are
alike aScctcfL. But tlicic am also «-Bricosilies in the smallest vi>in& of
the cuti», wbiah are scaroeJy visible to tUfl naked eye, the«e are oftea
tbt! only nnes affected ; this f;[ivcti an even, lipht-blue nodular appeal*
ancc to ihe ski». A» a result of this ilt*tenlJon of thr veinii, which
occim lerr gntduolly, more M-nitn tbuii usual escnpi-A (nxa tbe capil-
lary vessels, as the lateral pressure in them is jzreatly inoreaacd by
the (li»teotion of the walk of tlie veins, and tha vooso^ucnt Insuft-
vicDcy of the ralri»;. Tbn thinning of the wmlle of the rc&sels, aad
the trunsudeil cxeess of nutrient material, may bo ^;nulually foUowed
by escape of wandering cells, and their organintion to tM*ir tiasoe;
tJius we have a seroua, then cellular iiißllration, and thickeninfr of tho
tissue tiBTCTsed by the varices; red blood-cells raaj alao eaoape
tlirough the eapillaiy iralls {Cofmheim). We have alreadjr explained
VABIOOSE VEINS.
6U
rta.m.
{p*go 367) huw, b/ a (iirtJicr ndruioc uf this process, the tissue is
more antl mot« dmiigoi), «nd chronic itiQn.mm&tioD and uIoeratioD in-
^^diKvd. In thifl uajr iirc dci-elopctl oot only ulcer-
^K«tions but aUo »omc otbcr forms of chronic cuta-
^neoot infiunmutiutts, «npeciullj- a cbrooic eruption
^Brf vedcles, " eczema " of the leg.
^K Now wo must l&ko up the ciiiestioii, >V)iat ia
^■the eauBo of varices? It ia probable that th«
cause is an obatnictinn to Üie return of tiie venous
blood, a preesure, coiit|>r(.-9sioii, or aarrowinf; of
Bthe calibre of the resg«i in some way. But the
Dbstniotion caimut be of nuldea origin, for this
usually causes irdcina ; the same is Inic of liga-
tion of n. lar^ venous trunk aud rapidlyappeai^
ing tliromboses. The pressure must then affect
the vein graduidly. Still, even tliis is not enough;
often a graduaily-incrcusicig pressure doea not
«uuw nuicose vein», but frve collateral mode« of
eacitpe form, so that there is do cfle<cl, or onlj a
Blight, indurated cedema. Tb«ic must be n coin-
cident tendency to dilutnlioii of tlie vessels, a cer-
tain laxity or distcnaibiüiy of the walls of tlic
Anatomical examination of vnrieose veins
■hows that the walla «re »bs<dute]y thickened by
deposits uf conuL-ctive tissue betn'een the muacle-
oells, but the latter do not socm incrcAMsl, and, as
tbc calibre of the vessel is eix or ciglii times the normal »ize, they must
prove ioBufEcient to urffc the blocU oiiwiird, the more ho as the ralve«
do tiot grow as tlie dilatation goes on, and conse<|uenlly soon prove io-
sufficieaL Up to the present time we have had nodetalled histological
toreetiptions about tho formation of varicxr«, and (»pcGiBlly about
the relation of this disease to aneurism. In many ca«cs tho dispo-
sition to VBiiccs may be regarded as indiindual, in others it is in-
herited ; dtsease» of tlie vesftels are not unfrequently l>creditary, those
of the arteries, as well as of the reins and of the capillaries, by vhoee
morbid dilatation the suK-»lled mother's marks are caused, whose
iransmis&ion by inheritance ia known even to the tatty. IHeiioe, wo
can only regard the cause of raricc«, which wo are about to mention,
■a exciting causes acting on an existing predisposition. The disease
is nore frequent in vnmen than in men ; the chief cuxise is saiil to be
repeated preguancies : the uterus, gradually enlarging, pressM 00 the
iliac veins, and later on the vena cars, and oecastonilly tUB
VtrlMvln the part ■u(>-
pllnl br IIM gnu M-
S36
VARICES AKD A»BUBIS)I&
even induoe« oedema of the feet. Often there are viricex io all the
paita supplied bjr the naphcnous rein; a;rain|iii tbose supplied hy the
pudio, a« ia the lobiit major». It is üir more difficult to find the came»
of the nioru rorely-oocuiring TaricM in man. l^rg« ooWfetioo» at
fieoes «uty, by pressure on the sbdotntnnl vmna, pravo ao rxciting
CMiao of rariccs, but tliis is rarely seen. lu tuaoy ineu with rnricee
you will Hnd disproportionately long lower limbs, espmally long be-
low tlu:' knee; in iKHne cbmb tbi» may abo faror txingestioiia In the
reins. PutMtibly, also, the ««UecUoii of html iai, or else ahrinkai^ in
the falciform procc«« of Ibc fancia lata, may pnua« craif^tioa In the
saphenoiu I'fin, as tlic latter sinka into the Annotal at th!s point. So
far as 1 kaoir, there urr, no Rnetoiuical ioresttgatinnB on this point.
The obstruction to the flow of blood need not always be dii«ctly in
the lenilory of the dilated veins : for instance, gradual namnringand
6nal nblitpratioQ of the fcinoial vein, below the opening of Uie aa-
phena, might very re«dily causp enormou-it distention of tbebfUMhcsuf
t)ie latter by oollaternl cimilation. Varioe« nocur at some other parts
of the body, eep««ial]y at the toiver pnrt of tlie rectum and In IW
ipcrmatic cord. Varices of tb« bstmorrbcüda] rein« to th« lower part
of the rueiuin cause heptnorr/toidt, which, as is wütl known, occur
cbioily among persona who lend a sedentary life The disease w nrry
rare in otlier parts of the b<)dy; it occaaioually occurs io the heai,
uaiially without known cnwte, it may form after an injury, if this br
foltriw«'!) by iiiitou of the walls of the arteries and reins and pas8af{«
of arterial blood into the veins ; this wouUl be a rsrix anemrsaiBÜoiUk
of which wo spoke in the second chapt«r. In the pathological atia-
toniical atlas of Cruveitkür you find given aa a great tHrity a jMctm»
of largo varices of the ahdntninal veins ; there is » similar prv^ratim
in the pathologicial museum at Vienna,
The iiiag»o»ia of varices is nni difllciilt wlten the cutaneous veint
an} ftflectcil ; those of the deep muscular veins can rarely be dia^
DOSOd with certainty ; in the leg and thigh (he whole cinrse of tlie
tortuous reins ia so uvidont through th« skiti that ihm- may be readily
recognised, but in other ceses wc see only a few light-blue, fluctuat-
ing, oomprcssiblc oodulcs; these chiefly correspond to the saolili«
dilatations of tlio voins, and to ibe points where the ralrea ara He»
wc ocwBsionally 6nd bard, mund bodies, phlebolites or x«in-«tonr» ; on
examination, tbeae prove to be nodules in luyora, at first ooosisting
of fihrinc ; they may subsequently calcify entirely, so as to assume tfae
appettrsnoe of small peas. In the jrreftt majority of cases, varices o^
the lower eztreniities cause no ditBriulty, exoept, perhaps, a feeling
of tension and hcavlnoss in the limbs after long standing or wallrit)|r.
But in other cases there are occasionally thrombi in single venous dils-
TBEATJItVr OF TAttlCES.
S9T
tAtioM ; infismnMitton of tliA wall of tbc r^n and nirrounding cellular
tissue fellows, and, altliougli, uiulcr au\y troaiinent, tliti iiiflaininatioQ
usutilljr tcrmiiiBtce lu n-auIuliDn, suppuration or nbsocsii tnar evcuLu>
«Uy develop. Tit« treatment is the same as ha» been already given
for traumatic thrombus and plilebitia. Aootber danger tbat luaj
uiae frotn varix ia ita rupture, a very rare oooumnoe; if llie patient
be kept quiei, tbe bleeJiiig iiiar be rvoUily checked by oompraMtou,
and Üwrv i» mi danger tf uio<tienl nid be at hand. A varieOHu tiUxr,
in the strict mi-aiiiiij;, may furm from auch a niptunxl varix, but this
ia rare, for Iho wound usually beats quickly. If tho skin and subcu-
taneous ttssoe of the leg be flatly indurated, and it this induration
has also affecHed the adventitta of the cutaikcou:! veinit, they lie im-
movable, uihI, iti the finii, leathery, rigid sktu, tbey feel like half cwials
or fpitten. 1 coil your att(>ntion to this^ as otheru'ise in such oaei,
from llitfindurutioii uf the skin, you might entirely overlook tbe rarioeh
The trtatmertt of Tarict» ia very unaatiabctüry, aa wc know no
way of rcmnring the dtepoaition to this disease of tbc veins. Nor
can we usually control tbu causes of tli« preaaure ; so we may really
conclude that rartcrs are not curable, i. c., we have no remedy for
restoring the morbidly -dilated reins to their normal sisc. For some
cue* we must say tliat, physiologically conüidered, the formution of
Tsriocs is Nature's ntode of eqiuiliziiig abnormal prcssttn.' in the ves-
sels, and that wo auy Dot try to remove tbe varicc* till we can get
rid of their («uses, ri>r, if we rvin(jvc<l one or inure of tbow morbid
string othcn would form in their place. For this reason I reject all
opentiooa which sin at removing ouo or more variooae nodules from
tbe leg. If you bear in min<l that any operation on the veins may
prove dangeroua to life by onmplicalioii with thrombcsiii or enilxiliüm,
you will agiw with me in cousiitering tbc operation for varices eo-
tirely tmrnlled for. Nevertlteless, these Operations are often done in
France, and not unfrequcntly prove fatal; there are many metliods
of opcmlioii, about which wc ^h«Il »ay a fvw worda. 'ilic oldest
method, which was pnwtised by the Greeks, consists in exposing the
nrieose reins, and «ilber cutting or tearing them out. Ijuter, the hot
iron was applied to induce coagtiiation of blood in the veins, which
te«ult«d in obliteration of the TMsala. We may also inject liquor
fern Mtquiohlorati with a small syringe having a needlenibaped no»
idOi M you know this quickly causea onagulation of the blood. After
this eune the ligature of the veins, espeeially tlie sabcutaneous liga-
lur« aft^r liieord, and the atihcutaiMious rolling-up, the Borouiemtnt
of VUtal^ little operations tlwl 1 »liall show yon in tlie coune on op-
erations ; these are ver^- ingenious methods, but I am torrj to say
tfaej do not suococd, and are not free from daugor.
35
62«
VARICES AKO AXEORI&US.
But shall w« do Dothin^ for varic«» t To«, we dtould Uy to keep
Uiem witliin cvrtain bounds, and tbus prereut or leduoe tc a wimmucn
ibcir bad cSctria. For Üiü purpose there is onljr oae remody, «on*
tinmd (»mpn^ion^ whiob, liowerer, muet on]/ be ua«<1 m wash a d»
gree as is bearabte to the paticat. We use two different moeluoicml
modes of comprcAsion iu these casoii, the laced stocking- and rv|n^
banduKiii);. The Inccd stockixig oonnste cither of a carrfuUjr-ntade,
oloR^fittitig leather stocking, KpHt at one side, ami lacod up, like ocr-
seta, till il ia light enough, or else of a tissue of rubber thread, spun
over with silk or cotton, of the same stuff that niMt suspenders an
tnado oC These hur«l stockings, which ti)ust tw very carefully made,
and worn continually, arc unfortunately quite expensive, and, as they
cannot bo washed, must often be replaced, so that ihey are only pno-
tically useful for persons of means. In most esses a caiefuUy-apptied
roller-bandage suffices. For this purpose, you may best take a cx^tton
bandafre two or three Bnj^rs* breadths wide, soaked ia good book-
iHnder's pmto, and, ezce^iting the heel, bandage the whole foot and
leg; with care, such a baiidage may be worn fire or six weeks, and
even if the akin be confulcrnhly iiilillratcd, it may prevent the foraia-
tion of ulcers by obstructing the further derelopmont of varices.
It is some time stooc wo tpokc of traumatic antwUm, but yon
will remember thst we mentioned it uuder punetured woundc (p«^
ISO), and that I then told you an aneurism was a cavity, a Bac^ which
(Urectly or indirectly communicated with an artery ; you already know
that such saes may develop from injuries of tlio artery by puncture^
subcutaneous rupture, or contusion. But now we do not mean to
apeak of these traumatic, so-called false aneurisms, but of <m«wytnm
fierum, which develops gradually firom disease of the wall of the ar-
tery. To explain to you clearly how this occur«, it will be beat to
start from the anatomical «otMÜtioos. At preEeiit,you know but little
of the diiteasen of artrrieR ; the only ones that liave bee» meutiooed
BO far are thromhoüs after injury, the development of collateral cifoi>-
hition, and atheromn, which we baatily 8[K)ke of wbea treating of
senile gangrene. Anil ihesc! comprise almost tlie whole li»t,nnly that
so tar we have taken merrly a one-sided view of alberomatoua die-
case. Of the different parts of arteries the tunica muscuhuia and
intims are most frequently diseased, atul they seem to be aJIeel*d
primarily. The tunica media is composed of muscle-cells and sotaB
connective tissue; the tunica intima eonsJsts of non-vasoulor, clastifi
Inmell«, fenestrated membranes, and very thin endothelium. It may
be readily shown that, aft«r injufy of au artery^ its walls swell, and
CIRSOIO AXEURffiHS.
SSV
remain tliickcn«! Tor a time ; the pluiti« infiltntion of tbc vrallti m^j
lead to Bitppurolion, nnd small foci of mxtter nvty fonn in tlieiD,
thot^b this U Becu moic rarelj in iirtcrieii Uiaa in veitts. Witb thou:
procemea there is a relaxation of the membnuic«, the intima mftr be
drtaolipd from the media more readily than luual, tbe lattirr is aoft-
ened, the niust'Ie-cells may in part disinlc^niti-, ami, as a result of
this diminUbc^ n'sistnnor, th^tw maj bo a dilatstioo of the artery.
Such amte iiiflaminntious with pUiitio new fonnatioDa and partial
aofttniiujr may duubtlcts occur apontancoualy, and, altliougb w« hare
no sppcini obsorrationB on this point, etill, (ron» annlojrj" '^»tb other
ttBSuus, there Is aa doubt ttiat a spontaoRous, idiopathic, acute, and
subacute inflatnniation of tlto arterips may nin its cotirM* iii this way,
and probablj occurs with acute inflaiomations of other tJesucs. At
all events, tbp-se anitc »pontaneotis inflammations of arterit'S an- very
nire ; tbe chmtiio forma are ht more frequent. One fonn of aneu-
lism aloDC possibly dcpeada on a more subacute ioflainmfttiou of the
artery, with dimiiiished reaistanec of its walls; this is anauytma
einoideum, or aumrytima pn atiatlomotiH^ sbo called atmirytma
rawnoeum, Tliia funii <»f arterial dilatation is totally di:>ttnct
from the aneiiriama to l>o hcre<ift/>r mentioned; fn tbem there is not
circumscribed dilatation of one part of au artery, but dilatation of a
lorp? number of artrrics lyin^ cloeo together, which are, moreover,
Terr tortuoiM, a sign that they have also incroased in length. C'trtoid
anetiriam ta, th«n, a eonvotution of dilattd and dongated arf«riea.
For llir»e changes to occur, there must be a (onsiilerable new forma-
tion in the wall of the artery, longitudinally, as welt as in the circum-
ferenoe; the dilatation iit ]K»sibly due to atrophy of the muscular
oont ; usually (witliout, however, bein;^ able to prove it) parelyHis of
tbe walU of the arteries is assumed to be tbe exciting cause of this
variety of aneurism; alill, altbougli paralysis might explain n mod-
erate dilatation of the artery, and we have noltiing to explain the
pandysia, this would uut render any more compn-ltensible tbc cktnga-
tiOB of the artery, which can only depend on a new formution of the
dements of the wall. As already stated, I tlunk that thia varietv of
arterial dilatation, which closely rcAcmblea inflammatory dilatatioa
and looping of veasel«, must be referred to an inflammatory cfanngo
in the after)', and not to chrome iaflammation with atheroma, to be
hereafter deacribcd, btit to a more subacute, diffuse inflammiiliun.
This view is supported by various etiological factocs ; these ancu-
ristos not unfrequently develop after Uows or other Injuries; they are
tnost frequent at point« where numerous sinatl arteries nnaa1omo6e,aa
ID tiie MBlp, over tbc occiput, vertex, and temples; this variety of
aneurism might bo regarded as an exoessively-develuped ct^latera]
530
TAKICE3 AXD ANEHBISllSL
circulation; the oollntcrel arteries, beddcB dilating, become tortaou;
tbe process ia evidently the Mine iQ botb cases. We bare aUo to
mention ttiat tliese niieiiriMns are pnrticularlj apt to devcJnp in youts^
persons, in wbuin tlie tliruui« diaewo) tending to other ancurisnis are
Fm. to.
*=^«
"Xf'Vx
CtrMtd aBraHnn of Ihe ««Ip In *n tiA •toman i • f miR um»r m* m14 t« ^ra «aUlcd M
Mnb. taä to liBTQ dccilcipod KiodaallT t« Ibla slu. Aflw JtntdUi.
nrc Tic dia^noois of ciniMd iioeuri»ra b very simple, ii^ as U ustt-
»lly tlio ctise, It lies juAt utiil(>r tli« dctn ; it has l>eon found more
deeply setitvfl, aa in the glutcid artery, Init il I* more froc^uent on tlie
licad ; hcru wu inny feci, and occasionally sec, tbo tortooue pulsating;
arttirj', so tlint the disouse ia reAtJily roougiiized ; it is not frequeitt.
We tare »till to mention that the arterial wall may become Xb-
cased by a »uppuration or ulooration oxtoading Crom th« neigliborinf
parts, 6rst to ih« adrcotitin, then to the other ooata; this ia the caw
mom rarely in acute aliaepases than in chronic ulcerationa. Am an
example of this wo nee that, in the derdopment of caritiea in the
longa, it not unfrequently happens that the ulceration attacks the wall»
of die smaller artenes, and the advenliliii Is partly destroypd and
Roflencd. The reaulL of tliis isy that the arteT>- dilates at this pout.
iLTQECOllA OF TflE ARTERIES.
«31
BiMt B smiJI nnctirism is formrd, whose rupture cause« MT«i« luvm-
Ofrbag«: Other utceintions al»o may (tbough thU rarely happens) find
tbcir way to an artrry and drtttroy its walla, no aa to indue« tiurstüigr
of the Biiery, and fata! tinemorrhag« if Iho artery be a lai^gc unc I
have seen aereral Ruch caMf» : na old man hnd an ah^rens deep in the
nerk which npeiiei] into tho pltar^-ox; ihi» was diaguuMäd from the
gradual furtnation of a painful swelliii); in thu neck and the ircc vx-
pecitoratinii of Imilly-sttieilinp p«»; llw' piiticnt hiid only been in iho
boapital a tr\r hours irhcn he tiirrw up a larf^ amount of blood, vaa
quickly asphyxiated, and died ; autopsy sliowcd that, as a result of eir-
CumscTibed suppuration of the superior th|-TOHl arten,*, it had tlironti
out a quantity of blood whirh had pass«! dirpetly into the lar>'iix and
caused suffocation. In another oaae in a yomi); man who bail caries
of the right temporal bone, there were («epeatM hiemorrhagf« from the
right ear; I diagnotnl an abscess on the under side of the temporal
bone wHh euppuration of the internal carotid nrtrrr. TIte biredinff
oould not be checked by tampons to thc.ear; I ligatcd the right com-
moQ carotid, "nie bleeding ceaaed for ten days, then began again ; af^
ter repeated tamponading and digital onmprcsfiion of the left carotid
without pennanenl n^sult, I also ligated the left common carotid ; but
in two days the patient ilied of profuse biemorrhage from the right ear,
Dose, and month; the a1»oess, wliich was Ittled with blood, and could
DOW be regarded u un artcurAsma epurium, had also opened into the
pbar\*nx. Tlie^wwT rnorfrni fully confirmed tbc diagiKwis.
\Vc now coDK to chronic discaaca of the arteries and their results
to fru« anettrüm«. In adranccd age it is very common for the arteries
to become exceedingly thiek and hard and ooeasioaally even looped,
Mpecifdly those of the diameter of tl>e mdial or smaller. If we ex»
amine ilte*v arteri<» more aceumtcly, we find the tunica intinia
thickenr«), of «irtilaginous firmneaa, it ix more rigid than usual, and
gape«; in places it i» eren aa hani as rhnlk, or even quite calcified or
oeaificcL The chalky pari? arc not dilTu».'ly spread through tlie walla
of the artety, but form circles correspooding to the tratwverae muscles
of the tunica media; it is the muscles of the resaels that ossify.
Tn RUfli persona, on the inner surfecc of tho aorta and ite first large
branches, we find whiti9h-yeU<'W spots, etriw or plate« of chalkyfiim-
neta, or rough as if gnawH, with their edge» hollowed out. If we
cut into these spots, wv find the wbolcintimaofcnrtilngiitoushartlueaa,
whitish yellow, and completely calcareous or bard as bone, or dstt
friable, granular, or pulpy. Where this disease ha« »ttaiiicd a high
grade, the arteries become bulged nut. Tina is atheroma of the ar-
tery as it appear« in the cadaver. We often find the recent and old
■tag« near together or in different arteries. If we examine these spota
S3S
IRAUtaS AKD AKEURISHä
more carefully with tbc rnicroeoopCt especially in fine cioeB Bccttoos
throu^li epote of diSereiit nppeiu&iioe, wc find tliiit tfac first change*
ooem in the outer inyvn or the lutima, on the borders of the media;
here ft modentte grouping of ci>lU Itegius. Tlteyuuug cells may letd
to couDcctivc tiMutt aud acvr fonnatioii itud cutluua tlurkuain^ uf 11»
artori>l wall; but the; are uftuull; nhort-tived; vrliile new ones »)>-
pear lo the periphery of tlie a£'eoU;d spcit, tlie (int. ooe» dlAtategnUe
to a j^oulnr detritus, to « pulp formed of fine molecules nad £it,
wliic'h rotnains ruthvr dry, u id ciuoous df^gvaemtiuii ; tlw dvstruftiun
thus slowly cxtcudft laterally, the iiutritioQ of the media, a» well u
of tho inner layers of the intima, suffers; the muscloHSelis of the fof
mer become granular and futty, as do tlie elaatio huneU» of the m-
tinia ; the change thuK prof^\s5(^ inwunl till ihc lost laniclln and the
epithelial menibniDO are perforated, and the cavity filled with atb-
eromatous pulp opens into the oatibra at the artery. The atbenHD-
atous proeeui, beigiunitig us a hollow ulcer, has led to an ojien ulcer
witli undermined e<lges ; you teti tbc in«ehaiüs]U is tli« aatnc tliat you
bare already scci) in the »kin and lympliatio gUnd« ; there is a chronic
iiiflHinmation ending in Qi«eous degeiKiaUon, or, as tlie pulp 'a cftUed
in this poaitiuD, iu ntheruniu. Tliiti ia the essential part of tbc pn>
Oe0S| as &r fts con<^em8 the devcIopni<>nt of aneurism ; but there are
■OiDe variations, from the different slxuotures of the arteries. Tlie
lesa develofied tlto muecularis and intima, tbo Icsa atheromatous pulp
will bo formed, as this results chielly from breaking down of Ih«
iDtima. To eommence with the small arteries, whose diaoui» we
may study ia the micro6CO[>ic cerebral arteries: here we find the coi-
tions of coUa mostly in tbo adventitia, which is but Uttlo and only
üondarily aOTeeted in large arteries. Almost tbc whole adTcntitia
changes to crll», the fi-w luuäcuUr cells atrophy, the &nc hyalinr
membrane, which acta as intima, is Tory eUsUc ; thus the softctiiog at
the adventitia, caused by the colMnßltratioo, soon induces dilatation
and finally bunting of the artery, as the walls are no longer auA*
ciently Srm to resist the pressure of the blood. Occaüoually also
there is a plastic produi^tion of advenUlis; club-ehaped vcgetaUoos
form, which consist partly of ncwly-formod fibrous, partly m limit
ooDnectirc tissue. Wo oanuot here dioeuM this further, cspcciiiD/ as
It doc« not affect mirgery. A fatty dcgcnomtinn am! oali<i(ication of
the muscular coat also occur along with tin- plastio iiifiltrüliun of the
adventitia in the smaller cerebral arteries, but arc not freqitoat. I^
us pass to srtories the size of the basilar, radial, etc. Here the plat-
tic process in the mircntitja ucuttiioaally still oomtünes with thoaotn
the other coftta, although pulpy disintegration and calcification of the
latter do occur. Sometimes there are thick«ning and kioping of these
VABIBTIES or A>'BUni^-l(S.
sss
arteries, sciinctiinM disiiiUtgratioii and fiofteuin^, with cooMnqucnt dtla-
lation or ancurixtn ; for, when the tncdta and kdrcntitia become sof^
eaed to stberonui pulp ul Bomo poiut, the advcntitia is no longer
•trong eoougb to resiet Üio pressure of the blued, and it bulges. If
irc now turn to the large arteries, aorta, mrotid, subclaräo, iliac, and
Itiinurml, in wbidi, ymi know, Üie muscular coat i& reduced to a iniui-
mtim^or u even oooaaionally vanliiig, while the intima is <!oinpoand of
a largu niimber uf cluatic Ininellie, »iid lies almoat immediately on the
adventitia, whii^ huK mor» or li»s vlostic Uaoiuats — here there IB
least plastic process in the a<h-cntitia ; llie patholoj^cal chaiig«, the
disturbance of nutrition, evincea itself cliiefljk' in rapid breaking dowa
or caltäficat ion of the patliolngiral now romuition, Kbicb occurs portly
on the barders of the inLimn, partly in that coat. Aa alroady men-
tioned, cases do occur where extensive circumscribed coonective-tiuue
new formations occur in the intima in the forai of cartilaginous callosi-
ties; but this is rarer than the change to atbemma-pulp. In the last
mentioned aru>rii.>!8 true atberoina pulp fomu moot frt^juenlly, iienoe
anctu-isnis are most frequent in them. If you exsmiae thi« »thenmi»-
putp micro«copic-aIlt, bc«iHc4 the abore-mentloned molecular ami fat
granules, }-uu find fat-cv^'stais, especially of Cholesterine, and cmmbs of
carbunntc of lime, also hf niatuidia-crystalss which oumc from blooc^
clot» depositing ou the n>iigbaes»es ia the arteries, but the hfematoidin
developa from their coloring matter.
Voii have now a genera] view an<l description of atheroma in ar>
tencB of various calibre, and can now unduretand bow, by softening
tlie walls of the vessels, it may lead to partial dilatation of the artery,
or aneurism. The form of this dilatation may vary somewhat, accord»
ing a» the whole periphery of the artery is regularly diacaa«d or not,
UmI as softening or calcification prwlominaces.
The ditalation of the arlety may fur »oine distance be perfectly
regular ; this is odlcd aneurysma cylSndr^forme ; if the aneurism he
more BpiiMlle-shnped, it is temicd anfiiryumn ßuifom^ If tlio soft-
ening be limited to one side of the arterial wall, wc have a sac4ike
dUstation, anvuryema »accotvan^ M'hidi muy communicate with the
c«l)bi<e of the artery by a larger or smaller opening. A further varie^
in the foaination of the aneurism may arise from all the coats regu*
larly participating in tlie formation of the aneurism, or from the
intima and media beitig entirely aofteneid iuhI liostroycd, so ihit only
the gmdually-thiekening advcntitia and infiltrated surrounding parts
fnnn the mc. Finally, under the last conditions the blood may prees
in between the media and adrentiUa, separate the two ooato, as if tho
layers of the artery h:ul been dissected up anatomically ; this is called
aineurymaa Jmecana. These divisions may be carried still further,
634
rARICES AHD AVBTBISVa
but pnctic«lly tbcy have Tcrr little value. I »hail oa\j mention is
addition that, on subculsnoous bursting of an ancuristn eonposed vt
all the arterial coats, it assumes more tht^ aoatomit^l ]ieculiKr)l]t>9 at
an iineiir^'^inn Iraumaticum or ffpurium. A short time tüiice I saw an
appan-Titlj liealthf man, about fifty >'<^Ars old, who, irtien tumhlfr ^
bet\ liail III! ononiiouH tunxtr develrip in the tbigh, wliicli »oon piwed
to be a diffuse trnumalk- anruiütn ; I had no doubt ibat tbf^ fi-moral
artery was diEcaaoH, and had surldenlr bnrst nt »onte point In the
middle of the thig-h. After iximpressioo bad long been used ia rain,
the femoral artery was li^aled ; it proved to bt^ covered with yellow
spots ; the li(^lure healed well and ijeonme detached in four week»,
«till llii; iitieuriam b<K«mc larger and jiainftil ; tiw nixth vr(*ek after
the ligation gaugrrae of the fuot began ; I then made a faigli amputa-
tion of the thigh; the patient reevrcrcd. There was an immense anni-
rysma spurium, oiid nn opening an ineh long in the athcnxnatoua fe»-
oral artcr^% which was not ancurisniatic,
Tlie further late of the aneurism, and its cBcet on neighboring
tissues or tlie extremity affected, are veiy iniportanl. As n^gards the
anatomical rliangea in and about an anrurinm, one is its increase hi
aiae, which not only flisplacca tlie neiglilKiriiig tiasuen, but, by iU
pressure and pulsation, causes tbera to atrophy ; this refers not only
1o the soft parts hut Cb the bones, whirh are gradually broken through
by the aneurism; the last effect is especially apt to be induced by
aoeuriema of the aorta and anonyma, which may »nrfuc* atrophy nf
the vertebrtP, sternum, or ribs. A further accompaniment is inflan>-
mation in the immediate vicinity, whirli, however, rarely leado In sup-
puration, often beoomee chronic, and very seldom induces gangrene
of the anurism. Ijtstir, there is often eoagulatir>n of blood in the
aneurism; hard lavcra of fibrin« may form on the inner surfiue of tJie
eac, and at Inst cnt irely fill it, and so cause a epontaneoua oblttcra-
tioii, one variety of cure of the aneuriiim. The worst acddenC h
when tlio nneiirism increnae» in size, and finally bitntls; this may
take place outwurdly, but more frc<iuently, especially in the large
arteries of the tninlc, it is inward, perhaps Inlu the eesophagiK, tia*
chea, thompic or alxlomlnsl cavity ; sudden death from hiemorrhage
is the natiinl result.
It is not our pre-sent object to show wltat may be the results of
aneurism of arteries of internal orjfans; I shall merely mention that
partlolo may be detached from the elota whi<-h form in the aneuriMnal
dilatationa, or on the roughnoescH uf the nlheromat^nia arleriea, aad
may pass as emboli into tlie peripheral arteries. These emboli ocea>
rionally cause gangrene ; Init this is not so &equeiit as is believed,
for itsuidly tlie ooaguloe !□ aneurisms are Srmly attached.
AlIECRlßllS or THE ETETREUrtTES,
586
We shaül now iamtigitle more carefully aneuriam$ o/theta^tmi-
itUt, At Gnt, (hey cause Blif^Iil muscuUr fatigiie ami wimknvtiet, more
nirelj pftin in the affected limb ; if Uierc be inflamniAt ion ttbotit the
■ae, of course Diere are puiu, ivdnvss uf ik« »kiii, u'dtmia, and disturb-
ance of funrtion, whicb may go so &ir u to render the limb entirely
usclcM if tbv aueuriitm ooctinue to grow, and tiierc be coutinued
chronic or aiihacutc inflammation around it. Tbe formatioa of extea-
■tra ooaguln in the an^ urinm of a large artcJ7 may be followed bj
gMlgreae of tlie whulc limb below it.
Wlico «p«aking of gangrene, it was mentioned that it might
reaott ttom atlieroma of tbe artcrj, a.1 no-called gangrrna npon-
tsn«» ; but there tbe case was »oniefrbat different : the small urteric«
were diseased ; tbese lose tbeir power, from d«tniction of tlietr strong
mu)»cular coat, and can no longer urge on the blood, a» tliey i-snnot
contract. But here there is oblitcntion of an arterial trunk br coag>
uliB from an aneitri.>im. I will relate to you a enite obsn^*ed in tbe
Zurich surgical clinic A man Iweiity-two yean old, emaciated and
miacrablc, was brought Into the hospital ; hi» right le^, nearly as high
as the knee, was bluii<h blark, tlio epidrrtiiis ]>eeleil oflT in shreds ; gan*
grene was unmiatakabte. Exaiiiimilion of tbe arteries showed n apin-
dlfv(>ha|>etl, piilsatiog aneurism of the left [right ?] femoral ortory, clnae
below Poupart's ligament ; there was a seoond one, three inclieti below,
oo tlM aam« artery ; thi» folt hard ; there was a third one in the bend of
the knee, just as bnni, but, from the swelling of tbe siirroundiog parts,
the fonu could not be exactly mndo out; lietween tltc second and
tlurd aneurisms the artery continued to {lultuit« the first day the pa-
tient was in the hospital ; the line of demorcntioa was not forme«], it
appeared likely to ezt«nd higher; gradually the pulsation ceased an
high a-s Poupart's ligament; the patient died »bout a fortnight after
bis adiuittsioQ to tbo boapitaL The autopsy showed tlie araiirisnu
that had been recognized during lif«, and also extenüre nlherome of
•Imoat all the arteries. Taking this with what I told you, when speak-
ing of the ligation of large orlerieaiHlKjut the devekijment of collateral
circulation, you will think there is a ccmtrsdietion. Why does not
gangren« occur when you olose an artery by a ligxtuie, as well an
when it is blocked by a clot T The answer to this is, that a free
oollaleral circulation suf&dcnl for the nourishment of the |>eripheriil
porta only takes plai-e when the arteries are healthy and capable of
distentioa. But, when a coagulum passe« from an aiteurism into the
artery, the neigfabonog artcriea are usually diAcaned and not disteif
•ible, being oaleified, or already pnrtly obstruct«^ ; moreover, tho
I olosure of tbe artery is not, as in ligation, limile^l to a iunall »pace, but
I is very extensive^ perhaps even, as in tiie case above menlJoned, in-
686
VAAHOB AXD ANEnUSU».
Tolving the wbole tatory ; Utco (liere 18 oo possibility of a cotlatenl
circulnlion, inthrr by the dirfci route or by ocigfaboring bruDcbfla
The »nvriiM must b« very generally discasctl, sad tbe co>gnl»tio»
rery exteaäve, to cuus« gaogrene, m tbat it is not rery Craqoent in
aneurism; tliat would dso he very unfortunate for the trcatiDCot,
wbiob, liowever, as you will beicafter see, cbielly h&a (or its object til«
obliterntian of the aneurism, with or without li^tton of the art«iy,
We ouw oumG to tl>c tlioloyy of niicurisnu Although atbcron»
is a Tery {requeut diaens« of old iige, aiid oaettn evcrjivbcrv, ourunm
\i by nu ineati« cootincd to old persons. In Zurich, atheroma of tha
arteries in old peisoiut, and gaogreiia aeuilis, are quit« froquoDty bat
Btwurisoi of the cstrcmitica is raro. The oooummc« of oDetirism ia
onriouely spread over Europe : in Germany, anourisn of the extrem-
itipH is rare ; it is iioroewha,t mare fjequent in Fraooe and Italy, and
moAt frequent in England. It is diilicult to explain this, only it ia
certain that di&eajies of tlie arteries, in common with rfaeamntiam and
gout, ari^ more froquent in Kiiglaiid tliuii in any other country of Eu-
rope. [During the past fire yevs (1665-1870), of 11,344 caw!»of
disease and injury, in the New- York Hoapital, there were 33 casea of
aneurifim, or about one case to erery S44 paticota Of these then
were: of the thoracic aarto, 6 ; abdominal aorta,10; inaaminate artery,
1; aubol&vinn, !£; iliac, I; femoral, 4; popliteal, 8; Dot named, l.j id
regards age (of oouno we are not spBiiking of traumatic aneufim»),
the disease is rare before the thirtieth year, more frequent between
thirty and forty years, and moat frequent after the fortieth year ; men
are more dispost-d to aneurtsmH than wuinuii. Spccful cnusea are littla
knon-u; po[)liteal aneurism is must fruqueiit among' those in the ex-
tremities; the explanation of this has boon sought in the superficial
position of the popliteal artery, in the tension to which it is subject«!
on sudden movements, contusions, etf . ; thus this form is said to occnr
especially often ill England in ftmtmeii who stand behind the carriagva;
but I must acknowlodfr« that to me this scetn» as improbable a« the
explanation f^ron for chamber-itiaid's knee. I am iiMlined to betirre
tlint l)ie tendency lo diseases of the artrry, as to Rout, is due to hcredi'
tary iiiflucuoe; haid n-ork and free use of liquor ar« also given as cftuwa ;
in England especially, the latter is said to induce relaxation of the
wall» of the artery, wen witliout allieroma.
The diagnotia <iS an aneurism of the extremities is ont difficult,
if the examiitftlion he oarofnl and the aneunam not loo smidl. There
is an elsstio, more or lou hard, circuinscribed (cxix-pt id false or rup-
tured aneurism, which arc diffus«) tumor oonaoctcd with tbe artery ;
the tumor pulsates perceptibly to the sight and touch ; oo applying
the stethoscope, you may hear a pulsating murmur, cauaed by the Crio
I
DUGK06IB OPAN&nfilSV.
087
tioD of tbc blood on the oongulutn, or in tb« opi>Qing of the sac, or by
the rioodielting of the bluud in the saa The tumor cesses to pulsat«
if jou compress the artery above it. These sjmptoo» are ho auikiiig
that it night be thought the diagnosis could not be inttitaken ; still,
errors hare Iwen aiade even by experieiieed surgeons, at time« wltpji
thc^ did not tfaink of Um poftsibility of aneurism, and were hasty.
For, wlieii tlie »urrouiHiiiig iiarts are tnnch inf lAined, the aiieiuis«! may
be greal]j masked by the Rwelting ; it may be taken for a simplo ia>
fiamniatory swelling or aboc-eas; it may even liave originated fmin an
•beoess, as before stated. Tlw [attei miatuke is the most frequent ; it
is punctured, and — what a disiigrecable surprise — instead of pua, we
Itave a stream of arterial blood. TImt« is nothing at hand to arrest
the bntmorrha^ ; the eitualiuu is Hliockinfr, even if tbc cxxil surgeon
have preseiK-c of mind enough to make instantaneous compresiioo
till he decides what next to do^ But t will not picture afl'airs too
dismally ; and I repeat that, oo cxrcful cxaminatinn, sutrh an error
would scarcely l>e possible. If the aneurism be distended with dot«,
^e pulsation nf the tumor may cease, or be very indistinct, as maj
also till:? murmur ; ewn here, howerer, further aocurule obacrratioD
will lead to a correct judgment On the other hood, a tumor of a dif'
fercnt sort may be ntistaken for an aneumm. Id the booes particu-
larly, there ia a sort of soft tumor (central oatconrcoma) whidi is
very rich to arteries, and consequently pulsate« distinctly. Noxoeioufl
atnnll aneurisms may fonn on these arteries, from the softening of the
substance of tlie tutnor and of the walls of the artcricH ; the sum of
the murmurs in these small aneurisms may reseniUe a typical aneu-
rismsl murmur ; in these casca also, only the most accurate cxamtua-
tioa and obsetratioo can show us tlic true state of thccase. Tbeae
pulsating bono-tumun arc oßcn rc^gank-d as tnu; aneurism in bone
I <io iKit believe thoro is any »|>ontAiieous aneurism in bono, but con-
sider all these Bo«aUed booe-aneurisaiB as soft ssreomn in the bone
ver>' rich in arteries. Lastly, wc may be tempted Ui regtird a ttinior,
lying very near an srtery and moved wiUi the arterial pulse, a» an la-
dependently-pulMiting tumor, or an aneurism ; the abseuce of the
aneuriama] munnur, the consistence of the tumor, the possibility of
isolating it from tbc artery, aad the further obsenration of the oourse,
will ^ard you (rum error. Tlie pnxjnotia of aneurism varies greatly
with its loeality.'so thai ootliitig genend can be said of it.
AVe now turn to the tttolntmtt, m&aridng, Unt, that in rare case*
anetnism may recover spootanooMsly, by complete closure of the «ao
and B part of tin; artery by coagula ; the tumor then ceases growing,
and may gradually sulmidc. As before mentioned, also, ioBammatioo
around the tumor may lead to local gangrene; if Uh utory lias pre-
038
VJLRICES AND AKBCaiSUa
viuunly been occluded, the wliole &neiirtBm may bcoome gangnmntf
utid t)i^ tlironn o(F witbnut litemorrbflge. These ustunü curca u«
Ti-nf- run*, but iiiiliunte the itiodv of treatineot. I »Imll not tierc spcnk
of the medicul trc*tmcat of tDOuriMo, except to mcnlioa ooe metltod,
T^üd/wi'«. Tbl! niiii of llii« it*, (o reJi«* Üie voliim« of blow) in the
body to a miaimum, so us to weaken the la-ajt's action, aitd Earor the
foraiatioQ of OoaguU. Itcpcated rcucflcctloas, puigatives, olMoIilte
quiet, low diel, digitalis internally, and ice kxvUy over the tinuor, are
tbe reinedie» with which the patient is treated undcrtbin method ; the
n»ulta are duublfu] : the patit-ut« ar« very mtKb d«;biUtutt.'d, and the
sytn{itom.t iimy then be less; but, »Rtbe patieota rcj^atn tbtiir BtTengtli, ^
the fonn«r oonditioti generally retumo. We may employ tbe above fl
remedies to n niodrnite extent in ulle%'iatinfr M-rerv ayinptoms in in- ^
tomnl aiveitrismg, but they will not iodiicc an aetua) cure; unfortih
Dately, interna) aneurisms must almost always be re;^rded as iDcui»
blc Let us pass to the surgical trcatmcat of external aueurisma
Hiia may be conducted in two ways ; it may aim at the de«tTuctioa of
the aneurism, or its complete removal. In moat caaea the dfistnictioa
of the tumor will lie enough. The remedies for this purpose rmiT*.
1, CompretMon, This may be applied in rarious ways : «r, on tlie
aniMiri^m ; b, on Uie affeete«! artery, above (be luinor. Tbc latter b
by far the most effective mcllioJ, because even a mixlerate preMure <
oa the aneurism is often patuful, and may cause tiiflamwatioii in iti ^|
vicitiity. The mode of emplojnng eompf«>Miiiin also viiri">* ; it may h« ^
continued, and compk-tv or inoompletv ; it may be temporary, but ooin-
plcte, i. e., Hui-h na to arrest the pulsation. The mi'(I>oils of mmpres-
«on are about as follows : a, eompressioa with tlte fitigers, jMrticiilariy
recommended by Vanittti, and used by other surgeons with advantage;
it is made by the surgeon, nurse», nr by the patient liims<'lf. at inter
vals, 60 as to arrest pulsation completely for a few buur» ; if tlic patient
can liear it, this Is continued for flays, weeks, or even months, till the
aueurtsiu no longer pulsates, and has become quite bard ; A, cxmiprc^ mi
sion of the aiieurisin by fori^ed flexion of the extremity; this procodure, Sj
firet used by .VfUi^aiffnf, i» parliciilHrly siuted for )K>plitoal aneurism;
the limb is fastened in the position of extreme flexion by a baiKlage, ^
and retained thus til) the pulsation la tbo aneurism has ceasod; H
c, compresBion with special itppamtus, pads, cqmpresses, etc, whiiA "
must be so made thiit th>i> prea»ure may be as iltuch as posaiUa
on Uic artery, and that oedema may Dot be induced by simul(iitie>ou>
pnvvnire on the vein ; the pressure need not bo hard pjiough to arrest
puliatiun entirely, but merely to diminish llie supply of bluod. Views
roganling tlic eRicacy of vomprcpsion in the treatment of anevrian
vary. Irixh surgeons laud it highly; French and Italian siirgeou
TBEATMEXT OP ANBtTIHSM.
B39
inclino to it moro iban fonncrlr; cepeciallT aiooe the inTCBttg«ttona
at BroeOy int^rtnittent digital conipreBsion has showo some briUUnt
rcMilta. 7 think llial, in mottt caaes of aneurium, coDipreanon aliould
he first resorted to ; but obaerratwn nliowa Uuit it i» not alike suited
for all cnH4>ii, and is not of radical bcn<*lit in oil.
i. Ligation of lb« aTi4>r^-. Tbis amy be done in TnriouB w%ys :
a, cloec ubovu the uncuriittn (after Anri)fH, Tor «bore thi- aneurism,
at a point of election (./^ /funler) ; f, cIoao below the aDcnrism, i. e.,
at it« peripheral end (after Wardrop and Sratdvr). Of all tliese
methods, ligation close abore the aneuriam 19 pn>{iortianatc1y tbe
must certain; ligation close below it tlie least oertaia. Legation at
a distanee from the aneurixm will oiire the disease for a short time,
occasionnlly even pennaneutt^, i. e., the pulsation in the aneurism
iriU cease, but, when the collateral circuletioa develops fullj, the
puIsatiOD m&T bcf^n again. I hnvo myself seen sueb a ease; from a
puncture with a penknife, a boy twelve years old bad an aneurism
the size of a largo walnut in the femoral artery, about tho middle of
the thigh; the femoral was ligated close below Poupart's ligament ;
in ten da^'s the ligature cut throtigli, and there nas great haemor-
rbog«, which, huvTever, was iiisUiutly checked; tbeo, after dividing
Poupnrt's ligament, a )«eeond ligature vras opplicd half an ineh higher;
this ligature held well ; the wound healed ; wlien tlio patient left the
hospital there was again pulsation in the aneurism, whieti had previously
become perfectly hard, and had ceased pulsatinfj. But, in spite of Such
rolitpses, lignlion rcnkote from the aneuriun will retain iU iniportaoce,
and continue the chief nieiliod, fur, in the vicinity of the aneurism,
the artciy is oocastonally so diseaAcd that it is not advisable to ligate
there; for the rigid and OBsiüed artery might be so qTticlfly cut
through by the ligature that the thrombus would not be &rni enough
when the ligature lallei.
3. ICcmedie« which directly induce coagulation of the blood in
aneurisms. Of lbe#e, injeelioii of liquor Cerri se»qiilcldurati, after
J'ratiaz and J'c4regulH, is relatively must frequently used ; it must be
done very carefully; it should be mode with a small sjTinge, whoso
piston is mored by a screw, wilh every Iura of wliich a drop eaoapes;
■ few dropA of the liquor ferri should thus be very carefully forced
into the tumor. Simple cnagulation and sitrinking of the aneurisu
msy, and it is said do, follow this * but experience has shown that
[t is raarc frequenlly followed by inflammation, suppuration, and gan-
grene. I do not advise this method,
4. Wo now com« to the mode of operative treatment of au aneu-
which aims at its compleie destruction ; if this succeed, it Is,
of course, more certainly a radical euro than the modes above do-
840
VaRIC£S AÜD A\BCRISM&
5cril>ed, tnit it is « much more BenDus opcntion. It may be done;
•ocordiog lo Antylhu-, u foUowi : Tltc artery is to be compieBncd
abovv tbe ani-urisin, tbr» the whole ebc ta tlit up and the coagultan
tUTDcd out ; tlirough the sac prohca are passed into the upper asd
lower ciuJa of the artery, whidi is then llg»t«>), the probes of coane
being rcmorod — they nrc only intended to (aeilitatc finding the artety;
thin operntion, whii^b I hare nwn pL'rfunned several tttof« for aneu-
nHiiis reauliing from rcncsccticMi, is not always as simple as it appean,
(w it 19 oot at all times easy to find the openings of the artery iu tbe
■ac filled with eoa^lum, and often other arteriea besides the maia one
Ueed, as a coIUteral circtilution occawonally o])ena bito tlie aneurinn.
After the opcrotjan then; ia Boppuiation of the whole anenrismal
lae ; in thrae eases of tntnnatlc aneurism of the brachial, und one of the
radial artery, I saw healing occur without any accident. If the aneu-
rina be «mall and difltinclly bounded, wc migtit first li^tc abore and
below, then extirpote 1h« aneurism as we would a tumor. Of Ut«,
Sfftn« lias employed tbe method of Autt/tlut sucoessfuUy in lai;^
lurteries also.
I should like to ^ivv you some dc&uitc adviev about the choice of
method among these different plans of operating, but tlits Is searoely
possible, as one plan or another will best suit different ease*. Id gen*
eral terms, I can merely repeat that of Into so many furoimblo reenlta
from oomprossion have again been published from dilTerent sourcef,
that it should not be too ijuickly abandoned. If, however, as usually
happens in aneurisms from vcneaection, there be great diffuse awell-
ing of tlie entire arm, the method of Ant^tut appears to me prefer»
able to all others; with good lutKiRtants it is very practicable, and is
not so dangerous as is claimed by many persona. Whea we do not
wish to make vl»/(/ÄtM*4 operation, we may tfy An^t or Huni^9. I
have least to say for the injection of liquor fcrri in ordinary cases of
spontaneous and traumatic aneurism. In varicoao aneurism and
aaeurismal vam, liguting the artery above and below the opening
will be the most certain method.
We must Nlitl add a few reniarba about tbe treatment of ctrBoid
aneuri»iii. The «buve methods of operation are only iwriially appli-
cable to it. Direct compresrion of the entire tumor may bo made by
means of bandages and oompresses prepared for the special cases ; we
mean particularly the aneurisms of this variety coming ou the l»cad
which are the moet frequent, but compression has rarely proved
euocessful. The injeotion of liquor ferri may here prove useful,
for Buppurntioii or gangrene of tlie entire coovolutiun of arteries
ia not eo much to be feared as in aneuriama of the large arteries of
the extremities. The ficetruction might be accomplished by ligatli^
TREATMENT OF CIBSOID ANBtJRISU. 541
all the afferent arteries, but this is very tedious and uncertain ; the
result would be just as doubtful, and it might be dangerous to ligate
one or both external carotids in a cirsoid aneurism of the scalp. An-
other method, having the same object, is to insert insect>needles
through the skin at different points around the tumor, and apply a
thread, as in the twisted suture ; the result will be suppuration and
obliteration, perhaps partial gangrene of the skin. Total extirpation
may occasionally be resorted to ; it is done as follows : Around the
tumor we make numerous percutaneous mediate ligations close to-
gether ; then we may cut out the main body of the tumor, with the
dilated arteries, without hiemorrhage ; this is the most certain and
nuiical operation, but cannot well be resorted to wben the tumors are
very extensive ; then we might tiy mediate ligation for different parts,
and attain our end by partial extirpations.
CHAPTER XX.
LECTURE XLIV.
"TMliltliiii of (be Term Tsmot. — Qauonl Arutomical Bemorki; TcljmvfUmff
Viatvet. — Points of Ör)K>ii of Tunxm.— Iiimluilon dT tbc DcTnlopRUU of OtOaV
Certain Typ» of Tlontc— Holst ion to llir Hononitivc Ln^m.— Hodc pt OraWLi~
AnUoinical UctoiiiDrpliUBia of Tumora : theu Ettcnul Appcaruet«.
Grkiueuex : To-day we enter on the <lilGoult clwpter Uwt i
of twnors. The enrellings of vrliich wv liu\*c bitberto spokea depenkd 1
onljr on a few cmisea ; thvj -wen due to aboonniü ooUtrcliotui of biood
in snd outeidc of t\xv vcuvIb, to infJtnlion of tbo tuuuc witli Mnffli,
to it£ permeatiou with young ccüb (plastic intili ration), cither se^
ntely or in cnmbianttoit. In conlradistinction to tbcw «wcUtogB, «e
DOW in Uie cIiDioal »onso of the t«rni mil oew fonnstiona
or tumora when we suppose they are due to other causes than
of the infl&Riinatory new formations, and ha\'o a giowtli which na a
lule iios no typical tenitinatinn, but,a(i it vrere, goea on ad ut/iniium;
b«eid«K, most of the.'U' gmwtha are coin|>osiMl of tJSBue whid is tnare
highly organixed tliaii i tiflanimatory neoplasia. Let lu inrestigata
this more aocnrutcly. At prtM-ntyuu nru untr srqtiainted witli thai
TftHcty of new fomiation ctausiHl l>y itiflnmmatioa ; this is rety imi-
(brm, not only in its mode of origin, hut in it8 furtli^r development j^
its dorclopmcnt niig^ht be iiitvrfcrod with by dJ«intcgnttioDt diyinj; i
bnvakin^ down into pi«, etc. ; it might )>rf>lif(TBtc cxceiwivcly, Hiit
was always in suuh u uay us not to cliangu itschamctrr; but, (inallyj
if them existed no spodiJly unfavorable local or general cause, i
no vital organ was disturbed by the new fonnalion, it subatded-
again became eoniiective tissue; the inflummation terminated in rioa*
trisation. Then, if the inflammation was suporäcial, t)»cre was de-
velopment of epithelial or epidermis cells, the bo&y cioatrlz ossified,.
GEXBBAL RSUAUKS ABOUT TUHDBS.
N3
in the uGTre<icntrix ; in nil llic^c chsngex
]-v<;«ftcIe pUycd «Q importaut part ; still,
ss above said, the tjpical t«nniiiation of tbe inflammatioti, whether iC
WM wutc or chronic, superficial or deep, was in the dcatrix.
Although ccnacctiye tissue, nerve, aud Lone tuoioi^ may cx-
coptioaaUy form from coimectire tissup, nerve, and bone cicatrices,
Htill these constitute a ver}' sniall put of the viLriou» ti»siio<funnatioiu
fouod in tumors; forms tli« ino&t Taricd and cotnplicntod, such it»
newly-formed glandii, teeth, hair, etc., are occasionally to be found in
tlie tuitiont; indeed, tlsaue« are tliere »u«a which, as then arranged,
never under other cirexunetancca ocmr in tltc bodj or oven during
trntai life. To enable you to form a correct idea of the anatomical
c&ancteristics of tumors, I will rer^l to your loeinory a few gcnerel
laws from ^neral pathology about the fortnatioii of new growths; in
the larpfp work» on ihia subject by Vir^ow and O. TFöficr you may
find very e-xoetleot and exhaustive representations of these conditious.
When a part of the body is ubnomially uoloigod, wc make u dis-
ti action a» to whether th« enlargement is caused by aa abtiormal io-
cfcase of volume of the diffiurent element« (»impU hypertrophy) or by
a [brmatioD of new elements, which arc deposited between the old
ones. Tliis new formation may be oooloi^ous to tbe matrix, or mother-
tisBiie {fti>m<i!OpiaMtie), or not [lu^frnplasli''). The homceoplastic new
formation proceeds either Utim simple diviaiou of tbe existing ele-
ments (thus A cartilage-cell by segnwntation fonns two, then four
eartilagc-cells) ; then it is called hyperpUutic (numerical hypertrophy) ;
or At first apparently indifferent, small, round cell» form from tlio ex-
isting cellular elements, and from these a tissue analogous to the mat-
rix is dcvclopctl — homfeoplaKtic new fomatinn in the strict sen»o.
Heteroplastic tiL-w formations always begin with the dcvelrtpmciit. of
primary cell-tissue, ao-cAllcd indifferent fonmitive cellä (gninulation
stage of tumOfS, FTrcAow), and from thcrso develop« the tissue heterolo-
goiM to the matrix (as cartilage in the testicle, epidermis in the
brain, etc.).
This nouieuclalure, proposed by Virchow^ seemed perfectly suit-
able and natural in a purely anatomical point of view ; and 1 can still
accept it if the teim of hftero|ilii*iB be limited, as will be hereafter
stated, and if we dismiss the id«'« that homoeoplsstio is synonymous
with beiiignsjit and lieteroplastic with malignant We must here add
that there is every prubability that icanderiHff reUt escaping from tlie
vessels very materially aid in the fonnatiou of tumors, at least to the
formation of t«mors of the eonnr'ctive-tissue »erif*. But, apart from
Ihts, we should err if we supposed that in the alxive nomencUtwre all
cases of new formation, even considered in a purely anatomical poini
se
544
or view, oouM be euHy labelled, readj to be placed mvr»y j
miLseuin. The idmplo uiiin(»ical hypertrophies uiJ hypeipLuHir, at
though in sora«^ cns^s difficult to disiinguish, me at Ifact thrr>r4,'tion!Iy
fl^urable; the fiamu way with those iiew funuatioiis which do not
oooaist of similar, woU-fonncd tiseiu^clcmcnta ; a antncctire-ttasuo
tomor oooumog in oonneotiTe tiseii« would always be termed bomoeo-
pUatio; found in bone, brain, or Uie liver, it would be tenncd beteto-
pUstic, etc. Welt-devclopcd alvtx^ar canccroua tiasue alisu itMudly
prescnta no difficulty of ohksaificntiu», for it doe« aot oormally occur
in any part of the boily, it io «verywhoro beterologoits. But what
riiall we say of the iipuplosiiir which hare no fully^vreloped Dormal
or entirely abRoimal (una of tiasur-, hut ocinsiAt of olcincnta tJiat cao-
DOt be found elsewbcrc ; what bei^omee of thetn? or, can any thia^^
devdop from them (iodifi'ereut formative celbi, primarj^eell tiante^
gnifiulution-tiimon«) ? hikI wlieru &hitll wf. place Üio»e neopla.w» wbtob
mm Dot coinplvt^ tusuc, but are cvidcatly uonual tistRie ia Ihc stage
of development ? Aocorv)iii);r to the above definition of twterology and
hoiDoloKy, inRammatory new formation is at first hctcroloigowi every
irbem; but the cxinneetire-tissuc cicatrix developing Crom it subae-
queotiy beeomea a homologous neoplaeia in connectire tissue ; in muv
cle it almost always n^main» hetemlogoua, tbe «ante way ia tbe brain
and ill the lx)iie.% if it does not ossify. You sec that here parts,
which from their nature and mftde of origin natiimlly belong to^'tlwr,
aro sundered by tlie Hnatoininil uoinenel»tiiro. But let ua leave in-
fiammatory nuoplasiie out of the question. Every tumor rc&ulliog
from indifferent formative cells inuet exhibit a scries of stages uf <le-
velopnicut, if the eulls ure trutisfurmcd to one or several aorta of tj»-
auc. Wherever they arc grouped together, initißerent fbrraativ» oetts
are heterologous; if a iteopUsia stiow only such element«, we wUl let
it pass for heterologous ; but if it appear that n number of tlics« «ella
bave been Inuisfoniieil into »phu lie-cells, tlie quejition arises. When
does this neopl^isiu belung? Spindle^ells cnllcctod in groups aie
heteroplastic in all part« of the body; but these cells occur in fa^tal
oounec lii-e tissue, foetal muscles, and fiBtal nerves ; what would (inallj
become of t he spindlctclls of this tumor ? if found in nntselejs shooM
not this tumor still be called homologous? On this poJntwe can only
deeide atbitrarily; you may look nt It from different point« of view.
Now, what ahall we do with tumors tliat contain the most dÜferent
complete and inooinplete tissues? I will stop hero, to avoid nukking
you gkeptical ; it ia my duty to help you Icam, not to throw obstacle«
la your way.
As the enlargement of the individual elements (simple hyper«
trophy) cannot be observed, and 'Üie increase of the dements 6ou
OEXEKAL REMARKS ABOUT TITUOKSL
Ires (bjpeqiluiii) is an act often ubserred and oonstantlj.- go-
ing on in physiological growtb, it only remains to treat of the point
of origin of the indifferent formative oell», and their fiirlher couree.
Here w» find uursplvt^s in the same position as in inflammatinn, onlr
in neganl lo th« dpvclopmi'nt of tiintorK we unfortuiial^'ly rannol make
toy experimental invMtigations. Fonncrly the proliferation of con-
nentivtytifUHie nells wai not dnuhttnl, mid the«e were aisumed as the
sourer for th« dcrviopmerit of moat timiom. But moKt, possibly alt,
of tJi»>»c itnlifforent coll« are wandorin^ whito bIood-<'*>IU, TTi^pc ia
littlo duubt that on this point IhLTO was furmorly mutAx vrror, cünclu-
nooa having been too quickly drawn from the arrangement in gronpo,
and the mctaniorphoses of the formotivo cell» ; nor can I claim to Iia.ve
esmpod tbesp errore. For inatanfe, when ia sarooma we found small
indiffe-rent eella, with one, two, and then more nurlei near together
{whea between tlie ßlamcnta of the connective ti»me, wlicru the cxn»-
li«ctiT4v.tisgue oells lie, we s&w a small, then, near by, a large group
of indifferent cells), tbc conclusion that tbe new groups of cells were
derivatirea from the connective-tissue cells seemed quite unpn*j»diced;
also, that from these indifferent cells., larj^er multinucleated were con-
ftantly developed till the no-called f^ant-eelU were arrivtxl at. Know-
In^ now that an infiltration of the tissue with small cells may depend
on ««capo of white blood-cells from the vessels into the tissue ; as be-
fofp remarked, we also become doubtful about the origin of the indif-
ferent formative cell» in the tuniora. Of late, eapet'ially in glandular
nd epitlivlial cancer, I usually »eck in vaiu fur protifemting coiiuec-
-titwiie cellJi, although the whole eonneotive-tissue layer of these
tumon is genenlly infiltrütcd with young cells. A similar, but evea
greAter, obscurity also »hrouds the orijfin of the youngest epithelial
cells; they undoiibtedly develop fi^itn themselves by a sort of seg-
tnentatinn^ or from a protoplasm formed under their influence (Arnold),
it there is nntlitn^ certain on tliis point.
We have frequently spoken of indifferent formtaiv« «to, without
having euOieiently definei) tliia term. Uy tlicse we iiipati tlie «mall,
round cells, which vrery where fir^t appear after irritating the tisnuc,
and with which we became aequaint«d in ioflatnmatory new forma-
tions. Until within a few yean I belicvod Ihal these young eoll«
were a:Ctiiatly as indifferent as the primary s<^fmcntation-gtnbulefl of the
egg [vitelline splierea of DaUon'\, i. c., (hat any tissue might finally
develop from them, and more especially I thought that tHit only all
forma of connective-tissue stibstances ^cxmnective tissue, cartilage,
bone), veosela, and nen'es, but ahto epithelial liasuea, glaods, etc.,
could proeced from the derivative« of the oonnective-tiatne cello.
Againat this still-prevalent view, Thieneh^ in an excellent woA oB
640
TÜHOBS.
"epItHelial ouKer," hon prociuoed Bucb proo& tliat I must entüvly-
af^tc vrith faiiti. Aa I iiropOM rduminff to thio point h«seafl«-, trfaoi
treatitig of cyst», glnndulaF tumors, itnd cftirlu^lial c&no^i«, I sball her«
iDBrel/ poiul out tli« genenl oittliii» uf my views, ^'rom the bo-
oount of development you know that the body of the young embryo
very early sboirs three diffcreot layers, so-callMl itenn-layen. As
sooa ait the dinsioo of the cellular embrynnnl elementfi into the three
gemi-Uyers is a(xom|itiiihe'I, all nhanncre agree that each of these
three f^erai-layertt produo-it ouly a certain »tirica uf tissues. From the
homy lny«r are formed tlie nerve-nysteni, the ei^demiis, and their d©-
rirativos, the cutaneous glandn, the sexual glHucls, the labyrinth of
the ear, thv lens; from the middle ^nn-iaycr arc formed the oon-
neetire substanoc, thu mosele« {?), tbo vascular Rysl«in, the lymphatic
glands, the spleen, the peripheral nerres (?) ; from the inferior, or
glandular laynr, are formed the rpitlielitini of the intestinal cfinal, tliat
of the lu»^ (?), all the secreting clement« of tbe lirer, paocrcae, kid-
neys, ete. Tili« is one of Niiiure'» Inwa, for wlione ditconrj we are
greatly indebted to Ittmaie, Reichtrl^ A'olliker, Sets, Waktei/tr, and
otbcr^ and which may prohubly bo carried b&crk into the conapositioa
of the ovum. In the wholo subsequent <»une of development a de>
rivatii-e of one germ-layer ncrcr dcvctope a tissue whieh was origi-
nally fotTiied fn>m anotlier; in oÜier wordn, if the diriflion of tlie eel-
lular «"mhryooal plan haa advanced to the three germ-layers, the»
arc no more vholly indifferent rellA, but all newly-formed colls devel-
op(.-d Iriini previouK ones L'on only develop to tissues lying within tbe
territory of the gemi-Uyer whence tiiey originate ; cell« originating
from tnie gi-iiuiite epitlii'liutii cun uovlt pr«<ht'>> eonneotive tiscue,
and inic cpithchum or glond» can never com« from the derivatirea of
connoctJTe-tisBue cells. There is do reaaon Sot supposing that the
natural Uiw would be annulled if the eellular elemeata of the com-
pletf* organism were exrited to production by any irritation ; the
youn*; broud oan only develop to certain presciibMl t^-pir« of tieiie,
«hicli depend on the embryonal origin of the mothcr-eella. When
we have spoken, or in future sjmmiIc, of indifferent cells, you must al-
ways limit the exprossinn by the prinriplea abore devdoped. If we
now rclum to the system of new formation developed by FVrcAoir,
according to our view, there it) no sueh tiling as a true hetoroplasia,
for the gt^niKL'Us fonned from the derivatJTCS of one germ-layer can
only develop differently within reriaia houods, they can never become
one of tbe types of tissue belonging to another germ-layer. Fcora
the great movements constantly being made in histogeny, any very j
altMilute assertion is in danger of l)eLng oUiged soon to subtnit to I
some modiheation ; still I must repeat, that it seems to me ia the
GE}1ERAL aSUARKS ABOLT TÖHORH.
647
lifgliest degree probable that k Urge port of the jouog cells, cscajMng
■0 eitciisivvly intu tbe tissues during tbe derelopmeat of tuniora, ore
]DOT3ibl(>, «-ainU'riiig poiinec live- 1 issue cells, th«t ia, escaped wbile
bloodoells. Nvrertbülc-ss, I wouM »ot dcnjr to tlie st&ble elements
all participntioo in the tiuue uew fonnntioa. For inttonce, it bos
been proved of mtiscubir filmneDts that their cells pruHffrtttc aflcr Ii^
IJtation, hy division of the nudd, sltbougfa this may nut occur for
•ome time (in mbbit« alx>ut the end of the first week) ; the name is
Itue of the nerves ; the oartilage-cells alao react oa imtation, Iboitgh
not for some tiiiip. It is unmrtain whence the wandering cells rome
{thry arc idcnticul witb n'hitu bluod-^Uft and Ij-mph-oells) ; probably
ilteir orif^inal »ource U from stuhle element« of the lymphatic glatkds
and ^een; at all events, they muat be regnrded as elements of the
midiDt- gfim-lnycr, and hcnoc Uicir powers of development must be
leg&rdtnl uA limited to the tissues of this layer. Our times may l^k
Witli prid« at the progress of modem morpbalogy, whose importance
is proved by tlie very fact that it is so destructive to previous ylewB,
and BO fruitful in the moat divene direotiooa.
Let us now return to tumon. Their lifo «ml growth may vary
greatly. In the first place, the diseased portion of tissue, the firet
ttuoor-Dodule» may grow In itscU^ without new pobts of diarase de-
veloping in ita vieinity ; in the midst of the tumor ittielf, from the
cells MiUecied at a circumscribed «pot, new ones ounstaiitly form, with
a tendency to develop in the same direction, predestined as it trcn:
for the type of dovelopmcot taken by the now fonnation. It was
forroeriy supposed that the distention of the vessels was a very essen-
tial indiculion of inflammatorii' neoplasia; numerous resenrclies in ihifi
(liicctiou have sliuwti toe that tin; eaULTgemeiit and new formation of
TMaett in the development of the Briit tumor-noduloa are not inferior
to those in inflammiilion. Tlie original fiK'n» of discit.v.- may also grow
by new foci coDBtaotly fonnitig in its immc<liute vicinity; an organ
ooee diseased in this way is not only cumprcsse«! by tliu tumor, and
its elements sepafBted, but It beoomes more and more diseased, and
io beoomes infiliraled and destroyed by the tumnr, and is finally tnui»-
formed into it; for you have already seen that a neoplasia fiirms in
normal tissue, tlie nintrii ceases to grow, and is portly ininsfortned
into the new tissue, partly U destroyed. So tu the fint cose we have
*D isolated focus of disense whieli, ottoe existing, draws the material
for its ioerpase from its own eciUa; in tho seoood ease w« have n ooo-
tinual extension of the fbd of disease The 6rBt variety, the to some
exteul pure fentrai growth, U decidedly less unfavorable to the organ
diseased than the latter; the penfjpAenii growth, which, when it oo«-
thiues ad itt/inituniy must cause complete dcatraction of the organ,
648
TDMOR&
Just u when an iaflammfttion or inflammKtorT' new rarmadao. contiontjf J
progresüre^ A cotubiuatiou of thc«e two modes of growth is tlie moftt
ttnikvarnble, but uiifoituturtely is quito frequent. IT we study the life
of the tumor Itwrlf further, wa find that the ueujilutiu Lüsue does oot
hj any means remain stable, but is subject to some changes, such aa
are also se«n in infloininatton, From various causes, a«ut« and chronic
inflamiDationB may develop in the tunton, i e., with pain, Hwelliiig,
and enlar^Rient of the reasels, tbrrc is an iaSltnlion of snialt cells
into the ti»au« of the tuinor, this tniiy even lead to suppumtioa ; Üüi
disease of a tumor is tho more fre(|uoiiL thu less its c1eou.>nts are ot-
ganiz«] to a stnble Tital tiMue, especiully the te&s its rascular syst«m
is reg-ulated and fully organized. Tuionrs in which the ooU-fonnatioo
is HO pxce&aive and progresses so mpidly that the fcnnatioD of vesseU
only faIlo\Ts up the growth of the tumor slowly, are least c^paHft of
Hring ; slight dUtitrhances then suffice to impede tlie whole process of
derelopmeat, or, as they do not arrc»t it «Dtircly, to cause destruction.
We must examine soniewhnt mein; itiimiiclr the inetamorpliosis of the
tissue of tumors in inßuminatiuDs. They may come on in an acute or
chronic manner ; acute inflammations are on the whole rare, stiU they
may be induced by injuries, blows, or »mtusiona; (his trsuiaatie in-
fiaiiiniation in vascular tumors ricli in roniiective tissue may terminate
in reiHtlutiou villi or without cieutricial contmction; but frequently
tfacy arc followed by more or less extensive cxtrSTasations, gangrene,
or siippiirutiun. Oiroiiic iuft&Qimatious in tumors are ba more fre-
quent, both those charoctenEed by production of inflammatory neopl»
Na, fungous uloeratiotis «nth great vascularütatioo, and those marked
by torpid uleeraliun. Cuecous and t&tty degeneration of the tissue, and
its breaking down into mucous fluid, are not very uiifrecpieiit oooio^
rcneeH. In these process«« of solWiiiii^, there are thrombosis and col-
latenl diiatntion of the vessels ammit) tht^ itoftening point, as in the
transfomialiou of a focus uf iiitlunimation to an ahscess or to caseous
matter. All tlicse cltanges, by development and disease of the tunior,
may so racnplicate its appearance as to render it someliinea difficult
at onee to tell nnrrectiy, in any given case, what was the original linue
of the liiiiior. I.ii.sl1y, it somelimes happens ihnt In the course of time
tumors change their anatomical state ; for instance, a conncctire-tianut;
tumor which had long continued in that state becomes softer fay rapid
proliferation of cells, and greater vasculariution ; or, on the contrary, a
soft tunior becomes hard from atrophy of the cells, and cicatiicial con<
tract ion of the eonneetire tissue existing in the tumor. So you wo
what ait nmoutit of knowledge and experience is ncocssary merely to
judge (xirrcctly in cncli case of these nnstomical conditions, which
form the basis of all our knowledge of tumors; iadocd, we nay ooo-
NOMEN CLiTUBE OF TCMORa
M0
lly be uasblc lo (pve to the object wo hare examined a iiame bjr
rhlch it tnny be ^mply lahcUcd in one of tbc reg:uJar groups ; as «»■
''gnnlx tIiL> nomcndaturp of tumors, which are oompoMHl uf vitrious
tissue», wo griiprally dionue tlie nume from the tissue tbaii» pres«at
in the tumor in tlie largest amoiuit.
I have litllo to aar about tht> external gross ap|>canin<:PH of tumorcL
In most cast» th« (crowtlui arp rouDdinli nodules, more or less diathv-
guisbablc, hf sight nod Tccliug, from tbc surrouiiding parte, lliiü in not
•Iwayp Boctirate, however ; tubun-les also, at least in their snuillest alatc,
arc bouiHlcd rouadish bodies, which I should no more class among Üie
growths than I should papulca and pustules of t^e itkiii. [u tb« skin
also a distinetly-formed nodule may appear as a giowlh, juat a» an
absce*« may whicli hImi al first appears ns a nodiil«. Stilt, as cbrouic
inäamuialorv new furmatiuiis on tliu surface also Dcquuntiy appt^r in
tho fonn of papiUan/ proli/tratioti« (tuft»), a growtli forming on the
akin or iimeouft meiiilininu may also aamnie tbe papitJary form ; even
tbc surface of a tumor, or a ncwlyfomicd cavity contiiining fluid or
pulp, may produce papiilaiy proliferations. So you Bee that growlli»
aod inllamraatorj' neoplasia are not aecurately distinguiiliablc liy their
purely external anatomicid ronditions.
There arc a number of terms for tUfferint peculiafitics of tumors,
vrhich are frequently iiscd oven now, altliough they do not always
efer to any essential poiot. Thus, a tumor situated in a carity, and
attached by u iHxiicle, is culleil a poiypua ; eo, we speulc of nawil
polypi, uterine polypi, ete., but must add the histological peculiarities
(as fibrous, myxontntous, etc.). Growtlia that are ulcerated aitd pro>
ject Like a fungus are called ^tonffy^ or /'utit/i»4S, Formerly, if oou
wished to say that a tumor was very vaseiüar, he used the word "bsc-
matodes," while today it is called "telangiectatic," or " cavern ou«."
If & tumor was very firm or fibrous (not cartilaginims or bony) it was
fermerly called ** aclrrlious," which merely ineana " firm,*' and was
&p|Jied to inf1ammntor\' new fomistions just as to cancer. A tumor
was called tnt^ullari/ when it ha<l the coUir and consistence of tli«
bvaio, while it« structure nuglit be that of «aruoma, curciouma, or
lipoma. As tumors of this appearancu are reoogiiisieil sa prciiliarly
malignant, the terms "medullary Barcoma,** '' medullary carcinoma,"
hare been applied to maligna.nt tumois in general without regard
to their sirueture. Some growths are colored — brown, yellowish,
brownish black, bluish lilaek; this pigmentation may be due to
extransations, or to »{»eeifio cell-aotiny. Melanomata or milth
notet are rare, partly or entirely black or browpisb-blaek tumon,
with til« Blructme of sarcoma or carcinoma, and usually of very bad
prognous. Formerly oaly these and similar terms, and cumpaiisoiis
»so
Ttruoaa
to tili» or thttt tisAue, vrere used; il U «aouglt for/oci to know wlMt
Uiey rni^sii. ,
"Wc tDUHt agaia return to the term " tunmr,** Pure mtiAUnoaj «bould
oiiaply reject thi» term, for it oekoowledjies oal^ *impk oc corupoaite
tisBue-funnstiwis {ur^tiiiziHl iieojtlatiia uf RokUan«htf) ; from s Mvies
of obxemtiona it can shov how tlicae Etrui:turcs dcrclop, awl wbat
becoiiies of bbera; w« shkU not Üiua arrive at the tenu " tumor" io
tliR Aens« ill whicli we use it in patliolog^}-. Tumor, or f^wth, in tie
jMlliolof^^- uf tonUr, has a decidedly eliolo^icHl mid pn^g^iotiti« aigiit-
ficatiuu ; as atatvd at the opuuin^ of this ttccUu», it b a iit-vplaiiiu UuU
ha« not startc<l from thu saric oau»cs as excite iaflnmnuition, but frota
othvra that arc luikiiown ur but I'sgucty susptwtMl ; lite prucvas iu the
orgatusm (locnl or general) that produoos tumors U goocmllj ood-
Üdcrcd diScTGot from tnflammation ; »oni« regard the two prooesMSas
antagonistic Co a oertaio extent (we shall not here discuss the conecti-
aesH of this vicvr). Tliis p&tliolo^c or phyoiolnfciral vieitr, tt» I iniglii
term it, was not fonaerly maintained, but I do not think I err in »lat-
in^ that, ooiuc-inusly or uncoiisciouftly, it is held b^ most palliologlsta.
/\lt wrilen» UD tumors, as much ha ponaiUe, aroid speaking an tliia
point, as there is Qothinf^ more to sny oo it ; for wc do uot know bov
or w))on> we shall druw the dividing line betwfoii ehroitic inHiunnu*
tion and devdopmcat of tumttr». Su it is not pmuilde to have a
purely aoatomical idea of ** tumors,'* any more than it is of tJie tenu
" typhuH ; " t« understand theni wc mu&t make a compromiiic betwoon
etiology and patliologtR&l anatomy. The etiological expresstuu, "the
process by wliicli tumors ore developed," iiujiUes that Uie futu of the
produiTt or tumor will probably differ from that of the " iDllamtnatoiy
neopliisia ; " hence vri> might say of tumors thai tliey do not bear in
^cmeclvcs thccondittuns for» typicul tcmiiuution, as do tho infiam-
matory ncoplasiir. 1 would not sMCrt the inHammatory process is at
all tile opposite of Uiat by which tumon axe developed; on the oo»*
trary, I believe that obsci'vntion teaches that, in some cases, tbo two
proocsses correspond, especially in some fo^-ms ofchroDto inflammatioa
and Kamonia, while, on ibe other hand, acute metritis anil fibroid of
the uterus htc fnr enotigh a^wrt, etioli^ioally and atiatomically. Tbc
idea that the dci'ch>pmcnt of tumors has certain specific causes, both
in or external to tbu orgimism, is little disputod ; and, when il is, it is
hardly in L-amrst. Virclioto asserts thnt the dcvelopoient of tumors
may start front an invreusc of the inflainnialory diathesis; thus, jxilypii
of Ibe inucoua mnmbranes result from long-continued catarrh; avphilis
induces, first, inflmumations ; then, luniors. I would rnddcntally re-
mark that 1 do not cousidur any product of syplitlis a tumor; a gummy
nodule or a caseous nodule, caused by syphilis, «thcr bcels hj m^
ETIOLOGY OP TCM0R8.
<»
' tOfption, or, uRet being slit up, br suppunting and cicatrizing, wUle
in an inoised tumor this is exoeedin^y rare. JZ 3fKtie von Sem»-
^ich ftdvitnoed the opponitp idpa, e. g,, be mjb cnclKindronia of tbc
fin^C'cr is tb« iiiildMt «xprvMÜ>n of a scrofulous diitlieMs. If we ooio-
parc tiic products of ifitlmiiinAtion with the liiitUiloj^icalltr more devel-
oped tumors, it musl be uckiiowletlgrd ihat, as being tlie iiiorr slowlr
dcTcloped ncopluKio;, tumors are probablr due to a fevbl«r local irri-
tetion, more oJUimI to ronnal growtli. All tliesv eoiiM^li-Tations applT
only to true growths. In what fallows wc ahaU treat of these alone.
When VircAow classes encapsulated oxtravasatjoaa of blood and
dropsieii of serous sacs among the twnora, he goes beyond our pre»-
tmt views.
LECTURE XLV.
' <if Tumor» i UiaiiDutio Influene*. — SpiviAo InFMtion.^pocifi« B««e«ion of
Um [rrilctvd TUanr«; tta C«um is ilwtiyt «onBUtutionaL— Internal Imlntioiu;
Ilr)>olti«M« aa U> th« i'bsrasUr «ad Mod« of Ü»* Irritant Action. — Cnursv uid
Pragaoaias ftalitaiy, Mulü[)lui InfiKtiou» Tomor«. — Ufsonwia.— TnaUueiU. — l^in-
«ipU» of tlia Claaailcatioa of Tuuwra.
Let us now go mnr« minutely into the etiologr of tiiiiinrH. Here
VC should propciae to Knd the ilifTercnce» und point« of n^st-mblutice
between the pnvinvieit musing inflammatorjr neoplnftiie niid tumor«.
Let us start with the cauftes of inflammation, and oontpare them witli
those of tumors. Mao; acute iR6amtnatary proorssos (cxiinthemataf
typhus, etc.), and some chronic ones (intcrniiltents, scorbutus, etc.),
are due to miasmsu and «lotagions, which enipr the body from with-
out. I do nnt know any acut« miasmatic tumors ; but goitre must be
ooneidered as a chronic endemic-miasmatic tumor; goitre cannot be
Migarded aa a product of infinmmation, as it never spnntaneotuly ret-
rograde», sitppit rates, or shrinks up into a cicatrix ; the caune is a spe-
cific cxtvma) one, to which every one, especially Ibe young, ts ooo«>
siomdir rxposed, «bo oomea into a country where goiUx* is endemic ;
all are not equally disporte«! toil, there may bean hcretlitury tendency;
inEoctton probaUy occurs through the blood ; at least, wc cannot well
imagine how the ibymid gland shouki be infected by local infertiuu.
Bene« goitre is prolnbly the kxml cxprcasion «f a gcocnil infeetioa,
'vbich occasionHlly cnncc« itaclf in the whole nutritive state;, esp^
nallv in nnomalous du%-eli )[>ment of the skeleton und ilarosults (cm-
tlni^m). We may also consider Icontiasis and Oriental clcphantiaNs
aa chronic miasmatic infectious, in whicb large maawe of nodular
fibrous tumors form in the skin on diflprent parts of the body; still, I
558
TÜHOR&
aokiH>wli>dgo that Uli« i» ili«})Utif<1 lerritor^, aud that rensons maj I
advoncnl for cloBsinK tbtisc amoiifr the cbrooic inflammator/ disease«,
in»t««Ml of among tttmors. As regards loeaf inftttion^ or Uw Innafer
of fixeJ nantagioos fram wilbuut, wc know tliat inflammatimL)) of ra-
riiiuH kinds may be tlius indurnd. Bv ptilrid substaaoei onijf iaAna*
nwliotw ar« induced; here 1 clos», also, tbc ao^alled **(liaMctii^
tubercle," whieh I «annoC consider us a Iwnor, becaua« it disappeaia
spontatic-ouHtj, as soou as new iii&NrUou cesses to oocur. fnflnmmar
tion U <rsrtt«d bj inoLnilatiati with pus ; the cbaract«r of Uie pus
determineB the specific naliire of the iiiAR,mmation ; pus may also ex-
oite a onnntitutioaal diAeane, which a|j^ii niav evince itüielf by moltiple
localized proceftses, as in s^-^ihilia. C'nii tumors bo induced by inocu«
Ution with the juic<>ft of ttimom, or with »mall portioos of thi>mP
This is n dtspiitul puint ; I (Wtisider it possible, but not prove<l ; the
difficulty of oonung to a drcisioa lies in the &ct tKiU it is not allowable
to make euch exjicrimcnts on iucd, Wh«n such rx[>miDciita ofteo
fail OQ thn lower animals, it only show» that tumors from mao are dqC
trausfcntUe lo tliMii ; tiimnir« from beusts must bo iuoculatMl on beasts
of liko »pcricfl ; a few such cxpcrimmts hnrc hem made by Doutmte^
ponl, in -which the inoculntions of oar«»omn from dogs on dogs Tjad
no effect. At all events, wo cannot inducL> s tumor by inoculating
with pus, which again seems to show the spcciüc difiercoce of tbe
pcodticts. Perhaps some pathologists may here answer tJiut " molus-
cum eoiitagiosum " is an example of tumor>jniee or ctiitittituents of
tumors lieiug inomlnbte on other person». This (act, which has been
proved hy £bcrt and Virvfiote, i& very inlcrealiiig; etill, the right
of mohiNt^nn i-ontagloaum, u cy»toid 8ecretion-hyper|>lat>ia of tlie
sebaceous glands, a sort of largo comsdones, as welt as tbat of te-
tention-cysts generally, to a posiUoa among tumors ie dinput^d ; and,
moreover, the contsgiouenoss of this neoplasia is still too iralatcd
for us to draw any valuable conclusions from it. The moat etriknig
proof of the distiiietncss of inflammatory produets atwl tiimors is
ofFcn.'d by observation of tlie local and general infot'lion, which we
have iiinniiKTablp opportunities of making. We have ])wriouBly
said n good deal about piogirsaive uml secondary iuflnmmatinn of
acute l>inphangitia, which is idways sccoiidary (dcoturopotbic, Fu^
cAow), of tho st^coiidnry acute and chronic swellings of thn Ivm-
pbatic glands in acute and chronio inflnnunations, especially of
(be extremities ; I thcit told you that I considered it nxire prol^
able that cellular olcmonts frrvm the focus of inflammation pasae<I into
the lymphatio glands, and, by tbeir specific pliltigogenous action, in-
duced Inlhiinniaiion in the gland», which were analogous to tbo
prinuiTy peripheral inflammations ; tumors never develop through such
ETIOLOGY ur TUMOBä
«91
local inicctions from inllsmmatury foci ; if the priinar}- inllatDinatorjr
I0OU8 be removed, the Kwellings of the Ijmpbxtic glsads alao disappear.
SiiBiUr inrcctiuus pvculmrilics ul^o gccur in muijr tumore, «epecialljr
tfuwe whioh, like tho inflaminab^n.' neoplasia, ore very rith in ueUs;
ootonljr uMy tbe immedUte vii-iiiitj- be iiif«M:lc<], hikI numerous new
fbd be formed immcdiatoly htduiiiI ibc first qcmIuIv, but ronr often tJie
lympbntic f^Unds ar« siso affcotod, ond flc^^ondaiy tumors fonii in them,
wbicb ha%-e the bhcic peculiarities u the immirj-; nur arti tbvjr aujF
more ape to disappoar epoataaeously iban the primary, even vbcn Uia
btlw i> remored ; oa the <M>atrarj, similar turaore then frequeotljr
Appear in other <)uite remote parla of tlie l>ody — mttatUitic turners.
Here yoix again have the analogy vritli the rvurst- uf iofe«ltoti la in-
flammation, It* »'«11 in the specific distinction, fur motiutAtic growths
nerer result frum phlogistic iiifL>ctii>ii, an^ muru ttiiin metastatiu ab>
■oeases in internal organs do &om infection by a tumur. InfL-otion b
not oofumoD to all tumor«, allliou^h, unrortunalcly, the majority arg
iofiKtiouft; tbßse are called matiff'iiuil, in «mtnuliatinetion to tha
itn^n, or nnn-iiiteetiou». It is difficult to say on what this differcnoo
is baaed ; it is [urobably partly due to the uatur« and s[ie*:iltu charao-
ter of tlic element, in their easy mobility, and in the fact Uiat, like
tlie seed of some of the lower plants, lliey find almcMt et-erywbere soil
suited for their development, and can grow tn most tisues of tbo
body; probably it is iiUu piirlly due to tlio (act tliat the conditions
are more »r le^s favorable to the entrance of tlte elements of tba
tumor into the lymph or blood-vesHels ; for instance, it is remarkabla
that frequently very soft tumors (medullary sarcoma) coiuisting almost
eiitimly of ceJIs, when surroundeil by a &nn uonneetivo-tissue t^npsiile,
CBuae no infection of the lympliatie f{Uinds ; we notice the anm« thiu^jr
io some Wge «ncapsulated abfocsscs. In regard to mvt«»tBtio ab-
soeGsos, I have already told you that, according to my view, they are
due to embolism ; we should have to seek another explanation of
diSuM metastatic tnllaii)mnti»ns. DilTuso metastatic tumors are very
^mre; I should apply this term only to a few forms of pleural and
ritooeal carcinoma or sarcoma. As regards the mode of origin of
static tumors, the actual oourse of the infection, &oin aiialu}^', it
Ipeena very probable that they, like the secondary lumors of llie lym-
phatic gluQcbi, are induced by seed from the printary tumors, or froin
the tumors in the lympbatic glands, I uckiiovrk-dge I am much in*
cliaed to thiie ^tuppositinn. Attlinugh I could not f»niierly Ix'lierc that
tha ceUa &om a focus of inflainntalion or from a tumor could be iis in*
dependent u thistle-down, still, I think that, willi our present kaowl-
•dge about the iudopondent life ot patholugically-neoplsstic cells,
r tbere can be no doubt of the poeaibOity of soch a process. Although,
564
TCMOBa
on Ibe Gntt development of « tumor, u on the oocurreaoe of u io-
fiunntBtor^ new fomiation, the )yin])b>Uo veasels are partly olosecl,
itnd mny bv filltxl witti cells, stiil, Bubaequenlly, from compresuoo,
Ijfmplmtio und viukmIiu- Uin>inl)i mny form, into which spet'tGc tumor-
eleniL-ulH uiitL-r, hixI mmall pairticles uf thrunibi, which niighl farrn
during the soflcaijig of the tumor, m&j cutter the ciroutatioo, beoomc
attached at different places, and form oew tumors. In Tdos, the Coi^
m&tion of (lucli thrombi filled with KpeoiAc lumor^lemcnt* luu actually
been obeerved, and, nt the same iioie, anulo^iia tumors have boeu
found in th« bran(^ie$ of the, pulmon«ry art«rj. It is important to
ranicmber ibat inetttatAtic Liimors, like invtajslatic abHcuaKOB, are oliieQy
found in llie lungs and Uvcr, csci-pt la casna where direct motastaM
is very caay, ns in pleural tuniors, which develop aa a re&ult of priinaiy
mammal^ tumors, as in hepatic tumors found with llioAe of the intca-
tines or stomach; in these caaes a direct «ratide-riiig of ti88U»«lenieDta
through the lyinpliutic v-nutcls in very posiablc. On this point tbrre
is ttill much room for inv<>8tig;ntion, whicli, 1 think, will meet great
rmulta. As we have aUeady seen, the pnxluvts of aoule ioflamau*
tion mmitly liave a pyrogeuoos action ; tlio^e of chronic iuflainniattoa
lark this peculiarity almost as much as do those of tumors; fever
only octnirs in the latter when there Is <Iinnt<.>grution of the iKioj)lasia,
and the products uf the diuntegration enter the otrculatiou; more
frequently, infection with euch excreted matters shows ttsrif in chronic
inflammation in tumors by a general cachectic state, eepecially by dis-
turbance of the general nutrition.
If we oonntder what has been said about: the coutagiousncsB of
tutnorü, we see that there is sonic probability of tlieir transfer from
one person to nnother, though it is not provwl; but theri? can be no
doubt that the lyrnph^itic gliiods end other oigans may be gradually
infected by rarious kinds of tiimorh.
As regards the eSect of fairing cold locally and generally as a
caune of intlaromation. there are no obnen'Htions wliich would justify
us in referring tumors to a n!niilar muse. I du not know that any one
has ever oAserted nnd proved thnt tumors result from catching cold.
Views vary grejitly ubuut «ttehauimt and cftfnifeat ir^a«nce$ as
causes of tumors. Various as the irritations may be, and much as
they hitvc been experimented with, in no single caav lius a tumor beta
caused intentionally by mechnninLl or chemical irritation; infloinnui-
tory new formation» thus developed do itot long otitlast the external
irritation. Wherever imd liovrcver we apply sucL UM-cbuiiical and
chemicsl irrttAnts, we only induce inflammations ; if tlwre be any spe-
cific mechanical and chemical irritation (I mean one acting on the o^
ganism from without, not starting from the tumor), i e,, one from
EnOLOOT OP TOMOBa
S8S
irhose antion m tumor mtul clm'olc^ it is ml present tmtmovm. Thea
the question anses wheiht-r there arc any rcasoim which render it
ihaolutcl^r nei'OMwry to nMurtic tuch tncchnnical and clicmiral imtu-
tion outside.' uf the urganism. I caiuiut agree to this. It is true tbttre
anr mutiT «afs where a tumor Tonna after ■ blow, luck, or injury, but
the number of such cases is very »tiitiU id proporticm to those where,
after similar causes, there is acute traumatic inflammntion, with a typi-
cal txHirsc, or, if the irritation bo coiitiiiu«Hl, chronic iiifiaminatioualifo
with typical course. We must regard ihi» also as a rule: if n |>ortcr
gels « ibidcetiing of tht; skin, with new muuou« buna iindor it, on tlie
spinous procVHi, or if he gets nil ulcer at the tame ptHOt, it in to some
extent a normal reauU, they arc products of a chronic iiillammatory
itatiun, and disap|>(.>ur as »ocjh as the irritation ceases; but if from
same causes a person geta a fotty tumor, which doeK not dinap»
>, but even cxintiiiues to grow wh«>n the irritation cca«e!>, we can-
not here regard the irritation as speei&e, but must seek tlie pfKvdiarity
in Uie affected part. I'rerioimly in genend and hiod itif(^>(.-tious we
reoognixed the Bpecifiu effect« of irritatiun, now we must also acknowl-
edge that there i» a speeific, qualitative, abnormal reaction of the tis-
aue. VirvAatf »ml O. Wi^>fr e>|iOfiully have maintatned that exter-
nal irritation always plays an iuiportaiit rAte iu the development of
tumora ; thia follows undoubtedly from the fact that iwimary tumon
an must frequent at points most subject lo external irritation. Sta-
tistics show that the iiii_Htt freijiieiit M-al of tiiinorv is the »(«miacli,
then the portiu raginalis uteri, then fa^e and lips, then the mammary
glands, rectum, eta But the reason for the development of ttunor%
and not of chronic inflammation in such cases, must l>e a specific dia-
poaition of these parts in certain persons. Individuals who drink
much »pirit« usually have gastric catarrh ; if, among one ihouaaod
topers, one or even ten, instea«! of cntairh, had cancer of the stomacli,
he should be conaidered a» an ainioruial subject, when compared with
the mass who do not have iC Up to this point I agree entirely with
T'lrrAmr, who «jxyiks as follows: "-Althwigh I vaniKit tell iu what
particular way an irritation must occur, tu induce a tumor in some
given case, while in atMthcr ca«e, pcrhnpe under apparently similar
Circnmstanees, it merely cxeitcs simptu inäainuiMtion, still I have c^m-
mrniicated a series of facts which teach that, in the anatomical compo-
Bttinn of different part», oertaiu contiuuuus disturbances may exist
Inch interfere with the rxTCurrence of regulating prooesGes, and
hich, from an irntatjoii that at another spot would have induced a
mple inflammation, excite no irritation from whieb the specific tumor
developed." Among bet« ** which (each that^ in Uie aoatonttcol com-
ition of different parts, certain continuous disturbances may exist "
5M
TDMORa
whioh dispose to ilertdopmcot of tuniurs, FVrcAote mentions adeameed
age It \a pprfccÜy tnic thnt certain forms of tumora »re rnrr frr-
quently fnmid on pailioulitr piirts of tho bodj in old persons, e. g., ran-
cer of ihfs Up. Thiersch cills ätumtion to the facl that in ihv lips of
old tneii th«; conin^clivr tissue isoftnn eo mwh atrophied ihal the epi-
thelial tifisucft {sebaceous, sweat, and muooua glands, bAir-follicles, #1«.)
beooinc vcpy prominent, and, as it were, reoeive the prepoodeimiu» «f
Qulrilion ; that hence irritation hIiows ilsrlF cfairflr in the pn>lt (erat ins
of these cpitbdinl formations, ami thnt this explains tbc fr«qu4nt oo
CUmmoe of epithvtiul cnricor in the lips of old men. i fully recognise
tbc alircwd combination of these ohscrratioaa, hot I mtist add that
advanced age it just as much a genwal <u a local peculiaritt/ iif ihe
body, it i» also stated by Vimhoiti that pUecs u-hieh have been tho
scat of an inflnmniattirj ditieasr*-, which hsA Irft the part weakened,
slso oicatrioea, furnish foui for the development of tumot«. Thii U
undoubtocllr Im^ ; hut if wo company the inniimi*mhlc cases where
simple chninic itiilammation occun in |>iirl« that have been aoute^
discuod, and where simple ulecration otxnirs in cicatrioes, the oaaee En
whtoh tumors oeeur at euoIi points »ppoar very small, and it must be
acknowledged tluit in these few rases we may assume a apeeiße pr^
digpmition whith lead» to formation nf tiimnra. The mith; holds
good for llic fact that tumors arc partic^ilarly apt to form ia <irgaas
whivfa complete their fonnation and development late in life; h«*rp
"Virehoa riaases the articular ends of the hone (whirh, howerer, axe
tt»e »eat of tiimors much more rarely than of eltroiiic iuflamnrntioos),
tbe mammary gUnda, the uterus, ovaries, testieJea, etc. ^\^tile fully
rvoogniziiig the exercise of ubservniit»!) and brilliant ideas by wliidi
it is attempted to prort; the purely locul fiisposition to dcrelopment
of tnmors, 1 cannot eonsidwr the proof as at all conrinrinp, but re-
main of the opinion that tJiere UJusl aa nuteh a sftec\fic prtdixpoaition
to the devdopment of tumore as there it to ehronic it\flammatlona,
with proliferation oflhf inßam mat ort/ new formation, with tuppttrt^
tion, itilh cajteoug deyenemtioH^ etc.
To what haa just been said we must add that we oaimot always
deteet a ioeal external irritation when a tumor U de^'clop^l any nwre
than we en.n atwnys do so in local disease in a scrofulous pntienL
While refernn;; you lo what has been auid on the etiology of chronic
iii flam mat ioos, I would remark that ia rcfi;urd to primary tumorv wo
may assume in many oases tlmt there are also speeifie, so-called litter-
nal trritations derelopinpf in tht' Ixidy itself. M<mI patliolof^rists agree
to thb, but they consider tlie mod« of orifpn and development of
snoh irritations as beinfj^ different. Vtrehow tcsehes that the loeal
disease must hare a local cause, and assumes that at the point of dis-
BTIOUHIY OF TUKOBa
&S7
esse Ibere are certoio local cooditioos of debility. If this w«re so, vc
«bould hace to asmime a i|>ccific luesl debility for ttut must iHfFcrent
dJstur1»ncrs of iiutritkin and fur forrnxtion of tuiuurs. Riii^eiach
speaks very dcc-tdcdty of internal irritation aa follows: "By the
oliange of subetanoe id the tissues, oertain excretive eubetnneeB are
cooataatly being formed, which munt gradually be pa^ipd nlT from the
tiaBuCB aiid orpins in whirh tbcy furm. an ncll as from thu fluids of
the boily «t Ini^, in okUt thnt the life of the individiinl may be un-
disturbed. Tlii^se bodies luive their chemioil position bctuuen the
organopoictic bt>dirs on the one band and Uie excreted matter of the
kidneys, skin, and lungs, on ll)c other; thus they fall into the great
gap that exists in organie ehemistry at this point ; they are different
lor the diiferfMit tianucs, and on this differenre depends Ute variety of
pathological new formations. If they are tronsfonncd and excreted
noniiftlly tliey eolleet fint at the point of their origin, t)ieti in the
fluids of the ImnIv, nnd tliis collection is the immediate cause for tbe
cxcitcnicnt of that progrcssire process whJeli bcgine with muLtiplica-
tion of eelle in the eoniiixetive tissue, and ends with tbe development
of tubercles, cancer, cancroid, fibroid», li[K}mBta, etc," I can entirely
agree with lUin h^'pothi^i», but must add that it sceroa an error to
suppose that we here speak (ihiefiy of local proeeaaes. The pmduo-
tiou of bile and urine i« alan a local proceiw ; for iheni to be pmduced
Jo such quantities and uf such a quality as they are depends nr>t only
on the glandular oi^ans, but on the entire organism to such an ex-
tent that we must sock the original causes of the seorvtiun of urine
and bite not only in tbe blood, but even more remotely, ni-en in pe-
culiarities of origin, as far back a« Adam, if you please. In the »ame
way, I think Ihiit lUe original causes for Ihe lival reqni remould for tlie
development of tumors must lie sought in apeelRc peculiarilies of the
individual organism ; in tbe same way *re »peak of a«eTofutou8 or ti^
bereuloufi person, iiieiuiing ihi* |)ntliological «ce, as it were, U> whidi
tbe individual tx-lnngs^
I mu»t lastly add that the supposition that the cause of disease,
the irritation indu^nug the tumor, develops locally, where the tumor
sftenrard fonns, is as purely lij-polbetical as any ihiil has yet been
advanced. Let us tidte artlirili» as an analogy: HaivtJci indiiceil the
most ^^ieal arthritis in a goose by ligating the ureters; an artieulnr
disease restiltiug from disturbance of the function of tbe kidneys.
Possibly tumom might just as well develop in any tissue from dis-
terbaiice of th« hepatic furvction I Very many things are possible.
We know nothing oertain on this pointy and mo%'e entirely in hypoth-
eses. For my part, I find it just aa allowable to assume a diathesis
bore, as ia scrofula, ariliritie, etc. ; that, partly from unknown, partly
6fi8
TGÄOHS.
Erom known causoit of gencm] nutrition and ONUa&ry randltiotu of
life, abiKiniial nutters proceed, which have • specific irritant ictioa
on this or that part of thp horlv, analo^oufi to that of certain dnigs.
LmcIjt. if to this vre add iIimI. the dutlbt-sis for pmdui-lioo of tumor ij
hereditary-, aUhuu^fh not to BUcb an extent u» the cbraoic ioflantiDatvcj
diath4?sis, the dtwlriuu of wealmeM looilibs] in certain ejstems of tis-
sue, or certain parts of the bodj, setnns eittirdy lutteoafale. liiere is
certainly a local cause for the inenib4>n) of on« fomiljr having large
aosee; in proportion to tin- faoe, they bavo grown larger than in oth*T
mflDf still tb« largn nose of tlie fatlier cannot dcsci^d directly to the
SOD, it nan only be iuliertted from the fath<*r through the epemiatoau«,
and thore the original cause i« to be »ought ; nil pcouliariti«« that dc-
acend hy !iilierit«nei_* art« unquetttHiimbly to be lenned conslitiitionaL
I have now occupied you some liinc with refleetitine which auma
of you may consuler very tedious ; they will mV me. Of what um
are the«e Ihing^ in practice? Then, iiu fori una t«ly, I must acknowl*
edge that practice pays little attention to thcni, because they are so
hypothetical Tlio»e of you to whom such ideas as we liare just
spoken of do nnt occur, I advise to pay no furüier attention tn tiieint
iKit to be obiiffe<i to speculate as to llic final cause« of tilings is, Ui
a iiertutn sense, an cDviablv qtuility.
For oouveniencc, let us comprise, in a few short prupositioiM, what
we have said regarding the etiology.
Tuniora, like inflammatory iiedplnstse, result fmni irritatioQ of the
tissue ; the difference in tlie cauaca lies: I. In the specitic quaiiiy of
the irritation. Infection of healthy tissue about a tumor, neighboring'
lyDophatic glanda, ctc^ is eonsidervd sufuoicnt proof of tliis. It is
supposed that, wider some unknown circumstonoiw, tbi« speeilie irri-
tant may be fonned locally {Iiim(fieijicft), I think that, partly as a
result of hcTcdiUry pn^üsposition, partly from a developed tendency,
that is, where there is a diathesis, wo may imagine tlw formatioD of
materinls in the fluids of the body, whinh Ktiall have a specific irritant
action on on« or oilier tissue. 2. Any, uHually an iiilkninuiLory, irri-
tation may excite a tumor, if the irritated tinue is specifically disposed
for the devcloj)inent of growths. VifvAote, O, Wtitr, Jtin((fUiaeh^
and others, ussutne that such specific peculiarities are entirely looal
and limited to an accidcntally irritated part of the body, or to a ocr-
tain system (bonea, skin, muscle, nen-e«, cte.). I cannot imagine the
localimtioit of such spedfie peculiarities ; hence, even with this hypotli-
oaia« it seemn prolinblc that tiie apparent local specific pecuharitie*
are due to tlie intimate relations of the entire organistn.
Fn>in this representation you may see that the different views
only dllTer in the purely hypothetical [lart. If I entered into the sub-
PBOONOSIS ÄXD OOÜBEE OF TÜMOBS.
SM
ject more fully than seetnod neceeauy for these lectures, it was b«-
cauae this very important branch of general pathology has lat4>ly
been 8o exhaustively «nd cxcelleiiily trcHteil of by FTrcAow, O.
HWw, Bin<^it<k, Lücke, TÄiVr^tA, IHtb«, Waldtytr, and others,
that I oonsirlefed it neresftnry to (lovt'lop more fully those parts of my
views where 1 (ItfTcfcd TTOin the«e uuthuni, whose excellent writings I
, oannot too strongly [uoonimuod for your study.
n^nl to the pro^noait »nd eowte of tumom, from what bu
sai<l ymi naj infer; 1. That they tieltlom recover tipontan«oii«1y,
nor ar« lltey Moeuible to medicine«); and, 2. llial tlioy »tv {mrtly iiH
fuvtious, partly not so. The lattvr |»oiut is [wrtiuularly striking to
unprejndioed ohseiration. Tlierc are aomo tumors which do not re-
turn after exi iipatiun, and oUiers that not only return in the cicatrix,
but come in the neifchboring lympbutic KliUi'<I'^ nndutso in internal or-
gans, as already remarked. The former have for ages been called
benij^iianl, the latter maliynant or catuxroiu. This obserTatioa is so
simple that it would eerm siercly ncct^ssary to study exactly the
peculiarities of c«ic or other form of tumor, to arrive at an aooiratc
prognnsia. Uut accurate cUniral and anatomicJil study did not lead
to this di-Hfcd simple refill of this dualism, but it abowcd that the
latter did not exist, that the conditioas were more oomplicotled. After
an exhaiuitire auatomicsl study and description of benigiuint and
malignant growtlLs, they were examined under the inicrosco))« and in
[the retort; it was thought that tb« chamotcriatic marks bud boon
now in one point now in another, ant) soon ono di^oorery after
ft proved enutit^ius: it was thus shown tlmt an antithesis of
absolutu malignancy and bcni^nnacy did not exist in the sens« meant,
and that it was necewuuy to di«tinguixh not only solitary, multiple,
and infe<'ttoius luinuni, but that n KOilv must also lie made in the grade
of inffx-tiousncss. We must investigate this murv cloacly. Wn call
a tumor »olitary when only one occurs in tlie body and causes purely
I local symptoms; they are usually growths consisting of any fully-
»develotH^d tissue — fibroma, diondroma, oAtoom», etc. Wc speak of
I tnuUipft tumors when a series of similarly-organized growtl» occur
^Only in one eertain system of tissue; for instance, when uumorous
obon<lrümata occur only on booes, or numerous lipomiita only in the
Bubcutanoous cellular tissue, or many librom&la only ld tlie skin, etc.
I As gi-ni-rolty acknowledged, titerc la ut the mine time a predisposition,
which i'ircfioto regards us purely local, but which, as alrvndr stated,
I must consider constitutional. In general, we may «ay that all sorts
of tumors nwy oceiir as solitary or multiple, although the latter is
BCO
TUMURS.
very rare in some forma of tumors. M'c apply the term infectiottt Ui
a tiunor uliit-Ii not only growa into the pnru aroimd it, infiltrating
them and tlms constantly growing- by ■ppasitiaii of dbw foci, bot
whiirbnmy nbri Jiifefrt Lite next lyntphatic glantl!« and ßnally other or»
g*ni. Ju tlii& respect ttiera are very great difTereDcea: in some tumor»
the infection (>xt(>n(U rc^nrly only to the next lymfdintie glanda
(carrlnoniii of tlto Ii|i« iiikI fate); in other case« from tlist pobt
it extvndu further, ospecinlly to internal origans ((.'«rctnoaia of Ike
brenfti); liially, infection of llie entire l>o(ly with mcuuttatio lumon,
witliott ii)ff<'tions of ilw lymphatic glnndR, iKimctinieii ocrtins (scme
forms of Nircoma). Moivorer, Üic rapidity with vrliicli itifi-rlion fol-
lows, vurii-s grt'atly. If we examine iIm^ condition» utwlcr which in-
fcctioua tumors develop, and their anatomical structure, we shall sec
that tliey orciir efl[>ecially in aclvimced age, al>nut equally in Dieo and
women, and partit^ularly often in eerlain organs; that the age of ehiltt-
hood is diiijKDu^ to infectious grovrlhs, enperially to malignant sa^
eomnta, while iti youth ami the firei ytvi« of adult uge very few tu-
mors of nny kind, and espcriiilly few mnlif^ant tumors, dcvelopi
Jforie «if h'fe, pTMxl (>r bad food, poverty, riche», chaiaoUfr, nationality,
and cultivation, appear to hnvc no special influence OQ Uie develop-
ment of tumors generally ; nor cantfc recognize any spe(ä6c influenoe
of thefie powers on infeetious tumora. The Btudy of the anutMnieal
structure of lumorv hns been punned with greHt zeal of Ia)<:, and It
appears tliat u hirire number of muli)!^umt growths have characteristic
mnoroHoopie «ntl microseopie peeiiliarities, hut that a correct progno-
sis CHnnot always bo baaed on them ; in gvacrml wo may any that
they are usually very rasrular tissue formations, disposed to ulocnttinu,
and in their coun^e proving to bo infectious; As it is most probabli»
that the infection results from the locomotion of specific tumar<1e-
ments, some of the factors relative to reabsorption may here have
Bome effeet. The quantity of blood and lymphatio vesacis in th«
tumor and ilü immediate vieinily, the conditions inllueneing oi)eniDg
and cloflurc of these pasaagea, and tlie actirily of the circtUuUoa ge»
crally, arc to be roiisidercd.
IiiftH-lioiis nmiiin« are URually at first solitary, verii' seldom multiple !o
the scMiftU above i iidicnted. l^uinors lliut nn.- nmltiple from Üie start ore
mroly infoetioiw. When we use the term« dangerous, malignant, and
Infectioiiit, ax t*%TionymiHi8, wo do so without reganl to the Iw-ality
where the Ivimor» arc developed, A nolilaiy tM-arii|g:nant tumor in ihe
brnin is »Iwitya malignimt, from ita loriüity ; nn iufeetious tumor at Umi
same point possibly never goe» beyond local infection, as il soon
proves fatjil. All thesv things ore to be aircfuUy wcigbi-d, if we
would obtain dear ideas on these points.
TBEATMEST OF TÜMORR
991
TunooT» are not slway« U> l»c termed iii£tclious (malignant, cati(?(>i<-
Oua) beoaus« of a return at tlic point of npcmtion. In this case U is
T«y tRiportant to dm'id^f whtthwr tlic rpcttrritijf tumor lias started
from portions of the uri^nal tuninr, that have been left at t!ie time
of opcntton (oonttmioas rccurretiRp, TAieracA), or, pnesibly years xfter
B perf«.-t o]M.Tation, a nevr tumor has ooruncd from aimilnr c^aivw^ in
tfae cicatrix or in its vicinity (rt-gional ronurrencc). If tlii? jKjitit of
operation remains frcr, and, uftL-r the operation, swellings of the Ijin-
phatic glands, of ttic same natiuv as the «xtiipated tumor, appear, or
if, under similar eircumstanees, withotit swelling of the lymphntic
gbinds, growths oceur in otlter organs, it inay he considerrd certain
that these lymphutio glaiid.1 and other organs were already infected
at tho lime of tiperatio«, although this may not have been mseeptible
of proof on eiaminatioii.
WHien a person is infected from & tumor, we teim It a rfy*CTvwta,
just as we do when one is infected from a focus of inflammutioti. la
»uch pemons foreign materials circulate in the fluida of the body,
iiitluring in tliem a palltologieal eondition. In iofertioiis tumors this
dynonuiia displays itself by general disturbanee of the nutrition — ema-
elation, manuimus ; i*o\r soon and hnw ext4>nsiTely tbJH sliall otwttr
depcD<lä very esacDltalty on the »eat of the tumor and ita pecidiaritics
(aoltoaing, becoming gangrcooas, ulceration, bleeding, etc) as well
> oo the strenglli and age of the patient
About the treatment of tumors in general I shaH here merely
mention that tbej" nn_* rudy ciinible by remoral from the body, wheth»
by the knife, ligature, &;rutcur, caustie, or any other means. Tlie
removnl of intense and rapidly-infeeting tumors is uinuüly merely n
means of proloti^finglife orof alleriating the sufferings of tlie [Mtieiit;
'tumora that cannot )x- openttcd on we can oidy Irent sytnptomati-
'CftUy, to ease the patient. I «hall speak of the itHtications for opora-
^ting when treating of the diftsrent forms of lumora.
Now, when pawing to the eooiideration of the difTcrent forms of
tumors, we shrink from the mass of material before us. We require
a leading principle to enable us to arrange the various forms of tumors
H'liich dilTer so much anatomieally and cliniciilly, and to consider them
ill their relations to each other and to the organism at Urge, llie
prinriples on which tumors have Wen elssaed hare for ages lieen Juat
as different as those on which diseases gencnUy hare been and ant
still divided. Xoue of the classifications of disease jiropcMcd so far
fiäii
TCKOftS.
have lieltt tbeir place long. MedioiDo ü now taugtit in T&rknis gtouft
of Mnoller Hystoms, and the principles for fonning such groups are
choseo for various rciisoris, Ikiut« j>al1io]ogi«iI uiatiuiiy wn& Je-
Tclvpcd, some promiiicut »yttiptoin wM taken ; lieucc w oliil liuw m
medicine Uie t«n»» ictaru», apoplexv, etc., to denote rertaiu diicmee»;
in llie same way, a» you know, we haxc hiinocs deaij^atcd '* polypös,
Bcürbuii, lupus, fuugus, camnuma," etc. Aa eoaii ■» tiic ejiaptomt
icterus ftiid apupk-xy utTO unatyzod ami fuuiid to dopiiid on rnj
dificfiHit anatomical causes, these tcnua were bonUhed and nrpUocd
by others denoting ihc anAtoniical raudition. The pstbo1ogi«Huia-
tomicaJ amngemcnt of diseove, u propoied by Kol'iltiiiitly, for in-
Ktanr«, is undoubtedly scientiGc, M Is tlie system of gf nerul {ijilt>oIi^v
of Virchvtc ; still, □vitber of tlivm is B<;ce))t«d without mwrvc by
clinicnl tpiuvh&rs. It n-sa desired to divide dtMWSCS aoondin^ to Uidr
peculiar ualure rihI cause ; but 3c/t0f ibein's attempt to finiiid a ■ysti'ai
with Ulis idea &iled, for our kuowledgc of the eauees and luturc of
disease is not sulTioicot fully to carry out the plan, Mlial, thcti, is to
be done? Practical medicine and surgiuy start partly from the an»-
tomicnl system, nonhider this a« genrrally known, and use it for sub-
dividing more extended descriptiuiis of diaeaBC founded on ui etiolo-
gicsl, pn^no«lte, symptomatolngieal, or physiological basis. It vouU
certainly not Ik unscientific cwn now to write a tiiunofirajih ou icicnis
or apnpitixy — theu the anatomical conditiotts would come in the eeoond
ratUi ; pslbolugioal anatomy is used as uny uilier aid lo selence, as dieni-
LstiT, physics, eta ; wo always try to bear in mind that ilie object in
&tliot)üng til« whole process of disvnse lie« not in limply fallioiuiog
tlie morpholoffic»! eoudilions ; it is deeirable to understAitd luil ouly
thp aiiatornical change, but also the mode and causes of the physiologi-
cal disturbances. It would be decidedly unscicnti&o in typliiDf uno
if a number of pnlpublc ehnnfres wp^e found, to admit nolbiog except
ttie [»•culiiti iiitcsliiml infliiinnialion ; we may reganl this as aotiiething
of the pust. Could wc grouji all discMes from an etiolqgic«! point of
view, it would be an immi.<n»e advance; then pathological physjoli:^
would tahe the plaoe of pathological i»(>r^>ho)ogy, while with our
present knuwledf^ we ore quite praud if wc aecurutcly rcvognisc tbo
morphological dt-velopmi-nt of llic morbid product, fur we can then
say that we know at least one important faetor of the juitltolugiral
proocse. Jn fact, we know no mure about normal development; it will
bo long before wc iindentand (he pÜysiology of tlic growing fa*tU8.
After these cons I derations, we may not be any mrji« particuUr
about the olassificnttnn of tuiiiara. thH4i we are in the othrr diseases;
we most see that there will be a difference according as we choose
etiology, symptomatology, prognosis, or anatomy, as the principlo for
CLASStnCATION OF TTIMORa
its
dirinon. FonxKrly, sur^imns prpfcrrpd classing tumors according to
tbe proguosis of the individual forma, into uialignant and bcoii^aanl,
and adding a few Bubdirisioafl acrording to the appeanmoe or oon-
•Isteace of the tumor or the looks of its rut mir&i-e. TliI» wus enot^h
M long tB observntivits on Uivse subjucts were miulu tti the gross, ntid
Uie nngeon mnde no grent claims in prognosi». Dtit tUi; more accu-
rate the observ-ations at the iKMlüd«, and the more rar[cd the farms
in which the neoplastic tissue appeared under the microeoopc, the
mon^ impni^iblc it biK-amo lo mnko tho anatomical peculinrittes of
tumors agree with the old views of malignancy and benignancy.
While now most surgeons and patlxJogical anatomists gave up the
idea of letting the prognosis plaj a part in tbe olasnlioation, and sine«
J6ha»nrx Müt/rr'a works on this subject turned tlieir attentkiit to
working out lliti finer nnatoniv and develüpmentid layeni of the
pccudo-plasma, I still made some attempts to retain the clinically-
prominent symptoms of l>etiigTiHtinr ftixl itiulign»ncy in a man ea-
largcd form, oa a busi» for the ctussifieatioQ of tumoia, and undor
these to arrange the modem acquisitions of pathologicsl histology.
Either I did not und the correct form and expressions for toy ideas, or
th« task I tried was imposshle, fur I remained alone with my ideas on
this subject, and oon»ir!er it my duty as tfttcfttr no longer to hold po
bolated n position on this difficult question of olassification, as J
should interfere with your oomprehensioit of otlier excellent works on
the subJL-ct. Moreover, all I have to do with my former division is
to leave out tho geniml grouping of tumors in four eliief divisions
according to their roalignancy ; in geticrnl, I have (bllowcd the ans-
tooiical division of tumors, and may probably say tliat my own inves-
tigatioiia have bad some influenoe on the development of the histology
of tumom. Although I am «till of tbe njMnion that we should not
omsc seeking for a physiolngical (otiologicAl-prognnstic-, oliniaal),
rccogni^on of the process on wliich the formation of tumots depend*,
and althoiigb I should even now extt'em a dii-isioQ of tumors cm phy^
iologicul-f^-netic priiK^ipIes more highly lluui one on anatomic&l>g^
netio principles (which was VirfJtme"! idea in his wonderful dasde
work on tumon), still T abandon further attempts in this dircdion,
and follow tho anatomical principles in cloaatfication, passing grad-
uulty from tumors formed of simple tissues to thoe« formed of more
complicated tissues.
lAstly, I mtui mention that T Yoluntnrily and Sntenlionally limit
my lecttirct to those oases of tumors which, in the oomfiienoemeot of
the diseue st leMt, are sented in psru of tbe body belonging to sur-
gery. Iliis limitiilion is uol so important as it srrms ; we nftiy even
say that the peculiar ouursc of tumors can only be studied in its
594
TTMORR
purit}", when ihpy «re locatetl ia parts where tbej do not dirvcclT
cadan^r life; for the symptoma wliiHi thev musr wlien in Unr,
Sionaiiirli, or bt«iii, are QOl tlioee due to tho tuniors tli«uisetvo, bot an
chiefly düturbance» of function in the affecCed orfinn. If e^'i.T\' ivphus
mu ncii.x>ni[Mnif(] 1>y fatal iiitCHlin«! ho-mon-bagi; or jKTforution of tlic
iDtcatiof, wc should nc^'cr havu n pure rt-prcsi-ntiitiu« of Üio ■''■^f^^
prop<.>r, lis its courso would always Ihi <Ustiirbod. Wu shall here uid
there remark on the relative frcqueuey of primojrj locmliation of ti>
mors in the internal organs, but cannot go into Üio eymptouiatologj-
and histology of the cliBeBsed organ. On theBo poinla you uill bo
iustructud by the pathulogloal UiatoniiBta and In tliu medical cliiiio.
LECTUHE XLVI.
1. I'Artmtta: a, Soft; J,IIiinl!^t>ramft.— Hodaof OocuTrenc«; Op«nti»ii*; X>lgatu
EonMoD*!)!; Uklvino-oiuiiie. — 1. Üfvmatmf AaMooij ; OMorrvn«« ; CooraiL
1. HBBOMA-PIBeoCS TUMOB-OOirSECTlVK-TtSSDK TUHOB.
TcHORfi compoMfl chiefly of dorelo[>od oonnccttvi> tusate «re
oalled GbnmiatA. They u«cur in the following fonns: a. Softßbrtm»
or eomteftive-ttsmte timtcr», Thcsti are ipiiti' frequent, and are located
nimmt exclusively in the cutis; they are composed of a very tough,
soiiiewliat fvdeinatous, irliilc tiaaue, and »re usiuilly corored by tbe
thin pbpllliiry layer of the cutis. Microscwpic eiatnination shows
loose connective tiiuiue, as in the cutik. On the surface of tlie tumor
there are »lino»t always pointed papillop, even when the tinnor is do-
Tdopcd in a, part of the »kin which nonnally has no pnpillic; in tJie
retp Muljii^fbii of tli«!e fomiatioiiit, there is often a brownifth jngment,
which rari^ly extends deeper in tlie tissue; they niuy also have bugv
Tcsflela and abnormal onlargemcnta of the hiiir and sweat ji^ands on
their surfHCp; they an? usually loosely hnn;»iug (oiitis pendula, molu»
cum fihrosuni), often distinctly pedunculated tumors; tbey miglit be
termed partial hyiierplaaiaa of the skin, as they conatst eeacntiaUy of
the elements of the akin. The growth is very slow, Ireefrom pain, and
often gne» on to the development of ennt-mm» tumors. Occssioaallr
such growths are congt-iiitiil ; they »my be imiltiplc ; hundreds of them
may occur on the surface of the body. The congenital cutia-prolifer»-
tion is most freciueni on llie face, generally unilateral, difTuseor in Ok
shape oftoft, cock'»-comHiiie vegclntiou». Frcckk«, piginented hairy
motlicrVmarks (moles, bcuigitaut aiclanoec», melanoma, pi^^enied
PIBBOMATA.
M*
Fm. ]ua
fibromn) belong to this cUkx. lliese tumon are apt to occur toward
the eiiil of inidtUe life; in uoncn, we not imfnH|ufn)ll^ fiud Lheiit
haoging from the lubia mnjoru ; w growths uu this part arc conoi-Alcd
l.loiig tu [VHwible, llitvr uro usually quitv litrj^ wbvu firet seen by tho
Sorgcoa. VirvJiote tenos the disease, in which these multiple, soft,
fibrous tumors develop, ieontiagi* ; in the ci>urs« of time they »ro
OocssionaUy accompanied by general dicturbonoes of nutrition. Ai-
tiiou^h tbiise tuiiiore ure not infectious, in tbe meaning we luiTe At-
tributed to tbta trunl, they oocaaiooally lead to a «ulieetiu state, and
in the «oun« of y6«rs to death by marasmus, Tliere U aUo a relation-
ship between this disease and Oiicntal olepbantiusi», altliougli by thi«
[Dame wc mean a more nodular, but at the same tinici ruther diffuse
hypertrophy of llio cutia of certain part» of the botly (labia pudeaJa,
BCTotmii, legs), whifib run» its course with rupested erysipelas,
ft, ^Firm ßiromatOyßbroid, da-
moid tumor» appear t^i the uuked
eye to be composed of vcrj" (inn,
closely • interlaced filiruuii I is.siie.
They ore always very hard, and of
roimdii^h or tuberous form; their
cut surface is pure white, or pale
reddish; in the iinkeil eye many
of tiiem show on their cut sur&oe
■ very pecidior, rei^ular layeiing,
and a concentric arrangement of
filament.« amuiul dislitict axes (ace
Fig. 100) ; according tu tiiy tiivesti-
gatjonsi thia result« from the fibrous
formation taldng ploc« around
nerves and vossels, the liitltir being ci>use<|ueiitly cmbodcled in tbe
mklst of the Sbruua Inycr» ; &i»)ucntly ihc wives arc tlius di-slroycd.
With the cKtenial peculiaritice just described, the histological ap-
pearance r<>DdcrB ildillii-ult to classify these tumors. There can Iw no
doubt that those of them which consist chiefly of connective tissue,
such us old uterine libruidit, ahoukl be culled librunuita; but tho
jouDger tuiuiM« of this rarioty, witli tho same appearance and coa-
.siMence, show litth: coniiective-tissut) but numerous spindle-shaped
'Ceils. The signifiisuice of these cells ia varied. VirclvJte considora
them muscliMiells ; houoe, what luivc hitherto bceo called Shroida of
rtlie uterus, he dues not cIssh among the fibromata, but among my»
Bod terms them ** myoma laivicdlularo.'' If wo otinsider fibr^
c^lls »H young conneBtive tiaeue, we must cliristea these tumon
spindle-celled oansoiu or fibio«aiOQiiib Vou iee here, in apparcoUj
Soikll Sbtom* 'iDTivllbruniB) of Ibc ntcruB;
uiUinl lU* of Un »«etlou.
sen
mttm.
Htmpl« fibrous Hbhihii, fre beoome involved in difikoilti«« witli liistolog;
and luistogi-uy. Hicre luv ivj tilings tiiiit would iuducv niv Ui n.*t^rde
fibro-ct-llular lumcie &s inyomutH: i. «., th« oral and AdaIIt rud^ike^
wavy form of the nut-lei, and the vcrv distinct airangcmcnt of th»
fibrotiH layers iiito bundles, wliil« ihv. individual fibre-ccUs are iao
lilted with difficulty, perhaps only by aid of the recopiiaed ohenioal
means. At the anin« time th« noil in which the tumor is dttvetopnl
is very importunt, the probabjlitiea for a myoma would be very gtiM
if tbc neoplasia occur in the eubaUuioe of the utcnjs.
Fl«. lU.
;^
,A>
Fran » mjo-Dbran» of ih* «itrai. Miwntllpd no dtmneicn. Ohilqse tnd kmeltiidliia) Mali
or oiDHolihr wtl-buDdt«».
Fibromata arc oa^ble of 30mo «uatoiniöal mrtaiiKiqiboaoa. Pai^
tiiil miJcotiK goftcning, great seioi» inßltmtioii ()>rawny appoatanoe
and consistence), calcification, and even true osiülicatioo, arc iMt vei^
ruic. &u|>oriiciiU ulccrution ia quite (requcitt in fibromata lying close
undL^r a muooiis nienibruiio; it rpsului front rxtvnuil iujunoe in titti
usual way. The ulcer, (hua fonnwl, oftiiu shows good granuUlJoni
and 0iippuTatioii,antl, under favorable drcum&tanoes, it maybe brought
to oicatrin!. Elbrous tissue, though apparently poor in vmaels, often
contain« quite a number, both of arteries and vein», as may b« shown
by injo<.>tions ; occusioually a very ooane cavcnioiu netrwodt uf veins
llw iMMJiMi mik, l^)iHiiiriiiiiiiij.li« iilii Il>({i>iilwl •) dlmicur«.
toinio*] niecbniiical caus« (or blcfdinj^ from filMMm«tA Ixring ao pro-
ftiW, and why frequcntljr it is not «m^tcd without artificLil «id. The
rigid giping opeiiiug of ih« vessel n-iiden (he fonnntioii of ft tliromhus
rery difficult. Üccuionolly, in larffi' uterine aii<l in periont««! fibro
DUtA, wc find lacunnr fissures üllcd wiUi thin »iTuin ; po««iblf tbcse
ant eotatic pathological newly-formed l]riu]>h nduscs; thcru are do
certain oI>s^rr&tionB on thU point. OftWticfl, as large as the bead,
filled with ficrum, also oocui- in uterine fibromata {^>fne«r Wtät).
The localiuttDO of fibroim varioa grratly ; of all tho organs the
utenia is mo»! frequ^Titly afTc^cted (if under the general term " fil>roid **
we iftdude nyo-filiroma) ; here these tumors occasionally attain an
enonnou« niz«*, «nd then not ntifrrqti^ntly ralrify. ITipy are usually
roundish, mid an* distinotly and »liaqtly liotttKlpd: thnj arf nmst tn^
quent in the Ixxly of the organ, rarer in the nerk. und hardly ever
oconr in the vaginal portion ; llieir growth pmgressos upwmn) aod
downward, that is, into the abdomen, gradually stretching Uie perito>
508
Tuuoas.
muni, or thmuglt tbe os utori iiilo Uic vAgiiuu In the latter direeücot
the turaora contiiiur to grow-, bt-camc pLtluitcuIatcd, and often gir^
ride to severe luciuorrbn^s ; tKey arc <:»il<:djibrvus uffrirtej^yjn.
Fibrutnuta, starting ftom the pcricwttiura, are quite frequdol ; tli*j
are almost altvays Abnvsanximata, i. r^ tliej arc couiposed of fibtca
aad epiu<Jle-&liaped ctlL, tlic latter luay eveu prc-puudeinte (fibrw»
sarcoma, JtoX-ittJitxky). The periosteum of tbe bone» of tlio kIeuII ud
fice 18 piu-liciihu-lj' linblc to itiis (ÜHcase, cspt-ctsUy Uie Iiiferiui UirU-
tiatcil buuc ; fruin this {HÜiit fibrotnata projc-ct iuto ibc nasal cavitka
niul fnwes »i imlyiwius growtlu (fihn^us uaMt-pharyii'jdil f-olyi'*)',
by presMure tbey may uiiise rralworinion of tltc bone and grow into
the rraoiutn or autruta Highmon ; tbcy arc particularly va»cular. I
have ä]»ü St? i; II fibromata on thepurioKloiini of t)ie tibia and €laTirlc,uid
in booe itself, as io tbe upper maxilla, ubere I hare mot slTaii;;^ com-
iMnations of choadroma and ßbmma. lastly, we have to mctitnin tint
Bbromata arc not rare in and on tbe nerves (Fig. 103), Frcquc-utly aQ
tumors occumDg on nerves are called neuromata, but tljey are distin-
guislied according to their uiinloiiiical clianctexiatica ; mast qcutoidbU
VU.10L
NanToma. stlpr fUlHk
BqiiiII nodular ttno-tuttMatUion
ifntu» from iImi ajAlld Of a b«j;
iMtuikl lU«.
arc fibromata or fibro'finrcomata in the nerve-trunks ; other« conuat
partly or entirely of newly-fortnod nerve-filamcnta (/rw nturomaUi),
Sometimes the uerve-Bbromata follow the nerre-lrunks and form nod-
ular (xirds (plcxifonn neuromata, VerturuU) (Fig. 104), on wbfiae cod-
flnonce, as aln-ady stated, the peoidiar «ppearuooc of Ibc out surfkOC
of the 61)rcniia (Fig. 100) occasionnlly depends. Fibroma is f&n In.
FIBROlilTA.
n$9
the subcutaneous cellulsr tissue ; in the ^Isnd», except, pokaps, In th«
mamma, it liunlly ever occur».
Tlic filirous tumors just «numerated arc parti culoiljr apt to develop
middle «ge (from thirty to fifty years) ; they arc met in youth, and
II Rioi-e rare in advaoced age. Wb«n we find tbetn in the ut^^rus
I old women, tJiere will prohafaly have been tliere many yeui^ Oidy
ucurumala, and bon« and perioxteiU libnjmat*, occur iu young
porsuiis, nut exactly ill «.-hilclren (ihoiifrli 1 »tw oncouKCof iii'un>fit>roma
in a boy »even ycara old), but usually after puberty. Fibromata
«re somewhat more frcquvni iu women tkan in men ; uterine fibromata
develop about the tliirty-fifUi to the forty-fifth year, although the
trouble from tliem ia often experienced later ; they are rather more
4u«ul multiple than »olitar}' ; perioat«al Ghromatu uauiUIy remain
lUCAty, but not unfrequentiy return, though, pprhupA, not for yc*t«
»gioDal r^curreiiee ; relation to Mrcoma). Usually the growth of
fibroma ts purely eculnil, aud tlioy aru nut infectious ; but infectious
tibn>mata »rv Niid to oo^ur. Several such tumors nc&r toffether unite,
infiltnt« the aurrounding parts, and occasionally cause fibroid d^en-
eration ot the neighboring muscles, bancs, and lymphatic glamU. The
infectious fibrornnta that I have seen were always Gbro-eari'omat« ;
like pure sarcomata, they may appear as metastoseit in tlie lungit.
^bromatoua neuromata are (|uilc frwiucutty multiple, especially id
different bmacbcfl of the same ticrvc. Some time siuoo I extirpated
six ueuromnta from one mnii ; throu from the loft arm, three ftvm the
icft lower extremity. Cases have been seen where there were twenty
thirty oeuromat« at once.
Pure fibromata usually grow very slowly, and in ag«> their growth
IM occasionally cbecJced. This is best kuou ii of ribroin» of tlie ulurus,
which uAually c««ses to grow after th« change of life, and then often
bcoorno« ailcareoua. OomlMnatioiis with other ttMuofbrnutions» es-
pecially with sarcoma, u» already stated, otcvir, und take place in such
a way that the primary tumo» pmeata fibrous consistence, while the
during tumors nnd secondary tumors resulting from infection arc
ift cellular sarooniata. I have seen such cases. A man about 1 wcQ*
ty-fivc years old, of hcaltby appearance, had a lihro-sarooma aa large
aa a w»ltiut, in the abdixniiia I walls ; it was entirely reinored ; a new
icir appeared in the wound ; suhsequeutly several soft tumors a|>-
ired at other points on the »urfiic« of the Inxly ; at the same time
the patient bcosroe marasmio and died to a few months ; the whole
lung was fdled with soft aarcomnli »is tumors.
After wlial has bee» said, the diaguuois of fibroma is not difficult ;
the eonsutenoe, locality, age, modo of attachment, and fonn of the
iimor, ainioet always lead to its correct reooguitioa.
svo
TL'HORS.
Tlic treatnunt coaeitta exclusivply in tb« remonl of the tumor.
'Wlicu pittcticatile, this is generally done with the knife ; but pediui-
culkt«d or litngiDg oonncctive-t)»6ue tumora and tibroue polj|H admit
of other nivtbods of operation. Fornierlj tlte lij;f.auR> wa» much ro-
Bort«d to in such casu«, i, o., Uie pedlrlv of tli« tumor wus tiixl tightly
witb a thread, so thai it b«caiiM gkagrcuou» aud full oS; tlüa mctlKK]
■Ktks cboe«a espocdallj in caa» whore bleeding &ori the cut sur&ce
vi»a feared. Ligation has the great dimulvuntage that then the tumor
deoompoaeo in or on tho body, and that tln^ ligalun.- uiuat In.- tighltmcd
several tini<« before it cuts through ; this may induoe sercre bRtnor-
rfaago. The ligature may be combined wiili indsion, by cutting off
ihe tumor in front of the ligature, and leuviiig only part of the pedicle
to become detached spootanoously. In ih» uarcs and pharynx, as
well as in the vag-iua, thero is of couna grvat difliculty in applying a
ligature, and for this purpose numerous itutrumcnts, simple and ooin-
jilicvted, ao-otlted loo|>-beareTK, have b«oa construkcted, by uieitoa of
which the ligature is passed over the tumor on to the pediclo. But
tlie ligature is now so generally rejected atid so little used, that all
these instruiDL-ntK, some of vrbich are rery ingeuioua, arc Eur the tnoet
part only of bistorieal value.
But tbe desire to remove pedunculated tumors nnthout hfpnuo^
rbage is ctill atruug, and has lately led to new instruiDcnts and ucw
methods, wbidi, however, oould not have become popular before tbe
intn)du<^tion of cblorofonn. Crvn/ting and Intming off have novr
taken ih«? place of the ligature; Tlic expexicuoe that crushed wmmda
bleed little, if any, led C^tuacUgnaa to the idea of crusliiag off tv
mors; for this purpose be constructed an instnimenl, the ^erowtir,
which is coni]K«ed of a flexible iron loop, made of nunM>rous pieces
of iron united into a chain, which may he grrulually drawn into a long
shcutli, and crushes through the circumscribed part; this icroBcmenL,
if done slowly, is followed by no hiemorrluLge, even fiom arteries of
the diameier of iIr' nwlini; thf re»ullin^ wound Is |)erfcctly smooth
and regular, and licaU well without much sloughing troia the surface;
although lueiiiorrlitige is not oortninly avftiiled in all c&ses, it is in
most ; the instrument is made of various sizes; the smallest may be
[Msscd into the rdbc, and witli it we may readily crush off i^ouill pe*
duneulated naso-pharyngcal polypi I consider this instrument as one
of the heat applications of mechanism to surgical apparatuses. Tbe
ffoivano-carttiic of Mid<lied<tri'/ is a metliod of similur effect; its
object is to heat a loop of pintinum-wfre bctwoon tbe two poles of a
gnlvniiie battery, and with it bum tliruugli the base of tbe tumor ; the
result is a simultikneous divisiun aud arrest of h^morrbagc ; the latter
fails about as often as it doi-s in gcrasemeat, that is, very rarely —
PraROKATA, LSIPQHATA.
671
this method is «dmabl« in certain cases. Tli« trouble in pnv
paring a strong, active battery (which is quite expemuve) b sucli tlist
galvano-caustic ivil) prubiiLily never cucic into gvnvnl use; in s]iito
of its elftf;nn<!e, it hui been stmnj;loil almost M it« birth bj th« intro-
ductioii of the 6cnuteur ; thv modical [niblic lias already dccidet) the
question; almost crcrj opentling mirgcon has an Ä^rasour, only n few
bmpitals have g«lvano-«austic appsratuses.
Aa regards operation for nan-pedunculate<l, more depply-seoted
fibromata, some of them are not at all accesBilile to surgical treat-
ment; vre cannot recommend cutting uterine Bbromats out of the
kbdomen, not because th«^ operation is oxcwssively dHngvfous, but
because, in the coursi- of iiiiii.% thvsu tumor» usiuilly come to a stand-
still, and the annoyance tk^y «tuse mrcly bttlanccs the danger to Ufe^
As regards thuse* fibroraat», also, which arc not dangerous from their
seat or groirtJi, but to opciutu on trhich would be dangerous, we
should bcftr in mind that tbc9C tumors grow T«ry dowly, often come
(a a halt in BdvaiitM.il life : hence we should nut undertake such opera-
II too has^y, or urge them too strongly. But there arc many
whcK we mfty and must operate without hebitatton; exUni&ive,
frwjuently -repeated licemorrliagca from an ulcerated fibroma, thn>At-
ened dcütrurtion of lionc, or protninion into the nitiill, aro urgent
iadicatioiut. in ueun>-£br(>mata tiic piin is somcünics so «cvcrc that
e patients strongly urge operation, even if we tmve to tell them
that paralysis of the parts supplied by I he nene affected would be
the nere»sary result, for we almost always have to excise a portion
of the diseased oerre which posaibly still performs part of its liuio»
in«. If the neuroma be paiuleHi, it would be fodisli to excise it
1. LIPOU.\TA-PATTY TmOES.
Itiui
' Of coune, the disposition to formatina of fat, when it does not
nceed a cerlnin point, is not reganlcd as a morliid diathesis, but
rather as a sign of good nutritive <-undi tioii, niul varicn n-itli the age,
being grc«tc8t between the thirtieth and fiftieth yt^ar, and being es-
sentially fovored by a qutet, pleasant life and phlegmatic disposition.
^W« only begin to regard it as a disrnae when it induces fijnctional
^disturbance of different organs, or of the organism at targe, or if tlte
development of fat be limited to a small port of the body, when it
appears as a £iiUy tumor.
Tha anatomical formation of fatty tumon is simple ; they eonsiat
of fattjr tissue, which, like the subcutaneous fat, is «Itvided into lobce
by oonnectivc tissue. Tliis oonnectirc tissue may be more or leas de-
veloped, aod the tumor may consequently be eonietlmes firm (libro-
natous lipoma), sometimes softer (simple lipoma). He shape is
a?s
tdvohel
anially round «nd lobular, anJ the &itt; mu» sepanttcd froti
jncent Ktruotiimt hy a tliißk<>n«d Inyer nf onnnActire tlMiie (citGcn»
scribe*! lipoma, the usual farm), und may n-aclily be »^[mrntixl frrm
the parta uround ; more rarely, U|>oma &]>prnrs as a corpiilcn^rr limitcii
to one piirt of Uic bualy, »a a awelliag without dietitict bouinlann
(diOust; lipoma). TIk »cat of liponui is must firrquvDtly in tbr subcu-
tiiDcou« cellular tispuc, pupcfialiy of th<> trunk ; tlicec tumon) nmnott
frpijutmt on thn back and Eibdomitial iralla; tbey nrv rarer on thcN-
trvmitica ; in tlie aynot-ial folds and tufts of tbc joiuta, as well na in
tlie iJieatlis of the tenduns, there may be an abnormal dovelopnxil
of fat, net tliat tlie fotty Rin».<ei> may iwrm hmnclied lik^ n tr«>e (lip^
m« iirlxtresceiiB, J. ^filUrr); this id an aiialoj^y to the fatly pn>lifen-
tiun in the proccsae» of tlie peritoniciim of the colon (appctuUctt
cpipJoiwp) and other eenMis mrmbmnc«, but it w cace^liiijiiy lam
Tlie growth of lipoma is always very slow, ita dovvlopiiicnt in Imrdlr
ever accompanied by pain, udIchs it n>mcs close to n nerve and preaate
on it, which rcircly happens. Fatty tumors niay nttniii a firreat tilt;
the patients, being little tnnibled by them, rarely fe«l oblig^ tohaie
tlieiii removed early. SoeotidaryrJiangrain these tumors are notreij
£re<)uc*iit, hu( the thick councctire-tissue partilions in th« tumor mar
cnleify, or even Dftfify^ and at the aam« limp the fiitty tissue mar
change to an oily or cmulsion-likc fluid. The skin covering Uie tiuatf
ifl gmdiially expanded, and at first is usually much tbickcDcd, iOd 0^
casionnlly eolorod brown, but (renerally remains inorablc ovi.y the tiimcr;
exceptionally there is an intimate adhesion with the newly-form«)
Eat, and tlien a su|>erfidal ulceration of the cutis, widcli in auch eaas
is entirely atrophied; this ulöerati on, which maybe iudueed by et-
temal irritation, rarely goes deep, althoug^b parts of the fatty titsor
may bcoumc 5;uii^^nvu» ; wilder such circumstances there arc alinott
alwar« formed ulcers with alif^htly-dereloped granulations and serous,
bmdly-dmelling secreliuiis. Cnnilüiatiou» of lipoma with soft libmnt.
with myxomatous sarcoma, and with lymphoma, do occur, ultiiougli
rarely. In lipoma 1 have iereral times seen conaideiable cave
dilatatinn of the veins.
A (tisjKmlion to the development of lipoma most frequently ei
nt the time of life when the t«ndoncy t« development of fal g«>nermUy
is greatest, between the thirtieth and fiftk'tli years; in children it i»
\ery r»K-, »till it occurs congenitally on the bock, ucck,&ce,aa wcllu
on the toe», with coinoident hvpertrophy of thobone« (giant giovtli);
they f^rnvr little after birth. I'sually there is only unv liiminH. and il,
grows vtTy »lowly; inilei/d. it may remain at one point, cjspccially inj
old pcisonit. In the subcutaneous eellular tissue, development off
multiple lipoma lias been frequently seen; cases hare been noted
UPOHATA. C&ONDEOMATA.
vrs
«Imm Ally or more, umuIIj wnaU lipnmnlA, wm« devdopMl At once;
•nbaoqtMitl}' t)i«'r oetJwd to grow. Miili.i])li.- lijxtiiiiita ate often mixwl
tumorB, Simple lipoian is nrvtr iafcctioiu) ; ht-noe it norer recurs after
pxtirpntion.
Pressure mod friction »re ocoasionnny olweired m exciting causes
tor thf ilrTplDpirifHt of fatty tumors ; there is also a modcrat« degree
of hi>rr<lit«ry intUi'^io«' in fsttj disra«r generalt^.
The diflgnoMs of lipoma is generally easy ; the consislenc«, tbe
lobular feel, neciwionRlIy » perceptible cradtUng, front rcimprcasioo of
iDtlividun) fat-loliulrs, an the objective »yreptoms; other aids for (XH>>
firming tli« iliRftnosi» an>, the ninrabiltty of tlic tumor, ihv «low
grrivrlli, ngir of the imtieni, niul, ibore all, tlic region of tl>c body;
there is a possibility of mistaking them f*>r fibrous tumors, aorcomata,
lipomatiHis-ravcrnous blood-lumort.
The tTMlment ronsists in femoral with the knife. Healing is
usually preceded by free lUseliargc of gaogienouA tissue from the
wound; in very Ur^ lipomata it Id brat alwai-a to remote a portion of
the iJtin covering it, with the tumor; nf^er their extirpation erysipclM
15 quite frv<|uent, e!>])eciaUy in ven- (at pulicats. Tlie Inrgnt lipomata
nthv be remoT>*d with gowl n'jtitlt, ns th^y unnnllr occur in peniont
otherwise healtliy. Extirpation of difluse lipomata is more unlnvor»
able than tlutt of the c-ireiiniacribed ; the local and general reaction is
usually more consiJernbl«, but I have several time* perfonned such
operations with good resullsL
^*rari.
a. CHOKDEOMATA-CARTILAOE-TCMOBS.
Tliese are tumors consisting of cartilage, of l)ie hyaline or libroas
ipty. The mirroaeopic eiemertt» of patbologieal, newIy-<li*reloped
cartilage may vary ; nniuiinnnlly we sec exeecrfingly beautiful round
c»rlilngi>^*il9, such as are piartirulaHy found in the emliryo, and some-
^_wbat smaller tn the luticulnr and costal cartilage; but sucb aeomplete
^iBuuige of hyaline substance to a homogeneoua mans, as is tlie rule io
normal cartilage, is more rare in ohoudromuta ; frequently the inter-
et'llular substniice perlsitiing to tbe difleroiit group« of eclls is distinct,
and between the large groupa of cells the hyaline substance fonns Rne
fihim^nts. The latter is the cause of sections of cartilage-tumors
having the appenranee of being Iraversed by capsuUr-like, ooramuoi-
catiiig ronneel ire-tissue nipshes, whieh even to the naked eye show a
kind of Bcl-work ; the bluisli or yellowish glistening cartilage is seen
embedded between these conneotiTfrtissiie striir. The liMoe of chon-
droma hImi di»ttngiiis)ie8 itself from tliat of normal cartilage by (he
Eiict that the fantvcT is nsuatly i-ascular i» lite abore-mciitioned
Gbraus striir^ n-hile^ as is well known, the latter has no vosseU. Tbe
CBOHDBOUATA.
ItJI
of ttiMase in tlie tuunedbt« ricioitjr, p«rdy from traosfonnatMa of the
adjacent tisftue into caitilage (loool iafeotion). Amoag the kualomical
tDctamorph<^i!H.-3, the pulpy «nd tiiuooua Bofleiriug, timl Lltn oAsifUstion
of inilividual parts, hiLvc bccu utrcadjr meatioucd ; ttic fonocr causes
mucous cjsts in thcsti lumotv, wliicb give a feoliii^ of ])iirUiil fluctua-
tion to the otherwise hard choiuliuma. It is imn^inobic that, with
oomptete oaü6catioa of tbo vhondroma, the tumor would coasc to
grow; and this has been seen io some cases., altbougli mmly. In large
ohoudruniuta suporficiul ulwration la apt to ixvur, e^iXArially iT tlie
skin is rcry tense, at imm occuiuoqaI tnumutic irritutioD, but it is of
no ffreat iniporlancc. Uk^mtiro central soFlcning iind pcrfonilion
oulwmrdly are rare, but unce 1 saw it oocur in a trpicsl ciiondrotna,
the sice of a )ai:gc apple, on the sheath of one of the tendon» of the
foot.
i^rcÄoK chIIh Ui(! ossifying CülMaj^or betwe«ii 1h« pi'riostotim ami
growing boac, osteoid cartilage; hcuce he tt^-nns periusteal und us&i*
fjiug tuniofs, which hare a Üorraalion similar to tbta osteoid cartilugc«
*' osteoid ebondromats." 1 am doubtful about any uiiu being able bo
ndistioguish audi l.tiiiii»rs, whidi I huv^ oft«n eicamined, from jieriofiteal
OSsi^ug muod-oclled or spiutlliroeltcd sareomatn ; iieitoc I prcfur wit
scpamtin^ Vifvhc«'» osteoid choodrotna from the saroomnta.
Oeeunmee. CaKilage-tumot» are jmrticularl} apt to d<>ve]op on
the booM. lie phalsnge» of the band and the inetacarpid Ikiihs arc
the most frequent scat of cboadromata ; much more rareljr the auulo-
^OB booee of the foot. Ou tfao buud,olioudR>mAta are almost alwa^is
Itiple ; thejr ereo oonir in &uch numbera that scarcely u fingej* f^
moina tne bom tbcin. The Ixmee next most liable are the femur
tnd pelvis ; here the tuioors attain the largest size, and lead to oom-
Iplete destruetion of tl»e!*e boiien. Chondromata are rarer on the
. of the hoa and skull, but somewhat more frequent on the rib«
scapola. Th«7 oceasionolly, but rarely, develop in the sheath«
of the teodoas. In tbe soft part« also, e8[>e>.-iii1ly iii tlie ghiiuls (to**
tides, ovaries, mammie, sali^-ary glands, etc.), cartilaginous growths
liure been observed, somi-timcs in the Ehapo of fully-dcrcloped cboo-
idraiufli, aometimes as single pieces of cartilage, with a predominaaoe
*«( MTOomatous or carcinamaUMU growth.
He developinent of chondroma is chielly peculiar to youth ; not
that it oocurs exactly in children, but shortly before the age of pu-
berty. Must cboiidrwiimt*! tuv. refi-rable to tliis age, even if they are
first rcc-oguia»! much later in life. The tumon oocastOiMlly dorelop
after injury, grow very Hlowly for twenty or thirty year«, sod oooa-
sinually seem to oeasc growing entim^y. I bare beard patients as-
sert that the tumors had remained unchanged for yean, oimI somo ac
88
OBOKDBOHATA. OSTEOHATA.
an
lb] elements and conneotire-tisBU« framework atay become gelatinous
(tauoouK, oolloid, mrxocoBtous) in HbroniR, chnndnnna, and sarconM,
ss well a« tn adenoma and gliindular <-an<:«r, we Riuat alwaja ob>
senre vtirt' purtitruWly what w» bare ln-furtf ua : fr«<|uenUy we ^lall
be in doubt about tbe »ignificanoe of tlie hi«toU^ioal elements, u
veil as about th« projier itame.
Tbn oatjr treatmettt is rctiiovnl of the tnmor, if it can be doDS
witliout CDdaiig«iiip- life. 0/ courso wc would not intcrfcro irith th«
cboDdromatu u{ the fielviB, wbidi ait< usunlly VL>ry large ; tbtxM* of tli«
thtgb, wbioh are g«!ncrallv vorj large wbru tbo paiiciit applies tor
L trealment, can only be galten rid of by cxartictilatioii of tbe femur,
and wc sliould scaroelj do this before BpootaiiRoua fracture of tbe
extremity, from disease of the hnne, ha» rendered it uselens, Cboi»-
dromiita of thv fiogera are meet frequvDtly 8ubji.-cta for opt-ratioQ, not
bc^csusu Ihoy are (witiful, for tJiey urc luiimUy freie from (win, but be-
cause they impair tbr fuudion ; tliia tiikf» plim; «fry slowly und
gradnaJly, licatx the tunion irill have attained a ooosidcnble the.
So lung as the patients can use tti<;ir nodulaU>d swollen fingers, they
neither urge the o[>fnitkiti, nor ran we urf^-iitly adviite tbeni to sub-
mit tu it. Ab rcgntds tbu niudc vi upenitiui), in mujjy cuäcs nhcre
the tumor, ewen if firmly lullit^rent t« the bone, ia seat«! laterally, il
would be natural to try diridiog the »kin, and pushing it and tli«
tendons to one aide, then removing the tuinur vritli the kiiifo or anvr.
But th!« ia rarely practimltle, if we would remove the entire tum<ir,
wliicli is imperatively ittxestAXj ; for otten the ejtrtitaginuua maas en*
tirely pcri'udc!) the medullary cavity of tho bone, älorooror, after
such HD operation, there may be severe inflammation of the sheath of
the tendon, aa a result of which the finger may remain stiff. There
liave not been enough careful obeerrationa to nirify iJieß'enbael^s
aatertioR, tliat any remnants of the chondroma that may be left oaaify
' and beoonte «table ; bence tbe removal uf chondroma fmn) bene
iliould be limite<l to few rases, and to tbnne wbere tlie iumor la atlU
snwlL If the turuois have attained a conüderable »izc, we postpoiM
oxartictilntion of the fingen to a time wbeo tbe tumors shall have
rendered tJic baud entirely useleaa.
*. OBTEOMATA— EX0STO8K».
By thin term we dnxignnte ahnnrmally-fonned maa^m or bono,
whioh am ctrtrumtKribed, and have an independent growth, Dot de-
. pending on a cbitmtc iDflammation. Fonnatiut] of booc also occun
oeeaaionally in other tumors, eepecially in those Eonuing in bone, us
{very irregularly- shaped) occur in ovarian cjst» aiid tu Ute tuitnua
Higbmuri, but that on the Uwtb tli45tii8elveft oulgruwtLs of Iru« ivory
matter, ivoiy eeottota (odonton» of Virchote) hare been «Iwrrfdj
but these are rery mre, and may be regarded merely aa curi'wiUm.
Exoetoses constat partly of spongy bon&«ubstanee, Itk« tJtat in tbo
nmlullary cavity of boueH, partly of ivory-lilce eubsüincc, liki> tliat in
the regular lainclhe of the vortical nubstADOe of the liuUow bant» ;
hfiu-e we Hltall cli8Liu^t«h »jH>ngj/ exottOMi auil iVory c»o$tott^ A
third furm of osteoiiiHta iit formed by tbo OBufioatioo of Icrndons^ fu^
ciii% and musclt», whoM ri^bt to bt: claused aatoog tutnor& is, bow
ever, doubtful.
[a,) Spunffjf exOBtose», tritb oartilaginoua oovsring (exoitosia cw>
lUaginin). Tbceo fauDota ooiiur almost exolutivcly ou tbe cpijifayvtil
ot Uia loDfT bonee ; they u« outgrowtlis from the epiphyacal cartihigvs,
whence VircAow very properly vails tbem *' SechotidroeU on^ficamM'"
OSTBOXATA. aw
(Fi^. 109). Od Ibeir roaodish, nodular sur&ioc. there is a tnyer of
bo&utifullv-dci-olopccl hyalina eartib^, Rbout a line or a line and a
lialf thick, which evidenllj- grow» jiartlj in itooU, partly ppriplieralljr
front thff peri<isU-iiui or |>enchun<]nuiii, Üien rapidlv onaifie^ townni the
cvotre. 'Hie ncwly-fonned bony maM itself is, from iU start, most
Fm. MS.
PednncKlaHd >i>cina oivUMlt Itom Ihclvtremd oflbr tMnar, altainML
Inllmately connect«! with th« spongy niihstan«' of tlie cpiphj-oes, so
tfast tbe hard tumor is Immovably Mated on the bone. From the na*
ttiro of tfa«8c cxo8ta»cB they can only occur in joung pcreona, Ao-
cording to mj obsenration, tibia, fibula, and humenis, are their mod
frequent aeat.
{b,) Ivory esMiilote». Theae oomiBt of compact bony »uhstancc,
with BaveniaB canals and tsmellar systems; they develop on the
tmnes of the face and skuU (VigK 110 and 111), on üie pdris, scapula,
^reat toe* etc., ftod form rouodiah, nodulated, or oaooih tiunore.
OSntOMATA.
6S1
■re coTcred with twenty to fifty long, »harp, bony procwim, where
the tendons &re Attached to the boiie (Ki^. ^^ ,„
112) ; as in one case obserrcd in Zunc>i,
the osaifimtion occaslotutlly occun ia tiic
fucü of tlie muscle. Oucft Itavc been ob-
semxl where tUi« OMifiontioo vru» so cxteiv-
sire that nil the imiacles of the shoulder
and arm were osai&cd, and the upper fx-
trpniiir toulil not lie nio\*cd. Thi'sc boar
ncuplsAiitr, ns wt'll as the no-called ejxrcite-
bona, must doubtless be regarded as the
product of chronic inSammation, just like
the true bony formations iJiat ane abnor-
mally di'mloped in (lie tneinbranis of the
bnin and spinal medulla. Ky esercitfr-
bones wt mean the development of boiie
Id the deltoid inuitcie, particularly at tboso
poinU where tho inu»ket Mrikfs when drill-
ing. But theMt honva form in few sol-
diers, and their dcvcloptnont prrüupposes
• tendency to tiic formation of Iwae. Os-
sification of the tendons, expccially of tbeir
point« of attacfamcnt to the booc, which
occasionally occurs from som«? unknown
cause, is also very remarkablf!, and reminds
ua of a similar pmoeM in bird», which in
them is perfct.Ttly iionnni.
The predi»po«iition to formation of 0»-
teoinaia is allied to that for devulopnient of
vliondromata ; it abo oircura more frequent-
ly in the joun^, and in men than in
women, white children filniudt escape it.
Am reganla epiphysnal osteomatn, which mifcht be termed osstfying
obondromata, they of course cannot occtir later than the twenty-
fourth year. Uut other exoertoses abo ocour generally before the tfanv
tietli year; observations on tliis iK>int are not vcr}' numerous, as the
discu»; ia rare. Tlita experience about the occurrence ofoetcomata in
the young is the nvore remarkable, as it stands in a eertoin oontrast to
the genera) rule of ossification being especsaliy apt to occur in old
persona. Tbo cartilagcs of tbo ribs and larynx and the spinal liga-
menta often osaifF' in adi-unoed age; the vbalky «lepoaits in Iho ar-
teriea of the aged also form part of the almost natural senile maras-
mua ; development of oeteomata, however, rarely occurs in old persona,
OMMinia of lliiT msicillar mUadt-
&6i
TÜHORS.
but 'n-ben such himors ar« (buod id tbem ih^y bftve usuallr <lerelopei]
ill youth. Ofit«oinata are jmt as r)fU>n multipld a.« solitary; their
gruwtli IB j^iierally very slow, aad 1& usually tirre»l«<l wHJi adnmcing
age. Tbo growth oC epiphytcftl exotlMcs cctMs after the Bkeletoo
has oompli^t«! it« growth, and its epoiigy eubittance become« tatK
oonapact. Osiuiicstion of the tendons and muscles rarely goes to (a
.«A to entirely prevent motion. In some caaes dcvolopmeut of bono
has been observed in the lunp. The inconveniences caused br oeiteo-
mnta nre not uisually girat ; liipir dcrdopnient is not arcompanied by
pain, nor arc thvr »ensitive to the touch ; but oateomat« in the vicin-
ity of joint« often impair tbcir hioction. When thps« ttnnors occot
on the bones of the face, thoy cause unpleasant defortnitiee * exoctose*
on the big-toe prpvmt wearing tbc eboc; oasilication of the lendooa
and muscW impair« or entirely prerents ntotion ; but unfortunately,
froin tlicir size ami numb«r, operatire aur^ij can do little fur tb« 111*
tcr, and the k-ss »o, na the l«ndency to morbid dcrelopmf nt of bone
slUl oontinuo«. Tbc operation for exostosis consists in eawiag or
chiijolliug the ttiinor from the bone afFec-tetL But, as the latter i%
oocaaionally in the ricinity of a jninti, the artieulation might ihi» he
opened ; it is neither adrlsablr nor necessary to undertake surh opcra-
tionit tmless the impnirniont of function be bo great as to bnlaooo u
operation diLntrcrotis to The joint ami to life. We ahotiki be the teas
tncliucd to undurtake siicli i>perutiafu( vrithout mhoc special indication,
a? in the cours« of time tbeso tcmiors cease to prow. On efMpbyM-«]
exostoses we occasionally find mucous bursse containing adherent, or
loose ossifying ohondrnmata ; theao mucous bursa* usually conununi-
«te with the joint in whose vicinity the exosloais is situated, Aj>-
ooiding tn the investigations of Rindfltiiiich, the muoous bume arc
aln-ays nbnoruinl elongations of Ihe pockets of tlie iirticuUr nyiiovial
membrane. I once allowed myself to be induced, by the eiitreatiea
of a patient, to remove such an «xostoais on the lower eod of thp
icmur vrilb a large mucous bursa; the palieut died of wpUucniia.
la another cose the mucous buisa over an exostosis on the lower end
of thu Inimcnts openeil spoiitaiieoiiiily after modcmti' inflninmatioa ■
tbcrc was suppuration of the elbow-joint, with nnohyloats ; the patietit
would not permit r&sootion of the y»s\U
mrOMATA, KEtTROHATA,
68S
LECTURE XLVII.
I. Mjc«—. t. K««riKB*.— 7. Xnpotat: a, rfesifcnai I, Civcniov.— OpvnIlNM.
i. MYOMATA.
At pivst'Dt it rcDUÜns undecided whcllier there Are pure mf/omaia^
i. c, tiimun conaisting cniirclj- of transvcrsdj-stxiÄted muscIc-iUn-
iDcnts or their cells ; I do not knotr tbat noy sitch b»v-e been observed.
The ocourrenne of newly-fornied tranwerKclj-stristed moade-Gla^
menu hau been very rarely observed in tuntore. No tumor wis ever
vntircljr composed of tlicm; tbcy were UEUally rd Kucidvntal ocvur-
reo« in sarcoma or eareinoms (of llie tefltic]«^ ovary, or uammn), or
in tumon of Tcry complicnted formatioo. 1 have exatnined tomors in
wlUcli there were diatioct stages nf de^'elopoient of muscular filar
menta, but the nght of classin); aiK-b tumors tut mjomaUi has beeD
dispui«d. I con sajr little agaiust tble, as we cannot call turoon, oou-
aiating of fuadcs of dcrelopmcnl of connective tissue, fibromata, and
aa I formerly objected (page 660} to terminer uterus Gbtoma, compoftcd
of spindle-eeLIs., myomata, as we are not quite sure of tbe relatioo of
spimlle-cells to tnuscle-cells. In old iiien, extensive oevly-fbmied
smooth musctea ocvur in the pTx>statc, partly as iiidepcudent nodules,
partly as diFFu«> cnlar^incnt« of tlic organ. There is ecrtainly no
objection to tenniug these so-csllcd prostatic hypertropUe» (there
is usually some coincident glandular) myoma ; similar myoma-nodulcs,
are met in the rauscularcootqf the ccsc^hitfcus and stomach, CUnicuUy,
nothing certain can be «aid of myom&la in these conditions ; the tu-
Btora which I considered as youag myomaia in tho iiiu»t'le!i had, on
««clioo« a medullary fuacioular appearance un iosupcntblc Icnduocy to
local recurrence, aod tlius caused death.
e. XECROHATA.
It has already been mentiooed (page 569) that the name *' nearo-
■h" ifi often applied to (nmnra occurring on the Tierres; tit'i» is, if
you please, a praotical misuse, which, however, it is difficult to root out.
By " true neiimma " we mean a tumor eomposed entirely of nerve-
fitumeuls, especially of those with double contours; they appcnr to
oomc only on nen'es, nod arc very rare, Xcuromata in amputation-
stumps luve already been mentioned (page 101) ; many doubt whether
there are any other true neuromata. True neuromata are always very
painful Many of the fibromata oq and in nerves contain very peculiar
bundle-lilte £ne filaments richly supplied with nuclei, which may very
684
Timoits.
wntl be taken Tor gray ÜlamcntA CDtiUinin; no mcdallft, M f&eAmp
considers tbexa ; ilüa »-•nilü make Inie iteuroouita a \aTgc class <>i><l <^
TiiJß ttieni into mynlioe and om^-gline formt. I ilo Dul alvrays tmM
myself to di»tingiii»)i an amyline lu^uruma from a fibroins in a oerre,
find lieoce »boulit not ix-quirc it of othera. Tumors composed of spin-
<iltM%lU urmnged in buivllc« are probnbly far oftencr young myotnau
and neuromata than yuung übromata, but it would be difficult to protR
to which 4-lnss they belong. Multiplieity and t«Ddency to regional
reciirrenw> are ppculinr to n^nuramata, lien«* the prognoM» ahould
alwaj's be guarded. Tt m rarely potutible to dissect a nettmma Inns
the nerve; pari of tbe latter mu^t generally be removtd witli it.
7. AKOIOMATA-TASCriaB TTJHOBfl.
Jiy this term we mean Ittniors eumpoficd almost (.•zelusiv^y at Tea-
sels held together by a slight amount of oonnreLirc ttsHOc; tbey bare
also becQ called [nievi, mothcrVniarks] "eteoUIe Luuiors,*' beuig finn-
er OF softer, larger or smnller, according to the fulncM of the vejuiell.
Tlio oniiiiury forms of wrioosc dilatations of tlie veins eiid the antru*
neins of diffvtunt arteries arv exduded by this definition. Hut ömoid
aneurism and some form* of «neurismal varix might l»e clasMyl here;
yet, sa this ia not customary-, we treated of these diseases earlier.
Here we have to consider two dilFerent variel.ies of rascular tumors:
(a.) Tbe pkx^orm angioma or UhngitfiaM» (from w^oy, ayynw,
lurotfi^). l^is is the most frequent form ; this neophilia is oomposnl
entirely of dibited and tortitous capÜlarieSt and auastomo^Dp vessels,
and, according a« the prolifenktioo of the vessels or th« pure et-taoia
predominately it ap|)ears more as a tumor or as a red apot on the
akin. Plexiform angiomata, of the varifrly we are about to (ieMrflw,
Dtxur almotvt exclusivcly in tlie culib. They have sometime« a dark-
cherry, at other« a steel-bliie «olor ; arc «ometjmcs as large ns a pfn-
bead, again as large aa a hemp-«eed ; some are moderately thit^
olhei's snirerly riec above tlic level of the »kin. There arc Very ram
forms where there is not a red spot or a timior, but a <118iiso redne«8
over a lBi;ge surface ; in such cases, even with th« naked eye, vre U9i>
ally see the distended and looped fine vreecls nn the surfurr of the
eutis, showing through the ejridenniB. Anatomiral examination of
large exiiqialed »ngiomata of this variety shows that tlipy are ravn-
pOBcd of small tobuli as large as a bemp-eeeil or a pen; and, if, afler
artideial injcelion or other mode of prepamtion, wo examine thorn
mieroatxipteally, wc shall find thut tlietie lulndi «re forrn^-d \iy Iho vi»>
sels of the Ktrent-gland», bair-foUiclcs, fat-glands, and ht-lubuli, being
independently diseaaed, and that the different small proliferating, Ta*>
cular systems fonn the above-mentioned lobuli, which are vkible to
ANGIOHATA.
ses
the Dftked Kfo. Hie rcosoo for the color vf those tumors heiug aomo-
tirnes blood-red, sometimes pul« blui<^i, is that, in the fomier case, the
Cftpillaries of the most superficial layer of cutis, in the sürood, the
deeper vesads, are dis«iui«d. As a rule, this prtJifcraiion of ruasels
docs not go beyond the suhcutaoeous cellulnr lissue ; rarely it afiieot«
the douper tissues, such u tJie muscl«» ; trheaoe it appean> ihit tbes«
DDc^lasüc not oul/ grov oeDttnlljr, tiuL eepcciallj- peripherally, and
destroy the part AlTecled. Most of Llie«e tumors msy be »lowly cmp-
PM.1U.
a.
i
m
iVj
f.
V
Oj«clua»nl1"i>vrv<»ul> Irviu a |>liiilE>nB •utoma. MatuMwl SI <toM«tun. «. pronlmilng
naruUr lU'-.-wnrk aronnit ••i(au*xtt[id(i>hlctil> naltlwwD. MptwrciitcaiDpltcatiDD <Im
diairta«};*,pF«lUHMiN|t*MoiilwMt><r«th lnUwp«pnia«tilMoml«neM>niflnbiM«.
tied by pnnsure, ntid a^oln Ell as soon as the pressure ceases. Bui
there arc also modcratc-sizcd tckogiectasci, iu »hidi, besides tbo
proUferation of rcssols, iher« is also a ikcw formatioa of counective
tissue and &t^ so that Ihcy caiuiot be entirely rcmov<:d by pressure.
When these new formalioD« were euporficüü in the cutis, and the
blood has bi>on empti«! from lh«m after extirpation, vith the naked
eye we can hardly see futy thing abnomiaj in the morbid piece of »kin
that lias b«cn reuoved i a moderate neoplaai» of this variety appears
oo the out turfaoc a« a pale-reddish, soft, lobulatcd suhitanc«, in which
ire can see no reescls with the naked Kyc, b«cause the whole disease
le usually limited to the capiUarica oad minute vewuls, sod to a £bw
small arteries.
580
TCKOBÄ
(ft.) Cavemotiä anffzonuOa, or €arf«rjwus twnoiM tumon. We will
first determine tbeir anfttoiuy, so tliat jroa nia._v at oocq ootrvcilf oote
tbeir diff«n>Doe from pli?xif<r>nn ongionmU. Extir]i>tP(l atvpmoia
aogiofnatn m*y at once be rcoogniwd, on section, br luiring nlmcnt
exactly the fomintioii of tbe corpus c«T<eruo?uiti jK-nts. Vou sec ■
white, firm, umf^i net-work, whieh appcnrs empty, or at Ifsn eno-
tatoB only in spot« red or discolored ooagula, or poiwhlj is filled with
tstnall, round, cliallcy coocrcmcnts, so-called rdn-stoncs ; but ire nit«)
imagine the meitli-vrorli as diitlendul with hlcyxl prcrtoiis to it« extm
pattun. Tbe lioundaiy of tWs carernous tissue, which may fona ia «Q
tbc lisftuca of the bodj, ia eomctiioos evidently a sort of capsule; but
in other cases this cavernous degeneration isTerjriadiatinetlyhointd«d,
aDd at different spot», in a rather indifferent manner, it eulen the
tiasue. Microtcopk. ex<imm<ili(m of tiiia meeh-wor^i, whicli is fonnsd
sometimes of thin threads, Bometimee of membraae-Hke oapnla^
sliowB that tlie branches are formed of remains of the tissue in whieli
Pia. Ill
u.
bctWMvlhcaei-vorti. Jti^iUMlaOtfuiBl««.
the caremooB ectasia ooeu«. The inner wall of the space fillc«! with
blood is, in most cases, coated with tipindlc>«bapcd cells (vcdous end»
thclium), rK) tlint even these analomic&l conditions go to prore that we
have to deal chiefly with distended reins. The mode of development
of this peculiar ttnsue lias rrceivcd different explanations.
If we had any accunte inrcstigations about the dereJopment of
ANGIOUATA.
iB7
tii«cxirpua caTcrnasum penis, wc migfat drav some deflnile oonctuslonB
from tbcra, on account of the ^eal aualc^y of the two tissiu». Tbo
three chief bypnth«aes about the deToloptuent of oavcnioiia luinon
are B» follows: 1. Itis asserted Üiatthc caverooua spaces finttduvclup
from Uiti oonnt.'ctiTe-tiiKtuc, iitid «.-cuiKUirilj become cuitncct«.-«! with
the vosHelii; and it has c\'pn been suggested that blood might be do-
Teloped outaide of the uireuhitioo, 6x>ni ihe derivatirea of the cooneo
tive-ti»«ue cells ; the atria* of the meab-woriE would ioorenae hy lude-
3>et)(lent f^wth, by sprouting, nnd cltib^baped growth of the conne«-
tire liuu« {RokitanaAy). Thin hyimtheaia, eapedally ttie fiiniiation
of blood oiitAiilo of tlie riivulstiun, has some objevtiotiA. 2. It b
a«s«ned that circuinsi<rib«d diintationis of wnall rein» occur clove to-
gether, sad that at th« poiuts wh^ra they oome in contact the walb
are gradually thiniMNi nr cotirtzly disappear. Thin view is supported
by the tact that tbeac gradual dlsteatiotu of the reina poay oocastoo-
ally be disliootly followed out both in the outU and bone« when these
tumon are developing. Z. Rinf{fiei»ch rlaim.s that vascular «.-tasta,
eftpcciftUy in the cavernous tumors which form in tho orbital fat, is
aluruyx prw-ecled by intillratioa of the tiüsue» with «nail coll«, which
is followed by a sort of cicatricial shrinking of the ttssui«, and conse-
quent teaiiog apart of the vciucls, whose calibre must constantly be
ifwseaaed by continued atrophy of the intxn-mediatc tissue.
Pot aome reasons I have long auppoaed lliat both in plextfonn and
onrem<>u3 angiomata there waa »oirie proce« similur to itiflamiuation,
but n«ither the latter (aeaToely app]toble to the cavcrnou« Ikunors in
boow) oor the former two hypotbeM*« appear to fully explain the
causes nnd p<'«uliar diiTerences in thp diBtrtition of tbc resscls. Wc
have still to mention one difference between cAvemous tumor« ; they
are either eouuected with the large venous tninks, as sacs to tbc sul>
cutaneous veins, or numerous small arteries and reins sink into the
e^fieale of tbc cavernous tissue. I.astly wo must mention that these
cevcraooa Tenoua ectosi:« may oL-eiir ararideutally in other tumon an in
fibroma and lipoma, ka hus already been incDtionciL A few years
•iaoe I extirpated a lobular Upoma, which Lad foenie*) ui>dcr tbo
Bcspule of a ngorous young man, all of tho lobes of which bad
oeotrally degenerated to cavenious tissue. Oaveniuus nng^mata do
Tclop with especial rmjueiKv in the sabcutaneous cellular tüsne^
more rarely in the cutis and mwK'leR, very farely in bones, but quit«
often in the liver, particularly un its sur&oc^ ocaisionally also in the
Ipleon and kidneys. Tbcy arc sometimes quite painiiil, other cases
■le not at all so.
Tbc diagnotit of cavernous angiomata is not always easy ; wfaea
they occur in tbe cutis, Ibey may be mistaken for more deepty»oated
588
TÜMOSa
tvlungtoctoKcat, altbouj^h the bluod maj be preaacd out of tbe esTennMB
Tcoous tumor» moce rcadilj tl«ii from tclmifriectuc«. Deeplf-«eatcd
tttmors of this sort urc (tlwars diiHcult tu rtioogniz« with oertaioty ;
tbey UMixJly sttow decided Siictuation, ktc aomewliat oampTHuble,
swell 00 forced pxpiration; but the last two syraptotns are not alwkj'B
distinrt, hnnne the}* ninv readily be mistaken far lipomata, oysta^ and
otlier soft tumors ; KOmctimes, indeed, tliis iniirtake caniiot be iiTcmlciL
Probabl/ half tlie auKriooiata are congenital, or at least derelopcd
tooo nUer birth. If tliey düvel(^> during life, it is osusll^ in diildhood
or youÜi ; it is mrc fur vBSctilnr lumon tu occur tluriog manbood or
old age, vrbich is rcrr rctnarksblv, as tbc disposttion to Tnacular d»
eases, cspecinlly to vctasis of thti vvshvIs, grvully Ittcreasca with wt
vanml af^c. Not uiily tbc lar^tT uTtcrivs aad veina dilmc at thi*
tune, but also tb« small aoaBtcHaaeiDg vcesvU and capiUarics, at certain
lovalitie», show visible dilatations througli tbc skia. On the (avo «i
a ruddy, beoltby old man n-c kv red checks ss we do in (he young;
it is Dot, Itowerer, tho r^ular I'oay bloom of a maidcn^s cboek, but
a more bluiali rod, and, if you look more closely, you find numemn*
tortuous rraiselN, viflible to Um nnked eye; in some, lliis redne&s WKon
ill sputa. Ilkeae sioall vascular ectaaiw do not occur in hII old pLTSoii»,
■o that vrfi tnuRt suppowt tbcm due to a poculiitr prcdiapontion. Hence,
OS we said, in spite uf tlie fact l)mt advanced ttgt^ is luuru disposvil tu
disease of the rcsecla than any otbor time of life, true vascular tunHns
develop almoet i^xclusivoly in youtb. There is no doubt that tbo te-
liitigiecUsiiE, whidi jxipularly are often failed " motbpr's-maiks,*' »re
often infaericcHL Thih a]^>ean) to be jiroved hy a number of stories
about obildreu, that bave been lo«t, beiox subsequentiy reco^iüaed by
marks inherited from tlie fntlier or niotJier. We sboukl undoubtedly
k-um fnr mure of tlH.i hereditary triinsmissiuti of vascular lumors if we
would attend more to that of discuses of the vessels ||[coetuily. Kvcn
U-pleiifbrni aod oavcmoua aiif^ionmla are to be reganltxl as anatomt
oally dbtinct liom each other, and from the different rarietir« of v*>
rioea and aneurisms, it is elill clrur that a predispositiiin to diUUliou
of the vessels is at the root of all of them; ttiia la tmdoubtedly loa
great extent inherited, and the above disease« can only be regarded
H dilTereut modes of appeaiance of tliia prodispoaitioa at difiicnnt
agea. Hitherto att(*ntioi) hmn be4>n ko exHtislrciy paid to tbe an&-
loinii^l conditions of tlie tumors tliat the rlasses of diseases aocom»
pna^-iii}^ thnn have been too little noted.
As regards the further fate of angioma, t«tangieoUfli», which arc
almost always eongeiiital, may be either military or multiple. TWir
growth IS always slow, painless, »ml is sontetime« cliieily superficial
again in the depth, and usually at the espvns« of tbe diaeaBcd tiaue;
ANQiaX^TA.
&S9
There ia no doabtthat occasionuny ia the oounc of years Urne tumors
cease to grow, but remain unchoDf^ct). But in other ataxn the growtb
coDtinues so that the tumors, as I uiici- saw on l)w nvtk. of a boy five
yew* old, may grow almost as lai^ as a maa's fial. Frequently two
Or tliree telaiigiecteaes ocuur ooD^uitally, or occur in quick duoc««-
>ioD, eapecially on ibo R«ali\ mor« rarely there are six or cif[ht. I
hftTO seeo two auea of flat congenital plexifonn angioninUi of the Icii
side of tbc fecp, which ht-aicd at some point«, {Nirlly from ulocration,
partly troat unLnowu vauses; u e., ci<.-atrivial white epols oc-ctirrvd here
and there, where the vessebi were obliterated, while in the periphery
the proliferation jicogresaed.
Cavcrnoua ao^iontata are rarely «oogeoital, but geuendly occur in
childhood or youth, more ran'ly later in life. A» lUreiiily reinfirkwl,
iJieir aeat is cbirfly iu the aiibcutanoous cellular tissue, more frequent^
ly in tbc boo, more rarely OD tlie trunk and cxtrvmitica. Tbey
often occ-ur ia large Dumbors, but in mioh a way that a cortain vas-
cular diatrict is to l>e regarded as tbe seat of disease, as an arm, a
foot, leg, or fiue, etc. Ueaidea the dittfig^iiremeni, the nymptoms ia-
duocd arc a oertaio weakness of the niusoiea, and oncasionsUy pain to
the part alFooted. The tuinoni may attain contiidemhle .lize, and thus
ospocdally on the head prui-e ilun^truu», tliu uiüre so^ ns by further
progread they enler and destroy the boue. Some observations that I
koow of flbnw that in these tumors, as a result of thrombosis of tbe
c-avt^ntuiis spaces, tberr may be atjo]>liy luid rcCragiissioii (especially
io ibc cBvemous tuuKin of the liver) ; but complete diaappeotanoe of
the aogkHna by spontaneous obliteration has not been observed. —
S^tatntmt for vaaeiilar tuinots is very \*aned. Tlie opentioiis have
two di&rcnt object« :
1. Hetbods aiming at coagulation of tho blood, with (<oiuu>quent
obtiteratioa ami atrophy of the tumor. Aniung- tbiu»c are injecting
the tumor with liquor fern scequicblorati ; also traitsliunff them
with hot needles, or the gidvano-cauteri', nod «Irawiiig a platinum wire
tbnit^h, und Bub.>>equentlr heating it n-iih the galranoK^ustic apfia-
lafcBB (galrano-cauatic setaceum), We must alaa mention continued
i:omprcMion of the tumor and ligation of the afferent artctr. Both of
the latter have gone out of use:, as they hare proved entirely wnrthle&a.
S. 3]ctbuds aiming at the reuioral of ih« au^loiiia :
(a.) By ligation ; ia telajtgic«tuis with a lin^ad base this muit
be double or multiple. A oaedla with a douUe ligature is poaaed
tfamugh under the tumor; one ligature id titxl to one aide, tbe otber
to the oth«r aide of tbc bnse of the tumor.
{b.) In TmoRiiutir^ on tbe tumor, so that, when the vaadno scab
£illa, the tumor may be removed.
SM
mMB.
(tf.) Cautcriiution ; for tbia purpoe« fuming oiujc ocid ie best; H
should be applied by n nd sbnut as tliJdc lu n. guose^iufll, tiU tlie
auf^omii Btisumvs u yt^tlowiah-jrreeii eolur.
(d.) Bjr extirpatioD vritb the soiseon or knife.
After some experieat'«' iii ojicfaiiiig, the clioii» dT Ütese methods
in any giren cue is not iliiBculL In sup4>.räcial nngiouaUi, if nut nJ-
togeLlier too extensive, auid itot so situateil Uist the subsoqucnt clca-
tridal rmnlroction would caus« decided dcfomiity, m od some ]Mrt«
of thu fuof, I regard cauteriiuitioii uitli fuiiiiiig iiitric seid ss the proper
mctliod. In extcii&ivc pivxifurai, and iu tJii: cavrrnous aagiuuiata, re-
moval vritb iho knife and sciBsors is the most ocrtain operation. Too
pruftuc tii&morrbages in suub operations inaj be prevented {uirily bv
compression of tho parts around by »killed s&ustant«, niul tliu rapid
ftpplicatioa of iliv suture, p*rtly hy Ikh i»ediate tigation of ibi- wbvlfi
periphery of tlie tutnor. In msnjr oases of angioma of tb« ßuu* also
extirjiution is to be jtrefiTretl to cauterization, because the incision
may be so dircuttxl tbat the subsequent cttatriciaJ contraction shall
induce no dititurtion of tlio eyelid» or angle of the mouth. But tbero
arc cases where extirpation is entirely impraoticablc, partly iroot the
size, partly froiD ll>c scat or number of such tuniora, I Ireated ■
child, with a still growing cavernous tuntor uliifh extendeil frinn the
glabella, through th» no«e and wlxile ti[^jer lip. If it Imd Iteva de>
sired to extirpate this, it would Lave been tKJCciisary to remore the
«bole noec and upper lip ; of eotirse, this was not to be tbouglil of;
hence I tried cauterization mib boated needles, fha treatment had
lasted three months, nud would have taken as much lunger, altbougb
a iätgC pact of the carcriioua apace was alicudy obUleralod, when tho
mother of the ebild utifortuoately lost patieiioe, audi never saw it
again. I prcfi-r this uiodu of caut4.-rizBtJon to the injection of b'quor
ferri, a& euppuratioii and gangrene occasionally foUow the latter^ ami
as' the ttijeetiou ia oocasiooally rendered düBcult by the Bne canula
being stopped by coagula. Tho otiier methods are oif rery aecoodai^
importance ; vsucination frequently does not go deep enough, and the
ligature is a t^ious, uiieertain method, which is soioetiines rendered
dangerous by seooudary hoemorrhagt.
In the furm of an appendix I may aUo mention :
1. Cavernous fympfiatic tumora (lymphangioma cavemosum), a
TOiy rare form of neoplasm, which ia of the earo« aaatomical for-
mutton as cavernous blond-tumors, but uith tlie difference tiuit, in*
stead of lilood, there is lymph in the mcsli-work. Thia variety of
the tumor oocure cougcaitally in the tongue as a form of niac3<ogkii*
SARCOMATA.
«91
üia (tlKTF is also a fibrotift form) ; in jruuiig persous it sMinetitueä or^
cunt at cJifTerpnt ports of tbo subouUneous cellular tissue (Ii[>.i, <4iocttB,
ctiu).
2. ymBita vaaculoaua, the Bo-callcd firc-molo; this is s plcxifann
AD^ma of (be most superficiRl cutAocous Tosscla, which ceases to
grow from the moment of birth. There is no othar tüffL-reiicw bo-
tween firc-nioli; and growing angioma I have already said that tiicre
um ^-a^icnlfi combin&tioas of hvpurtrophy of Iho skin, pipnonlaliuQ,
ectufiia of the vcss«*!«, and fomtuliun of linir in tlifxo con^nttal marks.
If these marks be on tJie fu«% and nut too lai^ (sointM.iini>s they im»
plic&l« half the fiic«), wc may extirpate tbum purlly or onlirL-ly, uad
sutMequently make a plastic opcretion, or we niajr resort to utnlvn^U'
lion.
LECTURE XLVIII.
e. äoTAMUta. — AiMtomf : a, GnDDl>ti«nSunoiiu;ft,i(|>lndle-««11tslS«rD0«n«: --.Olut-
Mllcd 8MVoiiia ; it, Stsllau Swvoin« ; r, AlvnoUr ÜarMoia ; /, KüiDenieil Suojiua.
— Clt&itol A|>p««ruw- — 1>liwnoala. — Coan«. — I*nv(tiMU.— Mode ot lateetioti."
Tdft^nph^.— Cvnuttl Oi>un<uimim. — FolMtMl ^ueMaa.— 6«rMiiuiof tbAitua-
BM, of Ao 8^vu7 UUmda.— e. ZjNyJUntfla.— AnXonj.— K«Jatiaaa to L«kc*mis.
— TnatBuaL
1. SABCOUATA.
OvRB no group of tumors has th^rc so long been unocrtainty
about tbvir aiiatmniral jxttilioii sod oxt<_-ut as about surroina. The
old nunc, taken from Top^. Hesh, merely meant that on section the
tumor hud a fieshy look ; of oourac, lliiü did out make a diugnoaie,
BS it was greatly a matter of läitMoe what sboutd be called äetth.
The altirmpt to employ the mime *' «tarooraa" solely for tumors com-
posed of muscle 6lanicnts (•ScAmA), Hiat is, to identify il with those
tumors now called "myoma," was not popular. SulKw>qu4>nlly llic
term bvcanie somevrhat mure definite, as it was made lo include all
ttnnora rii-h in cells which had no decided alveolar (onnalion, und were
not CRivi noma tons. It id only for tho last ti?n years that the follow-
ing histological definition has received general acceptance and has
become quite oommon. A «orootna is it tumor cotuistiiig of li»sue be-
lODf^ng to the derelopmentsl scrit's of conncottv<vtit«u« MiK<taocc4
(oomiwlivo tissue, esrtilaji^-, bono), muscle«, and tH'r^'e«, wliic^i, as a
rule, tloca not go on to the formation of n perfect tissue, but to pecu-
liar dcgcnciatioDS of th« devoI<^)mcnlal fomts. Some patliolc^ists
would gladly see " muscles and nerres'* exeludcd from this dofinition,
but when speaking of spindle-celled sarcoma I shall show why I can-
A»l
TUMORS.
not admit tbU. If it is desired to term ^e inOautnator)' noiiplntiue n
titcir rariouK stsj^cs exunples of sarcoma {JtintfßeüeA)^ I BSMUt li>
il, na litis (I'^rmitiiiii would agree [iiT'ity ncll with miiiv.
AftcT ihia uuatoinicut \Mut\o wua fuiitid fur "sarcoina," ttaooo if-
peared that it could be diagiKiwd, even u-itli iho iiakod eyo, and tlul
clitiicilly also aooicthiii}'' could be suid about the peculiar coune of
ttii-sc tuiiioi^ As 1 tliink Uiat the aubdiviaions, aooonjia^ to biao-
lu^ii-al [Kx-ulwrilies, an* Ws iinporlunt for the dia^osia of llieM to*
mors duriug life, and that ihcir diagiiosia, proguosio, and ooutw, de*
pcud so much on thcdr point of ori^o, tbe rnpidtly of tlieir firowtli,
ete., ] prefer liereaf1«r cinitsinfr ingytthf^r the diiiteal rr'tiiarlci fin »u-
ttjina, aiwl here lUtM^ly coiiinideriug more aiLeiiLii-«ly ih« hiHtokjgjr.
Me slmll divide mtcouh into the follovriD}; lontia : I
Pm- us. {a.) Granutalioh »arcoma^ rcttnel-etlltd tat'
conui of VircAote. Tlils üsKue a the same, a
very like that of the upper layer of ^ranuUtiotn ;
fct it alwxys coutains cliielly amtill round coUa,l&a
^0^ IvDipb-eells^ the imerc«Ilulnr subatance ts soul»-
in V "w;^ times searKcly pereeplible. »gain it is io great«
*^r.Q^y?^' i{u»Dlities, and uuiy be perfectly bnuofcencoui^ as
^^5^\ in neuroglia ( Virehotr^ti giiooiu «imI glio-sarooma),
mSSums« "^ '' '* slightly striflled (Fig. 115), or even fibnx«,
or niity be adematoufl (na in large tnaniaiarT mr
coniata,]. Lastly, it tnuyalso b« reticiilsU>,andsuapproxinut« tbo
Buc of linoma.
rin-iia
>;
TiMno «r
Mnoiiii
dlunturt.
c
(dk) iS^ndl»eeäed aarcoma la eompoaed of eloacly-packed, tuuaUT
thtu, elongated «pindle^cUs, so-called filatDentMcUs. Csualljr iImk
SARCOM-lTA.
5BS
vu.m.
M no intcrocllular Eiul«t«acc, occaaiaDallr there is sonio ; it luay bo
bomogeneous aiul eoft, or fibrous ; IT ttic Gbroufi pnrLiou piupondcratcs,
tbe tunuir iit t-iill(^(l fibro^iarcomfl,
or flbnxna. Funntrl^- tbi« spindle»
celled tüsue wu tertned young
connectire tissue (tiskSiie libmpl«»-
ti(|ue. Lebert)^ but fmm my biab^
gcnvtic inveatigatiotut in tbu em-
bryo I liare Io«e |>njli;«l«yl n^icut
tbis vievf, fur spiurHf-cKÜL-J tissue,
M wv usuuUy find it lu those bu^
coma la, duM iiot occur in umtnyoiuU
tissue at any period, not c\'cd in the
tendoDs; tbn pliysiolo^col oxant-
ple of tbia tissue is yöung muscle
and tM^rre tissue; ihrsc aiiindle»
celled s&rcomata would tbvii be
young myoma ta or neuromata.
Vh-ehotf lisi« c«rw<i llie Mnie
fiew fuitbcr, (»pMrially aa fur ue
r«g;nrd(i fibrous uterine tumon (page
905). I prDt4»tecl against (bis
view of Vire/iow's, with ita cod-
BcquCncva, aa the diagnosis is always doubtful in opc-ciul cuses.
Whpn ft iion'O oontning a tumor onnsisting of plongnlod spiudle-
cclls, whose ends temiiDalc in fin«; Rtament&, it i» rory luilurul to re*
gard it na a neuroma wlwis*- plcnn*nta arc not fully developed at any
pnint. When a spin<tlf»-<-c]Jcd tumor is duveiojKx) iu rausHe, nnd the
tibre-ncUs «Ihiw band-liko forms, even fine granulation, u in tbe coot-
menoeuient of stnatiou» there onutd be no blame tiir calUiig these tu-
mor« ** myomata," under the idea that they were young inusole-tissue
t1i:ii. had not gone bcyoiid certain bounds of development. So fur
there ii tii» objection to this view. Bui when a apindle-celied »ux'^>ma
comes ill the cutis, or on the peni» (where I recently «aw a rcninrk-
able <•»«■), we may 1»e Tery doubtful wtictlier ihe «we i« one of y<iung
nc^uromn, myoma, or fihroitui ; in Ix^tb of these luitta there are niTrea,
miiBclee, and eonncctirc tinuo, If, then, tbcre Im nothing typit-al in
the amjigemont or fumi of the oeLls, and tho hislulu^^icnl incxle of
origin cannot be certainly determined, wc must content ouraelvcs with
the term " spindlivcelled sarcoma." At «11 ovoiits, we haro to d«al
with a fibrous tissue, whose development has not adraaoed bpynnd
tho production of apindle-cells. Moreover, I think I can ailtrm from
uijrob»crvstioii9 that tbe course and prognosis of these tumora Bcatooly
TlMniO or* iplDilIa-cvIlna ■iroaoM.
&n
TirUOHS.
FU. tUL
/
depend on Lheir oHjpn, but far more oa tbeir looatity, rapidity of
grvwtb, cou»i»tt.-iK-v, and other dioical conrlitimis.
(c.) Giant-^Bfd taretntta U a
name given \>y Virehotc to m ^luiMy
of «ironma containia^ rcry \argB
cells, wliich «V partly wuikI, caitljf
pnlyimirjihous, jiikI 5uj>|i)ic(I witli
many «flshouts (Fig. 118). IVte
odis, whicb normally occur in llw
nwiluUa of tho hone« of tlio fortni^
altliougL nut ito largt? »x In tuiuon,
have oxeitcd great uEtmiishment fay
ihüir size ; ihey are the largcet oo-
formed protnpIaKin collect ioiis thit
have I>een »een in man ; Ll»<>y may
contain thirty or mote oudci, and
their origin tram ft simple oell by it tivricH of traiigformatiuos fa geu-
vnilly easily foliovreii Tliene ^iant-cclls occur in Bpiodlc^ollcil, as
well ft» in fibro-«ftT<>oi«a ; lliey occur Bomcwhnt eniallcr spur»di<nI1y,
und arc al&o found in gniiiulaLtuu and myxoBaiconiata. They are ro«j8t
Oliuil-Cell* iMna ■ Mnwnx of th« towor
la«. MkcnldMl 3B0 dlamaMr».
Fm. II«.
1'^
. ^ V"
*>
GUl>^colll»l urcoma with tryiu lud o»tl>lnc foü ftoio Um loiMr Ja«. SL^rnlBtJ i
<]lBca«t«-i*.
frequent in ihe central, les« bo in periosteal aarcoma, bat I have teeo
Ihem even ia muscle-iarooina. Bythoir sise tliey occastoaallr gira
SACKOIUTA.
506
the tLSRUi? bh apparently alveolar (Fig. 119) »InJcUire, >□<] by Bo(t«D-
ing naj Itrtid to formfttiou of o^ta (ti), or may ossify (A).
A pocitliar fonnation from sarcoma wbJcIt u allied to tbe pant-
cell, although never gmuing Tory large, tnay be mentioiic«) hvrvi, Iii
a grsnulutioii-earDOiHa of tlie iluni inatur, whioli ac-
oideDtally fell into my hand», there wore great nuin- rut. isn
ben of globular, multiiuicleatcd ccllx, vrbich wvru
surrouiKltil with a mciiibnine-likt; cuniK;cto(l lart^of
spinJlc-oclis (Fig, 120), I haxar<t uo explanation of
those I'lpiiients, hut BU^j«:t that they are aa&ociiite«!
with the formation of tufts oii tl»! cerebral meiu<
braao9, and witli Lufied Gbi\>-8arconiuta, which Vir-
e/tom ciilU bntin-Ratt*! tumors (paaminone), when they
cotitttiti brniihiHiii(l.
{d.) Xri-C(äed aarcoma, Mueotu aareoma. {Qe-
Istinotu oarcoiiia of JiokitansAy.) For th« ol&Iwotfl
from celU tu develifp well and h« dUtintily S4>«a, Mtcoinkor tii*<ian
tbcTQ must be considorahlc soft intercellular eub- So'SlinMtiwiT'
Btaoce present. Hence sareomata with gelatinous
mucous intercellular suhstaiioH vrbich contain any stellate cells ire
the most Ix-aiiUruI, Rut this is not aliraya Utc case. Tlicre are also
grauulati OD- sarcomata, that
have a eliiim to bo regarded
aa mucous or gelatinous tu-
mors. If wc aboidd wish
to chif» llie tumors from the
alK)ve groups, when ihey
appoar gelatinous, together
because tliey oonlain much
raucous ifi'Sa) ire may ckII
tfacm myxomata ( Ki'rvAcw),
or retain their old namu, rul-
loiieina {J. Malfer.) Vif
cAowV true mucous tisauf
(Fig. lai) undoubtedly be-
longs tu lite derelopmcnlal
aerieA of the conncetive tis-
sues; uccaMonally it «bo (^
occur« in mucous grauula»
tion». But frequently also
we find ijpintlle-oelU and
ruimd celhi in myxoma, and,
lere uo At tiK same time ik* tfbciiieiMÜUa« Aww
rto.in.
M6
any dcvcloixMl curtilif^, tlie mtiooiu tissue may be ir^nleJ as jronng
or softened cnrtili^stimuo, which I>coomc5 tli« more probable il a
myosoma contains tioiiL'}--o(KiiMike Beptii Bueb a» arc found in ebon-
tiroina. Wc niny use tlic tcnna tiiyxoAatvoma, nyxcx^oiiilroiiii, etc.
(ö.) Ahff'lar mrromit. TTiis rate form of tumor (occurring in tbe
outisi, iniLvriu, and bnnc) is very difficult ta ohnrnnt^ri/e uistnimcallyi
6Dni tin* size ami nmingcmpnt »f its €vi\f^ it imy in spota so raooh
rcs^mblv ciiroinoirui, t)»t 1 vrould not trust mr:»clf to decide conrt'tly
OH every piece of surh a tumor placed uixlvr the micr>:»oopf>. Tlw
cells L>f tliese «lemc'iitfl ore much Inrgier ituiti lympli^x^Us, abuut ibe
«e? of cartilag^i'vlU, or of moderately lar^ Hat epiüielium, aad
u&ually iiav«> nn(> or more hrg» nuclei, villi g!i.ttoning rtucluoli, tlie
cells ar« cniljefldi'd in ii fitinius, or more rarely homogeneous, dlig^btly-
developeil intenrcllular eititfntinice uf evfuisite nlvculnr t^^'pe, in euch a
■vrny Dml they He tofrotbcr aepnratoly, or more rarely in groups (FigL
Iti and ViS). They are loont intimately cxMmocUitl unth the fibrva,
no-itt.
Pml til.
^i^
AlvpotarMfcoioi fhiin I)m deltoid nnKlc.
tUiiiitaril WidlatnuiorK
AlnykbfHrmmii Utm U«- ilbta.
lla«E>UlMlDa Oauutaf«.
and niyr dilÜciilt to detaoh frota the flbrous musa. Tho latt^T two po
ciiliiirities am important fur the hi8lnliij^^<al diagnosis r>f " »rn'omai,"
for lliey hlimv th»r large oclla are con uw live- tissue cell», nut tTjiihuUal
cella, as in true c&rciooma-t issue, Occaaionally tho cellular clemonia
SARCOtlATi..
697
,of tbrae S&rcoiniita lie in immcxliate otmtact, without any lotcrccUular
I'tiibstftncc; tbc resemblance to epithelial Cftrcinom» may prove de-
oeplire. VircAme ho» deKcribed and deduovd tbis fonn ä-om »oll
WBrta of thß cutin.
ij') PiffM-Hitari/ aarvoma. Mtittttotic forcoma. Melanoma, All
tliese nnmes iiKlicuti* pigmr^nt formation in Kuconiu. Thii« |ngrnont,
which is UAUiill^' gnuiuldr, nretjr diffiur, is brown or black, lies ahaoat
•IwBja ill the DcIl», nireljr in tbv iDtcrcctlulur EubelnDOc. Psrt or the
wholo of thu tiintur may be faintljr or distinctly blade. Any of tlie
•bow fortiu of sarcoma may ficrasionally be pigmented, but I have
moet fircquciitly found this to be the case in the last funn, and \a ihu
Bpiiidl«-oell«d sarconu. >feJanomaia develop most frequently in the
cutiji. rHi)ecialIy of the foot and hawl, but also on the head, neck, oiid
.truok.
^e nrmngement of the cellular element« in sarcoma depends, oa
lie one hand, on certain direc-lions of tlie Hbre» or tibre-eelU in tbe
'-tissue of the tumor; on the other, on the form of the vawiiUr net-
work } from these circtimstnnocs, as well as from the dc^'clopniciit of
giaiit-cella, or nmilur fnnnntiunK, th<>re may remit an arninf^>ment of
the tisMue of the tumor, Nciircely distiiiipuishable from tlie areolar
fonoalion forma^rly aeeribed cxeluaivoir to cikrdaoma-tJsaui!. Tlii.i
sboukl not asloniah you, for in eartilago also we have a typi' of cavi-
ties with enelnsed «ells, and also the net-wnrk of the t^inphalie glanda,
whifh iiiukMiljtedly belong to the nystem of conoeclirc-tissue sab*
Ktances, ImiC must alao b( termed alveolar EbrtnatioM,
Coming now to the symptoma of sarcoma perceptible to the tutked
eye, v-v riiikL first state that in nuuit rases these neopln^iie Iiavo a
ruuiidi»h, sharply- bomideil (brm, iiMleed, »n; usually distinctly cnca[>
mlatcd ; this is a very important distinffuu^Dg mark &om inGltratcd
careinoma. Sarc^oma verv- TarelytpiK^r« on aiirfaovs (whether free or
aaclike membrane«) in a jiapillary or pol^-poun form ; still, tliere are
Don-glaiidular ntwal nnil uterine polypi, ulso mft warts oo the skio
and mucous membrane, whieh, from their histolcj^eal atracttire, can
only be dassed among ihe sarcoumtn. The ooDsistenoe and rolor of
earoomata vary so much that nothinj; genrnil can be said about
them ; tlicy may be as hard as cartihige, or of gchitinous, nearly fluid
oonsistenoe. On incisiun, tbe tumor may appear bright red, whit«,
yellnwiMi, brown, funy, Maok, dark red, and different shades of al)
these (xilors ntay appear on the same cut »urface, apart from tbo pi^
mentation ; this depend»! esi^eeially on their vasculunty, and on more
or leas recent eitrai-asations of blood in tho tumor. Tbe vascularity
088
TCMORS.
Taricft ^-«tl; ; sonictioivs tlicro is oaly a ecaatj net-work of Tcswli;
again, the tiimor i» liko a sponge, iravcrseil bj carernoi» veins. We
muHt here tDcntioii unuthcr pL-culisrily of sarcoma: il is occiuuotuUj
so wliiti^ that, if it be »od at tb« same time, it ^really rcacmblL-s
bniir><matter. Tlii» medtiUary aareoma (t>nc<-iiluiloHl) hsuhUt ha all
tliu iiialignaat qualities of surcoiiia iu itie Uig-liest gindt?, nnd is mari
Cnirod; it muy liuve nay of tlie sbort^utM-ribcd hietolugiml dimiae-
ten. Tiitnors which may b« torn up into. buadVs in ceHdin diKctioU
have been oaIImI 8»n.-oiiin fHHdt.'utatum (fornierlj- carrinonm fawico-
latum). Tlic niiutnmical mrtaiaarphoeos that Lak(- place in aanxnns
am rurious : iho different tiiodva of uuftciiiuj; prvtlomioatc ; inurnut
sufloning, even to llic fonnnüon of intieoiis 0}*st8, fiiltj- and cbecsj
d^cnrrutiun?, nn* fn^jucnt. OssiÜcnlittu is \cxy conimoD id saru»-
mat« oonncctod with bouc, nud may go on until tiic w]iok> tumor ia
more or loss oumpletely trausfbniied to bone. Cicatjioial sbrinlngc
scaroetj' ever ocrur» in aarooma ; tbia is another Important diflV-mi««
fnnu careinntna. Ulceration from nitiiin outward, oixmiiig^ out llki^a
crater, is rare ; furcomata of the cutis uleerato early, without, liowcrcr,
caitaiog extensive destruetion ; ulvention of hard aarooniuta cxxüiaiod-
ally produop» well-deTclo|)ed innnubittoas.
Ilio dinj^o^U of snrcoma during lifo ia made by attending to Ihe
folIowinjT points: Sonioraata develop uith peculiar frefjueiicy aflrr
precedent locul irritations, e&pet-iully uflor injtu-ies; ciaitri<:c9, alio^
ar« not uiifrcqu^ntly the «eat of Ihcso tumors ; black Barcomata may
come from irritut«<l moles. Ski», muacli.^, ncrrea, bone, periosUnini,
aod, mori; nircly, gluud:« (unioug tlioti; the mainmu most fnMjucntly),
are the scats of these tumom. Sarcotnatu arc raicet in cliUdrco, rare
betwtNjin ton and twenty years, most I'requcut in middle life, and rurer
aj^in in old agn. Anrording to my observation, meii and woni«^ are
oQc^ed with riiuiJ fruipicni'v. Jf tbe6e tumors be not loratol in
or on n<Tvc<trunl{s, tbf^y are usually painless till they break out. If
th« snrotmia bt> in the sulK>wt»iieou# cellular tissue or iu the breoaif it
may be felt us ao encupsulnt^xl mnvnblu tumor. The growth is soto^
tiqics rapid, somotimes slow ; the consistence varies, so that it UO
scarcely be used as a point in diagnosis.
Cofurm ami proffnmis. A sarcoma may develop solitarily, may
remain so, find nuvLT rvtuni after 0|>emtion. It may develop as soli-
tary or multiple, and return nfler re|>eatod csUipntioo; metastAtic
tuinora may fonn in the lungs or lircr. and thus lids disease may cause
death in three months, Vou see that the greatc«t benignity anc)
greatcBt mtvligniiy miiy Iw united in this uiut group of ncopbuiaj in-
deed, I can assure you that tu-o Nnrcomala of the most similar histo-
logical qualities (usually, however, with different conaistoocc) may
6ARC0XATA.
MO
differ entirelr in course. From this ciroumstauce t3)e ffimtcst obje&
tjons h&vn b«en raade to paUiological titstolo^ ; it must Ik- nr-knowl-
edjred th«t the histological Btnicture of a tumor by no means c-om»-
sjY^ndii to it.s rlinioni <'oiiri« ; but for thin neas^Mi to cast a slur on
aniiUimy would be Just n» stnin;^ as to blutn« it b«0)iuae ure cannot
OPrtainly distingiiish !>otwecn the nticroscopic propftmtions of • bmO-
[^wy, Inchiymttl, or miiomis gtuiid, «llhnugli iViey play very difffrvnt
. in the OTfrnnisin, Wu must first orMr^omo tliv habit o( M^eking
iSc onatäinic«! form* for »pooiBc functions. Itut tlior« U no bu:k
of in<)imtiüi)s fur progoosU fn ivganl lo any sanxima. We shall
h«reaA^.T speak of tbc iinpoxtaocc in thia respect of the location of
the hinior; (he coneiatcncv is important, finn earconwla are uf better
prugno&is timn soft, ones ; alveolar form« are of espoeially Iwil pro^uosi«,
and «itill more so am tfae soft grtiDiilation and opindle-ct^Ucd sarcomata,
vhidi usually ap|>eur in the uedullaTj fovm; black sanxtmata are alao
eHpeciiilly ilang«*«]»!!, the linn ones 1>i>in^ leas m[üd iti their course tliaa
the soft. Til« mpidity of llie growth finsl apfK-anng it rery unpor-
tant lor tbc prognoeiii; Ihia is, moreover, in proportion to tho coiuisi-
vractf ; if a sarcoma ia» Iak«m four or firo years to attain tho size of a
ben's eg'g, the prognosis is not so bad ; if iu four or five veeks il has
grown to the size of a fist, it is very b3<l. A eurcoma muy be mis-
taken for a cold abscess ; I knoir of one case vhere a sarcoma of the
atxloininal walls develope«! *o rapidly (hat at fir«t it waa diagnoaed to
he furuncle. In a fcvr months the patient wo» ctn-ertxl with sarvo-
mat«, and, in less than thre* month» from tbc d<Aelopmrnt of Üid fit»t
! 'tumor, she died fnnn the disease attacking Ibe lungs. Sumeliines,
however, a slowly-growing, firm sarcoma is followed by one of rofiid
growtb, but tbc reverse of this oevcr occurs. Usually, «arcomatä
d(>velop in strong, n-ell-nourished, often in particularly healthy and fat
persons; I saw a medullary saroonia of llic mamma in a blooming,
strong, b«althy girl eighteen year« old ; she died of satooma of tho
luttga a few months after operation. The morle of development of
tairKKnata which appear suocessirely i» very clianuneri»tir. Th« Grat
^■iuiQor 13 completely extirpated ; after a time, iu, under, or near the
^" eiealrix, anew tumor appear«; this also is completely removed ; a^in,
a new tumor appojirs ai the point of Operation, or at a sligbt dista^CI^
ftom it, and near it other new ones; the patient begins to emaoiiitc ;
possibly further ti|>erat ions are not practicable, marasmus occurs, po»-
sibty lung or liver tumors, witb tbcir symptoms, derekip; the patient
dies from suppuration from the primary tumor, or from diseaai.- of in-
teroil organs, llie course just dcMribed difforH from tbat of caix'i-
noma, because in tbe latter continuous reeiureiice is the most frequent,
while in aarcoma tbe regional predomiiutc«, provided tho tumor has
OOD
TuMoaa
been entin>ly cxtirpstuL Tliü amy rcadiljr lie explaiunl b; ibr but
that the bounds of infiltrttcd c«rcinoroft u« mudi more difficult to
idetrrminp tlian nre those of oncapsulutetl sarvoom : bent«, («l«rü pari-
tun, llie Utter mny Iw more certoinly mnoTrd; if portions of sbt'
OOoM he left, uf tfurto tliere will be oonlinuou» refurretice. AtUs
OOinpIoto extir[)n1ii)Q of snrorann, vcan iniiy <>liipfte belcirc ib<> regional
iDcuimirL*, and snroomu xnity always renuiin a 1m«I titnil>le for yean,'
possibly till <Icalb. 1 knuw one ckac uf fibro>i!ar<.-oma vi tlic b^ck »f tlw
b««<l. wborc it was !«'<riily-tbnf yam fn>ni tin.- i!ovolo|iinciil of ib«' Gr*l
tumor till dc-stb from recurring tumura ; meantime, the patient WM
operated on five time«, and, on each occasion, he was cured for some
time. From an old woman I extirpated a meduUarir sanmnm (alronlu
caacetmifi form. Fig. Hi) Crom the deltoid muüc-lo; the wound had
senriM^ly Itcaled when a new eiLrTX)iii:i, like the lirst, formed ia it ; im»
the womso rerasined perfectly well four years, then, a new tumor isok
in the deltoid ; it wns n-niored by an ofM^nnium, probably iin[>erfoct,
and recurrwi iii the tncoinplet«- cicatrix ; txarlieuliition of ibr arm was
followe<l by recuiretiec in the peetoral and l&tissimiis iituftctes, and
death from Bareoma of the lungs and pleurisy. A \'ear ainee, I exür-
pated n melaiiotie, large-celled sarcoma from the scalp of an old mitu,
from whom iScAmA had, six years previously, removed • similar tumor,
tip to the prt^ent time there has lx>«n no rccurreiM!«, When we am-
putntc the thigh for sarruma of the leg, after years it may recur in the
amputntion-eicatrix, and bo followed by snrenma of the lun^ The
local t^'n<Ien<T to rcciir could be explained hy an extensive Bpriiikling
of seed in the virinity of a tumor, if tbe recurrmeea luccoMtMl aach
other niptdly, but, when year» clapm? between tlw rwurreiitt?», this ex-
pluiHtion will hnrdly answer, for it is not ver}' ]uii>hable that ciimcff^
cells would lie fjuiet in tlw tiiwiie for year«, ami ihi-u »uddeidy alioot
out like an old seed. I know no explanation for this mode of (o:ur>
Fcntoe. The oourte of th« infeetion is tatj peculiar in sar»>nia ; 1 tildok
I WHK on« of the fintt to show that it is an essential [>eentiarity of «ar^
cxjnia, thiit it does uot attack the lymphatic glands, or does so ijuil«
late in the disease. The course of saroonia-infeotioo goes chiefly, if
not exclusively, through the veins — not, as in narcinoma, tiiniu^h the
lympliatjc vessels. Sorromata of the lungs are mostly of nnbulie
origin; it seem« thatthe wiitl:* of the veine in larvunia aio very readily
tmrerM>d by the tuinor-Hubstnmv, and tlieir calibre filled with friabW
masses of it, whii-li thence pass Into the tungs. The mmiber of the
eecotidary saroomnla is often enormous, the whole pleura aiKt peri-
tonieum may l»e entered with them. In this reRpeet, the melanotic
fonna almoat appear to di&pute the precedence with the niediillan*.
Priaiorr, only portinUy-pigmcntcd tumors arc occasionally folknred
WRCOMATA.
001
by poffpcllv black and also by perfectly n-bite secondary* tumois. Sat-
atmnta of the lungs um almmt alwavR of the gmniilation variety. In
the liver I liftv« MN>n sei^odaiy, very beautifullT piffinenU<d, .tpindl^^
celled safconiata ; ihv funns of primary aiid «ecoodiiry sareoiimltt thus
■fwy greatly.
Topo^rftphy o/MfComa, As tbc above gunersl r«m«r1cs era in-
suffioient for ^iractice, we must study more aoourately difffrent fc
- of surcotna in ceriain tissues aod in ocrtain port« of tJie body.
Fm. m.
Fm. 1-a
OiaUal<M«MUcMn>cif tbc «Im. IVvm tht^Mllmlaa
oflknnkidellaleorik« UDinrttiju »miiL
Anilwqf t'tic IM.
Sarcomata occur quite ofteu in hollow batKW (myeloid himi>ps or
central ottteosnrcoinii), iiauully in the fona nf );^Tit-<Tlled Mirouma ;
thoy especially attack th* lower jaw, nort the tibia, rndin*!, and ulna
(Figs. l24aiul 125). Tbese tumom «ftpo contain nmcui« cysta and
sphc-rieal orbniiicho«) omcoua formationsi tlicyare circumsrrilKd nod-
ule«, mostly forming in the mwlullary cavity, «vhich frnidually dretniy
llw» bone, but in «ufh a wny that new bnin» i« oim^tiintly developed
Erom tbc penost4TUui, so thitt ilii' tiiinor, i-vun if very Inrge, nften re-
mains coTcrod entirely or partiatly by a idivll of boncj tbe diaäu«d
eos
TGXOItS,
Fu in.
■J I
bone theo appears puffed up like n bladder, and (ho tomor does not
alwBj3 cause a compleU? «olulion of its coiitiutiii^. \Vlii*n these, war-
comaUi occur in the lun-cr extremi-
i^, they heootav very nsoulRr ; num*
liers nf small trauinalic AiteuHiDii
ilfvelop io them, and a true »acaria-
I tiijil murmur maj be heanl in thaa,
!Mj tliat tlwy ore often oaoaidereJ
and dcscrihi»! aa true boae-aneB-
ri&nis. I1ic crftUiMrcoinalA amloom-
pound »-His, vrliicli nrc ocuuionnllj
aeeo in boocs, cspeciollj jn tbe loirer
jaw, ulito in Ur)^ liollow bonce, IiMW
ustially i)erelo{ied fntm O!tt<!>u«too-
iniila (Fi^r. UG). Ccutral oMeunr-
CDinikta are u»unl1j atttitu^r, rttj
■-«rely gtttmnUy inri>cUcniR, In the
lower or iipf^ier j^w ibt'y nit! apt tu
oniQc at the time of iLc soomul dot-
tJtion, rnroly at tbe firet; fo tlie
long IxHii-a I hare only >^fn thm
»t nmUiV; ugc; of tlie tuinont called
epulis (the word mcMi» locotod on
tbe gutns) a lar^ iiambc'r belong to
these giant<clIod Barcoiaat» ; tht-ir
location on tlie f^nts is ^ueruUy
only apparent; tfapy usually i^iHng
Ooaponnileir.wu«oftiKdiie!i,»fi«rJ*j»i. fpom cavilicfl in tbe teetJi, ami liare
st«rtc<l from cnriifua r>oU of UscÜu
Some also mil epitbelini ontirar opntlt ; it is well either not to ilw
sucli ((.Till» or to rcslrict Uteia by conaiii »djectiTM ; «a ■arcotnatous,
fibr»iij^ (^iLrrinnnuitou.i cpitlis, etc. PL-riphcml ostcosnmnnata or pcri-
ostwil (mrooiiiHln (ostiHiirl-^hiindromftla of Virrfiote] are quite malign
nani ; llu-y eillivr tiavo ^iiiuliilion structure uitb ostuoid tiKsiu- v in
ostoophitfs, and arc partly owitivd; or they arc very lai;gTMx-Iletl
myxosarcorimta, niso partly osaitifld. 'flic rti|Mdity of tbo course vaiiee
jrreatly ; »arci^mata of tlif luug» have been observed after them.
Sjiiiidli>collml sartximata are foiuid psppcially ofteo in tnusdea,
fanciip, and t-iiti« ; tliuy are locally very infections, and oOen return
tifti'i- pxiirpation. Myiosarcomata come in tlie cutis and Rubcutsncuus
L'flliilar tJAsiie, and with the naked eye are often (Iißi(-ult tn disttn-
giil.tli from a?dematoi)9 nnfl tihrnmsta. The ncrrM feltO Are rclati\'elr
otleti tbe «i-nt of multiple «irooma. The more npldlj tbe primaij
SaltCOXATA.
608
tuniM4 bare gm^i^t ami the mor« " m«dtillftrr " thoir ajipoirknco, the
more dAngerDus they am. I Hod that all ages, oxccpt perlia|M child«
I buod, &re eqwill^v ilispoeed to these tumora.
Fi«.vn.
Fiih ua.
/■v
P«t(«i«mI anrMina af ilf HUi fium a tmt. frnm Ibe
M Berlin.
HmUm »r Pig. M.
Wliuii ftarcfjiim t1ov«1i>p8 iu a glniui it almtwt always rontiiins glau-
dular vJenieiits, which may Ix: {^imtlv ohangod iu funn, ucd some of
which may be ocwiy fornitKl, Ilcncc, pure adcoomut» (which arc
vert' rare) ituiy bedilTicult UidiKtinL'tnKli tnnii Siin^iuimla lliul linvc de-
vplojicd ill glands (ailrno-«arcuiimta). Glundä arc by no nKiins fX|tiaIlj
di»pohed to tlie devrlopmcnt of sarrotDU ; wc shall bricHy state the
Icxnlities whure thoy are most frequently found.
Till* ft-iiuile mammn, mnrt; than any oilier gland, ia auhJRCt to tJieM
liitntirii. Sttivoiittttj) uf tlie maitniM are ruumUsli, lobular, nodulated
tumors of firnt, cliuttJc coniiiiit«noe ; the diaotuic may nttaolc n large or
eiiiiill portiijn of the lolje« of the gland ; as a nde, oidy otie brpa«t is
attnckcd and only at onu point; at utlier times, si^rcml small nodules
occur «t till? saiiw tinK- in one ^land. Tlics*' tumors grow vtry «lowly,
cause no putn ; like all sorooDiato, thpy are sharply bounded from tha
healthy pari«, hence they arc moraUc la tlic glandulär imrcnchyma ;
wh«a llicy grow large (in the oourso of years they may attain the
001
«vwuca
Bi2e of a toaa's bead) they almost altraj? form cjstoftar«imaU ; in
the course of time tliey bBcnmc sofl«r aud cause pain ; uloeratiua »im
occurs. The anntomy of tbeee tutncm has always excited fn****' intn-
est. As iIr- glandular elcmvats, acini as wvW h» vncrfUtry ducU,
wer« fuutul iu them, it wub fomicrly mppowHl tliat they had dcTcl«^«!
in the tuaior; lieaoe these tumors wcro callwl partial hy[>crtiu(iliiua
of the maoioia. I consider this ricw inoorrect, and thtnk that, by ex-
amining a great manyoTtbosc tumors, I have aHtii^titHi nu'^^lf that pri-
auiriiy and vhictly tlierc is a ucTclopniLut vl sueouia in the conucnttre
tissue antund t\to. noini, the latter lieiiiff preserrcd, al(bou){h they may
lie «.'hanged in various wuyx. Tlic distention of the glnndKliiris rauH«
cysts, at finst slit^huped, Kub»t-qiicutly more roundish, nith muco-
«erous ntmu-iit^, wliose develupnR-iit we alta.ll imuKtlinlcly fullon.
The tiastte of tiie neoplasia itself is usually conifiOMnd of Mtinll. round,
Bpiudlc-sha[)ed, mrely of branched cells, with oonaidenble dm-elupad,
fibrous, sonietimos gelatinous intercellular siibi-tance. In »oiue of
thee« tumors the librous tisane may be so prevalent thai, in nonaist-
cDce aud constitution, Ibo entire tumor may rctteiuhle fibronuw Acc^
dental cartilagiiwua and osseous tissue are ooesaiuually ulwerred, but
ate very rare:, and have no influence on the course of the disntac If
Uie growth of thfse tumors were regidar t-hrougboulf the eacrettwy
ducts «ud acini of the glaud« would be equally coUrijed or compr(*«*<l;
for, if yon imogine a part of tlie gland, say a lobule, spread out aa a
Burfiioe, aud suppose the basis to which this surface is Bltnehe<I en-
largingf the opitbelial eur&oe muat also enlarge. But the plaods
may be regarded as sur&oes bulged out in many places, so that this
representation la quite proper. Such a regular grofrUi in aU jMtia of
a gland never or very rarely occurs ; tlio result is, tliat frequctiily ocJy
tlie excretory ducts elongate or enlarge much ; this imliices (he slil>
afaaped, elongated cy»lit, visible to tlie naVed eye ; but. by Minultonr-
ous distention of the glandular acini, rouiulish ey«t« are often formed.
In this stretching of the tuimulated glandular »utDmv, the epithelium
iDcreaHea and (lovelojui to a higher stage, tttaamiK^li as the sinall, roun<l
epithelial cells of the acini iucrcuse greatly, hikI change to a layered*
cylindrical «pitholiiim. Tbc glaitUulur giibstnnec thua altered aecret««
a muro-atrrous liquid, a rery minute portion of which is apontaucoualy
evacuated from the nipple, while most of it is rtrtnincd iii the tumor,
and Berrea to dilate the already distended glsn<tuliir cavity (nrteatian
aod secretion cyata).
Then tlie tvnior^ubstance again grows into these e^-sts in tho Fona
of lobulated, Ißaf-Iike proliferatiouB (oystosarconia pliyllode«, proUie-
rum ; Jo/in JUcUer), bo that the cut surface may thus uo(|uire quite a
complicated appeamnc«.
SARCOMATA-
800
Tlu- niMtiuti of Urn cysUlcvelopmmt to the wreoma {the nnture
and TOuPse of the diwMO is not much influcooed bj tbc former) varies
grcntl^r iu tiiatto, tw in »11 cvfttnemrcoinntA.
Mniiiinaiy and cysto s«ixx>nmla are not very rare, but are &r iesa
freqiit'iit tiinn iIk- <?anoer8 of the brcoai, wliicli wf sliuU hereafter iiieii-
li.j.i. The ()i]«faM> is most fr(K{Ufnl iu young u»rriwl women, but
T».m.
...o.,.
"■■>i
10^
r
ft:.
^^
. >{
\ij:
FromanidPOA-MrcoinaorUielbcnatebnaai : a, dl1iixi1on<>r
•liul. niwalflaJtninamcUra; <, ■ (KhMdMiaoaiir lip- '
eplibelliub ; luunoadlale nb*!«!!!» roMnUlBKinaHlBtiuii-i
, U-flk^^^"' LUtf (ilAlllulHK.
ktso ocoiin «hortly before puberty — rarely aft«r thfiforttoih year of
ifr. Tht* growth of thr«te tuinor» is verj- alou-, am) is paiultrM bi-fore
tfary become taf;ge; later, howuvrr, tl>er are aocomimniL-d by pirrcinj;
, paiiu; lis tlio tumor may Kn>w as larfce as a man's head, and ulcerate,
It may ]iroi-o rcr)- trTMjblesom«. Sonie of tbeae sanonuta hare the
pcrultnrity of swclliiiff, nod tH^omm^ slijjhtly painful shortly Itefore
and during monBlnutton. In this disf^ae«, the ^neral health is not
alfcc(«d, eicept that i» large ul<%>rated tumors Üie patiimts emaniate,
booomc aoffimic, aod acquire a suffering look. Tlie ooiiise of ihe dis«
ooa
TCUOK&
eauf msv rar}* ; thtsre ore uoi a few cases where Bniull »«rcoinata of
tbc brciutt, vbidi perhaps cunc afW ihc ßrst coii&nciQtTit, sponliino-
ously disapptitrcd in tbo course of timo, or oIm nnnaiood for tbe ran
of lifi! without doing anv harm ; but in most oases these tiunon gmw
gnduaJly, until tlicr arc opcratcc) for; if this is notdoac til) latr, wt>pit
Ibe tiuiiora luire )>ec(>m« lat)^ aiul tbo uotueu ]ia\*Q attuineJ old age,
thfy may Ix^Ronie infeolioiis. In yriuiiff girls aud women, when a
»l(nvlv-^--r(^w!iijz' snrcontn of the mammary glutei is extirpated, h don
not iinually rcapfjcair. I^ Imwurcr, the sarouou brst ajipoan bölvrenn
lh(^ tbirtioth and fortieth yvan, woliavo to fear j>-<^iu!Tml «ammia infec-
tion, or B(;tual tnmsfomiiiUoa to cHn-ittoma by epillipIiÄl prolifpntJne.
I conai<)er it adriuablr, ia all caai^, to extirpate tlicM! imimiuar}' ur-
romata early, as we never know exactly what their fiitore «lurse will
be. Tilt) dixgnoMN ix often ditlioult; xmall, nodular, lolxilnted bani-
eniiigs may oocur in the bn.tists from dironic inflainmatiüiif fitpodally
durinjr i^xl after ln<-1«tio[i, wbicb pa*« off spotituneously, or under tlic
use of iotliiie. Wu oOeu hiive to dcdje from Iho course whclber llin
case ia one of cbrotiic iuflummatton u-bidi may sulffitdc, or ati nctunl
tumor. Even the most accurate anatomical osatainatioD is here of HO
avail, for young snroormi-tisiiiie mnnot he difttinguiühed from infian-
matory neoplasia. This in anntber ca^c where tbe ImiiiKlarv l)etwem
«Tronic iiithiuimalory neoplasia* and tumors oaiioui be aocumtely
drawn.
A aocond orjfHn, in which utleiio-sareoma and adenoma develop, is
the saliritry gtand. The. tumors tlist fomi brrc are usually quite tarn
and elastic, are tolerably morable and grow very slowly ; ibey oooat
in the pan^tid more freiitteatly than in the im1>-mKxi)l»ry glutd, «ad
very nin'l^- in tlie sublin^ial. As seen by the nnke<] eye, tbe aiistomi*
ent eharacteriAtics rary greatly ; the tumorisalwayAdüttinrlly Itouadcd
by H cHpKiilo^ wbtoli is very intimately eonneeted with ttiu glsnd-tJäauB.
Tltc substanpc of tbe tumor may be of pulpy, aiitltnginous or fibron
consistence, it may be oa»Ged, or calcified ; it often conlaiiia rysts
of briny, gelatinous, or eerotis fluid. Histolopcal examination of tkeae
tumors sliowfi that their softer part« contdst of spindle-eellR and stellate
cells, aoiuetimes with a slig-Iit, Bgaiii, >«itb a large amount of muom
or rnrtilnginnus intercellulnr suhstanee; tliere are also newly-fortned
ginnd-tulws. In nire easea, rhc tumor oonsists almost exclaaivelr nf
cartilage, but very frequently there is itome nrcoinatoua tissue present. ^^
T^efie tumont mny lievelop from the time of piibeny to the fortivtli ^M
year; they grow very »lowly and paiiileiMiIy, luid |>arliculnrly slowly
when they do not form till middle age. AUhougb tbey never rct*T>- ^J|
grade, small tumors (sny as largo as an t^g) of this rarietr may eeajw ^H
glowing late in life, [f these tumors be extirpated Drum youag pa- ^V
LYUmOHATA.
«07
UenU, 08 a rule, they do not return. But later in liJc ihej often recur
alwr (ixtirpstion, und Njturn so quickly, iL&t they gradually grow
deujier in tlw iitvlc, unA fiiisUy become inaocessible to the knife ; (lis
nöghbcHitig lymphatic glandx of ttie neck are Infected, bikI the disease
assutncs the character of oarcaiionia ; the adeoo-Bwoma becomes caaoer
of the ginnd. General dovclo|)(neiit or sarcoma sonrcely takes plaoe
from tlieae tumors. From the ooime above described, we might form
the rule of removing these tumors early io young patie^nts, but in older
one« of not being too houty about extirpation, \s rapid recurrence is
to be feared, vhilc oceaaionally the primary tumors grow slowly. Ssw
comata of the aalivary gland are not frec|t>ent. Similar myxo-6arco-
nata and myxo-cJiondromata oceaaionally derelop in the oral mueoua
membrane.
9.— LYMPHOM ATA.
ITuEKK neoplasia; arc very difficult to define accurately. Accordiog^
to thu mode of development wc rnay assume a seeondary InSammatory
Bwclling of the lymph-glaods from infection, and an idiopathic Iiyper^
plaaia. In dbieases from the moatTariedoaitaea, the lyinphutie f^litnds
almost alirny-i present a similar appearance ; they are cnlargocl, mor«
succulent, (irmer tliau normal. Tlio microscopic examination of l^tn-
»phoma shows tbc following appcorancG«;, if made from a liardcncd,
properly-prepared specimen: All the ccDular elements arc multiplied
and enlarged ; the lymph-cells in the alveoli, the eon nee lire-tissue
oella of the trabecule, tho capsules of the olvooli and the net-work ;
thus, tlie structure of the gland is gradually lo»t entirely ; tlie whole
Cgiui becomes n mo^s of lyniph-oelU, olthouj^h a line net-work is gen-
erally pn-sen'L-d, into which the hard cunnccti*-e lituue of the capsule
and of the trabcculic is also transformed, while tho blood-veweb arc
preserred, and their walls greatly thickened (Fig. 13Ü) ; the cellttlar
infiltration may be so great, that an exact distinction between lyn»-
. phoitm and glio«arcoiiia (Fig. 130) may be inipofiHJblc at ooine poitits.
^m Uiiuaily there are glands of various sizes, and we find the lai;ge one»
^'of tlie saiao atruoturo ms the »mailer. Neitlier the niaoroscopic dot
miooBtxipk; appcarancca will determine e^uctly tlie CMUCt of tbe
hyperplasia, whether it be idiopathic or due to chronic inflamtnation ;
we can only say, io general, that glands much enlarged by rhmnio
[nflamnialion more frequently contain abaoe&scs and caseous fod than
those wUicb are apparently idiopatluo hyperplasia. Perhap« I am loo
oonscieadoiis in using the tern " kUopnthio disease of the lymphatio
glands;" for in many of theae cases wc can di»oorcr no peripheral irri-
tLition, although many thioga speak in £iTor of the di&eaae of tbe
40
<08
TÜHOES.
glaiids bctag secondary ; it is pomblc that Blight, tenpontnr infkn-
m&tions have t^xisUtl, Ifint linvc excjlei) dif.cKu; of tlie glamLi, uul
bare disappeared before Uic uffucUoa of the glands luis aliuwn itaeiL
We fonni-ri/ spake of a similar secondary plastic process in tlic lym-
FW.130.
rimnUiotorttnl krcrnfa hTP^Tikuilccerrlail trmplnltcrluKl. UnnlAcdna ilbwMlei*. a
a. Mctloa nl rosMls wlili llikkm«i] w«lt*, brufhod-uitt üMibol prcpsnlloa.
phatic g-lands, after llie pdmar}- periplieml irritntioa bad i3c&xd,M
bcitt^ u chief STDiptom of scrofub ; hence wC mijg^t torm lympboiBata
as typical scrofulous tumors (scrofulous Barooraa, B. von ZiOnffenbt^).
Jjet iL<t study them farther, anatomically and clinically.
For a long time ihe ^landa preserve their kidney-fthapo ÜH Bnally,
as Ibp.y continue to grow, thJA also is lost, and the adjacent gloorlulor
tumom unite to fonn a lol>iiUt«d mass. To the naked ey«, tlie nrtir>
patcd tumoTH uppcar rouudiKb, oi-al, or ]iidii«y«hapcd; oa sccLioa,
thoy arc of a light, (rntyish-rcllow color, which, on exposure, chaogM
to a yi-llowish-rcd. TIickv tumors :iro firm and elastic; they are eanly
diagnosed, &oin their locality. All Ivinplmtic glands arc not equally
disposed to this disease ; the moat Erequenlly affected are the cervical
either on one ur both sides ; more rarely the axillary and inguinal,
most rarely the abdotninul and bronchial. These tumor« are haidlv
ever congenital, but they may occur frx^m the first to the sixtieth year,
although they are niost ftc(|ucnt bet worn the eightli and twentieth.
Not u J) frequently, h,\'pcrpl[uiia of the lymphatic glooda is maltij^e;
but only one w a few glands in tho neck may I>c affected ; if tliia be
the case, tiio tendency to such neoplasia nms out in ibe course of
time, while tbc tumors wliinli hare grown painlessly, and oontintied
free from pain, hare tbmr groirth arrested, and rony be osrricd fill
death. In rare coseii, th« nen- formation Bi:^>ear8 almost at tbo sam»
lime in all the lympbatle glands of one or both sides of the nedc, so
tliat the hitter is tbickoned, and the mnvcmenta of the bead are much
LTHFHOHATA.
em
iin|MMlM ; if those tumors continue to grow, they finnll^ oonip(«s)i tlie
traohea aiwl cxusedo«!)! by snfTocation ; but even in tliew Mvero case«
there ifl occasionally n t!|>oiil«n<.'ous amrat of tlic disease, iind tben even
large tumors of this kiii<l mny he BucoessfiiUy extirp«t«d ; eome of
these glands, too, are finally destn^ed by ulceration and oaneous de-
geneTstion.
The worst cases are those «-here the tumors quickly gwv to large
tnfdutiary tumor» (not unfr«H)U(mt]y undt>r the form of füsriculiited
znedullAn,- fungi), and whtTe tla- uviglibonng ti»Kuc is also changed
to lyiophotna. Patients witli auch tumors mrcly escape ; aDannia comes
t'Dii, Uie nutrition is impaired, »ftd Iiy[>ertrup1iy of the spleen may
''>ppenr,and the patient die of exeessive anannia and marumuK. These
maligiuiitt I^Tuphouiata, wliich 1/äcAe calls li/rnpfio-«areom<tla, cannot
be anatomically dislinf^iühed from the benignant forma, Hut tlicy
may be recognized from the fact tliat tJiey proliferate rapidly, and
especially that they unitu with lite purttt immediately around. It
sccmB to mo they are Mrtain to recur, and arc the most dangerous of
tumors.
In some of these case« of lymphoma, typical Icucocytfaemia has
been ohsflrred, and Viiv7,ow thinks tliat in these case« the increase
[ of white eorpuseles in the blood is due to the excess supplied by the
hyperplastic lymphatic glanils. 1 do not entirely share this view, first,
because even with «tensive tumors of the lymphatic glands Icucocy-
I themia is rare, and ureomlly, bocauft« it is v^' improbable that, when
their normal fonnation is entirely destroyed, the lymphatic glands
should continue their fuoetjons pbysiolc^cally, or even in exoess. As
frey^ 0. Wef>er, and myself, hare made a ntimba of un-meoessful
attempts to inject the tympb-vecflels of such gloniU, this alto would
fiiYor the view (bat these hypertrophic lymphatic k'"»'''* *k physio-
lo^^aDy insufficient, although in lymphatic glands experäaHy sueh
'negative results at injeetioo are to be rery carefully judged. Tho
fiict that MHUer (in Jena) sucoccdctl in injecting a small, t<li;^tly-
swoUen gland, of course proves nothing, as the destmction of the
lymph-ducts only comes on gradually. However, the interesting fact,
that leucocy thelitis occurs especially wilh mlargcnient of the lymplmtio
glands and spleen, is not to be denied, only the coni>ection is not bo
direct, there must be some other eausc at pn-scnt unknown, for the
dcTcIopmcnt of this disease.
What has been said shows that the profjnottt of lymphoma vsri««,
and can only be pronounced with any certainty after a [Krriod of ob-
serration of the rapidity of its growth ; in general terms, we may say
Uie disease is the more dange-roua the younger the patient, I bst-e
rarely seen it develop after the thirtieth year, sad fomeriy thought it
eie
TL-M0B8.
bardlj oocurred sAcr that; but not loiig sIdcc I met s tmtm d Wge
Ijmfihoma of the bmnirhial glands in n stout -nrainaii, fortjr-lirc yean
oI<), who had Eufft'rod lor five jfars from luthma ; the distmta bad
äjinllj* induced suffocation. In another case, in a mao sixtr-fire jean
old. tliere was imroensn Ivinplioraa of the axillary glandu,
'Ilie treatment of thi« diaeas« of the Ivmpbatic glands will at finrt
oft^n be isteroal, usually «ntiscrofiitous— ood-liver oil, briiio-baths,
and, if the constitutioD of the patirot doca nut contfaindicnlc it, indinc
remedies; if tlicrc be conaidcrablc aiiEcmia, iron alotrc, or »ritii iodine,
is indicated. In favorable cases, recent Ijrmphoniata disappear luub*
thin Lrcfltnient. In »till ntlier lavomblc coaca, trn atn»t the (rrowlb
oFthn tumor; but, uufortuaalel^', the uuiuber of cases curable b>-mrd-
cine in sltj^hr, niid iti tlioae very csjtea, where we wish most fram ibeae
internal retnedicrs,lipcuuse tlic tiuiion are loo Urge lor openitioo, the/
often fail entirely; indeed, I have evAo obeerred injurious efforts
from energetic iodine tn-atment in mpidly-growing tumors of tlii»
T&riety, in the shape of nipid softening of the Inrger part of the tu-
mor, accompanied by severe febrile BjTOptoms. Of external rcmedica
also, iodine is the most effective, mereury scar^^ely at all so. Farni^
able results bare also been attained by Baum &om corapreMion with
Bppunttus prepared for the special oases. I have thus cHu.-'e«! improve-
ment; oocaüonnlly a slig'ht diminutioo, or partial tuppumlion, but
nover perfect cure. We can only expect a cure from operation m
those cases where the disease of the j^lands has run ila eoursc. It is
true that, when these tumoTS lie veiy close to the traobca, we ftre oe-
oasionnlly obliged to operate on them when in full growth, but wo
must then always expeet lucal reeuirence or di.<>rase of other group!
of plixndi^ A careful consideratiou of alt the eirciimfttunoiM mivt de-
t4>niiino in any ^ven case wheiher an ojienitinn will probably be *vn-
ceasful. The upenition itaclf will be well borne in cnaea where the
gkndn may he isolated, and still preserve their capeulcs. I have 63-
tirpnted (or rather dug out with ray finger) twenty or more isolated
glnoiU from the neclc of the same patient wilhout subsetjuent reour-
rciii-c ; l>iit when the glands unite to one mas«, and are nofl, it is oa
the one Iinnd n sign of rapid growth, and local rceurrenee may be oor-
tÄiiily etpected; on the oilier hand, it will grtfltly increo.w the dilli>
ciilty of oi>enition. Sometimes lymjihoniata, developing deep in the
neck in young, oUicrwisc hc<hy pei-eons, grow behind the jaw into
(be throat and impltcnie the tonsils andphar}*nx; they usually soon
prove fatal ; the operations that might relieve them are so dnngcroua
that they rarely prolong life.
Of the other glands, which, aceording to reeent observation«, are
to be classed in the lymphatiogland ayatem, the tonsil* iJone aro
LTMPHOMATA. PaPILLOHaTA.
611
sabject to hyperplastic diseoae; but tliiA bypertroplijr of tbe tonails
wbici) i« oumroon, and iii childr«o and young penoiu is ({uite fre-
quent, inora r«N.'uibl«Kt cbronic iaDiuiiiiutocy •ecoatUrj* swelbng of tlie
lymphatic gUads; it is uauftUy tbe result of cbrcmio catanb of Uw
pbitrynx, while th« reverse is oft«n falsely considorcd tn be the crso,
BBinety, tliat tba hypcrtrophied lunsils am the cause of the pliHTj-ngim)
catiurh ; b<!noe, in such cases, extirpation does nothing for the chief
trouble, tb« frequeot iafUmmatloiie of tb« throat,
{hypertrophy of ibe tJiyiniu gland does occur, but is taie. The
aitalug-uu:* disessea of Peyer's glaads ood the »plecti have no special
interest iu surgcij.
LjtnpboiDa alao ocour« in tissue« vhich do not belonfr U> the lym-
phatio gliind». 1 class us lympli omnia all these mwhilliiry tunitirs,
usually 6uft, io which, by baidc-oing and preparation, we may sc« a
net-work anslaguus to that of tbe lymphatic glauds. In this sens«, I
have itxa lymphomata of tJic upper jaw, acapü«, ocIluliiT ttssuv, eye,
etc. ; tuiitore ivIiohc ätructurc frequcolly can only be imperfectly dis>
tiiigiiiühed from pranuiinion sarooma (espeüially from FiVcAoifl'* gl»0-
snrcunia), ami u'hiüh foriii their ordinary iiiecluUary consistency, arc
briefly called "inedullnry fungi." According to my experience, Uie
tnirturc of the above forms has no special prognostio signibciuicp, as
these tumors are alike malignant and infm^oua; but the iiuportaoee
of the most accurate examinatioa of these tumors should not on tiiis
account b« limited or luiderralued ; during the last ton joars wo bare
learned interesting and important clinkal differences for the more uo-
ouiate distinction between sarooma and Carcinoma. Ton years ago
we could not bare spoken as decidedly about sarooma and lymphoma
as vre now may. ^Vhat we now include under ** lymphomata " were
fbnacrly treated of jwrtly iiiidrr glandular bypeqilaaiie, jiartly as sar-
comata, partly as medullary fungi.
LECTURE XLIX.
Ul Afa»waft.— n. Adm»mai*.—lt. Ogd4 mnd f.y*<o<iMte.— F4llUnil*r Cr»«« ot iU
fiUn and Ma««ai )lcinbnuM.~N«apluäe 0]^u.—OjBta at Üt» Tkjnnil Olsad.—
Oraiba Cjita.— Bkud-Cjat»,
10. PAplLLOMATA-PAPILLABr UVPEBTBOPHY.
HrraBBTO we have spoken eEcluidvely of new formations from the
seriea of oonnecÜTe-tisMie subätatioe«, ni^iacles and nerve*. We now
pass to tbe neoplaaiie of true epithelium, derived from the upp«r anil
lower gvnn*layer of the embryo.
eis
Ttmoibx
Tbe epitlicliums fonn a gmt piut of two twmul Uhihw, nuDel^,
of tlie papills (tufts, intvsüiial villi), auil of tbe ^UMfa; tb« Bonner
an: w»vy or fingcr-liko olcvBtioiu, the Utter poucbod or ojrUndiiaJ
sinkings in of the metnbruiie», wbivfa tlic cpilholUl covering aoountdy
follows. Ikitb gi\'e Ibe phjwologioal paradigms for oertaia forms of
tumora, of whicb vre sball mentioo tbe purely h^-perplasLic foniiB nf
Uic hnt usics, papUhmo, ind tbose of tbe seooad seriea, {utmoma.
Boib aiQ ncuoinpiuiied by txwreepoading coouective-tissue ami tu-
oalar ncopluia.
Horny pkpillomata come exclusively In tbe cut!*, nu«]y in tbe
vulls of sebaceous eysta. We tnny diBtiiigiiisb two cbidf forms:
(a.) "WbrU. Anatomically thens consist of an excessive groTth id
loDgtb iiud thickueea of ibe pupUIie. Tbo e{Hderiuks on Uiose aboor-
nwlly large pnpilliR homificx in the form of nmuU rods, of which every
wart is composed, »s yuu may ruadily sv« witb ibe naked eye (Tig.
131). These warts whicb, without any knovra cause, appear cspo-
dally oft«n on the liandg in great numbers, arc rarely largiir tbso les-
tils or peas,
FUi.ai.
O-
Warti 0, laDgltDdtuI Mi;ilan, b, cnuu Mcltali. MagnUliM J^
kA*Htt*vtW>.
(6.) Homy KKreaetrte*» are to some extent large wart« ; tbe epi-
dcniiis of the cnlnrgrd papillio adheres to n firm sulwtance, which ji^
oreascs rnonnously, sothnttbt: bora, wheÜier it bcstnugbt or twisted,
may grow to thrco or four inches or mor«. Although cxtcmUly tboae
boms greatly reaembbt those of »ome animals, their anatomical stnin»
ure ia different, for tttc )n.tt«r alwiiys haw a baaifl of baac. Ilomy
oxorescenoes are of a dirty-browii »lor ; they occur cbic6y on tbe
face and scjilp, but may also oomo on the penis and other parts of tbe
body, and uccusiuitnlly they grow from Btberoina>«yiU.
PAprLLOHATA.
ns
The tlevelopment of warta Btid bonijr excre«ceii«e« U eritlRiitlj due
to a gennrnl Ufwleiicj' of tlie skiii tliut wny. Tliia is chiefly eTitlcnt
final the fact that u many as twenty or tliirly warts oft^n ocour OD
the bamls» especially of childrGm iihurtly b«;fure piilM-rty. IrrilaliDg ex-
temal inHuenccs, ufTcL-tiuff tbc hands [«rticularly, ■ppon-aLly combiDo
nitli the £ftct that tho cpidcmiis on lb« lianda is uonnally very thick,
leodenoy to bonty eusvscenc«, rare as it w, rather helonf^ tu td-
VBIKX^ age, just as nuwt of the oilier cpideniioiti iieopiH.'ij»-, of which
we tiioll heieafter «peak, AiiatoicicoUy, hyatricimiu» would oLsu bo-
loog to ttu> above forms of homy growths, U^Mrielxmu», or porcupine-
dbease of ihi^ skin, is a pcctiliu- variety of [«pillar^' hypcrlrc^hy, with
hurnirring of the cpitlcnni^ of Buc-h a nature tliat porcii])inc-likc
formations develop on thu cutis. Like ieJithjfoaia (a sealy thinkeaing
I of the epidertnis over the whole body), this aSbctioa ir mostly oongeo*
hal ; Init I have nee» analogous rorinalioiis iu sonie Fonus of elepbmo*
tiasis noatras.
The predi8|X)«tkin to wart« is entirely devoid of danger, and in
BMiiy ca«c« ceases Hpoutaneously, Popularly, wart« «ro oonsdcrcd
coiiiapriuus, poswbly not alloi^thcr wititont reason. I saw a ca«e
whert) an ordinary waii foniiud u» thu «do of a toe, and, on the
^^'port of the neighboring toe lying in contact with it, auolher wait
^" formed. Homy excn-«oeu»»i aiv more iniportant; although they ocva-
sktimlty break and fall aS spontaneously, they grow again if they are
not oiK'nited u])uu ; Indeed, in Mjhie irvses eptlielial cancer forms at
^^ ibe point vrhcrc a homy excrcsocuco was located.
^B III most eases warts may be luft to tbemsclvos. As in all di*-
«•MS tliat recover spontaneously in the cours« of lime, there aro
mnnerOQS popular romeilies : old women rcganl the plariiig of a
hand covered with warta on the hand of a corpse, or rubbing it
^_ Willi varioiLs leaves and weeds, as sovereign remedies. If you wtvh
^Bto get nd of certain large waiis tliat are peeidiarly aoiioyiug to their
owners, it iituy best be done by caustic*. For this purpose I use
fuming nitric acid, applying it to the wart and the next day cutting
off tbc cauterized portion till a drop of blood Bows, then repeating
Ui« cauterisation. Tbia should be «ootiiitKxl till the wart lias entirely
disappeared.
^^ Elomy excreaeenoea oan only be cored radically by cutting out the
^Hpieoe of skin od which they are looated.
^P By »ofi, mreomatom papUiwnaia^ wo mean Dioso mnplauiffi that
have tliu {tyrm of papilla), consist of soft cuimecüve or sanxMuattnis
lisfiuc, and arc covcnxl by an epithelial coating auakigous to that of
be matrix.
Sarcomatoua |iapille {soft wmrts) occur rarely oo the cutis, but
614
TDMOfiS.
oocBaioDsUjr appeu" congenitiv^Jy on one »ide of the face u oodcV
conib-likc proHfcratioos. llic hnoA una also the point«c] coodylomat«
on th« muuuus inernbniiu» are pruduoU of sypliilu and of the spedfic
trritatin^ pus of gonorrtucn ; wc do oot cIrm thetu among Uimonu
S«rcom&tous p&pillomstn develop tnuoh nvore ficqueatly oa the
inucnus nKiinlirsnas, especi&llv on the poitio VBffnmlis, more rareljr in
the rectal and nasal mucous membrane. According; to the aufgkal
nomcoclature hitherto iu use, lltey canto in th« catcguvy of rauoout
polypi. Ttioy are often complicated tuiiuin<^ in which proltftsvliea
and cdasia of the g-landa, fonnatioa of sarooiDatouii iiiUn-uK*4ltat« sub-
stoDce, and pupilloitiu, all go together, l^ey arc mofttly pv4uuculatod
tumor»; occH)«ii»ially a lar^ surface of muooos mombrane beeomei
diseased at tho same time.
Ilieae papillomata are rarely infectious, but they ocoaaiomlly reoor
after extirpation. The extensive papillomntn that oceasionally occur
ill the larynx in children a.re [>er)iBpa alwayii of syphilitic ori^u.
I formerly calk-d timiürs with papillary Janaatton, which developed
from vitreous muooiis ttMue, (yUndromata ; but tliis formatino is not
so chantcterislic an I formerly euppoHcd; ituccuni bothinsBroomatous
nnd cnrcinnmatau» tumors. Fihroroatous and sarcomatous papilla
may develop on the inner surface of oyst&
11. ADENOMATA-PAETIAL OLASIICLAÄ HTPEBTKOPHV.
New formation of genuine, tegularlytleveluped ghiods or pnrts
of glands is not frequent., ultJiouf^h wc t^all hereafter learn that, hi
cancer, incomplete de%'eIopment of fflaads is one of the iuo«t coouuoa
fbmiH of neoplasia.
Although aaicotaa of the mamma was o^ea spoken nf as (uutia)
hyperplasia of the gland, ho^auM gUnde were fotmd in it, of late it
ha* appeared duubtüil whether glnnd^icini wore really d^'i-eloptvl ia
the tumors formcrtv dcscribtxl as odenosareoiiia ([>age 603) ; fruin my
own obAerratiotie, I must consider true adviioroa of the braut as
very rare; I have only seen it onoe, it was then la a tubular Ebrm.
^rsftfr and others, however, dcscril>e a«iDOus adenoma of the mamma;
On account of this rarity, ttot mm-h can be said about the prognosis
of ttiese tumors, which usmtüy remiin smalt. They nrv generally ooik*
sidercd m entirely benignant ; but, on anatomical grournts, it Kernt
to mc probable that they cannot differ so much in progsoais (rotn
carcinoma.
So far as my investigations go, the to-called ftj/ptrtrophy ^ cAe
lTro9tiit< is never aooonpanied by devulopmoit of aduuonia, but only
ADÜrOHATA.
019
by ectasia of the «ciiii oni) epitbelm) lij-pcrpUwa -, the frequcntly-ob-
•orvod «nlni^iMnoflt of this glftitd depends ewootially oa diBusc or
nodular mvüiiia ([lagc 5H3),
The glands of thi.- Kkin atid soma mucous mcmbmnca may alno gire
rise to dercloproent of ad^Donia and ftdcnosarcotna ; it ia Sftid tb»t
tumors of the skin, which are Ui be regarded as pure sdCDomatn, majp
result from thi- glandular epithelium, analogous to the glatid-clevcl0]>
meat in tlic foetus. VerneuU Grst described an adenoma of the ewcat>
glands. I have never olmen-iKl such tumors, but do not doubt their
oxistenoe, sinee Ritu^fleitcK has deronnstrated to me an adenoma of
this rarirty. Those ^laiidtilar fonnutiotiB tliat oceur J» tlie mueous
membrane of the nose, rectum, and uterus, nnd whieb are embedded
in a gelaliiiuus, (edematous coimeeliv-e tissue, more lareljr in soiM
other form of sarooiiwi-tissue, arc more frequent
Flu. m
©*?
Fram k Diueaa* V'^JV» tadniMn» of Uw tmetvm -A • chlM. lb(aU»4 U <1IuikI<cm.
Tumors are thus developed whieh, in geneial tcnns, are called
mueotu fiviypi : sonielimea tl>oy arc in broad folda, aonietinee nodular
pediHH'iilated tumors; they have the color and connsteooe of tli«
mucou« membrane whence thoy spring, are also ooTOred witli lU epi-
thelium, czi.-«|it only the soft polypi oi tlw extcna] auditory meatus ;
fllO
TUMORS.
Btnn^ to Bay^ thoso mre noniotimca covered with citnted eptthdhiSL
All of these roiMOUS polj'pt 6a not contain glBods ; tiiey nre «uiUj
abfleut from tbe aural polypi uid the tunnll, l(»(>Uke jimlifetvliuci» u/
the female urellus, tlte Docalletl urelLirul cAruncleH. Tbti latter nco
plasia) oonust soletjr of ccdctnatoua and gelatinous conaoctif« tissue,
with an L>pitli(?Iial rovcring. Illost luticuux polypi of the Dans, lugt-
iatostioc, and cs|>ociBli>- of the rcc:tum, consist to n great oxtcut a{
elevated and also new ly- formed ginnds of tho mucous mecnliniDe,
wboBe dosed euds (ioaiiitiiuvK dilate to ruucous eysta. Hence, in thn
anatomical system, according to tho glands thoy contain, muoaia
polypi may be da«scd aiooag pure adenotna (as rectal mucous polrpi
in diildren), among adR[io<«*roomata (many na&al mucous polypi),
among oedeoiatous Cbromato, or, lastly, among the myxusarvomata.
Tbc pnnliipoaition tv mucous polypi reaches from iofimcy to the fiftieth
year. In cliildnüi the disease Is limited to ibe rectum und large intes-
tine, where sometimes one, sometimes sereral tumors uf the same sort
tlovclop, but the latter occurs even ofteiier in atlulu than in chtklnsu
Frooi puberty till about tbe thirtieth year, it affeete ebielly the nasal
mucous membron«; sometimes fifiving rise to singh* [xitypi, again, tu
pruUfenitious in both aide« of the nose-, the latti-r is l!ieinon_-frequeut.
Towad the thirtieth year, mucous polypi <tf t)»c ulcru« occur ; under
some ciieumstanccs they may etmng« to cancer. In all of ihe«
poljpi tSii^re is 11 greiit tendeiny to reeurrence, especially in iboMof
the uo9e, which often do not cease (growing tQl they have been re-
moved Lhreo or four tunes. Getienilly, in tlic course of yean, tb«
dis[x»ittun to these new formations ecaaea j^Dtaocoualy, and they
cease to recur, or the smaller ones even cease lo grow, ns, for inatanoe^
in the uterus. Mieroscopie examinatton of these ttimora may give
some clew to the prngnoais, tnasmueh as those tumors which conalst
entirely of o^leniatous coiitiecfive tissue hare &r less tandeucy to fc-
cur than those which consist of tissue analogous to infiammatorr new
foTDixtion; laittly, in some eases nnatomJcal examination aloao csn
prevent mistaking them for epithelinl carcinoma.
Mucous polypi of tho nose arc most readily removed by t«aring them
out u'itii the forceps niude for that purpose; we do tlie sam« for Uiosa
of ihccxtcmnlaudiuiry meatus [the latter may bcmost effectually cured
by free applications of liquor fcrri porsulphatis] ; those of tbe uterus
and ivctum we may cut off at the base with scissors ; if we fear bmuor-
rliage, we may previously apply a lipattire, or employ llie towwur.
Of tbe glands without excretory duct« we bIihII berc conüdcvooly
the fAyroid, as it is a true epithelial gland ; adenonn of the ovary ao
often becomes cyslold in form, chat it may be more suitably trreated
of io the next section. Tumors of the thyroid gland hare long be«a
ADENOM ATA.
CI7
caUed ^ot'/e, ^ruma (in the middle ages ** stramous " indicated vhat
wo nt present call "scrofulous"). Cotisidonof^ Uie anatomicnl r«la-
tiuu uf tlie*e tumon to the gland, we- fiml chat there are diffuse swbU-
in^ of the ffluud, affcotiii)!' on« or Jioth lobes, &iid others that are di»-
Itootljr bounded in the gland, the latter rcmaiiting oonual or but
sligbtty h^-pertiophic If we eiclude simpl«? cysts of tlie thyroid, «o-
oalled atruiua cystica, moat other forms of goitre arc pure »denoma or
oyslo^dcnoma. If the tissue of ilicse tuntors, whidi may Tiry greatly
in consiitcuc«, be not metamorjitioved by aeeondary cbaikge», on suction
it appean to the naked eye ulmoKt ibe aitine as the cut surface of a
norni&l tliyroid gland. Mtcroscojiicully alao it is very mudt the aame;
almost all thyroid tumors on inicroecopic uzamiiLation &how a Uif^
amount of conucctivo-tiasuc capsules, which contain a clear gelatinous
subftl&noe filled with more or Icm round pule cells (Pig. 133). Hie
<^:
r*^'--
PraM u artlaanr Ann tanor nt ih» thtrrMil-arimMOiB «f Cb« Ikyrotd: p*nlkl lolvcllaa.
Hanüsä 100 dluMMra.
■iae of thvsc i-arics grcntly, the youngest, which ax yet contain no
gelatinous suhetanoc, but only oclla, being analogous to tlic fcelal
thyroid resides, while tlio larger are six or ten times this aixe. Ooo
of the most frequent change» in goitre- tumor« u tJie formatioa of
oyBts, whicli come Crom a numbor of the dilating ^^and-rcsidcs uniling,
aikd their thirk gelatinoua contents becoming fluid. Bat, besides this
formation of cy-sts in goitre», there »re other just as frequent change«
that oo<-ur ahnost regularly if tlte goitre existe u long time: these are
extravasatifins of hlooil, which arc mnstly rcflhsoAed, but losre more
or less pigin dilation. Caseous and fotty degeneration is uLio A^uent
in old goitres ; lastly, calcareous degeneration often occurs, so that by
these socoodary chat^es Uio original picture of th« tumor may be
818
TCMORSL
much altered. Goiuowt tumora, whinh msj lie in tbe middle of the
ovvk or to bout allies, in uuniben or sotihiry, maf attain a oonsider-
Kblu size, cAmprucs the tnchoe, «nd oaus« euflbcatioo. Much man
rarely the Regular double-aided hjipertrophjr of the tliyroid uttAioi a
.dangerout fixe. Goitre is chiefly rciiiftrlcAUu for its endeiitic oocui»
reooe; it it found uiuelly in mountaiuecre : it la soon iti the Harts,
Tliuriiif^an, Silesian, and I^ohemian tnouutaina, and in tho AJpi^
although nut «xjuully fri^xjutnit in all |mrts. Some valleys of Swltaer-
land aad of the Austriuu Alps are entirely free from It. It bas been
ascribed to tbe most different causes, especially to the wuler aud soil,
without any definite scientific reason having been fixind by nocoirmle
iiiTestigntM)o& Undoubtedly, dUnuUtcol and ((«ilogical conditlooa
bare much lo do with thia disease. Complete similarity in the ocm-
RlituUon (probably often liennlilary) of ^trous patients can hardly
be proiTxl ; a certain connectitMi with cretinism cannot be denied, in-
aaiouch as most crt:tina liavc ^itre ; but the disea»« i» inorr fr«?<]ijcot
IB pemooB with well-developed bones und brain, (jrcutre may hv cocf
genitjd in nome nire cnRi>s, but does not usually increase till the com-
menecmcnt of puberty ; tlio growth rwrely ountintic» bcnroad tlic JIftJctfa
year; goitres which have continued huTtnlesstill then, usually cease to
grow, and subsequently cause uo trouble ; to this rule there arc oclr
a few exceptions, where cancerous goitre develops from th« abore
}typeiplastto form, infecting the neighboring Ij-mphatic ghuids; these
aimoat always prcnc futat by sufToL-atio«!. Ii is scareely necessary to
consider rtruma aneurt/nmatica as a peculiar variety, as it is mereir a
^itre ncoompanied by great dllutAtion of the afferent arteries. Prep*
anitiotis of iodine are usually employcxl against thtg dtBCosc; tliey arc
only efficneious, however, ut llie conimcnceinent; later they are nlinost
useless ; they nre, however, used both internal] y and externally, lu we
have no other remedy, Extirpntion of hypertrophicd lliyroid glanda,
aa well as of large goitrous tumors, is very dangerous; it i* often fol-
lowed by severe hirmorrhaf^ or occasionally by sudden deatli tmm the
cxteut of tbe operation, eo that wc should only ti^- it in «quU movnble
goitres in young persons. Even then the operotioo is oocosianally
dangerous, and some experience is ncoesanry to tell beforehaad whioh
tumors can be safely operated on. In geueral, I would warn you
against piTforininfr suoh operations for the eoKmetie effect ; if there bo
danger of suffocation, we may be obliged to try even doubtful opera*
tiona. llo best chantx» are offered by movable goitrous tumors In
the medinn line of the neck in young persons, whilo the removal of
even oniall ones deeply embedded in the hj-pertropbied lat^rral lobes
is (lilBcuH and not trae from danger. I^ven th« slightest operations of
this sort must be performed with the greatest care, ospcoioity In rugard
CY8TÖÄATA.
Ol»
to aTTCftting the tuemon-lisge from «rterics and Totna (hy niodiato Ugv
tion before Uietr division) ; in rl^Msching tlio ^ncapsulntBcl Uimor it m
better to use the linger, u prubc, or Bomc other Uunt uistruniciit^ tbut
the knife or Bcisson.
W. CTSTa AND CTSTOMATA-CYSTIC TDM0B8.
A twnor formed by a sao filled with Buid or pulp is called a <^t
orc^'stic tumor. It way develop from a sac alreadj existing (cjrst),
or it may derelop eatirely new (cystoma). If the tumor be formed of
a oonvolulion of very many euch cystic lumors, it is called a " com-
pooite oysl or cystoma." If in one of tlie tumors already de«rribed, or
in aucinoma, -vre fiod cyata also forminj^ an c»cntiai part of the tumor,
wo give thorn iiam<^-8 like eygtfhfibroma, cjftto-tareoma, eyato-ehon-
dronuXj c\/»to<arcinoma, etc
As previously stated, VircKov reckons encapsulated extrarasAtioaa
of blood, lumnatoDia {i^aravaaaiiom-ejftlen), among the tumors, as he
also does dropsicnl effitsions and hyprrsccrction» of Mtrous saca (liy-
drocelO) mcnitigiK^elo, droptty of the joint», gmi^ion, etc, exu^ition»-
eytUn), According to Vire/ioi^, the rftenti/m^tfs form the third
class of cyslic tumor«. Of the«e, we leave tlie retontion-cysts of the
large canals, such an hydrops vanctc fullm, procerus vermiformis,
tubarum, and of the uterus, to int<^mal medicine and oh«tctries. nnd
oonfine ourselvos to those tumors that Vire/iota has gioupecl under
tlte name oKfoUicuiar cyoü. The glands of the skin, as well as of tho
mucous membrane, have a tendency to the formation of cj'sts. Cyats
of the thyrmd have a doubtful position between exwlation, follimlar
and neoplnsti« cysts. Closed folliclea of lymphatio glands seem
never to give rise to cyst».
Among the glands of the cutiii, cytita develop from the sebaceous
alone ; I do not know that eyat« of t)ie prrspjraiory i^Und» hare ever
been described. Tbc reasons for secretion coUecting in the sebaoeooa
glands are ; (a) its becoming inspissated ; {t) closure of the ezcrotoiy
ducL If from cither of thcac causes the «ecretioD be retained and
ooUoct in the gland, the pouched secreting suifiK« becomes cxiMiiidfHl
to a simple sphere; the oollected eecretioo eiereises a meelinnknl
irritation on the Kurrxiunding eonncctive tissue, which consequently
bvcomcs thickened and surrounds the «eoreticMi like a vesicle. If the
amf., not yet gr-oivn lai^gc, can be evacuated by strong pressure, the
Bmall open cyst Is called a eomtdo, or " maggnl." If, from any irrita-
tive inOammatory process, the excretory duct of a sebaceous glaud bo
closed, there may bo atrophy of the gland, as after a bum with vcr>'
eso
TfMORS.
Buperfictal destntctioa of ihu skin ; but id other c««ai llie Becretion of
tlio gland ootitinucs, and it distcndu »lowly to a lar^ s»c Sucb cjsts,
filled with fattj pulp and opidcrmis, nre called pap-ba^ iffrAOituUf),
athemmnta. On microttoopic euminatiOD we God tbe pulp to cooriM
of fat-drupB, rnt-crjntals, eapocially cliotestoarinc, cpidcrtnis-ccUs, and
small ptaUts. It luu very varied color and ooosistenoe ; moet atfacro-
mata on the scalp, which dßvelop at advanced age, contain a dirt^
frmjisii linitt-D, badl^niclling, pulpy, ]>aAty, sticky »uhstaooe. Other
tumors of tliia «ort, especially tiioAC that «r« coDgecütal, on thg fore-
head, t^tnplm, or face, aro älted with a milky or light-yellow [mlp,
wbicli, under the microscope, shows little besides cpidcnnii»«ailel
and cTy.Htats of cholcatcarinc. This Torm of atheroma u called " diola-
gtestoiiia." Tlio sacs of these cysts are usually thin, and are com-
posed of coonective tissue ; their inner enrfacc is usually distinctly
bounded by rcte UaljjNf^hii, and is wavy, or elevated into papUlie. [
have found no other r<>)icmhlsnef> 1o ciitia in these saes, but otben
have found hstrs and sweAt-glaods in them. The content« of thean
cysta sometimes become colcsreous. Atheroma may ruptun as a
result of injury, or, vv^ry rarely, spontaneously ; the pulp 18 uracuafced,
tlie edges of the opening are everted, antl the inner surface of the aaa
becomes a bud-looking;:, uloenitecl surface ; except on the bead and Jiwe,
wlicro lliey are frequvnt, tlif «e tumors nirely oe«ur.
In tJie neck, salivary- ducts (dosed internally and externally, but
open in the middle, whit-h are lined with epidermis) may, in the eounu
of years, become laiierc choleetealomata by the deposit of e|»dercBi&
Those show themselves in tbe roouUi (as raoula), or externally on the
neck above and heliiml the thyroid.
In tiic raucotiämeinbraiics,Blao,ii)Spissatioaof thegtartdalarnnicai
and conse{|uent hindcrHnce to iis evscnalion, may cause development
of raucous cysts ; but probnbly the more frequent cause of rctcotioo-
eyeta bore is closure of the excretory duct. The sccrctko in Uieso
glands is usually a tenacious, often tliiHt mucus, of B booej-aolor (m^
lieeiTs), reddish yellow, or even ehocolate-brown. On mierosoapiaal
examination of the contents of the cyst, we find numerous lar^, pate,
round cells, often containing fat-globvlee, in homogeneous mucus, also
Cholesterine crystabi, often in large (|uanti1ie8. In tlie nasal muoous
mcmlinuie theee cvaIs are rare, but they occur in nasal mucous polypi,
often to such an extent as to give them the name of oystio polypi.
XtMcA^ often found small cysts in the mucous roembraiie of the
antrum Hi^hmori. In ttie oral muoous niembnme they oerur chiefly
on the inside of the ups, more nircly on the checks ; they an an ordi-
nary occurrence in the uterine mucous membrane and in oterine
polypi, In the rectal mucous membrane, on the contraiy, tmwaui
CYSTOXATA.
«SI
eyats do not occur, and they are very rare in the mucous membraaeB
dMp ill tlie body.
A'eoplattio cytU. Tbeac result mostly &om »oflening of ttasoe
proTioosly diseased by eell-Jofiltration, or of ürm tumor-substanoe.
As soon as tlie new fonnatioo has seponifatd iiito s»c and fluid cxin*
tentA, in somn cases a eecrßtion from the inner noil of the sac beginn,
eo that ilic softening cyst becomes a secretion or exudation cyst, and
thus growit. Any ti^ue rich in cells may be transformed into a cyst
by niucou!) metamorphosis of X\k protoplasoi, or, as others express it,
by separation of tb« mucous substance through cells, without any
connuction with develofinivnt of mucous glands. In the foetus, wo
know thrrre is a development of cavities (i. c, the joints) by mucous
solteoing of the cartilagc-tissuc In carl ilu^t issue there is often a
mucous softening of certain ports, by which ohondromata with mucous
cysts are developed. I» the Mme way it is not uncommon for parts
to become Quid and encapsulated ; the same thing occurs lu sarooma,
especially in giant-cclled sarcoma. The ofUm slit-shaped, smootb-
walled cysts, with serous or sero-mucous contents which occur in
uterine myomata, arc possibly mnrmously dilated lymph-spaoes.
JSone-oyit« always orij^nate by softening ; the often glistening
smooth racnibnine lining such cysts may in the course of time
actually secrete.
'Wliiln the above varieties of neoplastic cysts bare no relation to
gland new formations, those we are now about to mention develop
from adenoma. The cysts of the tliyroid, cystic goitre, already mern
tioued (page filial ^f« a somewhat uncertain position tn this scrica;
tinocrtain because they ore not due to iMwIy-formed glnnd f<iliicle8 or
duds, but to collection of mucous secretion in one of the tliyruid resi-
<^es. If we t«7m the contunts of these cysts secretion, as we mijHit do
for some reasons, we must dass thenc cy"ts as rct«ntHXH;ysts. But, as
it might be urged on the other hand lliat it would be questioaable to
speak of a flecretion of the ihyroid gland, as some state that normally
the contents of the thyroid vesicles consist solely <A cells, we inay also
ooodder the cysts resulting from softening of the contents of the vesi-
dcfl as newly fbnncd. Whiehercr view we take, It is certain that the
cysts of the thyroid may be solitary, and may attaio great sice. Moro-
orer, in almuet orery large, aud in sonw snsll, otherwise firm gnitres^
one or more cysts occur ; they osnaUy have very smooth walls. The
Urge, tsolsted cysts of this variety, particularly, give the impression
that they are chiefly secretion-cysts, while other similnr «i^vities in
other parts of largß goitres, by their softened, ragged w»lU, give the
impression of being softening cysts. In the thyroid gland Ibe process
of softening usually terminates in the fonnntion of a mucous fitud ;
622
TUMORS.
but liiere are otlier oysU in these gUnds that oontain ■ gny, fruble
pulp, wliich loolca like tliat from Bebnceoi(» j^lands, but AiOcn esw»-
tiolly from it because it cMXitainn onlj the dctritiw oS tliyroid tismie;
1 luki-e nerer seen genuine nthoroma-pulp in tbpuid c^-sts.
Among thu cumplicatciJ i.-yi5tic< lumoni nrc the cjrstoiuurcDinsta of
the brG««t, of wliich wc Imvo alrouty spoken (pa^ OUfifi cyvtomai«
of the ovaiy and teaticle, 4^Bt<)-adeooi]ia, cytto-aueomtL, aud eyst»
oarcinoRUL According to rMcnt inTcMigations, in the grrai mnjnrily
of theae CMOS (here in a. new dev«loj>uicut uf ginad MLiclca r>r duvts,
fmin nliiclt terminal awetlingii beoome choked off, aa TexuUü tioniialljr
in the tlevetopmenL of thjnHtl or otratias foHiclcs. A mucoiis wino-
yellow, browniah-rcd, or dark-brawn Hutd is secreted in thcso Dt'wljr-
formed follick's (perhaps alto in the norm»! orartun foDioles) ; tht«
gntdually difitends the follicle, which was at 6rst microsct^ic!. Sanin>
tiinea immense orariun tuntois (dist4!ndmg the abdomen more Cfaui it
is in th« ninth month of pregnancy) may develop from such a follicle,
or fmni llie «onlluenoe of (utreral of tiii>ni to a oommon cavity. In
other CUM, hundreds or thousands of euoh folliclea develop, forraiag
tlic multiloculor cyclic tumor» of Ü»c ovary. Tlic latter proowa «I«
ooeuT« in the tE^tlirlc, although muro mrc-ly tlian in the <n'ary. Id
both of these organs, as in the mamnia nnd thyroid, the rnDtuita am
mucous UN a rule ; but, in the netiplusti« follicular cysts of iho ovuy
nnd twlicle», thero arc ocf»«ioiially eecretion of fat and exteniÖTO pro-
duction of epidermis ; these may n-main as epithelial or t'pidennU
pilaris (rholestcatoma pearls, page 620), M hag as a raUleltic«! or a
pen, as I have seen them in tumors of the toeticle, ur fonii large cyit«
conljiining ftit-pulp. Ilie walls of tbeae cysts, which ore found the
si«! of a child's head or larger, in the orariesof oIduororn,arc usually
mote liighly organin^d than those of cutis atheroma- large quantities
of liair, »obiiceoiis glnnds, »»-eiU^lands, papilltp, even waity growths,
arc not un&equently found iu them. Indeed, plates of cutiUge and
bone, with teeth of varied form, have been founii in thc*e cyst«, no m
to render it probable that they were aborted fmtu&cs from nn incom-
plete ovarian prc^ancy.
Besides occurring at the above positions, composite cysts ore ocat-
sionally congcnilnl alwut the saerum ; they oftra contaia ciliated epi-
thelium, and, besides otlier tissue«, th«y socnetimea have glandular,
follirular formations. The tissues in thcsa oougenital tumores coo-
cygei vary from the relati^icly simple forms of cysto«««)»« to the
foetus in f<rtu, and cnnnot here be farther entered into iritltout goiag
into detitils oml fine disnisMon.
I must laMly mention i^ysts containing perfectly fluid venous
blood, and having smooth walls, which are bere and then nkentiooed
CYSTO «ATX
«S3
m litemture. Some of Uietn reHU rapidly, ntliers morv slowly, after
punntun*; «uch ry»U hsve been obuvTeil in ibe axUln, on the tlionu
and iiecic. RxrItMlitif t\moc cum<» wIm-ti- i'fTitalon» uf I>l4>ixl bavf (rii'cru
a «Inrk bltxxJ-oolur to tbc mucuiia of tK-rou« cuntcutis uf u o^t, and
eODaidertog onljr tbow in »hieb th<<rv is bluud aloiiu in Uta «.-jats,
tbey oould acwtwly bare been nnjr tbinp but large sacs on tbe veins
or aramousTeiioua tumors irhosQ framevork bad been entirely
atrfiplnefL AH the cases of this Icinrl so for ivportctl have beca
cured b^ puncture und injcolioii njüi iodine, to that iiolliing cim be
Baid of the putliolt^ical anatomy.
Tlic fli'i'jifttt« of oy*tie tumor i» onsy; if it can b« certainly p»l-
pnlwl, tbe fluctiiution will hn full ; <iiN>ply«(>at^ cyst« are oftün (Uifi-
cult to rccogniitc. They may Ik mistaken for other encapsulated
fluids; IUI cxplonttory puncture with a very fine trocar ia admissible
to cunfimi tho diugnuuia, if ibis Im> necessary to delcmiine the tntat-
fnent. Tbers are various thiogafor wbicb a t^ysl may be niLtlaliun;
e. g., ooUl abKCMes *r« abo patnleM, occasioually very slowly enlar-
ging, fluRluating tumors ; also cystio pantHites, of vrhii-h two vnricliM
occur in tbe outer jxu-t« of the boity, e»])ecittlly in the sultcntaueous
tiwue \ cytlicfreusctiluf^te and <eAin<fe<Ketu Aominw, aJthough ntrc, do
«omr in tin; ivlliilur tissue (and stiil iikm« mrely fn btpue) ; ibo fomcr
is a amall, Uic latter a laifte vesicle, whieb may contain many smaller
ones; the miete of wliiob tbe animal nmsistft always biia a neo-
plastic sue arciund it; us may be readily setni, tbe whole thing gives
the iTHpressiua of a cytiLic tumor. I bare 8e<eu cyatteen.ii8 i-eaielea
removed from tho tongue and iKMtc, ecbinoeoocus vesicles removed from
the back and tbigh. ■ The diagnosis of cysts vas rnftde in all tlio
casoe except in on« of the latter wboru absct^ss ww diagnosed, and in
fact, instead of tbc cuatomury cDcapsulaüon, there was suppumtion
ftrouad the dead echinoooocus vesicle. I have introduced thiA as a
sort of appendix, beeause we have nowhere else an opportunity of
euii.siilering the parasites. Tbe millions of Irichinm occauonnlly
sctitlered through the muscles cftunot be trcaled surgically, even
when, aoeordiiig to the brilliant investigations of Zentw^ tlie diagiio
sin may be, snd luui been, made in ninny OA.ie«, Dropsies of tbc »ub>
outaocotift-iaixous bursic aodof tbe tendinous almtbs u well as spina
bitida may also be rewlily uiistakeo for eystio uimors, if we do not
attend to tbc anatnmicul scat of these swelling^. Cystooinla may also
b« mistakfiD for other getatioous soft sarcomata and cardnomat«, «nd
for vBiy soft fatty ttimora. As stated, when an intention of oper-
uling renders u certain <liagno(ds necessary, we make an exploratory
puncture. But what guides us clüeQy, iu Ibe diaguoüs, is tbc expe-
rience about the relative Irequcncc of different tunioi« on dilforent
41
624
TüVOBa
ports of Ihe bodj*; I \iAve gireo vou llie eum of l]te«e experienees in
mcli fcinn nf cyat, and in the dmio shall hereafter direct your spedal
«Uenlion to Ulis jKiitil.
Ab the iiWi'c include» tlic pr^nofit o^ cjslio tumors, all of wbiirli
grow slowly whna they exixL an cyst» withnut coniplicalion, wp may
pass at imce io their treatment. We may rt-nrove cysta in iiro wan,
▼it: by CTMCuatiiif; the cotitc-nts, and locally npplyin^ rctnwlir« ibat
mny exfiU' »II tiiflstniiHitioi) whidi sliall causo atfopliy of tlicatr, or
by pxtirpating* the sac; tlic latter ia always the simplest and inort
mpitl, aud wc ativays giro it the preff^reocc wbere il can he dooe
easily and without danger to life. But in eysta of the oi-arr.thymid,
and other glauds, that are deeply sealed nr from other caiuios dajigw^
oua, some other, safer operation is of ooiiix; iletinible, if it ofltTi a
proepect of buoccm. We may induee ahritiliagT^ of the s«e after pt*-
cedent evacuation of tlie conteoUt, l>y a »iiiipurntive or hy a milder,
drirr iiiDnmination. If you slit iip thr wall of the cyfit its whole
len^b, and keep the cut cdg<>s apart, there will he suppur^ilion and
granulatioa of the exposed inaer wall of the cyat, with <U;ta«lii»eat
of the porcions of tumor or rpitheliiim clin|rinjf to it; Ihe sac thca
pradimlly ^hrioks up into a cimtrix, then dcvrvades m Mze, uud finally
henla; ImjI tiiiii may ret^uire months. You iitayaltiiitt Uio-eonio thlBg^
in a tnorL- subeutaoeous way, by li^iiturra or tulva> thrnu^h th«
tumor at diRcrcot p<unt« ; the irritation caithed hy thenr, aa. vreJl aa
by the untrsnt'p of nir, eauses suppuration ami jirrmulation of the
inner wall, and in &vorab1c cases the^te may lead lo atniphy ; tttUa
this does not occur in the manner desired, or els« it may nrquln
months or years ; so that of these two method« the firrt i» prefcmble;
it is particiiliuly aj>plirable lo cyaw of the neelt. VTv may attain
abrinkaijä of the cyat and dning'up of its oonlcnta io another way^
namely, by pimcturi*, with snlMequeflt injection of tincture of iodine;
we have alreitdy (paffc 478) said cni}ii]^h ahnni the effect oftliiik treat-
ment. Ilrrc, too, the injection ia folloned by spverc inltatitmniiun nf
the sac with sero-fihrinous exudation ; then the «crum ig rcabaortied
and the sac contract«. The Utter methoal ia parlieularly applieablo
when wc hnv^r to dt-jd not with coiitenls of soflciipd liMiic, Iml with
a fluid secreted by tbe walls of the nc, that is, chü'fly uilh cyst« ^m
whuKc contents arc sen>im, ami tome sorts of mucous cysts. Cya1^^^|
mats devcIop<^l from softened gelatinous substance and fat-et-Rl» an* ^^
not suittxl for iodine injections; for they are ai)t lo he followed hx
aerere inflammntion and BUpi>umtion, with fonmition of pwt, »o that
we are NuhHequently obligeil to slit tip tlie entire sac. And very thick
walls, which contract very slowly or not ni oil, also coiitraindlcat«
iodine injections. Hence among e^-ets of the neck wa find soma that
CTSTOHATi. CARCINOIIATA.
996
«nr 9uIto<i for tliis Irciitmcnt, irtlier» which art nol, he«ni»e ilictr tmlU
arc too thick. Of the ovarian cj'sts, too, imforiunntcljr but fcvr «re
Biritcä fnr l-reHtmcnt by iodine liijiNTlion, so that recently Hie czttrps-
tion of tlieso tutnani by laparotomy is conxideied th* only rertaia
0|jrrativc prorcMÜiijc ; nf lalc yrnra the results fmtn this oprration
htre constnntly been growing more fiivorable. Lastly, ire must 8t«t«
thnt in Home msip« it in be«t In avoid any o|>pniLinn ; for iiiiitiiiioir, I
should txtiiaifler it folly to pcrsitncle an old mnii, with a numherof
AtheroniatA on his hocul, to bsre 1li«m removed ; for, if the oporatioit
vera followed by erysipelas, it might pnn-u fatal.
LECTURE L.
it. dgtrfniwkK«.— nUtorkal BcrniA*.— Gcacrtl D«»criptkia of tin AnrtffmkilStnKt-
nrr.— McTaiatirphiM««!— Ponn».— T'lifOj^rapb^. — !■ f^ltin •ml Mucous Upicbrnne*
vlih PaTf>Ricnl RplthcUum.— S. Uilli OUnili,— 4. Haooua Ohnd* «itli (.'jlinitrieal
Eptthdiout, — 4. Lacbrrmol (tIuiiIb, Kalirtr? (iUnds, »ud ProaUU GUod*.— 3.
TttfTiiU Gtmdtalid Ovnrir*. — TtcMiDouL — Brii'l* Bcnurk» Bliout tlie I>iagTU»ia.
It rARCraoMATA-CANXEROCS TOMOIH.
To (rivo yo« on i<l«« nf how tumors wflnj formerly dia^<>«^, nnd
of tbo orifpn of mimy of the lutine« still Ui use, I will rrttd you a pw*.
■Age from tlte rlaRsical, ainl, in ita time, nio<tt pramincnt, work of
Xorer» BeiMcr, the thirU «.-«lition of wliich, published in 1T31, 1 bive
before me. Here {p^ge 220) it sajs : " ITie name acirrhits is given
to a painless tuntor that occurs iii all part« of the body, but e^pe^-ially
in the (glands, nnd is ibiv (o Stagnation and dryiujr of tlio blood in
(he hardened p«rt." {P'^g*^ 306) '*'\^^len ascirrhu« is not re«l>«ort»ivl,
cannot be arrested, or is not rcmovwl by time, it either spnnlHnniusly
or fmm maltrratroent hccontm midignunt, that is, painful nnd in-
flan)C<l, and then we begin to mil it ra««T or eareimmiit ,■ at the
eamr tinw« the veins svrpll up arvd dwtcnd lilce tlie feet of a itub (but
l!ds d(»e^ not happen in «II cssiCb), irhrnrc the disraac grta its nanir ;
It is, in f)u>t, one of ihe wont, mnst borribtn, and mnst painful of dis-
eases. "NTliilc tbc skin romMin« iniart over it, it is temted ftidtten (eati-
DPT ocrultiu), but, when tli<.- skin has 0]V.-ned or nloenteil, it b ealled
OfMfr, or ulcerated caneer ; the latter ustully »ncoccds the former."
Tt is not long atnce men lived in the simple belief that there was
something real and truly practiivl in ibis mode of comparison and
description. In \ hundnil year» will Ibcy laugh at our prc»eut ana-
inmie-iil nnd elinio:d definition^ as we now do nt good old HniM&'f
"Wlio knows ? Time muvos on with ginnt itrltl«« ; things come to
696
Tl'UORa
light, aitJ, bt-furc wc have time to look around, they an; tamed bitn
history by the careful labors vt ciicrf^vtiu young expentneuters.
Id tiiR natural Aciea4>cs w« always dislike to give Kliort defimtiotut,
because this is often impossible, on account of the paasage of ooe pro-
pra, or of ODC fonnntioD, into «notber. We may any that can-iuo-
matn arc very iufectious tumors, and thnt thi» iDfectton, which tint
attacks til« lymphatic glauds, afterwan) mon* distant organs, is prob-
ably due to the passage of elements froni the tumor (whether of cellit
or juice ifl not yet known) through the lymphatic vesseU and reim
into the WooA
Thift ooinmou elinicnl definition of cnrcinonia diould be oontmlled
l>y the aoiitomi<'«l structure of these tumors. Anatomical pccuttari*
ties, easily rvecignlied with the naked eye or with the micToscope, ant
sought for. Tlic classical monographs nt .lutkif Cooper oa disoscs
of the tcstifl and breast (thä latter, uuforluuutcly, unllnifibed) show
that, bv a careful study of the point«« pereeptible to the noketl eye, a
great deal may l>e ntlalned by studying a singlo organ ; btit h general'
izalion by aid of the auatorntcal jH'epumlions alunc is impoAsiblr, as we
have often felt, in tlie course of iheÄ- lectures — il is fre<pi'--ntly itiffietilt,
ei'en mth our present aids; so that I cannot blame VirrAoie for try-
ing, in hia great work on tumors, to give meet minute dcMriptions ot
the different forms of tumors at rertain tocalitioa. Here, wherf we
must etprcss ourselrex hriefly, to giro our dot^crijii iuna an anatomical
basif), wv must be somewhat more deeided and summary. When the
naked eye no Ioniser mfiiood fur tbc diagnosis of tumors, the aid of
the raicroBOope wus im-oked, and cbaracteristio appmnuioes vnro
sought that might occur in the same way in all ibc tumors we hare
described. Still, whether tlie characteristics of the cellular elenimta
were sought in their proeeases, the size of the nucleus or of the tiuele<
olus, tbc clinical and anntnmical ppci]1iarilie> would not alwai-s remnhi
congruous. When the cells i>rove<l iuoßicaciotis »a i-vidonce of oarci-
uoma, it u'fts nought for in Üie general stmcturo of III« tuniiw ; aleeo-
lar /ormation was asserted to lie the aiuitomieal peculiarity. W«
CTcn come in i-oIUuion witli tliis idea oocusionaJIy ; the net-like fornw-
tion of iieoftls^Lie lyniphittic gland-üssue may also be termed *^ tdreo-
lar,'* and even ueknowledgiiig tbat the lympboina Det*work is so pecu-
liarly characterized by it» form that it may bo readily excluded, UiCTO
still remain some forrns of chondromata and sarcomata, MpFctollv tho
gianl-oelled, and other large-oetled aareoniata forms, which wu hare
already designated ns ah'colar sarcomata (pages 59i and 3IH]), aa the
ghosts of cancer.
The more I fee! obliged to suppose that in tlie iierfect orgvaism
there arc no culirclr iiidtfFcnmt cells, but that the cletncnta of the
CAfiClNOlun.
middle grerni-lajer of the embrj'o «net or th^ two cpiUioHul lavcrs arc
alvavs somcwlmt tn o)t[Ki»üoii, tlic more I nm inclined to us« tliis
fbndaoKDCnl liistuf^riivtic Fuct fur tliti ilt^vrlopiiteiit »ikI divUiou of
tumors. Iq ncconlone« wiili this, I only caJl tbosc tumura true curci-
iiiMiial« vhicb have a funnatiori giniUar to tlist of true ejutlioliul
glands (not tlic lymphatic glantlt), and whose ccUs arc tooatlv actual
derivHlix'es from tnte epillii-lium. I urn oonvinocd that thia view n-ill
constantly hxve more adliorcntü, ami that thu» the differvncw aljuut
the aiiiitninical delinitton of '^cniriuurMa'* will constantly diminish.
llios« invnttigaboni who, during the Inst fuw ytiins with all the mod-
em aid«, hare worlswl without prcjwiiw on thi» pivtion of the atwly
of tumor^ n^otigiii/e thv groul iiupurlanvc uf «pithi.>lial prolif«mlioii
in those tumors that wc call mtiocr, still most nf thum WM^k fur a
compromific belwee« the different iiialogeoctio viewa, and wish Btill
to admit, in a moditied hma, tJie development of true glandular atnl
epitlK-lüd «-lis from connective tissue (I'^t^'^'ligy proper) [fttnd-
/ki»cA, ]''vU:rnann, Mitt», /.QcAx) ; cnly ThitrKh, and rvccutly Wal-
jftjlW, maiutain, as I do, the strict bomidaiy Ix-lwrnm »pitliclia) anti
connective- tissue cells. WaMcytr defines cnrcinonia as un atv])iral
epithelial neoplasm. But we must here state that in canccr-tumtirs,
beeide» the epititeliums, tJicre are usually numerous young, small rouitü
cells ntiirh, iii61tmted in tli« ooiinective-tifcsue ptirtion of the tumor,
fban au impijrlaiit {>art of iL This trniall-eelled conrieetive'liM>ue Jii-
filtmlion, ivhi<'h exist« in vitryinj» quantities whfrcver<^itb*'lbd pro
Ufenitions grow into the ttunie, appcjirs tu Ix! caused hy a sort of re-
action, and to be the result of the pctietmtion of Üie epithelial ocw
forniatlons into the tissue, ncmnling; to ih« miniber of inRIlrntcl cells
ami their future fate, as welt as the degree of vascularity, just as iu
iitflutnniation it sometimes leads to «ifWniug, tn atrophy, anil cicatri-
cial thickening of the tissue. In some onae» this small-celled infillra-
tion is so CMmaid^mble as almost entirely to hide the epillit'lta) npw
foniiiition (from whidi it inav lie very difficult to distinguish, if tlw
Iatt«r bv »mall). We may then he in doubt if it should not be re-
garded as entirely inderpendent, and occasionally, perhaps, as the sole
coastitueot of eauccroua tuiuurs. Formerly I mysclf thou^t it ncce»-
sary to a^rree to this, and even supposed that thia oompoocnt of car-
einrana possessed a spontaneous power of infection ; but further ob-
apTvationx with new aids hare nuide it appear to me more probable
tliat, even in the smallent cancen>n3 nodules, epillielial elemetits al-
ways gave the first start for development. This has been coofirmcd
by Wul>iej/er.
It is especially im]X}<rtaDt to make a distinction between adciioma
and carciooma, a« the two forms of tumor« have some points in ooio-
638
Tcuooa
mon. Pure «deiioroxU arocoiu|M»vUof ii«wly-fomMdgUBd4Ut
irbidi is «■nlirel^- uniitugoiii* u> ot tit Itut»! very iniu'h like Uie tiuruuil;
Uie couuectiru liiuuc umiiiKl iJic Dcwlyfomicil wüni has the same r«-
ktioD to UieiD M to til« nomul
til ■(lout>«un»iuii tht!tv is liltlo if aiiy nun- furutuüun of glaodulftr
■ciiii, but the sarcoDia nii'rcly cdcIqsc;» tlic gl&ndular üpuicpA ubich
bftvc rcinuiocd Qomml, or aru dilxti»!. Bill it is cliAnctviüitio of osr<
citioma that the ^^[üthcliaJ cnveriiig of a skin nr iiiu<!ous mcmbmiMs or
liic epithelial liniiifr rtf glanilulur cuiviiic-»), grows into tlie xkiti, nad
cvvu dci-pvr, iu iIil' form uf ruundiali auduK-a (itciuoun), or nf round
tn'lttiilcrs or rollers (lulmliir), juet ns occurs in tlio fwtus, WliUe so
doing, tliL> opitliutiid coUa usually' pn>Bprve tlieir lunn, only thoy oft««
gTuw mucb larger tlioii notmnl. Tlic funn of the glaiul« frrim ivlikli
these forn)ati<«8 proceed generally remains typical for the nwplaciB
also; but it remains iu incgular fartos of glanda, it ia ooly rarely tiiat
cavities fire foniied, and tliat autnid scerction goes on iii thvsc citritica.
Besides llie c^lbvlial iiarl« of tlit'Se tuniorf>, the conitcctirc tiasuc^
boni>!i, tiiusdeSf etc., into which the epilhelitiiu ent4>ri«, txindin't thent-
aelvos iUi fulluws : W<; Miuictiint-fl timl them »f nurnial, ugoiii uf uImiui«
mal tirnmcsd^ souKtimes very soft, ultiiost mucoiu, ordituuily in lea
quaniily tlitui ihi.' e|>iLlK>li»l mas«i>e^ It ix i)f:uidly jH-naded by smaU,
round (lymph) cells, ul'teu to sueli tm exteut tbut ^i^orcfly any fibruiu
tissue in left; geucralty tlic infiltnitcd small cellular elcuieDt« ant ecat*
tered diffusely in tbe eanoeruus (cDniieetive-tifiSue) fnunevork ; very
nirely, we find numerous ctrtLi, ciilleclml tt^tlier in a fissure between
lb« couoectivl^tt&8U^ huudlcu, \\1it:o tbe liiu>or adraocea luto the
bone, ihc latter is eaten away, as in caries. I hnvo not been able to
satiiify myM.'lf tlial there is any new (omuittoii of counediTc-liaaua
lilanicnts in thv nodular und inliltmied furut» of tlieou ttimiirg^Dur bare
I boon- able to find any osccoua new fonimtiou; but thiTO in no doubt
that such a uow formation occurs iu tlie papillary and villuuK forma,
of vrliich w« shall hereafter speak. From ibis dracriptitm j-ou see
that Wal'iei/er'e cxpneaUm ntKiutthecpilholial fonnation in carriiKNnA
being ait/picai{(iMU hit!;roadati^iu of RtAiii) is also well stiilttd for
diatingui»hiiix ean-iiiomata from adenomsta, as lyjiical new fariitatious.
Aa regards the reasela in these turoocs, ve miiy sjitisfy ourselvca,
by nrtifidnl iiijectluaa, that thi; dilaüition and new foruialiini, by tof«'
tiioaily iiud louping, are ix»tiiid<.*niblL- ; only the connectave-Liwue por-
tion» of tbe tumor arc Twtcularized, the epitliolial portions remain free.
Icaiuiot go any further into Iho gmeral hisUiliij^ml doscriptlun of
ibefu* tiiniOT^and hope tliat they maybe rcci^nizablc from tbo »bore,
altliuuf^b I avknowltxlgu that it is aoinetiinea very diificult to cLstan-
guisli can'inomJi from adono«arcoina and alveolar sarcoma.
CAECDfOlUTA.
eso
Arcnnlinjr to my whole bUtogenetio view, I must regard It us im*
possible for nii epithelial cancer to occur iiriiimrily m a Iwdc or Ijm-
pluti«^ gltinil. Tt>c otfsenralions tli&t I know, to litis effect ^iii tlie
lower Jaw, on the untcriortturiaccof the lib)», iti the Ijriupfaatic glaiitlB
of the neck), do not Men to tne suHicicDt pcoo( becniiM- the »kiu and
f»iKiou!t raombniie are ao nexr; tliere may have been sii inHignifieuiit
ClUcinomatoUB dtscase of tlto skin or inucoua [nQmbrane as a tttarting^
point of the disease, vrilhout its bnTtDj? beea nutjocd.
Tho appennitiec of the cut suriiico of this tumor, and its ooDBist-
atcci, vary so, that no genend description can be giron of it.
In the great majority of cases, carciuonui appears in the form of
nodules; also as indurations of otherwise soft tis.surs, or as papillai^
prolifi'nilioiiH. n^in-ly, the diseased partjt an- gepaniteil from tiio
tteiUUiy ti^iie by n i-oiineoUre-tissue capsule ; but, in must cases, tlic
paungc from healthy to diseased tissue is more j^diial. In eome
eases there is no mtx'eruu» liimor, luitn raiieerous iiifdlrution, there
bciuK no cular^'iueiit, itossiblv cvi-n ii dimitiution in size of the
affected orgnn. It is also eliaraeterifllic of CJirnnotna that jvirt of tho
new fbrroation is verj- Hliort-lived, disintegrates dircetlr or after pre-
cedent fatty degeneration, is rcalMtorbcd, aod then tite infillriited
Sbroue tissue oontrads to n 6rm cicntrix. Besides this dcatriciul
shrinking, and not unfn^iuently along with it, there I« often soflcoing ;
it la, perhaps, even more fret^iK'nt than conlisetiün ; at uU events, it is
more extensive. This softening is mostlr preceded by futty degen-
eration of the cells and casooas meliuiioTphosis ; central aoftening,
opening outwardly, formation of a putrid ulcer, with fuDgoun edges, is
very characteristic of csrvinoma. Mucous iDotamorplKuiix of tlie cell-
protoplitsm also takes place in some glandular carcinomata, relatively
nn*at r>ften in tlwise of the liver, siomach, and rectum ; in mre oas«,
this nUo alfects the oonncctive-tissiie stroma, Tliiü mucous (maccTis
also enlled ffetatinoua or eoUoUi. \\^en cancemua d^ienerations oc-
cur on the surface, the pajMllary layer may develop so as to heooma
very prominent, a» in nonie /ttipUlttry earner« (lieHtntctivc pupUloinata)
of the muc'ius membrane of the lip«, stomach, and portio vagiiuilis,
nitd as in viOmu caneer^ wbidi develops ciu the niueuus oieinlirane of
t)ic bladder, in the form of dendritio, braoohcd, largn pupillie. If the
cicatricinl conttaclion pr^lmninate in a eareinonta (as it does iQ soibO
forms of cancer of the brt-asl), hard tumors or uloerB are developed,
nlitdi hare for ages been called acirrhv*. Some earciaonuua are
brown or black, but still meiano-cartinoinata ar« rare. Most soft
melanomata are sarcomata. Von will more readily acquire »ii idea
of tlie dilFerent iorros of cancer by stitdying attentively ihoir origin
and tlie localities wber« they chiefly oceur.
630
■nruoBS.
1. Bliin (cutis) «id muci>iu mciobraDcs witb pnvcmcot-cpitbcliuni,
Common epitMi'ai carcmoma (specially so called bocAuse it was Ue
first, and, until lately, the ouly Utim in vrliinh thp main body of the
CBDOcrouB lumnr mb« known to f^insiiit of ofiitfaplium), or canaroid
{c»tuXT-\ika tumore ; lliia uam« waa «bo»«n Wvslue tliese cancc-nt o( tbu
skin were (X^neiclfivi less mnlif^ant Hum tlioRe formx oliRerved tu tliu
breast, wliich were ooDudered as the type of true caooer). The cratia
is oovcn.*<l l>y a Itiycr of t-pitbiiltum, Iroai wbidi in Uic fuitus tbcrc are
Tarioitt iiigrowtlis into tlie xulijaront tJSMie, namely, ilie Itiitr-t'aliiplca,
bair, aclwceouB, aiid swcnt glunds, Muouus glands arc fonnctl im rntf
cous membranes in tbc anmc way. Many asecrt that all tfac.M* Iiasum
may havL' L-pillicltnl outgrowlliB. I nhall not deny this, b«t <*]vttieI)iU
ingrowths may be most readily proved in tbn retn Malpigbit. Next
to this, a ooDsidersblo colleiUon of epitiiulium in Üw wbacM)u5 ^»ds
and glands of the oral mucous membrane, and tlieir enlargcnuHit, arfr
also fretjnently wllnwised ; less fre<itie«tly, ib# liur^UtcJeB and sweet-
glands are iui|i]icat«tl. Dur'aig this ingrowing, tltc yonog ocUs of the
Fm. hu,
t^Hitnmrlnt! rpIUmli »1 nmon of Iha wnnllTflfi b«i<liir»f fh* Da.— OnwU> oi m* rvtm MaMcfall
toio the llMd« of Uia U|>.-Ilofiij «pldemila.-TIi« Uwi^«»«!* ]mitaMi- m^X!sm
rete at first preserre their aiw and form ; even thttir relation U> the
ooiia«ctive lissae of tlie cutis remains the same, for those cells lying
CABC^KOMATA.
081
next to tbe connective tissue preserve a cylindrical fram, just a» on
the normal papilbc of tbe cutis.
It is rerr |irob«blc (Jut Uic rpiiheliftl, ^land-Itkc iMfnwwtha not un-
frequently grow into the 8p&o«8 bciwiNjn tfao conncctive-tiMw) bun-
It-';
*>V
Pin. lai.
^1
:-ti^':.s
,*■'■ ■
iwcilTC tl»i>e. InSllratvd wlihimkllMU*. JlacntlledWUdlWMtDn.
dies wticrc lymph circulitteü, tnr th<>rf> t>H> liMU4> offers IcAftt rceJst&Qce,
KUtter tliinka bo ha« provo<I itwl nil th«««> Itilx« unil cylinders tie
BoWj* in the lympluitic vusacls. AJlhough nil hb cridcnct- in fiivor
of tUia view i» »ot ten«ble, it is still rciy enticing, for vre might then
readily iindcrstand wbj* the adjacent l^tnpbatic glands were occasioD-
alljr iiifecu.-d early.
Sabectpicntly, changi-s tnke place in these epithelial tubes ; i^Toups
of cells »nile and form globuh^, which gradtinllv prow hy the depoät
of iirw cells of the fonn of fhit cpit}H.'liuiii, »nd tlitufumi the cabbag«*
like, coa)]K>und cpidcnniir^lobulce (f^bulc* ^pidcrmiquee, tvncruid
globules, epithelial poarb), which so much excited the astooiahmcat
of the dm penoti that examined them.
It is most probable that tliebe globules are <levelo|>ed trvm n niiin-
bcr of conglomcmtod cell«, inerewing by dirision, and the peripheral
layers of cells being flattonod by prossure against llie parts nround,
vhieli arc not very distensilile ; hence the larger these pearls bcconie
the more they project from the ccli-cylinden», and hence they often
appe^ar at the terminal points of the glandular acini. Among tbe
cells in tbe pearls, u in tbe epithelial part« of tlicso tumors etso*
634
TD1I0B&
io tbe «nlargecl papilln of a gtaua [wtiis, mt it occurred juat at the
dcrclnpineiit of the first epithelial prolirenttioiis.
Whil« in the last-meattoiifN] case, aa often happen», the papillan-
hjp4>i'tro|iliy uppeiLnjd nt the V(>ry commeooeoieiil o( ihv d(?V(.<lupiu«iit
of the tumor a« an essentially cbanctirrrisUo pait, in oilier cu8P8 it {■
of an oiitiroly secondary' aatur«, t. e-, the epithelial ruds uti the sur-
face of the »kin or mucoua ra4*mhrauc noftcti, fall out, and leave the
vascular ooniiLt'tive- tisane porliuii in the form of a pouched uIcft,
from which differcat pupillary- tuftfi protrude ur suhscqueatly grow.
Carcinoma of the aUin may bcgitt aa indurated pupUloma, or as avut,
but just as often it begioa as a uodule wheu the proliferition is at &m
cin'iini('KTil>cd, grow» into the akin ; it enlarges slovlj, without fin/w-
tag by apposition of aavr^ small curcinnma nodules. Tbe carctnotna-
toua prolifemtioii luny als» enter and grow tluough the culü (n>m
a prndiuilly-incrciisiug eurfacL', without cauaing any great prooih
nen«*,
Thi'ru is a deuidod differvtioe betworu cauccrs of the Ekiii, accord-
ing a» the epithelial proUferalion cnl«>r» the cutis diotc or less deeply ;
some case» reiuaiii quite superficial, scarcely ctiteriiig tlte subcuta-
neous celltilur tiiwiio, nnd grotriiig very ttlnwly (tiat epiliielinl oant'er,
TtiifTtfJt); otlien grow rapidly and eiiU-r the tl«sue deei»ly, tlcstroy^
ing it (inhltrott^d epithelial eaiioer, T^iierech). The aborc description
of cancer of the skin ia ft^m the iufiltratcd fi:)nn ; in flat epithelial
cancer the outgrowing nell-cylinders mrviy grow deeper tban tbe
deep layi'rs of Llie rutis, and oonsist rhiefly of the small, rtnind orlle
of the rcte. Al&ng with theac proliferations tbo sebaceous glandi
ber^iiiip hirger, fill up irilh develripi^l hirge^elled epithelium, and Die
connective tirsauo is richly iiirdtnit<-d with suuill-celled eleineiils. In
those new formatioii» the development of epidcrmi» pearU is rela-
tively rara As vieived on the patieiit in this coninienetng f.txigi\ tlie
whole forms o hitrd, Klightly-clevuletl in hit ration of the cutin, cm-ercd
with desr|uamatiiig e^ndermis. Thie epithelial proli ferst ion ih mH,
however, very solid- oeejisioually there are diBiutegrstkiu, boflimiug,
and detachment of thi- glandular proliferations and sebaoeous glands.
The hiffhly-vanciilar uoiiTicctive tissue reiuatue, and may cttuUntic Io
grow HA gmnulntiikuii, or it may partially eicatrixe. Wliilu this goes
on ill the centre of llie new fonriation. the latter continues to grow, it
may bo very slowly, in the pcrijibery.
At their \-ory commencement, the cut aurfaees of epittieltol mneer
are p»le rc^d and hard ; in a short time they appear white and granu-
lär ; (xa-aaionally we may see tlie large epithelial pearls and rvwla wilb
the naked eye. UleeratioQ takes plaoe from without inward, even
more frequently than by medullary softening Avim witbiu
itward,
CABCIKOMJTA.
ast
and usually quicklj toliovn tbeir development. Mucous sotWning ia
rftre in th«Ae forma,
In ivgiirO to ihe topoffmpht/, u-e nmy tuention the following regions
of tlic IhhI J us the itiost fn-qiiL-ut smts : {a.) Head and necJi ; Imn
theM tumors develop ohiotiy on the eyelids, conjuncciv», skin of the
noeo and faci*, thu lower lip, oral muuoiis niernl^rano, gunM, tilieeks,
tongue, lanmx, craophiiKiu, cur, and sculp. Tlic first uppeuroncc tk*
ricfi greatly: tho worst cuses begin aa nodules in the eubstaiioc of tlie
mueouB laembranQ or skiii, and quickly ulcerate from eenUal «iften-
ing ; other cases bc^n on the sui&cc ; a fissure, crack, indurated cx>
COriatJon, epidermoid seah.orasofl -wnrl, fortivs; this at first apparenUy
insijpiifieaiit affection may remain EUp«^r&ciul for a long time, ttlowly
extending laterally, leaa so in depth, and having indurated Ixmlers.
If tb« carciuoma develop from a wart-Uko foniuition, it may pertna-
m^titly ]>rc«erve tlic papillury ehnraeter. The ports oiiee di:'«nscil are
furever dcslruyed hy tliu nielamorphusis into csoceroua ti»auc; in
typical epithelial curcioomutu there is do cicotricial sbrioking; tho
ulevrs whieh rapidly duvclop from tlicso new fumtalioiis rary, like
other cancerous ulcer»; aoinetimes »mailer or Urgtir shreds of tissoa
üota tbo ilcptlis or die uIdct Iwoome gangrenoua, leaving a crater-tike
los» of substanOG ; sometimes tlie itew formation proliferates, forming
an ulcer with fungous, overgrowing edge*. Not tinfrequeiitly, a
cheesy pulp moy be squeezed &um this uloeratcd surbcc ; it oomcs
out in a worm-like shnpc, just as the in«pissiiled sebaceous matter
does from the glands of the skin (oomcdunus or maggot) ; Uiifi pulp
is a mixture of softened epilhelial masses and fiiL Sooner or later,
there is a graduatly-iDoreasing swelling of the neighboring 1^-mphalic
ghinds of the neck, wliich is not unfrequeotly jmuiful ; by degrees
the ghindidar tumora unite togi^ther, or with tho primary tuo^or ; new
point« break out, and the local de«trtK*ioQ gradually progresses; tbe
new formation also extends in depth, destroying the bones of the face
or skull, and taking ihcir placo. Death may renult from suflboatioii or
hunger, duo to pivuur« of the tumor on the aii^paasages or«E«oplw
gU8, or from pressure on the hmin after perforation of the skull;
more frequeiil !y, uficr gmdually-inoreimiug mnnuumtis, it reaulta from
complete exhaustion, with tbe »igtu of excessive cachexia. On ou-
Uipsy, we hardly ever find niotastatie lunrars to iuteninl organs.
All of these carcinotnaia on the bend, faee, and oevk, arc much more
froqueut in mco than in woinetL Tbe average durattou of life of
pulienls with eHncvr of the tongue and onil muooiis membrane is a
year to a year and n hidf, Oauccra of tbe Ups arc radically curable
by early and complete extiipatioo.
In previous works, I have termed tbe above fonn of fbt carcinoma
(130
TUMOBS.
of tbo skin, " cic«trizii>i|:, ttropbyiog, ci»tbclitil cadc«r, or scirrlioui
ruli^" to dirßiie it more morunitoly from ordiiiaTy cpillK^lial CHneer.
But Dovr it seems to ine bt-ltcr to mukü do Bpcdal suHUriaioo of it,
honce I at once stat« tJiat this is tbc niildcst form of cuo-fr of iho fkiu,
HnJ, tPitti few exonptions, attacks oI<l pentnas ; the duenee occmsioo-
•II}* begins M an infiltration of (lie papillary l>J'<^i «itii atruU nixiiilni,
always sMijwrilei«! ; usually there is nt firet a locnl collection of jfUow-
ish cpidormiit, a Kmall »onh, nftor wlio«^ rfmoral the tkiii appear« at
finl only slightly nxiclened, scarcely infiltiatwl; when (letaclictl, the
eruift font» ofcum ; after Tvpeatcd detachmeata, we find under it • noall,
rou^h, fin<> pnpillnry, (In*, tilccratod fiuWaee, n-hidt occasionally has,
even nt this pcrtoci, linnl, ttlightly-elpvnted edgiesi; lite small uleer, on
which new, dt^- cnists eonstanlly Turm, estvmls through tbc ctitis, Intt
rnrcly into the subcutaneous ttsmc ; its tendency is rnthcr to spnati
Iateniily,occasiotwHyitovoti hents in the oentrp, forming it ciralrlxand
new healthy epidcrmiK, while a nioderale induration and ulncratiao
dowly progfrfH in the peripher^'. In some caecs there is no ulcen-
tiott, ooiy inliltration of the ekin, with epiderniia-«culce sod subse-
quptit riratririnl shrinking.
The most frefpieiit neat of flat epithelial ooitcer is the face, e»-
pecinflr the cheeks, brow, nose, and eyelid« ; still other pATts of tba
skill, which are suhject to any form of i>pith<^lial oiircinonm, may be
attacked hy this funn ; it is mnat frequent hctwei-n the fifiieth and
nxtieth year, and I find it as often in wonteu as in men. Often th«
whole cutaneous surfiice, and «specinlly tlmt of the fore and haiul«,
appear» veiy dry, unti is curcred by nanicroiu dr^-. Rat, yellow epkle*^
mis-cnists, as well as by nunibcnt of sinnll inültratioiis, which often
di8*l)|>ear «pidn. Tliis wmcenius infilliation rxteudB verj* slowly;
ocensionnlly it is six or eight years before n portion of »kin as large as
a dollar, or a side of the nose, or «n eyelid, or portion of the ear, ta
deKtroyed ; it nin>ly proeced!) miire rapidly. As the patients are gea-
orally old, they occasionally die of other disease«, and, for tlie mni«
reasoQ, there is often no recurrence after operation. Dut, e\t;n in rase«
not opeiHted on or treated in any way, this form of »reinoma nppean
infectious in but few cases; tlie infeetioii never extends 1>e_\*oiid ii»-
Sltratioit of the lynipliatic g-Iaiids, which does iKit occur till lat*-, and
then goes on just as slowly as the primary infeetioa. Some writers
hare wishe<I to banish ibis fonn of cutaneous r»iiwr from tlie lisia of
cart-iiiOfniitii, hikI (o pliioe it among chmtiic inllammntioii» iia ulcus
rodpns {H»teMnmn)^ oras n form of hipiis pecnlinr to old persi>nEi,
Tlia I'lirious comlnnntions of this neoplasia with dislinctly-miu'ked
cancer in some point« of the infiltrated edges, the posxibility of Its
changing to prolifemting cancer of the skin, and »ome other anatomi-
C.lttO[S<l¥ATA.
esr
cal and dinical peculiarities, render it certain, in my npinion, that tliJa
form of intiltratioa and ulceration heloiif^ among the cnneers, and is
the mildest suit most foehly iuf«>clioiis animig thetn.
{fi,) Hie svcond pari of Ui« Iwdy where this Tun» of carcinoma is
frequent ia alMut tho genital«. TUe portio raginnlis uteri, rngins,
labia minora, uud the elitoris, lh<f [MMtit^ osperinllr the glans und pre-
puop, arc the parts ino&t fn-quently nflcctcd, Ot all thc»c part.s, lUc
porlio vaginalis ut«ri ia ««peeifllly liable lo tl>e disease^ and here nur-
ctnnma ukemtcs rapidly, and, as tti« surfucc of Üie tumor becntnoB
deeply liittured and agNuine» ihe nppearaiMre of a caulißower, this is
oßcii (."«Hod cuuliflowor canwr, but, as NLrcomalous pupilluinata may
produce Uli; »into funmi, tlil» de^ignatin» is unccrtaitiu On ull of
tbc above localities the ulocrnted tumor tnay have a «lestnictive ul*
ccnitiiig or a fungui» clioraclcr. it way also bu cither inSltrsted
or superficial. Ttic scpanktioii of utcritte cancer is aceumpaiiied by veiy
badly-uneUtng saniea, and often with repented parenchyinaloua
lumiorrhnges. An reganls the »ubscqucnt onuree of tfa« disease, the
retroperitoneal lymphatic glands arc alTected eouner or later ■, death
UHuxlly resullA from marauntn; in tlx'se cases, also, we very rarely
find mclaBtasis in ll>e intcrniJ orgniin, except in Uie neightwriog
glands n-liich arc direetly infected.
(r.) Ot other parts of the Ixxly that require the attention of the
surgcdii, we have lo mcntioo the bond, and especially the hack of the
hand. Not lung since, I saw an epithelial careinoiiia oo the right
forearm, ivfaich had developed from a fontanel, ke]>1 up for ten yeara
vcitJi jteua. 1 also &aw on ulcer of the foot, which, after lasting for
yeans without any known cauae became cnncerous;
[il.) We idso mention here the oarcinomata growing from tbe
Tcsical niucoua raemhnuie, which also hn« a paveim-»! epithelium.
Inacoesoblc as it ia fur »urgicid truatineut, th« »tirgeon iniiBl etil) be
veil aequainteul with it, to enable him to makendiffereulinl dingnocia.
It liaa abvad}' been frequently mentioiH?d thai papillary proliferntioiia
occur in carcinotna ; this is particularly often the cose in ameers on
the inner surfitce uf tlie Uadder, widcli frequently grow iu the elmpQ
of hraocfaed tüIi, and bare oouBcqucntly received the special name
of " Ti-fllou« Cancer."
Caneen starting front tbe eutaoeous epithelium and glands have
the «ame relation lo villous rancer that adettmna baA to papilloma,
^\ltcn papilloma asniimes a peculiarly luxuriant growth, and at thn
same time cpithclinl mnMea grow into the part of »kin affeetcil, soft-
ening the cutincelii'c tiMue or mii»cle, in nlturt, ivlteii tliu tumor as-
sumes a distinctly destructive rliaract<T, it may be regarded as car-
d&omatmis papillonw or I'illous cantor. Th« boundaries between
988
TCMORa
BÜDple papilk>nR8 and rilloaB caooer majr be jasi u ttIRrült to i
as those Urt^t-cii adenoma and can-tnüDM.
Aa ibtne siated, a tomar litce a niusliRXKii Soma on tbe inner :
free of the bladder, growiiijj itito tu earit/, and floaling in the
rn. tm.
>.•»
'r*/ r,
PuilItorT faita*tlgo of » tW»i «antw of Uw W««er. «lUr JwoW. ol wthMt, », wUft
ihroiua: <r. bcibud^SältlMliafaMTtllL K«calUd>a>4BuMMa.
iu base belog altariied to tbe wall of tbe bladder, like a cardnoma,
and its lixi|;, branched villi bettig oorcred with rtry largv irpJtttcSal
cells, "vhilc tb« frroiind-work of ihc papilliv is «ompcw«d uf oontMCtif«
tissue, \tIius<! tnL*slivs cimtaiii epitbclüd cvll-cj1ind«ra,8ucb as ooour
in carcinoma (Fig. 130).
Nov, B fuw words about the oour»e of tbe nbovo cardnoinata aa a
daaa. TIicv muully nifpt-ar iti (.'Iderlv penoDS, saj from the (brtietli
to sixtieth yc-ar, rarclv later, bul, uuforhmatclj, it is not so nn tar
them to come earlier ; I liiive mx!» caiici-r uf tbe tongue in a bof of
eigfateco, and cancer of the uterus in a woman of twenty yean. On
thpe whole, country people arc more subject to cancer of tbe lip than
dtv people are. The earUer tbese carcinomata a]^iesr, Üie more pro-
liferant the local tumor, tbe earlier the Ijmpliatic glaodaare Implicated,
ai>d tbe more rapid the whole course. It has oCiea been obscfved
CAROISOMATA.
88»
that, tfter cntiro removal of the tumor, there Is no rocuireucc. In
some cues the disease runs its course very quickly, in a year; in oth-
en it hat» Uiree, five, ten yean, or loogcr (flat cauoer of tlie akiu) ;
aomctinics, also, tbc rwunrncc is only io th« lyiDphativ j^Uiuds, n«
when ft cauvor of tb« lip hus been oümplctely oxt iqwted, but ut the
time of operation caooei^rms were already prescut ia tho wrvical
lymphatic glands. Tlic now formation in tbc gland at first appears
pale red, is a rather bard, diäuse inliltratiua, or a white kcruol, but
with time it beooines softer, and, to some extent, pulpy and purulent.
The oerricnl lymphatic glands iuliltnited with cancer have a great
tondcDcy to ulcerate ; their micmoopical structure is the same as tluit
of prinisiy cancer. I think there is no doubt that soooudaiy cancer
in the lymphatic gUnds is always due to tmnsplontattoa of cancer-
germs from the original focus (ee« page &&3). The above forma of
cjuioer BcATcely ever go beyoiul the lymphatic glands ; infection of in-
ternal organs (liver, lunga, sjiltwn, kidneys) is very rare. Tlic con-
•tancy with which carcinoma occurs at certain points, especially where
mucous membrane posses into skin (vafpoa, penis, li]»), has justly
always excited mudi attention. It was natuial to svek tlie causes of
the diseaso in the stnicture uf these purts, and iu the initatiuns to
which these openings were subjected ; the dislike that most modem
pathologists have to specific, unknown irritations has induced ihero to
aeek diffen^nl causes for exphtining the obecurity nixmt the »[»eciiic
causes of tuniont of t)K«e piirts. In n^^ord to the lips in ohl pcrMns,
Thienc^ attaches great iinitortanoe to llie fact that there, as in the
cutis cbewhcrc, cousidcruble cluitigcs take place with advancing age :
there is decided atrophy of the coonoctivc and muMular tissues, so
tlmt the epidenni^^fonnatiuiis, liair-fuUick-s, seboioeous und jKY^pim-
tory glands, as well as those uf the lip, attain the prepundcniuoc, and
r«ceiTe moAtot the nourishment; hcnoo all irritations affecting the
lips (bad shading, smoking tolneoo, wind, bad weather, etc.) chiefly
' aitodc tbc glandular jtarts nf the lip, and induce hyperplasia. In
England, epithelial cancer often altacka the scrotum of chimncy-
sweeps (chininey-HWeeper'fl cancer), from the irritation of the sifot, it
■■k supposed, Tlicse things may ocrtHinly have some effecl, hut it rv-
iiis uncsplaiutxl why they sliould be followed by caoocn or infoo-
' tioDs tutnore, and not by elironit^ iuSaiiimationa, catarrhs, etc. I shall
not here follow tliis discusnon further, hut merely refer you to what
.wsa said about tbc etiology in the introduction to the section on
'tumoTB.
2. Mammary ylatuJa, 1 place cancer of the mamma here, as this
gland is also a ilerivative of tlie epidermis, a cutaneous (at^land on a
Inrgc scale. Tlic mammary conccra, hovrcvcr, differ greatly from those
48
640
TraOBS,
already deaeribed, and, although true epidennwomcen oonir in f
breast, slurtiDg jturiicularl^' fmiii tlit^ areola, Ui^ are wry rare.
Miiaiiniirjr cuiicur, which is uu fui-tui)«U*Iy very froqutnt, »ecoig to
me almotrt «Iwaj-b to begin with a ooinciiU^nt enlargi^iiicnt of ihrr «truill,
rotiod, epitlii<liitl cvlla iii tiiv acini, eui] «nth KinuU-^vlloi] iutiltnitiuD
of the coiincctivc tissue around them. With our prescm nx-thwla of
examination it is impossible to tcU whether tlie firrt changes cnxur
ia the glaad-celU, or in tlie ivnoective tissu«; ft» the grouping uf
siiian, mtiiid cells about the adni aoon beeumes so rxcesüivf, that it
coiiftiintly become« more difficult to inuke out llie further fulu of the
^)»iii)u]iir itoini. From inj tr>Ienihlj' nuiniTQtüv nhservatioiis »□ lliia
subject, mitile by «id of the must iinproved methods, I think I may de-
scribe the foltoning as tho subtcqucot oourse:
Tlie colleetiou of cell» !d tbe aelni leud^ (irsi to their cn1urgt>mcnt,
which is occosiunalty accompanied bv s tmcc nf eviTclirm (as is shown
bj tbe escape of scrum firam tbe nipple). As the coUoctJou of mils
ooutiiiuee, there is more enlargement of the aeini, and in &ue)i diflt^rent
wavft. that tre ma^ distinguish »n arinoin (often large-cciletl) an*] a
tubulur (ciiicfly smallimlled) form of mutnuiurr caiiecr. Tlie former
Icodft to th« derelopnit'iil of Inrf^e, lobuLiloil, glandular notluli>&; hence
I call this tbe " acinous fonn,** since b it' tbe rougti outline« of tbe
aeini are prcsnr\-cd. The following picture is a slightljr-aiagiiified one
of the borders of such a tumor:
Pis. ue.
-«ÄjfeV
MwuniH^ caucrr, kcttiou* fom.
lt<ctiU«d n aMii«lm
llie groups of epithelial cells, which are enlarged ind gfown to
thicic glandular clubs, are enclosed by infdtrated connective tiaai».
C^BOlKOilATX
e4i
and trsTcrset] hy a fine net-work of coonectiYO tiseiae (strcmin), irbicli
I re;;rard •« the rciiminft of tlie tonaer putitioos betiveuQ the ncitii,
but whiüli »Üien considvr as moetly new forniatioii.
\{ wc nudcG a section Uiroti{*b u honlcncd prepantton of qd aci-
nous, soft, mammarf caocer, «ben mapiiücd more stroiif^lj:, th« titsuo
appears as abov«.'. I consider the cells in the Larga coiinvoÜTe-tiisuu
incsbcs as of epithelial origin (Fig. 141).
ri«. Ul.
Soft
«»fwr; tlteolar IImo* of UM mi liiniiit . kkofcoUc pnpknUoa. MtiIIIoiI
l«0 dloBcten.
Tbis rarie^ of iT)aiuinai7 naiicer is mostly soft, granular on »ection^
grapth white (mcdullnry). If wc scrap« tlic ctit sui&ca of auch a
(.■flncorfMis tumctr, w runditr rtiM'iKitv u thii>k, whitish pufp; ifvro ex-
nmtne ihia while ffL-ah, wc 6iid oudular cells, wry puli-, composed of
large, manv-formcd ■.'clls with lar^ nuclei ; many of tliC6e cells ooataln
stn-cml nuclei ; tbpy may perbapa be B«j;regatmg'.
Tlie conntHrtire-tisauR fratne-wrork in wliirJi th«se pJeinentB were
embedded, when emptif, looks about as follows, if atroiijjly inaj^
ntiieil :
Tlie second fonn, which Is more frequrat (is harder, and on sectiOD
pale rc<l), may he termed Ifae " tubular " form, as the acini do not
maintain their form, hut ^ruw into the <x)iiuective tissue as very thin
ceO^Uadera, wbil« it becomes iuliltntcd with cells. As in this form
CJÜtCISOHATA.
C13
tissue occasionatlj lie tog«lh«r in groups, it is evident that it must be
verj- (lifEcult to dvcid« whicb of tlipso caocera come from Uie cell*
masties of f^lniidulur epithelium, »nd vhieh are pufc dcrirotiFCS of
connective Itssiio, funuer waaderiDg cclla
Pl»-14l.
.•.\<
■^:
;1S'V
CUMtol IhstifMat: f nlnCar (dm. UauU^lul lUilUuuiim.
HeiK""! all nhwrrers are not wl poininred that these fn?(|iieiit
fonns of luamiiiary rurcinomnta »n- tnic (»mt-r, ns 60R>e üf them
ref^ard all the cells oc<nirTiDjc here as derived from conncctiTe 'tis!U&
Tlic final dv«i£iioii in tlii» iiuilter can tinlj" be made bv (Ik- bislory of
dcTclopmimt ; as long as vre luivv no means uf niwaj's distiti^iahing
the young derivatives of epithelial ««Ms from -wuixlcrinf^ wbit« blood-
oells, aiHl the derivatives of (Wiiiiectivu Itssuo, vn shall 8ean!ely be
able to Mjr fruiu every prrparHtiuo vrbetiirr this fonn of cancer of the
maiuuta is tnoce of an epithelial or councrtivc-ttsaue iiatute.
Allhnugfa all forms of eaocer of the brenst hum a tendeney to
alucrate, this is n>ore the ease in tlie softer tlian in the hanler forms.
Thv hanliieas of aiiieer of the mainiua does not alway» dt^peml oii its
riehnoss in sells, btit even ai^nou« eaiwers tliat are rich in ceÜH niny
be banil, if tbe cells are enclosed in tense coiinertire>tlsfliie rapsules,
as the Donnal acini are. The Kifteninj; ia cenlniliii nodul^'» lying
near the *kin, or i» the harder fonns it is more frequently fmm with*
out iniranl at points vrliere the tumor pK«Bes against the skin aud
QU
TITUuftS,
haa bccotno united to it. Mucous »fWniDfc occui« mrctj*, maeoiu
m<!taniorpho6iB nf tlip gland-cüUe i» prulmbly never sera. To tb«
naked eye the Boftcnt-d epuls appear whitisli-yellow, ^ninulitr (a»-
eou», (»ity stifteiiing) or gra^-isL or dark red trom vascuUritr, espe-
cially if there hxve been estrnvmsntiona. By eofleoing und encap-
sulation of tlie aofteiied spot, which miij be deeply seated, cysts nmy
be fonnud in thcM* canänuuuta ; ictenliuo and secrutiua cysts mity
kIso be dereloped Ui the maminti «long with or in the oKneerous
tumor.
Tia. la.
--*:
'T^-S.
Catioer of tlie mwmaa. (Tuai k ucaukUltr-auutdiM fui. MicniOod MU iQuaneM,
Atrophy is a rccy (rcquvat proocn io cancer of the inamtnii ; the
uipplti or otlier part« ure tlius retructod like the naroL On mienv
Bcopic cxaminiition of these Btrophi(!d parts we aoc conncctive-tiasue
strisB with atrophied conn<tctin>ti£euc corpUBckfl, and tl» section of
fine, brancHed caD&hi (ntrophiod alveoli) wkioh are BUed with cell
detritus or Int. This atrophy of the neu* fonnatiaii la )i) some fsuuxn
of tlie iiinmina such nn iiuporliiiiL factor, lliat tt \i»9 ^veti rise to ■
epcciid form of ninoer, " ain.phying, eicfttrimng oaDcer." It iimnnot bo
denied that in it« pure fonii lliis viiri«ty of cancer has certain pecn-
Itaritlea which distinguhOi it from the onliimry, matA frequent foniis
of cancer of the mamma ; hence wo prefer (o dceoribe it acpanteEy
hereafter.
The devclopmeat of cancer of the mamma la aocoinpaiiicd by con*
siderable disteatioD of.vessela and oeiv foritiatiao. In the youngeat
parts of the new formation tlii^re arc Dutncrotis fine vuasela and net-
work» of ressel» ; in the oUlt, cspödiBlIy in the softening parts, th«
TCOaeU grow wider, then arc thromboeod and destroyed, ao thai,aboat
pcnnts of softeniiif; in tumors, similar net-works of dilated veaaels
fiarm M are dev-ulojicd on the formation of abscesaea.
The following are the clinical symptoms of the demlopment and
&46
TimmB.
lonrer part, thera forms a tumor, at fint flmall nnd p«inlass, lliat BOiDe>
times remains unnnliiml for months; it Is hard, firniljr aeatoi] in Ui«
ghind, but nt first movable under tb« uiin aud nvcr tii<> pootonl mua*
cles; at firat its growth i» motk-rutt.-!^ rapid; pu&sibty a year panel
before the tumor reaches tho »izc of a small apple; it« volume is not
always the same, occasionally il ie largvr attd more SKtwiÜTe, especially
before aiid during the menaes; but oceanionaJly tho tumor i-ollapMS
somewhat, and is perfectly indoloDL 'Dii-ti« synipluma are ponly
dependent on coufreation of the mammary Rhind, partly on atrophy
and cdcatnzstion gotng on in tlie tumor itself. With tim«, iti the
course of some months, the tumor gniw» latter ; the skin over it i»-
ooiiH'a imniovnhlc, and bnlow it adiierca to tlie peolnral tiiu!«t-!e. THk
patipntH frwjuently do not noliee the oommeoccmf^nt of the swelling
of iIm; nxUlary glands, and, if the suifeon's nllentioa be not ^Kt^ssion-
ally dimied to this rt-giuu, the eulargemciit of tbese glnoda, which
appears as a hard swelling of th«4e pArt^i, u not dt«<o\'crc<) til) late ;
sometimes also tlieso glands lin so tk'vp and so high under the pectomi
musele tliat they arc not felt till they hure grown quite lafge. The
Ijinphatic glauds of tfac neck are lc«8 frequently affected in mm^er of
tbe hronst ; when they are, the prognosis is more unrarorable. If iIm*
progress of the tumor goes on undisturbed, tlic course, when modern
ately rapid, is as folloWH; The tumor of the mammary gland and
tboee of the axillary glands gradually unite, so as to form a Dodiilar,
wavy, immovable awetling, which at some points ndheres to tbe skin ;
the pressure of the tumor on ihe i»en-ea and vessels in tli© akiHs
cuwes ocuralgic pains and (cdema in tlie arm ; the patient«, who pa«*
viously had felt [ler/oetly «-oil, are eoiupt^lli-d to keep In bi-d by the
pain and swelling of the arm, whicli eonie on mure espocislly at night,
and li&re a picnüng, boring clinractcr, while previously lh«y may lia«c
been able to attend to their Iiousehold duties. lu this stag« (say two
years after the eornmeiicement of tbe first tumor) another sj-mptntn
has usually appeared, or d(K.-{t 80 shortly, namely, uteenilioo. Tliis
generally begins with tho following symptoms ; Port of ihe tumtMr be-
comes prominent, the skin grows thinner and redder, 13 trevonteid by
visible vessnts; finiilly a fissure or reiside forms on tlie eleratcil, (rU,
fluctuating tumor; now part of the caneerons tissue which is exposed
to the air becomes gangrennus, breaks into shrvds, and a rratcr-likr, ■
exoavnW ulcer is left, wliii'li long maintains ibis Bhape, if the siir-
rouDdiDgs and base cf the ulcer be still hard ; but, if lliu part« about
tho uIcOT be alppady suft, tho sulistancc of the tumor begins to prolif-
erate at the (xlges and ft'om tlie depths, and to cover ihe parts art^UDd
lik« a fuDgtw. An ulcer, sometime« torpid, ROmctimea fungous, h
thus developed ; its secretion is always sen>-«anious ; badly'smelliag.
CARCINOHJlTA.
gangrenous shrnJs are often thrown off. But, what is still worse,
pareociiyinatoiui or iMrcn arterial biEimirrhagcs oocaBioiultjr occur fitmi
llie surface of the u1<^j-, aud exhau&t the patient. We have followed
tlic <y>ndiHon of thiv piitii.>iit till lu'- ha« bec<Hiie jwrtiy or entirely bcti-
ridden ; wv now soon cumv to ihv catastTiipliir : lite jiaticut lx*comeii
pal« uimI gn'jitiT cmaviatcd ; thu appetite is lost, the strength grows
less, the nights are oft«n sIcopWs from the pain ; opiates must be
nworterl to, to give the patients sleep an«! teroporarr relied We oow
hare Ihe wcll-inarked piotiirf- of raamroiM <lt/srnuia or cocAexjo. It
maj gv> on in this way for months; the smell from the cancerous ulcer
infeiitx tbp ehainlxtr, the patient« become ucwker, the skin gmwa
grartsh-ycUan' and clayey. Pain» on brtmthiii^ uod in iho n'gioti of
the liver, M well as in tlH' bones of tlw limb«, come ow. The patient
becomes ntarasmie, and dies in agony after protmeted, painful sulTeT-
ing, unleaa the end is hnateoed hy pleurisy or iNrrilonitia. ÜD au*
topsy, in inoät cases we litid careiooniulous tumors uf the pleura,
lii'er, and ootTwionally of the booe«, it imiy be of the femur or of the
vertebras, or else of the rib« on the side where the tiimor of tho
breoüt was. The wlit^e diseaHU lias lasted two yetin and a balC
For miny eases of cancer of the breast the above doHcriptioo vrill
be very aivurate, hut thurp are some modifications uf this course.
First, the rapidity of the liKal cmine vnrie»; the tumor may remain
oonfined to tJie breast, without any affection of the Ij-mplialic ghind«
— a very nire I'sae. llie diuiuie of tlie glands apjieam almost »luiul-
taneously with the tumor of the breiut; this always leads us tu ex*
pect a very rapid course of Uio diftc*«c, while oonrersely a very late
und tiiodenilo local spread to the lym|ihat.ie glaiMU inilieales a mild,
slow course of ÜM^ whole disease. Caieinomata maycome in the two
breasts simidtancously, or in one soon after the Other ; this makes the
poogna&is much wotm!. In some cases there is uu isolated tumor of
the brwasl, hut the whole gland, with the skin, becomes diseased at the
same tim*-. Lastly, an adi-nomn or nn adcno-sarooma uiiy have ex-
istnl eight or ten years, and then rapidly awiiime the diaraeter of n
cancer, i. e., Iwcome immovable, painful, aud aceompaiiied by hardeii-
inf; of the lymphatic gland«. Oses also occur whore the tumor oS
tlie mamma dimini^es so much that it is mipposed it bu entirely d(s-
sppeared; unfortunately, thi« iloca not prevent tbe geneml outbreak
of the disease, altliough it appear« to re tanl it, or only to occur in
mild oases, such as ran on from four to six years. Some patients die
early of nnopniia from tlie uteemtion and hiemorrhage, without any
tnetostatic fumurs having formed. The period for the occurretxv of
metastatio caocerous tumon in the internal organs also variea ; gener-
ally, wlien the local growth nf the tumor is skiw, metastatic t^irnons
648
Tt'UOEta
nppcar Ute ; atill, tiicro oi« cxccplioiis to tlib rule. In cmticer of the
breast tlic l<x»lizatiou of the secoodary tumor» i« very re^fcufau-, u
■Insdy slated ; thv plvum, liver, bdiI botws, miv the mwt frequeot s«k£i
of metutatic linnont.
ITie Twryiof: counc of cancer of tbo bmst r«idfn! it veij" dilE-
oult, indeed almost iinpussiblu, to compure the ruitult of cutiy or Ule
operatjotui with those casps lIiBt run thar cxHirse without ofienlioD ;
even the age of tlie patient («uses fcrcat diffcreuocs: in old pcnoMi
tho diseoAC almost aln-nys runa a slower oourso than in young oau;
nninemim entirely unknown influeiutn come in phty. Tbe niO»t ex-
perienced surgi-uns have ^reii wry diflerent opiaionB alioul oj>eiatiii|;,
some docliirinj; Ümt Xht ooumc of the ditca»« is hafttenrd br operatic«,
others tlinl it I» returtled. T\ns sliitislionl labk-s that liuve btren pub-
1i»hr<I Old little in soiviotr tJii» question, beotllAc oiaes of all »ortaare
tlirown together in them ; to obtain a correct result from tliea, ÜM
oases must first bo soparated on <M>rtaia prineiply«. But what p«xl
would this do? It wntild always be a qurstion, in each ease, wlicthtr
we should aid the patient hy an oiwration or not. Tlie tuniocs will
almost klwtiy» n?tnm in tim nioatrix, in it« victnity or in tbi> nei^blx)^
inf^ lyinphatio g^Uiidb, h<x-uii8e t/tei/ are tuuoBtf operand on loo tat«/
the patieiitE wili then die of mctaatutic tuinvrv, if tlicy uc Dot cuiicd
oBf socaier by soppuration, haemorrhage, or «cute disease. How mucb
doe« the patient »uffer fVom the tunKv f What dar^r docs tt imluoe
locally ? Tlieae are llii- lir^t UT:^rit qitefttiooB. But I am antit-Jiialing
by contidcHn^ he>v tbc treatment, whi«h wc propo&c studx'iu^ inoie
Pw. itt.
i.^?_* j^a*";
-if
ntloo. HannUM SSO ilUmeUn.
attentively at the end of this eection on cancerous disea&es. Baaal-
nution of the eol»rg«d lymphatic g'laads, which jiartly adhere ttwethet
showa fitat tbo soiallcr arc more suoculent and «-aacalar Übao nonuJ ;
CABCnfOHArA.
04B
the IniftCr citttoiii luird white or (rniy'«''-whit*' ikhIuIvc, and »re occa-
sidiuilly eoftcoed, casL'Oui^ nnd have a gnttitiUr mi BurCucc. On the
wbok-, the Ivniphatü; glaada sbow the wimc cimractcn us pritimry e«ii-
crre; thia also ezt4nitis to Uie niion)e4X)|)ir texture. Although it cou]d
probtihlr r»a\y be proved in pif^minited ciirctnoma that the lirst ewell-
iitg of ll>e lymphatic glRiKlK dciM^iid« on tnnxrummtioii of t umoi^cells
into the lymphRtii' g^londs, still I consider thtr same thioK tnic of ill
coreinoniiita ; in some cases the epithelial nature of the nexr forma-
lioD in the lymphatie glands is just as striking as in the prtouuy tun>or
of the breast, in oilier« »iich a distinctiua is inip«j«sible.
CorciDonintoue ooditlcfl of the pleura, which develop after oar-
cinoinn of the brra«t fmtn direct «mduelion of the seeds, are iitiually
hard, pore white, and »mall-celled; the »nine is tnieof thp externa]
appeannccs of fteoindiinr catieer uf I he lungi» and li\-er; Hut tlie latter
are not unfre(|ti«ntly larp>«clled and adnoiii^ Althouf;)i I re^rd it
as probable that these carutitomiita lire nleo diie to direct rmlgralion
of curcinoma-cclls or to transporUitioii of the latter by the lymphatic
or blood resecU, this cannot be proved
Some raecs deviate from the above course, na is abon-o bj cat^j
and rantinued shrinking of the uenr formation. This form is adled
teirrhtui ntainmi*, ntmpbying, eivntrlziiig, slirinking rarcijionia, con-
nect ive-lissue eaucer. The picture of tlie disease aud the auatoraieal
ehanjres will appear from what follows.
Ill ilie uiummary glajid, mrely befrjre the fiftietli year, there foims
■ banl sput — ne cnnnot say a swelling — but the faardeniitg ia rather
accompanied by a parliaJ or even a total decrease in size of llie gland;
this liardeiiiug usually ferms without, rarely with severe poiti ; It roinea
OB Tcrj- slowly. If wc now suppose ilic hardened glands remcii'ed
and oxamioc the diseased )Kirtiou, we find the tissue so liard tliaC
we can seareely out it; to the naked eye, the cut surface shows a hurd,
fibnni« «eatrtx, with connective-tissue stiiie gradually extending into
the compamtirely healthy parts arautKL In typicaJ coses, oecpt this
cientrix, we shnll scnrrely diM^>rer any thing pathological with the
nuked eye; but, at the periphery of some of ihew» tumors wc seo a
palcTeddiAb part n-itb a fatty lustre, more marked tu spots, Ijntig be-
tween l)ie cicatrix and the healthy tissue, aod poanng into botli. If
we examine üne sections of tbe deatridal tissn« after previously
hardening it still uwre in alcohol, we ßnd little besides connectit-c
tissue and elastic filaments; but the connective-tissue striie bsd'c not
th« same peculiar regular course lliat they have in {broma ; they are
irregularly intertwined, aud, as abore slated, they are accompanied
TtmoRa
by many elastic Glflineiits, whicli rfttcly bsppetis in fibranis. Bot
exxmiiiatioTi of the bordcriiij^ tisMic Riv»;» llie following : Tbrre i»
oeli-iiitilinitiiia, to a very alight extent, it i» tnjc ; them i» dr>vf lojimcnit
of CnwU groupK of pale bndioB, liko lympb-oellfi, with single Diirlci, u
in the cotnmeiic^Rieiit of anv new formation. Part of ifaeae rtfltii am
amiif^d ill \vn(i frr\>u|)s (ttibiilar), eucnewbat hirger Ihaa the rot;
t1ie«c arc diMibtlMft deriraticos from the epith4.>]inl r<>iiiainii of the
ahruntcen glandular acini. All the «wlla of the »euplftam appear to be
very »hori-Iive<1, for they are acarocly fbnniHl belorr they comnieooc
to tk'<aiy, without going on to furi)>er dcvtrlopcuent ; then the cm-
ncctit'i' tixHu^, wiiich ha« lieeji ft()ru<>trliat disteudeil, ghriak» together,
and, as a resutl of ihiA procesa, w« bare the oioalrix; but p<>riphBrally
Hub alight OL-U-in fill ration coiistanlly uxtends; huuce «ximplete, apac»-
laneous disappoarjincc of theiiftw fonnatioii very rnr«lT, if ever, occurs.
If the honlen of this tiimor h« inspected iiiiiler a li<\r power of the
mtrinscope, ire »ee how tiie small-cellnd tnTiltraliun aih-nuccs betvreco
the ueshea of the oonaectiv« tissue, and closely fc^o<»-s them.
Ciiiin«<(l*«-tlMaa InlllimUiiD atlTuicliiit Inio Itic cvlU from ibv b«rdcn at •MDevmni Mdal*
nf ihf minima; Ihn lUrK ihidlnjii corrwpotul to Ihn (drandait itiwa-cellDd tnlltrttlaa.
M><«ulfl«l SO dU metor*.
The extoiidoii of this infiltmtion into ttie (alty tissue oorara just
ftS in iDflaniinatioii ; niost of the youug ocUs are fuuad in the neinity
of the reaaelA, so that wo can s<'-ar<:rly oroid thinking that iii the*e
cucii also white blood-cells escaping from the vessels cause tho cdlil-
lar iiifilt-ratJoD.
As in tlieoe oases Üie mfilintioo of the oonnecliv« tiaaue vith
CARCISOMATA.
«81
lymplioid cells ia TC17 decidedly tlic predominant mortiid prooom,
while the epithelial proliferation ist very secondary, 1 formerly tried to
give this ioTtn of ranrer nf tin? l>reiL»t tlie name of ** rtmnective-tisaue
ciiucer,'* But, as tlii» lius led to misintcTpretutioii in rrgunl to Uia
modern Bnalotnicul itndentanding of carcinoma, I shall doC try to
presen'e this tenn.
Fm. tKk
.>-.
V
•^
0*1lidirliiBltnttloiii>rili«lktmi»ni-)ii iliap'riiihorriili UtnlrnnmuruurbnaM; tbel
The pwuliar annlomical and cliuicnl course ha« caused eomc sur*
getins to strike Lhis iwv funnatiun from the list of (tiniors, atid pai^
Ueiilsrl^i' from that of ranccn^ If wc examine mnre clos«Iy the clinical
oQunu tif ihuM: cu»cs, wc have already aoticod that they usually only
occur 10 old pentonH, and that tbe local disease progresies slowly;
atnnv ca»es lust tevc» or eight years before half of one brieasl is aln>-
phtccj. The (ceoL-ml heallli meantiuK; reuiuiiis uniii)]»irt:tL The
iymphatie glomh occask>iii(IIy portidpiUe in the diseam» ; in ihi« cose
the pmcvss fp.)e* on just «a iit the roamina ; there is rery little «nlnrß»
mcnt, but lauuli iianlenin^ and ricutricial ährinkiuf;. 'Hie more rap-
idly sod completely the iww foniintimi iilro[diie«,iuid tltc nton' slowly
the procHSH extends, the mure tnjurioiu it ia; after CKtirpation or
<muteri»ition this variety of caaocr docs not recur for n toog time, if it
ilo^ft Ro at all ; met»stiitir tumors an? rare ; in the main, the inRltm-
tiiH) d»«'« not appear to differ much, anatomically, from that in ehronio
liepntitts and iiepliritis with »ibBci^ucnt shrinking; why, thi'n, ilintin-
j^ifili this (tetTTlius &om those processes? WtmAtr terms tliis di«^aie
of thi? miimma cirrfiotU mnnwifT, I recognize perfectly the jiisUca
oC doubting the carciooioalous nature of aonte oaoea of soirrhoua msto-
MS
TimOBB.
mje, but must still insist itpo« diissjng tfacm genenllj Mnong cnnoet^
for tbe iullowiiig n-4isuas: As jrcni alrend^- know, antong luoion Üu*
pmonss uf cuiitmcting ü pixtiliur to cttuctrr«; morcorirr, ibc ocnatiBCl*
iug cancer isnotun/rcqucntljroorolwno*! with ordinary cancer; indeed,
it is more common for more or leas cauoeroim pruliferation to go ud
along with tliA st-irrhoiis afTcclion, nttUc tbo wlioJIycicBtrixitig concn»
are räL>tiv«lv nre. Tliifl coinbUifttioD, wliich occurs neither in ctrrhcK
Bis of the liver nor of the Iddnev, sjwaks entirely for tlie near rplminn
of Ulis ckalriziiig new roniintloii to cant'er; in iJieae combin^-<l rx^es
there Arc il«o loooj recurrence« of tbe extirpat4!d tumore, tumor« of
tlie Uiiijiliiitii- gltuitli^ atul even nielasbtUc mncers uf tnteriml orguiis.
Ill llic tuiiiüna Ihut nmsist <^Ai<f?y of cl<»Ir{d«l salutaDce, ami hctnv
are to be classed rather witli seirrhus thnn with cnlltmry «uiccf, «<
may give a tolerablu pcugnusis, iuoauiueh as tlic dtseo&e alwajs luiis
a ^uw course.
We now mention another form of caacer of the brewt which alto
begiitx XK an induration in the gland, but anon extendü (n the ikio,
and tlii-re, in the form of smull IlodllIt•(^ (|ui<.-kly spreads uvi-r tbe
whul« »kin of ttie ant<.Tior wall of tlii: thi^rax; tl>e sicooihL brL-aaL la
often nfiocted tbe same vrnir. Ttiie t^ueer t«t>tiryUiri9 (iifhuh)^ Mjuinbc
pufltuleui QU ilissctnini- ( Ytljxau), appears partly as a pnmnry, piutJy
a» a recurring form afler exlirpalioii of hard cancer of the breatil, and
not 4>xselJy in »Id notnen. Tlwi Rtnall onduW (we might ulmustt any
tuben-uUled) form may, by confluence ai«! cootractioti. le«! tt> aoLual
toeing iu of th« skin of iJie tliorux fruiii ih« Etont and aide» (cnueor en
oiiinui!(4>, Vel]t€tiu')\ llic course tR nlow, the tendency In inKlastime*
to internal orgaua is tKrt great, but tbe pmgnosia ts T^ry bad, Ijeoaust
every attnupt to prcrcnt load osteuBioo by operation ia in viLiii,
3. MueoHt Tuanhrants with ci/lhif/ri'-nl rpit/tdivm. Mnsl mnorn
that form io tbe nose and antrum Uigbmuri, nud gradually extend to
the n]>per jaw, clhimiid and sphenoid IxMie, ax well as into the otblt,
start fniOT the mucous membninps of ibe nose and antrum Hifrbnn.>ri
The ciliale»! or non-ciliated cpilhuUum of these membranos only rJt-
tend» to tbe npotiings of the mucous glanda, and even in tbe devi*lit]>
inent of cnneei-9 of the gland» at th«se points nindy gruu» into ihe
deeper ptrt». It ap)xwnt to be rattier t)»e acini of the Rland it««;lf
from which the proliffinitioii pH)ceeds, for these »incurs npfiear tn be
ino«tly composed of acini or tubuli, which have Kmidt or larger round
cella, raruly oyliuder-oells, »till more rarely ciliated cells. Tbe shape tX
the nowly-formed acini and their Mze here differ rnonnotislr. iHit onrn
CARaXOUATi.
«53
are »o duUiiiot, fo nonnal, tliat they may be misiaken for noimal tiui*
coiM glnmb ; to render tliis d<^ce|rtioa oomplcb*, iL not unfre(|ueiitlj^
happens that the na-wly-fonned noini M^rctc mucus, wtticU n.-inaiua
md eollocU iu tliom. If tbc (C(;retiun from many acini be i«taiiiO(l,
Fw. ISL
OMMr«llh««BiBau|lud*lkwnlk»taltrfaM-<irtk*MN«^ lUnlMliaodltaiaMtL
tliti fonn of Uto oeoplaiitin glaiwlulnr acini he perfectl;i' round, iui(] tho
iotentitial ainncutire tmue be but slit^tJj^ ile\t^lopL'il, tlkc hardcawl,
finr scctioiMi of tat'h a luittor maj vivr much reftomblc tüutuc of tfao
th^Tuid gluiHl. Tlu: Intenttitial ti«sue is usitnlty reiy wiytt in thvae
tuowre; u in Uic oom.-sjx>ni) inp tniK'ou» iiicmbnini-s thtniiAelroB, it
m»y be almo«l maoous. inUrstittiil pnpiUnrj' prolifontions of hyalioe
Tosailar (.■onuective tisahe (cjliudronm) hIko uGcasionally occur here.
Tbi'sc Luioon ans almtjs rcni- soft, white, mcdullury, or gelatinous,
except wh«n very vsKular ; llien they arc dark red. TlMf bones ar«
deatrored hy caries, without a tracu of reactive boor dbw fnnnatioa
or osteophytes. Tho appcaraocc and clinical course of t\ufnr Liiinors
are Mtoewhat peculiar, differing from other carvintxiiBla. lliey occur
any lime after tlir twpnliethyear,gTow rapidly, and projert M^iiictiince
ifaruugli tlie narca, »pun llirough tlH> cheeks or ium-r caullius of the
eye; tliey are ooensionaMy very sharply bounded or encapaulated,
wbieb iiiay \to known by paljialloo, aiid prorecl on operation ; some-
i
654
imoaa.
times ihcj are more diffusely' spread in Üie upper jaw. In tbcsc mo-
4:ous-glaod cancers of the Tace I hav« avver fieca infection af ibc lym-
plialic (flaiida, and am oonviiiccd tlmt tliefte patliriiUi n~^uld be saved bjr
»>i euriy (-uiiiplute uperatknu In all tlie pAlit-iil» ( iial 1 liave opcmU'^d on,
1 havo never been «atislied that the tumor was onlirely N^tn-ed by tbe
ojienUoii } it »Iwn^s projected tuo far posteriurty or upward to per>
mit thv opcmtiun to be compIcUrd with satvty. Uron*, 1 tj»uiillr wit-
nessed lo(«l rccurrcuces, which proved fatal by marasinuft or prt-ssurv
oa the brain, or ulse the pulieiitdied froiQ the ext^^nt uf tli«ijp«raiioo;
in iHHie of the cases examined poat morion did I fmd intcronl (umnriti
In tlio stoniadi gland-catkXfs are frctjuent, eepeoially with niucou«
»oftenii^ (gelatinous caneer), and seooiuliiiY eaneer of the hvi>r; eath
cer of tJie duodeuuin is vei^ mre; of (he pcul» of the iut«&titia) canal
attacked by tbisdlsviute we or« utily interested in Lbe caiioer» of the
rectum. These are ahnust cxduüivvly gland-canct-r«, and iIk- prolifpN
alien pn>oeedfl from the largv glands of the larj^ intestina, which
grow in tbe »hupe of tortuuim and branched tubes; the calilite of the
gland is of^en niaintaitied, und they till with mueus, and tl:e e^'lioder-
ceUs may maintain th«ir fonn and become very large, Tbe int«nti'
rw.\M.
I^/-'
r:.
1 -^r- w -' «^ > a "
Ad«iotdcane«rof UMMetam. Uignlflod MO dl*n>*Un
lial Qonnective tisRiiff is strown with small, round cells, someLiuics
iKifteneil, and often very vascular, üsuully at tiret the muwulai* c»at
of Um intestine is bypertrophicd ; subacqumtJy it also la HfTeeU-d by
the uleoration, which gonpridly begins early.
CARCIKOXATA.
es&
As the Erst symptom» of cancer of tlw* rectum are usiully conati-
pattoii, discburgc of miunis. Bad «lif^it liicmorrliu^, tLi.-sc pitlinila
are mostljr trcnted for ■oino time «s if HufTL-riTi^ from liivitutrrhoids, be-
furt* the dix^osis Jr made hy digital pxiiniliiattou. Inüurstioti and
nodular ioBltrntlan, Ic»f-likc- proliferations oomtncmcing cIcMe above the
itpliiiM'tvr atii, soon extend lo the whole cirfumference of tb« mucmis
memliraae, so that a Ihirk, prominent ling, a utricture of varmble
lecgtJ), may be felt. This new formatioii oan otily be rcmornl by ex-
tirpating tli« reetutn. When the rectum is t«ken out, wre (t^ncrally
find an ulcer witli cIi'vnttMl edges and ludunittHl baat^, and the ]»rtB
anmnd tiifiltratcd with uiixlullory subetanoe; at some points also
tbciv are cicatricial contractions, The inguinal and retropentoneal
gltiiwls are afTectod rarely and late in the disousu. The patients gen-
erally die fmm the striclun' of tlic intcsUnc, from maiaamus, tiuc to
luemorrbag\.-8, aud putrefaction of the cauceroue tisMie.
OocnsioniillT also canoem, composed mostly of cyltndrienl rptthe>
lium, start from the /«ww cfrvicali« utfri. These first attack the
uttrruH, then tbe surrounding |>itrt«, and lastly infect ami iufiltmtc the
rc'tn>[>eri loneal gluiiilti ; they combine wiHi flat epithelial canoers, and
do not differ &um tJiese in their cuun)e.
4. I/Oc/irymal^taiivarj/, an^ prv«t<ttic fflan<i«, Tlic anmc kind of
tumors grow from the hf/iryuial glntida that we have alrcndy de-
scribed as growing from Üie nasal mucous meinbranp, acinous glan-
dular new formations, vritli eofl, oocaskmaUy mucous, or even (MpUlaTy
hyaline interstitial connective tt««ue (oylindroino). They develop
about the ago of puberty, and are tharacterized by great tendency
to local recurrence. AU the cases of this nature tluil I have known
of finally died from tlie local recurrvnce; it might be not for sev-
eral years; neither the lymphatic gkods nor internal organs were
affcvted. O. B^ktr has deaoril)ed tumors of this sort, in which roost
of the glandular acini cootaianl a certHin quantity of mucous accre-
tion, as also oocun more especially in the glandular cancer of the
rectum.
lite salivary glands may also be the seat of glandular cancer, but
they do not oome till old age ; them, liou-ever, tboy grow rapidly, and
not unfre<|ucntly resemble ohroiiic in6ammatioa. The newly-formed
Bcini an.- often raatv (fibular than odoous ; epithelial peurU occur OD
the roils of the tubuli, covered with eylitMloreelU, Tliese |uilients
iiKuully tinivunib to the ulceration of the tiinior and the general ma-
numus; internal i-tirciuoma is a rare scqurol.
In the prontalie gland I have m-cq glandular cancer n few tintes ;
it was i-ery »oft, and in one case where partly extirjiated it wa» very
vascular, and of ucinoua stnioture. From tbc czoclleut statistical
43
MS
TUllOBa
trodc oa maligiunt new ibmiatioiia in die prostate bj O. Wj/s», i( np>
pcftn) UuU, ill «linost ever;' c&ac, tlieM carränomata also prorp Älal
solely from the looal symptooH. L}-mp)iatic glands and ■djacmn
parts become iofeotecl ; there are very rarely secondary cancen ot k
ternal Of^ganBi
&, Th}froid giand and Bvary. I plaop these two ofgfBiie toj,'et
n« t)>ey twtli originate fniiti tnie gbndular e[)iOieliti[n, and both <
taiii follii-ies, funnud by choking olT of j^aiiduW caoalicuU. In catt-
cerou« cUäcsec both organ« ^ back into the cmbryooal iii'pe, i. &, the
fc>lli<!lrs gruw agnin to tubes and oanaliouli, fiom which again arw
IbUicJos nro dcreloped; but snnie of thrse caroinonuita, whk'h an*
rare, consist entirely of ot'lU-analiculi, vitliout any Ut'relu|>mmt of
JbllicJML Young persona, us well es old one«, tnny bn nttttcked hj
Ulis form of cancer. Its counw ta uauRlIy rapid, for ibe caorcn odf
ill« thyroid grow lato the wiadpi|>e or cIom; it b>- preeson.-, while the
ovarian tumor» are cliarapt^rizml by tfaeir pnormouB fjrrotrth and rapid
adhfjtirHiB with the «umtuuding pnrl^ aud by the speedy developracDt
of ascitc«.
From rariatSoas io theü ooume and anatomical stnKftura wp must
Bep»rat4; Uie different fomns of oircinomB ; ire may ooooider tJieir |
Ircalnictit togctbor. IVeatmcnt of the cardiwaiatoat dyacntsja (mr-
cin<iM-<i) if, ummlly rej^arded as ».partie honttv»* of medicine. I oan-
noi lultnit thin. It is true we cannot cur« the disease; but is not this
also true of nuLuy other acute sod chronio discBsea ? Can we arrest
a cokl in tlic huad at anysta^f Can wo eheck the eoursa t>l tlie
acute exanthema or tj-phus? Can we cure tuljereoloaiii ? (.%?nainly
not ; in all these cases, as in many other», the disesAe ruo9 it» typcal
«ourse ; we give littlu niedioine, at least we avoid all heroto remp-
dies. In can'inoKis our thempoutio impotence only appears so i;rr>«il
1>ecause tlie diseanc »Inioeit iilvray« proves fatal, and we can do nothing
IO oppose it« course; in fact, our trcabnent is as inefficacious in
oorynt as in carcinosia; but tlie former is not a fatal disense, beaeo no
special demivnd is made no the phj-sicLBii. We Enre beccme iioou»-
tomcd to lätlin|7 to ciux: cold in the bead ; wo must grow aoouBtoawd
to the course of caiirurous as to that of some other diseases ; tJas
will not interfere with our s>inpathy for thei« poor patients, nor must
it prevent our strinng fur incrcasetl knowledge and iniprored tnal-
meat of the disease. I think that much may yet be attmned in this
directioa
Tlie indications for treatment arc to nrmore the canccmus lunMir
u soon OS possible, so as to arotd inrcdion, or at Icaet obstruct its
course, and thus dimiuisb the evils accompanying it.
CARCIXÜMATA.
A« lonp an rnnper has bewi known, ppmwliM for it haru been
KKißlit ; iLrre U no nclive mediane, no fonii of dietelira, or mineml
gprinjcs, that have not been rcoonun^ndcd for cttaoer, ood, to xnno ex-
tent, sc'tuallj- 1>i>ti(.>v(>d in. I shoaU) Iiavi* lo root up the «nUre old
anrl Dew materia medira if I would tell vou of every thing tlist has'
been thougbt und vrritten on tliis nubJ4>ct. Okc all iocursble di»-
eas<n, cnrcincMb nUn hna been n wreatlinf^plaee for the chaHatan, and
even of lat« years IialLins mtcl AmfricanH have claimed t« cum the
disease bj spKial nostnimK. Unfortunately, all tUvfe ar« dfceptioua,
or at least what port of it i» true haa been long known.
Cnfbrtiinately, the efiofojry of «anoer ffif«« no clew to treatment ;
we know too littlo of tbe causes wbj certain tuoioni are fto inft'etiou»,
while others are not so. A blow, kick, etiC., May occaflionA.)ly indiieo
an outbreak of the disease in some few caaea, but cannot excite tbe
prc^pofliUon to (cancer. In aonie cases inberitanec of the disease ia
evident. Care and anitiety rnay hasten (he ooun« of the discasie, but
do not iiiiliK« it. All thin ia of no arail for tbe treatment Thpr? ta
no tipceific for carcinoais ; but by this we do not mean lo say that
all internal treatnumt ü uttDeccBsary or useleu. By BO means. The
disease abould bo tr««U>d inUTnally whrnrver thete are indii-atioos
for treatment, or any »jmptoms pointing to the use of certain rcme-
t^es. A9 ouweaia is not unfrequent in mncerous patients, iron in va-
Hona preparation*, or ehatvl>oate mineml wate», nay be employed.
OeoftSionHlIy, in persons with faulty nutrition, oodOiver nil, el4'., as
vr<Ai aa bittrr medtciiieft, prove beneficial by aiding digestion. Very
debilitating treatment, by aweating, purging, mpreurtaiR, ele., i» to
be avoided, for life will be preserve the longer tbe mon; the strength
Is maintained. Among the mincml sprtngR, the aetivp ones, such as
Aix-la-Cliapelle, ^Vieebnden, Karlsbad, Krcuznaeh, and nheme, are
injurious; only tite milder indifferent thermal springs, sueb as Ema,
Gastein, Wlliibad; also, milk and whey eures, atrengtboning moun-
tain air mny ix reooramended without injury, if their tue eeeios on
other aeoonnts desirable. Residenee in snuthem elimates i» usually
of little benefit for rancerotis patients. Toward the end of life, when
debility i« increasing, a strengtheoing, eoJitly-digestcd diet ia impor-
tant; and lastly, as (he pain ir»creasi*s, 1)11- «kilFiil use of rarioiiK nat»
eotics rptieves the suficringa and death of the patient. The disrasc
of internal organs may offer spcdal indications lo which I alta!) not
here refer. 80 mueh about internal treatment, which I only fallow
when not quite sure of the diagnosis, or when t do not condder tbe
OMO suited for operation.
As regards attmai treatment, the finit thing always is the re-
moval of lb(j tmnor, if this is admissible, fnta its locality. The opera*
65S
TUMOBS
tion ouy be dooti with ihc knife or caustics; the lifpiture or £cni»enr
can scarCL'ty ^rer be «mplo^ed b(>i« (the Utter, perfaspd, anikvi>m onljr
ID ampufAtinff thn pcoia or tongue). Rutf before ptusing lo th« cboioB
of cither of tlieae metliods, we must consider Uiv question, wlictbcr it
i& ndvisaUfi to opentic nt all,, even if it «in b« done oawl; and witbwt
danger to lif«!, for the riBWS of experiüncLtl surgoons d'litvi on this
point. SoiDc iiur;i:cons oevor operate for cancer. Tbc^r attcrt that
tbc opcnttioti is always in Tain, because the disease recurs; if the i«-
purring tumom be operat«) on, new reeurrenee take« place thp sooiker;
theü« »iifgcoiifl errn a.s»ert that, the mnre we operate ItHrnlly, the
aoDiier secondary lymphatic tumors uud metaatatic cuDOer» form, the
local tumor acting as a sort of derivative for the tujnoe-dis««»« ; tlial
this produce of (Itsease cannot be romuvi-d without broring tlie out>
break of the <Uaca&c vlscwhcn' ; that, if we navortbclesa wish to r«-
tno%'e thi^ uiinor, we sliunld lend tin» morbid juices to some other poinl,
as by estaUishin^ an artificial nicer by means of a fontanel or setoo.
Concerning this view, w)iich comes from tlic oM huiooral patliologj«
VC may »ay that it renuJns uiipmved, and is partly also dinprovod bf
expiTieoc^. Wg ooD!id«i* it as dmnoostnihle by daily experieoce thai
the >fhitidulBr Hwrllinffs arc ctiscntiully due to the development of the
primary tumors ; we have already stated om Iwlief Üial the participa-
tion of the lyiiiphntio glands in can'iiionui ii, oonordiiig to oil antUog'y,
caused by local contagion, let tJie prucess be what it may. %Vhea
oases occur where, after reraoral of canceis of the htvust or lip, swell-
ings of tlie l)Tnp)ialie f^landit iippeiir, tlKHif^li pn-viously imperceptible,
we must cotisidL'r that the cotnmeucemvtil uf the disease was so slight
aa to escape obecn-atioa — How far the existence of a primary and
secondary cancer of the lymphstic glands ioBucnoes the subsequent
course of the disease, the ai^>aratiee »f metastatic tumors and gf^eral
caclicxin, i:^ u question which cannot be nnswered, because ܻe diacuo
does not run its course in a regular time ; if it did, we might form a
rule as to the adviubitity of operating, by comparing äsen thai wer«
openiteil on n-illt those tliai were not, ApprvxioMite rei^ulta might
be attained by classing together ease« that were alil<e in «ge, eouAti-
tution, variety of the tumor, et«. ; but, aa the acuurat« lUstioction at
the variettejt of carcinomiita, and consequently an ciaet arTmiigi:tDent
of the «ses, has only lately been attained, and even now is not geoei^
ally known, we »intiot at present expect much in this directioo; in-
divMi'i-1 .^l>i.ifi-in;.'iis mrf^Y suQlec for definite ooiicliisioDS. Tlie ex-
p''' tlie bice, that the most cxtcositx* tii»ciuw
of 'jAnii'd by mrlastalio
bill -!-use is not mulo mot«
itetir« < -d lot»! tutnocs^ and that carcinooiala
CAHCINOUATJL.
659
of tlid lympbalic g;lanib do not inoreaae the pradiftpoeition to mctasta-
lic tumor«. — In reply 1o llie c|D«ilii>ii, wbpther csrrinoma »boukl ever
bo opcratfd on, we may say Uiat operation ftrobaljly )ua do direct in-
fluenoe on the dwibesi». nnd that the opentioo, if done al all, must
be don<> fnr ntlier n»son&. Wo siud inteiitioiuilly th»t (lie o(>i'mtii)n
ban no lUrtct inflticiicv on ibc oourac of the diac&si-, but uc lliiiik it
bu 4D indircst iaflucnc«, as the tuciur iixluocs other caoses ol disease;
the weskucss, ttiuiMiiia, and dislurbniive of nutritioa cuused by the Blip-
pumtioa nnd p«in from a cancorcnis tumor, perhaps nlso the couBtanlJy
gnnn-ioff care with the cvcr-recurriog rcflcctiou on Uie lucunibli; ituturv
of thoir disease, are factors which tnay well hasten the course of tJie
malady. I'nder Aome drcumstuioe« i oonnder it the duty of Ui«
physk-ian to dec^iv« the patient abuut tiie iiKunbility of this ditwanc,
vhether he <^onftid4>r!t an o[>cnttii>n a« pc<whl<! or not; wbpit' ih«
phy^ii'ian cannot aid the patient, lie should ulleviatv hi» sufferings,
mental ;ui vrcU as phyaioaL Few poraonH have tltc quiet of miud, reo-
l^fttirtn, firmness, or whatercr yoti r)t4os« to call it, to enjoy whtt
remaiuB of life, if tliey kt>ow they have an incurable diseasr. Althoi^h
perhajM externally quiet, patients will tliaiik 3'ou little for coiilinning
what they Rtay have feared. On this point you will hare tflaoy tmla,
ami I mnst leave ynu In i>nch nase to do wliatevef is dictated by your
pcrtutuil slin-irdneHt, knourlLii^ of uien, and jour fceliiig:^ — Although
we may not gc* riti of tlie diatlteftis by tlic operation, »» when, having
removed a diseased purtiu» f>f breast, we fail to prevent new nodules
fonniiig in the remaining portion wbieh was previously healthy, or in
the other healthy breast (rcfcional recurrence), soon after the cicatrix
hns hcaloil, still by tbo early removal of tlic primary tURM>r we may
prevent the neighboring ^ands, or the adjacent portioQ of mamma, from
bcroming diseased. Pew na an? the complete rrcorcrie« from caoocr
of the breast after operation, T believe tliey will grow more frequent
when the family-doctor, to whom they are generally first shown, urgen
operatlrtn earlier, for at present they usually let the beet time for
operation slip by, and the women do not consult proCHsed surgeons,
t ill tiie load <liMtBH> am) tlie affeclinn of tltc nxillni^' ginnds arc bo far
sdrAnced thnt n complfte operation » no longer praeticable. The
DftTOrable refultt frixn early extirpation of true onooer of the lip should
embolden tw 10 r\>mnve other «<snocrous tumors early. If it has bitber-
lo rarely been p"w?ible to operate on cancers curly and oompletoly,
thero are still important local cause» which indicate cvcu late opera-
tions, to prevent as long as possible the advatiee of the tumor to parts
where the disease would Dooesaarily destroy lif& Altliougb in nMst
cases there will be local recurrence, this will not take place for months,
perbapa for u year; meantinie, life will not be directly endangered;
TTIMOBa
oc«a«ion&ll}' »Iso it i« a quoetion of saving from entire destructioti cer-
tain parts of tiie Gnc«, as the Upe, eyelids, or nos», whidi may subse-
qnentljr Le replioMl by a plastic opeiatiun. It would be vei^ uujitsc
to coDsidcr »ucb opcrntioD« ascln«, bccaus«; Ibcj ctuuwt cur« tlie clia*
ease, for tbej ivn<leT tlio patient's lifo eaBier and more a^rCHbl»— if
only Cnr a lirae, atill, possibly, for Um gr(>at«r pait of tfae time tlut he
yet baa to tire. We might be very glad, if^ by «o opemtiom or otlier
treatment, we could lemporarily reatore to tb« pleaiuroa oS lib *
patient «litli uijvancod tuberculosis of tlie luugti, as is tliu case io opi^
atiD^ for aomc cmnccruus tumors. In abort, tbure are many caaea
vrliere wo do good by tbo operation ; very often 1 ahould oooaider Ü
wrong tn n'fut«» to o{>^nte. — We see other oases, bowevtr, wbtfc it
is mote difSctilt to denid«!. In «lowly-pfogreaHtig canoen of the breast,
OB in oooDeotire-tiasue csncera, I ooDnder «ii oporatkia, whidi is bwe
from datigor, as a<lmiiutih1<>, but not neceMary. If ao eyelid be de-
Rtroyifl, or llw novi^ partly or entirely tosl, an operation is advisable,
in the 6rBt case to protect the uyvball, in tlw bi-coik1 to r«tnovc the
deformity, aod tb« ratbor so, because to tbcse slowlyprofn'essiiiff flat
oaiH«ra of the face frequently then» is no loual rrcuimion ; in sixdi
<xse» only one thing would |>rcvcnt my operatiiiK, viz., grr^t debility
or advunc«d age of lite patieul; at least Iben extensive plastic open*
tions are no longer advisable; even Üie unavmdable Ions of blood, and
ke«!pin^ the patient in bed aft«r tbe operation, may sutBre to extin-
guish tlio fnelilK vital spark. Tbvn comns tbo question about tbc od-
tniasibility of tbo operation, wlicre the tumor Is in a dang«rous loca-
tion, when nn opentiou ts necessary that may end fatally, iv at least
is just as likely to cud fatally as to rcault in cure. Here wo have to
drop general reflertioiks, and cousidt^r tiie iiidi>-idual cases; tbe danger
seen in an operatlun varies greatly with llieexperienoeof tbe >UTgeoii,
and tbe individuBlity of the patient ; one principle we efaoukl adhere
to: only to operate when after careful examination wc can bopc to
remove all of the diseased ))art ; a half-operalioii, k-avin^ be hint! poi^
tions of the tumor, should never be doae. We sbonld be runrful to
operate only in hiulthy tissue, if posaible a contitnctro or more from
the perceptible infiltration, for in this way alone ran we be certain
of removing all of the diseased part. Oeeatiionally in despcimle eases
wc may prolong lifo by a bold operation, oven if the canooous tuntor
be already very large, but generally in sucb operations wc shall see
more pati(>nta di<» than will reco%'er.
"We have now to critieist» the caustics chiefly used in oaaoctlL In
the course of time opinions about caustics have diRered greatly ; at
times they were greatly preferred to the knife, itgnia üwj wore ct*«
tirely tbruwu aside. The views of most surgeons of tbe present dajj
CABCINOMATJL
flai
as well aa roj own, incline to the latter view. I de^idedtr prefer the
oponitiüu with the knife or Etcissoni, bi-ciUM^ I tlH'ii kituw i-uictlir vrliat
I rcniorc aatl 1 cau jadgn more certainly' if all tlic discoiKd part bos
bmm excised. Hone«, I rc^id tb« opuntir« ramov»] of caoocr as
well aa of other tumors to be preferable att a rule. But wbere there
is a rule llurc arc csccptioos. In very nld, antciiiic, or timid patients,
caustics may be employed, and, if ihc treatment be continued till all
the diaea««d portion ia dentniyed, iJie result will be bromble. I*byiiio
logically cauaüca would hare suiue adraiilages; for it is supposable
Ibat tlie eauterizinit fluid may enter the finest lymphatio tcss«!^ and
tfaiH more cortaitily destroy Ihe local dtsoHse. But this doc» not oc-
cur readily, because the tissue with which the caustic comes in cuutact
instantly combines with it, and its further flow is thus pi'cveuted.
Formerly it was asserted that recurrence did not take place ao
soon after the use of caustic aa after operation with tlie knife, but
this has not been ooafirmcd ; heaee I only Duintain the ubuvo cx-
ooptionft,
For a caustic T prefer chloride of zinc to nil others for destroying
cancers; you may Ufe it aa pasto or as caustio arrovrs. If it is a sux-
Caoe yoa wish to cauterise, to equal parts of powdered chloride of
zinc and flour you add euough mterto make a paste, which you ap]^y
to tiie »urfiice. If you desire to cauterixe mure deeply, yuu mix one
part of chloride of sine with tliree parts of flour or jypun and some
water, and let them form a cake and dry ; this may roudily bo cut tip
into small pointed cyliodura half a centimelre or more iu thickness;
with a Uttoct you make «a opctiing in the tumor and press the caus-
tic arrow into it ; you repeat this operation till the tumor is perforated
with arrows at about three quarters of an indi distaooc Gram each
otber. In four or five hour? this cauterisation is followed by moderato,
often by verj- Revere pain, which you may greatly modify by giving
a subcutaiieotu injection of morphine directly after the cauterbsation;
the next day you fiud the tumor changed to a whit« slough. This
heoomea detached after five or rix days, enriier in soft tuoMrs, later in
hard ones. If tlie cautcrixation luis extcudnd far enough into the
healthy ports, alWr the detacbuicnt of tlie eschar there is left a good
granuhiltng wound, which soon cicatriz<?a; if the carcinomatous mass
again grott-s, the paste or arrows should be again applied, etc.
These cautcrizattons arc oocastooaUy very painful and uncertain
as regards the extc>nsion of tlie caualic, but they oocaHioiially uro
advantageous. Other celebrated caustics are Vienna paste, aiseoio
paste, butter of antimony, chloride of gold, etc ; iodide of potash,
rbromic acid, concentrated solutions of chloride of »ac, fuming nitric
acidf Buiphiu'ic acid, eta, are le» emplojed.
COS
TCUORfl.
Now a Tew wonls of «dvlcc about the locnl trealmeot of cooeer»
Ulis uk'tT» whicb br: not, or >t Icaitt iiru no lon^r, siiitctl for 0)>cra-
tliMi. In Romo of thvsc cmos tlio prolifcrntion of the c-anoeim» moM
from tliv ntiuiid is enormous, and it oft^a nuaoy% anil ili'ljiltUit«« tbe
patient; bcrc wc may make partial cauterizations or nmploy tbr bot
iron ; liy tbe piilliatir^ dt^structioa of the proUf{>niting muss, we octm-
sionally attain tolerably good ksuIia. The chief indicfttüm f»r irval-
mcnt in dulse patJ«ntt> in ouppuratioa of tlie iilwr, wliich is ofcataotmUy
horridly fetid, and somctimPR the pain. Kor pn>7eQtinfr (he di&ogree-
ablr sprrptiim, the hot iron i» a good reinwly; the smell m»y be les-
aeoeU bjr compreadcs w«t with ohtorine-watt^r or purifibtl aortic aokl,
oreoaotc, carbolic aoid, penrunj^aiutte of potnsh, sprioküng with pow-
(!en>d rb«rt^)at. Tlie lutl«r re:idily ab«oib« gaaea, as you know from
cbciiiistry, niid ia here an excellent rcnicdy ; unfbrtanatdy, it dirtipa
the wouod, BO that wc abttaia from its frequent use. For the paio of
carcinoma to UK uloers, iinrcoticii have bi>en ujipUed locally, as by spritik-
ling on powdered opium ; but, when injt^ctcd aulK-uunpcHislr or ijiTen
internally, the napooti« net more certainly ; hence at lii*l we nlwriiya
resort to inorpliiite for these poor patientn. I partioularly enjoin on
you paticQOC in caring for and alloriating the HufTerings of iIm^mi unfor-
tunates ; it is indeed sad for the phyaician to be able to do so little
good in tbece ca^es, but still you must not abAndou thctn.
BKIEr KEHAKKS ABOUT TUE CLIXICAL DIAGNOSIS OF TI7U0K&
1 cannot take it amiss if you are at ftrat somcwiiat cnnfusetl by
wbat I hare said to you about tumors ; if it will eucourege you, I tiuy
aeknowledge that formerly it was the same with n»e when I waa in
your present position. Only long study and prnrtin; in tlie dißerm-
tial diagnosis of tumow, for which there is opportunity in tbe clhiio,
render it pnasibte to attniii any eertainty on thl« difficult point. Tbe
c»»»i»(eaioe of Uie luintir and it» appeanint-e, its n'lation to tbe |Hirta
around, it» locntity, the rapidity of its growth, and the age of the pa-
tient, are the points from which we start in judging ; soinetimes on«,
Bonietimcs another, of thctte points gives tlie decision. Let us take ao
example: A muu about fifty ycsre old comes to you, ruddy and strong
for his age ; for many years he has bad a tumor on ibo baek, whieh
fomiurly gave bim no trouble ; it ha» only been ioooDTCoicnt since it
Ins reached nearly the size of n rbild^s head. Tbc tumor is cUetic, aoA
but not t«nflo or tluetuiiting, tmiviibk' under the skin ; the latter ia uil>
cbanjfed ; there has never been pain in the tumor, nor is any eausod
by the examination. In thia owe tlio diagnosis is rery easy : from
CLINICAL DiAfiNOSIS 0¥ TDVORS.
063
tlit^ lociiiion, {rom its Mst in Uie connective tissue, its slow, painless
growUi, cxc, it can «arccly b* any tiling but a liiwiun, or powibly a
soft coiinectiire>tiBSue tumor; but the former is most probable. Let
us take atiotlier cnse : A woiimn with ■ ttimor of the hT«flsl rorars to
you ; this tumor is hartt, nodular, as ifgG as an appl« ; or«r ibe sur^
^e the cJtin is letmotetl at apot«, and is adberrnt to tlu> tumor.
From tEtne to timv there has been piercing paio, tlie tumor U »ensi-
Uro to pccssuro, tbe axiUaiy gland» on that side fcvX liarU. llic
woman b forty-6ve years old, well nourished, and looks hoaltliy. Hero
rnlao the diugnosia is easy ; it is a cardnomn : 1. Because the patieot
is at tbo age when canccrout) tumors of the breast arc moat fircqucot,
while adenoma and sarcoma usually occur earlier; 2. The consistenoe
might point to fibroma, but tliia very rarely occurs in the breast, and
the swelling of tli« lymphatic ^nds speaks «gainst this view, and in
fevor oEcarrinomn; 3. Carcinomata are painful, a# this case is, while
urconuta uid fibromata are not so, ii»ually. We niiglii giv« further
msoiu for the diagnoeis, but tlirae will Bufli<-e. Ixt ua Xukv a tbinl
ease: A lK>y ten yean» old has had fi>r two year« n «lowly-enlarging,
moderately painful swelling of ill« middle [vurt of tbu lower jaw; at
tilts point tlic tcctb have füllen out irttbout being diseased; the en-
largement of the bone is evenly ro\ind, and rcaehos from the first, back
tooth of one side to the simitar point on the other; ImUow, it ia hard
as bone, abore (in the mouth) it is covered by mtirous membrane, is
firm aitd clostio. Can this bony awellitig be the result of chronic ia-
flammation, of a caries ornecmsiK? This i^i not prolMdile: L Uecsuse
the pnin has always twen slight; 2. Because there baa been no sup-
puration, which would scarcely fail to occur ia an inflammattoa of the
jaw that Itad lastcMl two }-earfi; 3. Because the swelling is more
bounded and regular tliuii it is apt to be in bony dejHisits in curies
and necrosis ; i. Because, at the paticut^s age, osseous ijifiammatioa
!d tbe lower jaw is not apt to occur unless from phosphcveous poiaoo-
iogf which has not oocuircd bcre. Hetioe this is a case of tumor ; ia
itanotfteona? The part projecting into the iwuth is too soft for
thU; we may pass a fine needle into the tumor from abore. Is it «
chondroma? Consistence^ form, mode of growth, and age of tbe
patient, agroe with Ihia view, but the locality does not ; oboudromata
in tlw* middle of the lower jaw at thb age are \-ery rare. It is a oer^
tral i)s(eo-8*rooina, probably a giant-cell«] un'onia ; all tbe symptoms
speak in favor of thifi idea, and you know that these tumors are fro-
qtient in the lower jaw during youth. I say you know — I might Ix^ter
say you wül gradually learn ; and 1 ran only advise you, whenever
you hare examined a paticut with a tuuKir at the clinic, to rt-nd about
h vhcn yon go home, and to compare tlie individual case with the
664 TCUOBS.
general characteristics of the tumOTS tlist I have given you. WLen
you have done this for a time, and in the coune on pathological
histology, under the iuBtructiou of your teacher, have examined
many tumors, you n-ill obtain a better idea of them, and will have all
their peculiarities painted on your memory.
REGISTER OF NAMES.
Abeniethy, John f f 1831, in London) 481
Abulcuem ( + 1106) 1
Aebj (profesBor of aoaton; in Bern) SB
Alexander Ton Trolles (G25-60S). . . 6
Alexundriftn Bchool .* 6
Anel, Dominique (surgeon in Tarin, beginning of eighteenth century) 089, 640
Astjllus (third century) ft, 640
Arnold, J. (professor of ptthological uutomy »t Heidellierg) 7S, 646
Asclepiftdes 4
AaelU (1681-1626) 10
Auerbach (teccher in Breslau) 66
Avenioar (1126) 7
ATicenna (980-1037) 7
Birenipnmg, von (ie22-18M) 88
Barton, Rhe» (Philadelphia) 218, 507
Barwell (London SDTgeon) S28
Baum (professor of surgery in Qattingen) 87, 166, 610
Baynton (English physician) 898
Beck 24S
Becker, Otto (professor of ophthalmology in Hddelbei^) 666
Bell, Benjamin (1749-1808) 11, 120
BeHocq, Jean(l783-1B07) 84
Bernard, Claude (profwsor ofphyriology in Paris) 68
Bergmann 886
Bernhardt, H. (physician in Berlm) 84, 096
Bienner (professor of the medical cUnio in Zurich) 860
Bilgner, John Ulrich (1720-17B6) 12
BinelH 8«
Boinet (surgeon in Paris) 479
Bonnet (surgeon in Lyons, f 1868) 18, 288, 498
Bouvier (surgeon in Paris) 608
Boyer, Baron (1747-1883) : 12
Branca (fifteenth centur?). 8
Brasdor (1721-1799) 689
Btaunichweig, Uieronymns (bom 1430) 10
Breschet,0. (t 1S4Ö) 680
C66 RKGISTER OF NAMES.
nam
BreaUu (1620-1867) 861
Breoer (phfaicUu in Yieaoa) 85
Broca (professor of surgery in Paris) B89
Brodie, Sir Benjaniin (1788-1868) IS
Bromfield, WUliam (1118-1793) S7
Brown-Sfquard (phjsidaD in Paris) 101
Brücke, E. (professor of physiology in Viemu)) 136
BruDS, Ton (professor of surgery in Tübingen) 166
Bubnoff (physician in Russia) 108, 109, S34
Buck (New York) 188
fiuhl (professor of pathological anatnmy in Huniüh) 206, S83
Burow (professor of sui^ery in Eönigeberg) M
Busch, Wilhelm (professor of sui^ery in Bonn) 8S6
Celsas, Aulas Cornelius (2G B. a to 45 a.D.) 0
Chassaignao (surgeon in Paris) 160, 431, 570
Cheselden, William (1686-1798) 11
Chopart, Franfois (174»-17e6) 475
Chrobak (pbyaiciaD In Viemia) 85
ariale (1792-1867) 18
Cohnheim (professor of pathological uwtomy in Kiel) 58, 61, 178, 367, 382, 461, 534
Cooper, Sir Astley (1768-1841) 12, 51, 119, 626
CruTeilhier (professor of pathological anatomy in Paris) 817,319,496, 526
DaJtoQ, J. C, Jr. (New York) 546
Delpoch (1772-1832) 12
Desault, Pierre (1744-1796) 11
DieEftmbach, Johann Friedrich (1796-1847).. 12, 86, 88, 44, 46, 97, 115, 117,
210, 36S, 402, 481, 603, 516, B77
Dorsey (Philadelphia, 1783-1818) 121
Doutretepont (professor of sui^ery at Bonn) 662
Dubois-Reymond (professor of physiology in Berlin) 63
Duchenne (de Boulogne) (physician in Paris) 623
Dumreicher, von, Baron(profeaBorof the surgical clinic in Vienna) 187
Dupuytren, Baron (1778-1836) 12, 174, 801, 520
Ebert (professor of diseases of children in Berlin) BSS
Eberth (professor of pathological anatomy in Zurich) 65
Esmarch, Friedrich (professor of surgery in Kiel) 80,358,388, 430, 470
Eustachio (tl679) 10
Fabry Ton Hilden (1S60-16S4) 10, So
Falopia (14B0-1Ö68) 10
pick, Adolph (professor of physiology In Wuraburg) 3S3
Fischer (professor of surgery in Breslau) 810, 336
Flourens (1791-1667) 445
Fock, Carl (1826-1663) 809, 496, 497
Förster (1822-1865) 898, 412, 614
Follin (1823-1867) 18,409, 412, 417, 668
Foi, Wilson (physician in Loudon) 862
Frey (professor of loölogy in Zurich) «09
Ftoriep, Robert (1804-186J) 102, 108, ll»-iai
REGISTEB OF NA3[ES. 687
rAam
Qdenos, Claudius (lSl-201) «
Geredorf, Ton, Haaa (1620) 10
Goll (ph;8ician in Zürich) S58
Qolubew (Russiah physician) B3
Gob (professor of physiologf in Eönigsberg). 189
Grsefe, von, Csri Ferd. {1787-1&40) 18
Grmefe, Ton, Albrecht (professor of ophthalmology in Berlin) 3B8
Gross, S. D. (pTofesaor of surgerj in Philadelphia) SO?
Gruber, W. (professor of anatomj in St. Petersburg) 488
Guido de CauUaco (fourteenth century) 8
Ourlt (professor of Sui^ry in Berlin) 17S, 116
Halford 8BB
Haller, Ton, Albrecht (1108-1777) 12
Harrey, Williaui (1578-1068) 10, 384
fiebra (professor of dermatology in Vienna) 248
Hecke, Van (Belgian engineer] 849
Heine, Bernhard (inst rumen t-maker and honorary profeesor of surgery in Würz-
burg, contemporary with Cajelan tod Textor) 445
Beis 69, 648
Heister, Loreni (1683-17öB) 13, fl26
Henle (professor of anatomy in Giittingen) 04, OS, 499, 600
Hennen, John (t 1828) 284
Hering (professor of physiology at the Josephs Academy, VieniiB) SO
Heuter (professor of surgery in Greifsvald) 220,344,346, 0O4
Hildanus, Fabricius 86
Hippocrates (460-377 b.c.) 4
His, Wilhelm (professor of anatomy and physiology in Basel) OS, S08
Pjelt (physician in Sweden) 100
Howship (English surgeon) 418
Hu&chmidt (physician in Silesia) 84
Hunter, John {178B-17B8) 11, 18, 889, 640
Hunter, William 11
Hutchinson (surgeon in London) 830
Jackson (physician in Boston) 13
JacobsoD (professor in Eijnigsbe^) 84
Jobert(deLambaUe){17BB-1863) 13
Jocbmann (f physician in Prussia) 166
Kern, TOO, ViDceuB (1760-1829) 12
Klebs (professor of pathological anatomy in Bern) 882, 609, 637
Kolliker (professor of anatomy in Würzburg) 040
Eöstcr(leacherof pathological anatomy in Würzburg) 460, 681
Krause (professor in Hanover) Ill
Kühne (professor of physiology in Amsterdam) 486
Laennec (1781-1826) 881
Lambl (professor in Charkow) 038
Lanfranchi (f 1300) 8
Laugenbeck, Conrad Martin (177&-I800) 12, IS, 113
«88 SBQISTEB Of SAXES.
Langenbeck, Ton, BenlikTd (prafenor of ■nrper; in Berlin). .. . 112, 114, SIO,
911, 213, 241, 8fi8, 403, 470, DOS, fiü7, 614, itiO, SOS
Lwrey, J8MiDoniinique(17e«-l»43) 12, SOt, 314
Laudlen (phjiiciai^ In Königsberg) M
UwrHice, Sir WaUam (1788-1867) 13
Lebcrt (professor of the medical •^inic In BreaUn) S82, S»
Leroy d'EtioUea (1768-1881) II
Lcyden (professor of the medical olinic in Königsberg) 88, 8 S, SU
Liebormüater (profeaaor of the medical clinic in Basel) SS, SBO
Unbart, Ton (profrsaor of Durger; in WQribuig) 4U
Lbter (profeasor of surgery in Glas^«) 4SI, 4SS
Lö«cb (phyücian in SU Petersburg) 81
Lotze (professor of philoaophy and medicine in Guttingen) 62, M
Lücke (pTofeBsor of BUrgery in Bern) 310, 346, C28, BSD, 6U0, 627
LuBOhka, Ton (profetsor of onatomj in Tübingen) 620
Kalgaigne (1806-186B) 18,222, 227, 6»
Uartin (profeaaor of obaletrica in Berlin) S8
MaalowBky »
Vatthysea (amy surgeon in Holland) 188
Meckel von Hemsbach (1821-1896). 428, Ml
Menel (r^mental surgeon in Saxony at the beginning ofthla century) 212, 22S
Menzel 382
Meynert (teacher in Vienna) 86S
Middledorpf (professor of surgery in Breslau, 1824-1868) 13, 3«, 070
Mondino de Luui (fourteenth century) 8
Monro, Alexander (1696-1767) 11
Morton (phyeiciun in Boston) 13
Mott, Valentine (1785-186R) 13
Mülk-r, Johannes (1801-18.18) 488,563, ST2, 090, 604
Miillor, Max (phTHii'inn in Cologne) 189
Müller, W. (profecaor of pathological anatomy b) Jena) 609
Keatorians 7
Neudurfer (army Hurgcon in Vienna) 39
NicDieyer, V. (profeoiior of medical clinic in Tübingen) 880, 383
Ollivier (physician in Lyons) 443
Oribasiu,* (326-403) 6
Panum (professor of plivKiolofcy in Copenhagen) 38, 39, 3S6
Pamcelsus, Bombai-tu« Thcophraatas (1498-1004). 10
Pare, Ambroiec (1517-1590) 11, 27, 240
Paulus ab .ligina (660), 6
Pcan (professor of surpcry in Paris) 679, 603
Percy, Pierre Fran^oia (1754-1823) 11
Petit, Jean Louis (1674-1 760) 11, 81
Pötrequin (surgeon in Lyons) 039
rfolsprunilt (middle of the fifteenth century). 10
Piorry (professor of medicbe in Parb). 838
I'irogoff, Kicotans (professor of sui^ry in Russia) 185, 234, £88, 431, 473
BEQI8TER OF NAMES. MS
MM
Fitha, TOD (professor of surgery »t tbe Josophmom in Vieniu) S09
PoUi (profewor in Fkdua). 60, BBO
Fortt(pTofe8eoTofsar^r7 m P>Tim) 110, III, 118
Pott, Peprfy«! (1713-1788). 11, 160, «1
Pr«Tix(f phyeiciu) in Lyons) S89
Purminn, Gottfried (»boot 1679), 11
Raynaud (Frencli physiciui). SOS
Recklingtuusen, von (professor of pathological auatom; in Wiinburg). .66, B6, 09,
70, 108, 220, 824
Kedfem (English physician). 6»
Reichert (professor of anatomy in Berlin) 060
Remak, Robert (flSCB) 266,616,622,0«
Rhaies (880-632) 7
Richardson (pltysician in London) SO
Richter, Ang. Gottlieb (1742-1811). IS
Rtcord (surgeon in Paris) ■ . , . ÖS7
Rindfldsch, Edouard (professor of pathological anatomy in Bonn). . . .07, 93, 160,
266, 381, 607-009, 0S3, 087, 061, 610, 697
Ris (physician in Zürich). 188
Robin (professor of anatomy in Paris) 628
Rokitansky (professor of pathological anatomy in Tienns). .303, 600,062,063,087,660
Rose, E. (professor of surgery in Zürich) 804, 608
Roser (professor of surgery in Harburg) 232, 202
Rom (1780-1804). 18
Rush 86S
Rnst, John Kepomnk (1776-1840). 12,406,468
Salemian School 7
Scarpa (1748-1882) 11
Schiff (professor of physiology in Florence). 64, 100
Schmidt, Alexander (professor in Dorpat). 61, 66
Schneider (Saxon army surgeon beginning of this century) 212, S26
Schneider (physician in Königsberg) 88
Schönlein, Lucas (1793-1864) 668
Schuh, Frani (1804-1866) 18,691,600,662
Schulze, Hajc (professor of anatomy In Bonn). 70
Scnltet (1090-1646) 18»
Benator (physician in Berlin). 88, 84
Seulln,B«ron (1768-1862) 18, 18«, 187
Siebold, Ton, Carl Caspar (1736-1807). IS
Simon (professor of surgery in Heidelberg). 43
Simpson, ^ James Y. (professor of obstetrics in Edinburgh) 13, 32
Skutsch (physician in Silesia) 176
Smith, Xathan, (Baltimore) 188
BUntey (1791-1862) 13
Bt«udener (teacher of pathological anatomy in Halle) 266
Strieker, Salomon (professor of general pathology in Vienna). . . .06, 08, 860, 371, 384
Strieker (physician in Frank fort-ou-the-Uain). 200
Strräneyer (formerly professor of snrgery in Freiburg, Hünich, Kiel, stalT-physician
in Hanover) 117, 147,234,809,016
670 RE0I8TEB OF NAHKS.
SnsrutM (first centnry?) 4
Sydenham (1624-1889). 88i
Syme (profeasor of aurgery inEdinbui^h}..' 040
Szymanowsky (prafesaor of surgery in Kiew, 1808). 186
Teitor, Ton, CijeUn (1782-1860) 18, 850
Theden,Chr. Ant. (1714-1797) 12,3«
Tbierach (profeuor of aurgery io Leipzig).. .62, 76, 108, SBB, S40, übt, fiS9, 061,
627, 6S4, 639
Traube (profeMOr of the medical clinic in Berlin) 82,83, 8S, 154, 153
Troja,Miche!e (1747-1827) 445
Tiotula (twelfth century). 7
Tachauaoff (Ruaaiui phjBicIan) 109
Talsalv* (1666-1728) SSS
Tuuetti (profesaor of surgery in Padua) SSS
Velpeau (1796-1 867) 18, 479, 658
Yemouil (professor of aurgery in Paria) 068,615
Veaaliui, AodrSa* (1518-1564) 8 10
Vidal (de CassiB) (end of the last century) B87
TiUemin (physician in Paria). 362
Virchow (professor of pathological anatomy in Berlin).. 51, 53-50, 57, 09, 93, 96,
179, 319, 820, 324-326, 846, 365, 371, 382, 386, 412, 418, 417,
438, 451, DOS, 081, 548, 046, 050-552, BSC, 056, 008, 009, 068,
06S, 060, 068, 075, 578, 591, 093, 090, 597, 608,609, 611, 619, 626
Tolkmann, Rich, (professor of snidery in Halle) 160, 218, 266, 287, 412, 418,
417, 420, 424, 404, 469, 485, 000, 627
Wagner, A. (professor of surgery in Eonigsbei^) 212, 445
Wagner, E. (professor in Leipzig) 386
Waldenberg (teacher of medicine in Berlin) 3SS
Waldeycr (professor of pathological anatomy in Breslau). 046, 009, 63T, 628
Walter Aug. (English surgeon) 08
Wallher, von, Philipp (1782-1849) 12
Wardrop (f English surgeon) •. 089
Weber, Otto (1827-1867) 13, 83, 84, 85,86, 98, 99, 105, 102, 274, 328, 340,
428, 461, 487, 043, 555, 558, 0S9, 576, 081, 609
Wells, Spencer (surgeon io London) 349, 567
Wemher (professor of surgery in (jiessen) 651
Wertheim (physician in Vienna) 405
Würz, Felii (f 1667) 10
Wunderlich (profe^eor of the medical clinic in Leipzig) 82
Wutzer (1789-1860) 13
Wys«, 0. (professor of the policlinic in Züricli) 882, 656
WywodzofF (physician in St Petersburg). 78
Zaieski 8B7
Zeis (t 1868) 8M
Zenker (professor of pathological anatomy in Erlangen) 274, 6SS
Ziemseo (professor of the medical clinic in Erlangen) 528
INDEX.
Abseen. (B, 131, WO: cold, SOS; eoagestlTe,
no, 4aS: at kidneys, 313: of liver, 3W;
metMUtlc, 3IB, 330 ; pfirla[tlcDlar,l&(; sab-
cntanoooi panclnr« of. 431.
Ac«Ute or alamlm. 90, 30a.
AeoDice tn pjKmU, 3S0.
Acorn-Dotltee, 380.
AcDpreaaiir«, 3t.
AeopUDctnre, SIO.
Acatc arllcnliir rhannutlBm, 990.
AdennmA. fllS, AI4.
AdeaoHrcoma. «OS.
AdhDrlve pl&Hlur in turn», 318; Ui Itivot ab-
TOrpllon, STS: In Dlctn, S98.
Advaoced age a« a caaiiB of (nmore. 356.
Agar yeda, 5.
Air. EDtniDCe or, IdId vein«. 38.
AlbamlDuria froni anppanitliiti. 413. 449.
AIt«o1ai fürmailuD as a p«callarlty ot cancw,
tm.
AmbaUnce«, 334, 33T.
AmpnlailoD. «econdary, IM; for gangrene,
306; fur pjnmla, Kl.
Amrlnid dpeencratliin, 438.
ADÜmla cadilni: gan^ae, SOI.
Aneflbeiila. local. 30.
AiicbTlonU, 2il, 458, 497; cartlUffliiOUB, BOO;
eslenBloD or, G03; OBBCons, 608; apDrlooi,
4S8.
Aueariim, 190, BIS: dieMcting. ISO. (>B3; of
tbe eitremllles, fiSS; popllleal, S3A; apa-
rlouB or tniiniatlc, 118 ; varicoBO. 1 jl ; cir-
■old. br anaBtomOBla, ntcemoae. B3R, SS) ;
criludnfonn, fliBiriirm. «accolated, G33.
ADearfamal varU. SA4.
An^oioB, ft&t ; cavernoa«. Sat.
Aathru, 300.
Antlsepilca, 163, 306.
Antram Hlahmorll, cylU of, 690.
ApoplezT. 1 j7.
Aqua BIduHI, as.
Amlca. 138.
Anerlil ihrnmboBle. 301.
Artery, healing of wonnd» of. 103 ; book. 87 ;
IlKatloD. 37; mediale llfcatjon al, 38; pei^
cutaneouB mpdlAIe IWatlon, 38 ; mptare of,
In open fhictun'». 191
Arthriti! rtn\\e. 4NB.
Anbiitlii. »H : defonnana, 490.
Arlhrocaci-. ItO.
Anhrocacolugle. 463.
A*pli;ilc locale. 3U0.
Atheroma, 3»!, 638, SSt, B90.
Baker'« leg. S14.
Bandy leg. 614.
Barbrn and batheri, 9.
BoallDg ezpertment, VS.
Bed-Mrc. 396.
44
" Black eje," 1».
Bleeding in delldom tremena, 851.
Blennorrb<Ba, SK.
BllBlen. 88Si
Blood-dot, 103.
Bitte BappatBtlon, 310.
Bone-corpUfCla», 179; ab»epM of, HI: alro-
phy and hn^rtropby, 417, 465; exBiciae,
G8I; reabaorptiiin of. 179; aofteoing, 4S8.
Book of the art ot life. 3.
Brain eand-inuiore. 695.
Brlaemenl foreö. 60i
Bnm/UId't artury-hook, 9T.
Bnllet-foTcep«, 311.
Bnrna, »4.
Bnmt ap<Mige, 380.
Cadaveric potion, 369.
Calcnii. vesical and renal. 881.
CaUn*. 179, 181.
Cancer.63e: atrophying. tM4: of bladder, 637 ;
of bone. 83U ; roullBower.eB? ; colloid, gelat-
inous. GTS, W; en cnlrasse, eai; epltha-
lial. 630 : of band. 637 ; of head and neck,
633; lenllcnlBr, 653 : of skin. «30 ; TÜlona,
68T; stomacb aod daodennm, 664; laChrT-
mal, aaliTary, and prostate glands, OBB;
thyroid «land and ovary, 666; o[ lip, 600:
papillary, 039.
Cancroid. 6B0.
Canine nudnesa, 86a
CarbiiUcacld. a». 431.
Carbnocle, «57. 361, 303.
Carclnonu, 60; c. Ikaclcniataa, B98.
Carcinosis. 6fiO.
Carle«.«». 413; DDcrotica,41R; sicca, 413; of
■null bones, 433; ofvertebnB, 430; mpe^
dotal, 409.
Carlilage-diinorv. 5TS.
Caseons deKebeimtion, 870, STB, 381.
Cataplaams. tea
CaUrrh, HM. 966, Sftt.
Caicblngcold, 1B0. »6.
Caastlce for cancer, 600.
Cantery, actoal, 36 ; Iron, SBO.
Cavemoas. 519 ; venoas tnmors, 586, 690.
Cells, Stachel and riff. 633.
Cellalar tlasns, InOamnutloa ot. ceUoUtla, S&l,
sn.
CeplialhMmalonia. 1».
Cerebri, comprcsslo, contoalo, UtL
Chancre. 386.
Cbapa, 138.
Chemical ferments, 161.
Chlckon-poK. 451.
CbllbUnt, SSI.
Chill, IH. »13.
Chloride of line, 4in. OSL
CMoioform, IB.
07a
IKDBX.
ChtnnMla.puKMOo In, M.
CbMilranMa. kn.
OwnildUK nuUrtktl(i,Ml.
aeolilcUil lalNiila. Ml.
UtuHt. cuuMiUdmlua of. S*: dcfnimiilM
cniarl bjr. Hi,
Ctntrliallcrn. M.
ClnoatMr an-thod. M. W.
Cirrluwl«. MO.
CitMid toniri««, «9, SN.
Clap. Wl.
Clavt^'i^. it*imtnni* (m.UV.
Cl<i^' 'I.HU,(M.
Cu. ■ ..läü.
<^. ' «t.
Cncvv , <>[iu> I'.be trsettUana, IM.
Coittlrcr ui.. 40Q.
Colli iItt'^t*!? TiianinUaUai; mlOi lUtplijae*,
Ci.i.. '..iM.
CliI. .llou. «1,111.
CUIIniKO». UU.
QimnliK Sift
Comrn»*. (niMtntnl, M.
C>>inpr(iHtaii of artarlM. tt; nt hnchlal. XI :
«bujUiI. U; Almond, SI: •abcliitliia, 30;
Of rwlciWB T«)n>. w; or Irinphoiiia, aiQ:
M nodK i>r treamiMtL. nv, 109.
Oo»cu»-l"r! nf nrrrr», W.
C-.i
C-.i;. I- <orpiwcle«,ae: [anii>T, B6I.
C^uiri'K.n ><v t>iillcl«,«l3; or jnlKti. Jll: of
nfttvf, liati of Tnitci*. iMt; uf »ort pwu
wtlliaiKii.itiMi.l'Jl.
OonMa, vnxitjj ot. 71
CO(»l«MPxii/fi*lou, IM.
" DpFiii^, in.
CwurthniMcv. «a.
CmliaHnn, ITI. «H
CMliü<>rD, Kll.lin.
Cn>lnn-nl!. Wl
Ctvuiioii» LiiAiianiAUODw W.
CDrtri', !t.ML
Cuvklun <>r •jiluD, S13.
Ctttl* pciidnU. ML
' aeai« InlUmnutlBn of, tfiti
CrlUidromAU. ni-c
Cjar.nu: lifsjiili.ilr. Cl!; uf «nuy iMiUI«.
br^Mt.&M; «I'.'iiilii". »otrplloB, «M; ooo-
tUnlnit iiBin*. Iiluud.tfc
OjWlMtra* MllslotB.on.
QJMOCU.*!».
O^O-uicoou phyltDdo«, MM.
D«Ai>** fmn ODcull«in,IOI.
Dveiiblitt*. tm
I)»f»n»<noa (Fotn cleMrleo«, SU.
Dtllriniu ncrroniHi.H?: poUMMVMiln itptn
rmourv. tn-sa.
I>rrlTiitlv<«. in
I>t(il*nipUUc. Ul
DMvlM nMllta*. Mfbiuida K ast; i»uh
of nniirviiit. «0.
ilapMtaan, S8S.
glapMl
laitby«*», dlxiMO of. fit,
DUlbralB |Mt Il)'*crai>i>'i
iMfCMAOAlV outMlloii r<)rlMMjalTiL9U)L
uidulU. »a.
Dlpbthcrla. tKT: of wotuid*, IS, 808 : liwimal-
k, ISk
DMnhrllHu RtiliU. Ba
IHdtMaüca, «H; ..f hi», Jiw, ■btvUer.nS:
tuMliu). VS<: Domullcaicd, 8H; oooacol-
Il|Mn:llu|[wnuiiil,SUl,SW; nlwnlM.tlH.
OlMOTtlon. SI&
Dlttrwilcm* iDfifaodo, m.
DoivTt* «Moucofil. «n.
Doutdtjalni.at
OnlMM-lubM, 18ik 4BL
nnuiiSrd->iMnb.aDI.
DmkMUMu, IM.
D}n«»iiow<or, WT.
UrimiU, tili la— to, BW; nnrariHtt. MT ;
Mnffaloof, m. STTi tutctvnlou', SKi Ut.
mar. B8I.
Bir, bMnarrbaHD (nna. in.
CDtBDOiInvU ohIImih. KK.
KockTnoal*. CMbrmoiM^Vt
BehtnoeafwDthomtaif.ai.
biwm, ant. .
EcMOM Mbr«. 918 : m»iM of Im, BBl
ia*clrl<ll7ftrc<>iimcU>aia, Sia,HB.
RMlropaocnr«. tiO.
nephuiutb. an, eu. BB.
IinW*Bi*bi.3e.
KlDkrtDB. 101. a«, 8M.
Kmcllc». 3H. »1.
KmpUaimiD evmum. n.
KmpyiinB sf hiliit, -jW, M.
Bno<(ibakild.uii
BDdMBt« nbuHatirtatMn, 5U.
BDli«<s^liU^ our Im; KuacnuB, m
fCotltbti ai»t%tr. Ul.
Knrutilniiiml uf viri<iHMt wIih^BR.
Rpllef>IIfi>nn Dpunw, IIT.
Kpldatatmciim*, UK.
RpUkinlMcU. OB.
Kplthelu: <uae«t. HI.
pnria, Dtl. ML
KpnlU. «M.
BrMlk unnot. SSL
BrMblllc LmioluiOM, tL
Bntlpt^Ut, iBOi anMoa, til: Valla
ßOirr, la.
Biunihiiimtii, ifal«, SW.
Bicuriatluii. lH.
ExfalUloii. lan
B»u■(o•c^ 67; ^ iTorj, ms, nil.
Kncn*lDn. V» \ Iit «MchU, (88.
BxUrpAÜou of luiip, «B.
BxUBTOMttoiMoriiinriit, raotiMtpUan gif, UD;
MpintmlM ot. lit.
PBlK]i>(nc.M1.4n.
ITarni. ai3.
Pc'brit« nwtlAn. 1SL
I'oiuiil« pupil*. T.
PmMinitMl haniUn«, SG8.
Fi'TTr, boclk, >T*t actinidan. ISI; __,
iln.lffl: tnnn«U>t.m,l&3tt.aai'..^
pn>niaM,llbma*taam,tM: »lmaabid,M4.
Fmre8.aM.
If&jnn, cbonarMUM of. 9n
'* tonolooiT IMiMl
n n-airn* Int a»H. aH
Fln-mnto. Ml.
pinnu. snu «0.
PIU-loM, &IL
FijiDK tiofpiui*. m.
FuiitalH). OL '
ForcvJ rxrnnilvn. m,
FomMli« C«Bt, MS.
PtMtnrc-lM«, It«.
Fncnmenr Miiw. IN; t«aBW. IW: uwnpll-
ntod. 101; uuiubo«. SH: opni. Nt : pnsi-
iMal« of. IH i ot MA, IM i ijn>IM«nu. 168 ,
UBion. IK): nrlfMM, IM.
FWninni* iif tiuua, rwoalUon ef, tM,
Frnftlni. SOI.
I' iv-.' J I III,-. 1,'vuiiniMBI.
riiriioiidiuad. in
ri'"i'.i'«.»ie.
: Fnmai'iilMU. no.
ISDEX.
era
GiilraD»(aii*tlr. St. SSt, W.
QanslliHi. «A. «I».
Ctenitn«. «B; hoaptnl. W: fHim Mnnrrt-
tluD, IWi tcnllp. Wi c aiiwi-omUItt, am.
CitutXt faurrh. OU
»rlHitanaw. IM.
OatHrnnio a^Uoca. 39,
(l*Tin «ann. KU ; Tal^wn, U4.
Otmn-taTrn. M&
ci.iii rrii. r-tv
r.i. . ■,i.i.
<<i iilqoM.OI.
(i. ■ :T.
(KUKiI^rucocr. Mi,
UoBonihiM, »I, aM.
OonUWt; Di>lttlea,3n.
u nuntiat ortlii, II.
OrioalMloni.6»; JlaMfVofiWi eraapAT.tS;
nmhlUc. IM : taupio*. 3S.
OranaiMInn tliMna.sT,tti g. tueaot loBMr»,
M&SK
nn*ia.n4.
Unnmr tantun, yw.
Oontel' »autdii, MH
Oall»>|>«Rlu «pllnu. UK.
Bamirlhtna. SI4.
■brculodr«. Am.
Bwulioin*, 1«L
Bmatimttgt, U; innrUI, fl: capUlirT. 31:
rrum MmtitMit vuni»lf. IJT : Ir-xn imuvlkil-
woBodti tn ; (piin phnrrnx, |Hi«l«rii>r
D*Ra.>vrln>u,3l: iiar(iicbriii*'i>n«,n.lf1:
pahnouty.IN ; nt-'oitrj, IM; HDbfntao«-
oiw. Iff; tviiiiu'. U.
HKBMnulctllailwala. banmhlkni. M.
BmmtfUtk.itT.
Bair lb witlp^ »t.
UalhtrHc niruphf «f bone. 413.
IlanUp loturv. U.
Hiullaz tj Am tnlmtfcii. fli V '**■ •fd
fMXMil bUMlgn, n : bt Itlnl iotontloa, R.
ItaM,m.
Herta taca*. M. _
UotMMnr lnln«M«. Kt. BSI. SB. BR, BTin«.
Hantla. «ior<UI«al(ou Id «InivnlBM, 3M.
HelkoldLT. «»
llotvir i-nwotie«*. Hit.
Uu*plul f«tii[rT*<x lM.aM.lM.
" i<U, S»; flrlBc, OL
BnvwmaU-t Inee; St.
UaiDotaHaia, S5 ; riew if tclaao», Wt
HjalinM*, fK
nrttntphwa. sm
liirii^rtx artlcabniia. W; gtm MoUt. «•:
I'tiMiiikm, 4Uk ink
Ujiironia nmalelUrll. MO.
Ujp('i''ni|)&7. »' : homNplMtlA Iwtcra^la*-
(k. hni-rpIiMilr. iia.
Brttrfcleniw, flIS
Ir" tti cttroelc iDÜinuniTloD, IM, W.
Irli^rjT'lil«, SI*.
Irhlliruilt. tu.
If<"r-i. rrnm anak*-blu, M; ftMi nwuBM,
»IL
Iinia(«>lnn. IM. «ID.
liKlinmal cnlU, Ml
InttrMtcna. «Ml *& SM. Ml
InhvUoa. t.>uL i».
Iaiflltiattoa,o«no1aroip1u>ltc,07; «ihttBiona,
fil.
ttillamiaallan of c«nl iiHiJ uuiihiIj. 1U; pltl*!!-
muDoaia, WIj K>ondarT> IW. MBj in tn-
moM. US; af wmiiidi^ »^
InfaBdnaton iwir fbfinnlOB, ilL
iDRaftlrai. ini. »M
U^MtlOiia. •Dbculaaaaifi. 8»; Brlaititr,m,
luulatlcni. >ei
Mm^Ma-phatBt-Oi
■■e>7 p«i(a uard In pawlirtbfcwla, 110, 4I&
AHtdh« («a Ictcnu).
Jelut muDM. ttL
fulina, «fllarrlial Inflammatlno »f, MT: ceU
•tan>Mn «unninnfrailux wllli.Wt : orupaj
lt5,»a.9M ilUtDlnal'on.KR^
pnmlr-, C/j Bt; pnMiHml,
»Si a«Blt.^ .. ^ -. u,-.«t: !««■ iHrf-
iBi In. Wl: oiuuiiiiia uL lis; peoeiniliw
ir-iiun^oC, t1l): ■llff, KH; aiipiianlkiiM M-
luwrdbr pnlmiuiaryiabtTvlr.nt; IsppIflK,
-in : irMUDMt or idAuoai. «a.
K*nit(«-n»«lli> a> fbralsd fcodj, IIB.
Knod(4tt(«, &■«.
laoid •t«cUnr. WL
UnhiMld.in «M.
Lanmar oerrovlon*, 411,
Lapatoteimy.qB,
LtoeoevthMBla, iDI.
UonHanlf, ai, BBBl
LsadB. TD.
ti(pun»tnt, i)l*1>(ini of. SMi
IJ^Uiia(iranitrla>,91; madltw.S: ofpol^
pt. Vn ; of tflaagkclaMa, m.
LfraWrv. ». Sto.
LlEhtnlTll^•lrak«. m.
Ubw. «M. 4RI.
Uns Of rfrauutaiiaa, WI, m.
LlBOaMta. in.
Llqlthl clMMlraMltUM. 1ST,
Liquor ArrI aeaqaleCWaU. M Wt ■&
Loina nliHtria ■vtlfwiit«, M>
Liii*l!l4id. ZK: cm.«»: I»l«r Mrtim Mmd-
I^mptaiiKlanM ratmMtiun, Ml.
Lmplunirttl*. uo. xuk««.
I^nnhtit« elaibii, OIhsm oC nvi,
^' ttBKli. lufluimaUMi (< SIA,
LfmpUiln 111 ajomlal aiembrMM, Ml
Lrnpbuna, on.
Uiil£Daa« carbnncla. m, M.
Mahn» ««alt« cdi*. «n.
Maalpslailan, Alt.
MaraMntr Uronbaa. Ml. tn. .
Halcfa-naltaT't pohoälua. Hi.
UoUaic llaitlM. M. ^^
M«dBlk)77U9.
MtlMa Ckidaamtu, «ft
Mtlwoia. DMluaU, Ufl, (OT; bnlcuai.
MalUsrf*,nn.
jfaBbMt«"*, nc
H>rti£omp. nia.
Marcafr Id ■tsMH« W7.
UtttMatlc iWcnae*, tn ; IsflaiHUtlaM.
W.»IO:o.™ii«IU^»« ' ^^
UIBaiy tnbrrclm In knw, «10,
MWarr mcfMb*. M.
llbMT>lital«n,M.
674
KDEX.
Mitoiis. im.
Uol't giiTii,'reae, 99B.
Molet wnrmUi, SSI.
Moll», Ml.
Moluicuci oialaslwTim. BM ; m. Bbroanm, BM.
»urtH» Brii!l«tl.C«9«e>>rg«>lg»in,80Bj wllh
MürUflciLllaa, 3».
MiithiT'B nrnrlis, 035, MH. SSI.
M<'U, SBO.
Uaroaa bnrem, InllMnmttion or, ?RS, 116, 481.
4»!.
Kncoiu iDembmie«, Inflimmotton ot MB.
Mulltiiivlntr i<iiMei(«, iJH.
Uuiiimrii'nEInn. 'i»,
Marra «nlrulun''. JIM.
MuBolee, iiiflaiuinntlnn of, 1T4: coDlnKlioii of.
mt: O'LiJAUonor. 501l;«rt(flcl«l, 6S8.
Unectilsr cimlratUoiU, primary, MO; »aeond-
nr*. !>U.
Uy trill ia i-EiLniilU, S53.
HyelnlJ laniiiT, GDI.
UjotoB, 533. &l)l ; IwvlcGlliilire, US.
MyoBln. 70.
M^wltln. UTl,
MyauiiaT. 57 H.
M>£(M:)ii>Ddr()rua. JlOe,
HyxoiuiM, !W,
UyxChea reams. GM.
NcvTii. BNl : rnC'CulaanB, CM,
Nan», [ilU^Si;!, 31.
Nasal niacnb» polypi, fil*.
Niirn]!><>-. IQK. 410, 13fi ; illBeni»'« from carlei,
*-K: Liiijucuil, -1.TI; from pbovpborat, 4U,
14".
Neodlp-liiiyor, «.
Needltd J19 r<iTi!lt;n bodiOB, US; extraction of,
IIB
Nerrw, Sninn-il In rpen IhKturoB, 193 ; regen-
eiallonof, li>1.
Ncnritis of mi-dlan nenp, 511.
NLMiniiiatti«. MS
Kilrale ot bIIvlt. 1^.
Noma, m
Oahnm *s itrrfHlnp, 891.
Opnlar nnn'i'lud, tenctloraj of, HI».
Odonr-Jiiw, ST*.
(K'Oiiluii^ü. QKi.
Oil uriurpi-iitltic,aO.
Oil twiircKl In woiudi, llO.
OnTJirthr,iT"ö, IKJ.
OocorotiiT. lITBi.
Opi-a rmcluriif, 191 ; [TMlmatil of, 901
Open tri'iitiii' III or n-ouiide, W, ici
Opliiin. lii-l, 3311 -:&7.
Oripihir Ih'Itiit'. dfviiloptiiffnt of, nraTrnted,
IK! ; Hi CHaMt of Innammnlloii, «W.
Ünriinci(>iiit.'ik bndio». ^57.
Orijiopnlr. Blfl.
liopi .
Oa»ouijs ^rumiliilionM, IBT.
OneuuiD ''fivrotii'', 417; Iconllafrls,'!!?.
OnloociTlc palii», 40».
(i'ir'<}A chiiuJriinin., ETS, (103.
Unlx'nruji. &i J.
0«l«onuilJirU. Ifli?, 4M). 4X1.
(■«[■joniTi'llllTi, iWI. UTS. IBO.
0'li>-j;>tilvhiIf,<, -tsa.
O^Waptiytvs. fflli, itr7. 41,1,137, «»,
Oileiipln-dr pKrlucillIn inil iivlllli, ISO. 4(n.
QflTpOJl1>^It^l.H., ^.M-.
Oilm'in-iiinn, S.17. «11 . I*n.
Ü»IIHii. %:IJ. ion; ru.-'.'ou». 4111; fuDimM, 413;
gnmmoei. 4^t : Inlt'ruo. 117: nire^lng,4KI;
VOBrnlUT, lia,
Orarj, Mlcnuma of, G17 ; cvkI* of, %3i.
Pita, ms. ..-._»
WInmr fiMl». «ntiOicaoB or.SlinCfc
Piinarlilnin,»i7.i75; pvHOtUta,»».
PnrBKlutiuHn, 711.
f^imlvslf. flicl»!. SH- ^ , „ „
Piiralytiif fniin lumora of brklll, etc, BK.
l*n m pU I ni im i ■* , 5!W-
PHiaBiua. cystic, OiS.
Rminycliia. 30*.
I*ap-linL's, liSU. „ . _ ,.
[■»plllnrj pruMiratloQi». MB; p. ojptnn^ibj,
(ill,
P>l>llla!nii, ail.
Pdi:iiiR carliialum, 4SI.
Pt'luK, «iHnnirutuH uf, BTT.
PnrJuilL'ulLlB, ^IIS-.
IVriliriiphaueill«. 31 S,
I'.-ri.i't.>nni luft In w-udihI, 4iM; fDppmmtlon
Of. 486.
Pcri(>stlti>i.nS,40e; au«oplUI>e.lBO; MippB-
lallve, WI,
Perl|MiiHJ».4la.
t'DCLUAUeat ^xWIkI'i«, 197.
Fanilune», iM.
Pet> Pinna«, .114.
Peytir's Kln.uila. hjpertnrpliy of, «11.
Phiivrii. chruulc cilAirl] of. SU.
Pbleblllf , IM.
PhlptmlithfT-. B«.
Pli Icjiruiondu- Inflnmnutitra, 9QT-
Phloip.ii.i'nouii, Se.
Phiibptioniv-itulr'OEilii}^, 445, 44fl.
Pin In vcflrai cilctilne, IH.
Pltrrtmit! TtMlculor, STi.
Fin-HT, 40: ocllief m-. 41 ; «pllut», 181, 184, tlS.
«7, iW, aia, 4fl8, KM.
PIfarltirt. WO,
FLfnoiultiiinii, 3^.
PfpdHrihnxHpp. 4SI.
l>>l-fnert wciundB, BPH.
polniilf,419. SSO; «arni.eiK; critic, MO; n«-
ew.-üUl: lUDCcia?-. HIS: iiaeop iiBTI>KB>I, US,
ri'^rlJil. lllfl; iilerins, W8.
Purcnpluc iHae»«!;, 813.
PoplEIni^ iLn a naodn of Ifi^AlmeliL, lu.
Poslerlor niirN.-?, (»Incijiii:?. 3t
PiUI'n b.)Bs, 4ai ; knlft. IW.
Pourrihiri' rli-n HOpilaiil, 306.
Pressuw for cuir uf dralrlMS, 618.
Prostfll«. brpunrolibf of, eii.
Proleifoii. 70.
Pravlflanal iJn>Felnz- ifH-
uiiia^, m.
Pmmmone. riD5,
P**nrt«niLnviilii STT.
Pn^inJij-crvtipelm', ä6T.
PoiTpemt fi'Vfr, ««. MSI,
Pu[fU III lllilBlUIlMlllIQ, 9i,
I'Ul-iotiBH.vtili'ni, W"J.
Piinriun-il wiiandi), 113; of •rteriea.117; of
l^nvl^l.t!^, 117: i>r norrc«. 117; of Telni, 1-a.
Paak. S6.
Pii9. rfl. (in, 969 ; ln]oi;ti»d1iitatbe blood, SB.
■■ (iln?ii"'.B58.
Pumlirtii ihfMiion. pTiFmia, 31B, R3B.
iufliirBMim. 309.
Pmtiilfl mailcmii, S"1S.
PalrtdfLTtr, \Si.
■• mutlpr ItijtrlMl Int<> tbe blond, SSI.
Pysioln, Sill, 3£'.i ; iii nvivii bom, KM; In open
ftudurv«, äU4 ; iLpm uui^uoi, MB.
Pj-olucmia, H*^
I^roitenoa». K5.
Qalnlne, 1«. «)0,
Rachitic roiie.g«rlsDi), 419,
RacblllB, 4S0.
Rannbi. 8«!.
Rn pill II la. 308.
lUi>pBlarlam, 449.
INDEX.
m
Beabiocptloii of dead booe, lit, SUX
Becdnence or tamort, Ml.
Bed blood-ceiU. empe ol, thTongh w*11b of
TMFelB. K7, SSB.
RedneiB, Vli.
Bei^Iilter or naine«. 66S.
HMeettoD(iffrii£ment<i>. SIO: of elbow, m : of
hip, m; of filn'Ji, 471, BOT; of knee, 4TS,
GOT; uarttal, 4»; of iboalder, in; tolal,
asi; <tf WTlit, 413.
Rnolventi, 388.
Beet, IHl, SUT.
Bbenmaiivm, 489, 491.
RIcketi, lea.
Bnptores of miuclea, IM.
Salh-aiT Klaade, adeooms of, 606.
Balt-wtter teths, 880.
Sand-bttEi'. 188.
SBicoma. BSl ; alTeoIat. BG« ; block. G9e ; geW-
Inon«, 500; glftul-celled. 6M; pnonlatlon.
alio, All ; faiTkulate, BOB ; medullary, BBa.
iS6\ mucous, B95: mamma^. 6C»: mdan-
otlc, GOT; of'IBcatlon of. BflB; plraoenUry,
5VT; DBt-Celled. BOB; iipliidle-ceUttd, B6G.
Sareooatoai paplHainatA, CST.
BcaldB. U7.
Bduuider-Mfn^i apparatus. 96,
Sclrrhuo, M9. S35, ^; manmue, 649.
Sclero'le o«ii<iiD, 41L
BcolloBca. til.
ScorbullF. 385 ; to cbtldren, 401.
Scorpion. IBS.
Elcrorulous tumora. 606.
SabaceoiK gland*, cj-at« of, 61B.
SecondBij Inflammation of Bnppnmtlos
wound M. IBO-
Seconriary or BnppuratlFS fever, IBS.
Bep»ln. 83S.
Hcpi-I». -ZTi.
BeirtlcKmU. Ifi3. »M, 8M.
Srptlc polKOaa. xa ; phtogmoa, 145.
Seploprsmla. S44.
SeqaeBimm. 19B. 43B. 499.
Serous b«cb, hypcrBBcroUon of, (IS.
8e!OD. 210. 390, 668.
Shock. 189.
Rllk. 4S.
8Uap>. l»e.
Snake-blleB. 3S0.
Snutlli.-B, 'iSS.
SpbacflDB. a9B.
Spina veiiloita, 491.
Splreu. hypertrophy of, 809, All; In pyEinia,
311.
SpllntB, plaster of Paria. 184 ; dextrine, white-
of-cKK. paste, ISG; e^'^a-percba, 186; liqnld
glaBB. 1ST: BUrch, 186.
Bponey bones, laflamiuatlou of, 383.
Sprain, SIB.
Spurred rje. rteeale cnrnnlum, 30S.
Sqnlrrhe puelalcai. 662.
Starch-dreKBlni^. 184. SOS.
Ptpnio cleldri-nuBtuld muBcle, dlTlaion of, GI9.
Stiff Joinle. 456.
Strablamuii. operation fbr. 519.
Btmma, 817 : aneitryBnuHlca, 618; cyatlc«. 617.
BtyptlcB. «<. 88.
ea>iink.BiioD. tsa.
SiiZBt In urine. HSi.
SufzlllatlonH 137.
BnlpharetB of the alkalleB. 350.
Runhum, ■»»: Bnnntroke. U8.
BnppurBllon, ȧH; blue, 310.
SuppuralWe fever. 33)1
perioslltl», SOI.
Surgeon' B hnol. S7.
Borgical npcdlee, 43.
SalnrcB, 41; ol bone. 910; cst^t horsehair,
44; Interrupted, 48; twlitad, 44.
Swedlah mornneat-CBro, SSL
Swelling lu loBammallou, Vti.
Synovia, eacape of, 916.
BynoTltla, ISB; pareucbrmatoni, SBT; cbronlo,
seroae, 4S6. «6.
Sypblll«. S8R.
ByphllODU, 886.
Tadpole*, regeneration of, 100, 103.
TampOD, 3t.
Tipplnr the Jolnta,47B.
Tarantula. aS9.
Tinar«mellc olnlment, 389.
TelaueiecIaBlB. 54i. GM, 566.
Temperature In dlBcase. 83, 161, S^
Temporal bone, carles of, 581.
Tendo Acbllll*. raptors of. IM.
Tendon«. «iTi.'Ctlou; of Bbeatbs of, 37K, 480, 488.
Tenotome. 4R1.
Tenotomy. B16.
TetanoB. triBman, BBS.
Thfdr^^s dresBlng, 88.
Thermometer In dlseaBO, 89.
ThrumbuB, 104 311.
Thymus Biand, hypertrophy of, 611.
Thyriild triand. adencima of, 616 ; cyalof^fllT;
tumor« of. B51.
Tibia, abmmala on, 568.
Tlnclnn? lodlnll. 388.
TIbbo flbruplaBllque. 393
Tonalls, hypenropl^ of, 610,
TrauafuBloD. 38.
Transplantation of caneer-genna. SSS, 6ft.
Tranroallc fever. 8S, 158.
tetano», 117,
Trichina, 63».
TriBmat in open fractarea, 901.
Trocar, 113.
TnberculoBlB. 880,
Tnmur albus, 867, 457.
Tumora, Mi ; benUm, SB3 ; canceroiu, 550 ; of
brain. 560; colloid. 571 ; connect iTe-tlaane,
B6S . conta<rt»UKne«9 of, BBl ; ttilCy, STI ; In-
fectlooK, 560; malli^natit. melaBtatlc, 568;
multiple, 55« : pedunculated, 661; «econd-
arv. 563; Bolilsrr. U9,
Turning the foot. SIB.
Turpeuilne for hiemorrbage, SI.
Tympanitic soond, S74.
TyphuD* dlseaaea. 886.
TyrOBln, TO,
C1rer.alonic.395; eatartlial. 394 ; calloaa.aSSi
ercItalticSOT; fnngoaa.Silg; BflolonB. slnn-
ouB. 400; lupous. 403; open. 870. 39"} ; pba-
gt.'denlc. 4IKI; pmlireratlnfc. 895; Bcorbn-
tlc. 404 ; «crofnlunB, 403 : Buppuratlng, 400;
Bimptomstlc,40J; aypbihtlc, 40S; typhona,
891 ; varicose. 5*7,
Ulceration, «(6. 368,
ricu» rodens. 636,
Urethra, «[ricinre of. 518.
Urethral camncles, 616.
Uterine lymphani^tis. 817.
Vaccination of aniHoma. 689.
FoJHi/ra'ii treatment of ancnriam, BK.
Varlcci-, IM, SM.
VarlcoBB ulcer. BiT.
Varix anenrya mall CUB, 131. BW.
Vaacalar tumors. 581.
Veln-Blonee. 686, 5H6.
Veins, Tarico«c, 516: tnjecilon of ammonia
Into, 350: InjecllOD of Iron into, 691; Id-
Juiedin open fTactorea, 198.
Venesection, 184
Ventilation, 819.
VeratrlB, 860.
VIpera, 360.
676
INDEX
Tllelline ipfaerw, S45.
Waits. «iT
W&Ur-luIb, IBT, 899 : caDksr, 308.
While of eeg, 186.
" Wind of tbe ball, SS5."
Wire ralnret. 49.
Wool ae dreMlne, !91.
Wonad-donche, StmareK'i, 89.
Wounded pereouF, cre of, Bl.
Woands. GODtniird, 1)6. ÜB; flap, 18; iDcbed,
17, 87; Rtuitbot. SBS; penatntliig, 18; pol
•ooed, 8B8.
TBE BND.
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