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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 


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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&lthy  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. 


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PRESS  NOTICES  OF  NIEMEYER'S   PRACTICAL  MEDICINE. 


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PRACTICAL    MEDICINE, 

WITH    PAKTICCli^B   URKtnOB  TO 

PBTSIOLOQT  A2fl>  PATSOLO&IGAL    AITATOMT. 


By  Dr.  FELIX  VON  NIEMETEB, 

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"ÜinrxBaiTT  op  Oxpord. — The  followlDg  aDDODDcement  bu  been  mads: 
'  Regios  Profewor  of  Uedicioe,  Henry  W.  Adud,  D.IC  Snbjeot:  OliDloal  and 
Geaeral  Medicine.  Text-book :  Kiemejrer's  Tmt-hooh  nf  iVooftoal  JMfstM, 
(New  York  etl.,  1869.)  "• 

Pnym  the  Dublin  Quarttriff  Jowntai  <{/' JCnIMm. 

"The  task  of  tbe  reviewer  is  an  easy  and  gradcnu  one  In  reviewing  aaob  a 
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"The  tritnülation  on  the  whole  is  very  creditable,  and  the  volnmea  are  hand- 
some and  well  bronght  ont** 


D.  APPLETOK  <t  fO:S  PUBLICA  TIOKS. 


THE  PHYSIOLOGY  OF  MAN; 


TO  REPRESENT  THE  EXI8TISG  STATE    OP   PHYSIOLOGICAL  SCIENCE. . 
AS  APPLIED  TO  THE  FUNCTIONS  OF  THE  HUMAN  BODY. 

By    AUaTIN     P'LINT.    Jr..    M.  T). 

Alimentation ;   Digestion ;  Absorption ;   Lymph   and   Chyle. 

1  roIniiLe,  Sto.    Clotli,     Pria»,  t4.M. 


BECBirrLT   PvaziasMD. 

THE    FIRST    VOLUME    OF    THE    SERIES 

AUSTIN"     B'LINX,     J*.,      M.    X>., 
cost  AI  NINO 

Introduction;   The   Blood;   The   Circulation;   Respiration. 

1  Tolvme,  Bto.    Cloth.    PtIm,  tCBO. 


"  Pmfctinor  Flint  Ib  mgnged  ID  tlie  pre|Hiration  of  an  extend  cd  work  od  human 
phTciologr,  in  whit-h  lie  profcjsea  to  consider  all  the  subjects  UBually  rc;;ardwl  ss  ln-- 
|i>nfciii);  to  tliiit  depnrtmont  iif  physical  ddonce.  Ttie  work  vill  be  lüviilml  inli> 
yi^parnlc  mid  distinct  ptiil»,  liiit  tlic  s?Fera1  volumes  in  which  it  is  U>  bo  piililislied 
wilt  form  a  connectwl  series." — Prorvlmer  Journal. 

It  is  free  from  tech nieali ties  and  purely  profciinnil  terms,  and  instead  of  on!» 
being  adapted  to  tlie  use  of  the  medical  faculty,  will  bo  found  of  interest  to  the 
general  reader  who  de^iirea  rlirar  and  coni'iso  infonnattou  on  the  subject  of  inun 
pliyslciil." — Evening  Po*t. 

"  Difcestion  is  ton  little  undemtood,  Indij^stioQ  too  citenMvely  sufTcred,  ti> 
render  thi*  n  work  of  aupererojration.  Ptomaclis  will  liave  their  revenge,  soonor  or 
later,  if  Nature's  Iiiws  are  infringeii  upon  through  igiior.ince  or  stubbornnei's,  and  it 
If  well  ifaat  ail  siioiild  understunil  how  the  penalty  for  'high  living'  is  assie^'sed." — 
CTiimijo  Evening  Journal. 

"  A  year  has  elapitcd  F^ince  Dr.  Flint  published  the  first  part  of  his  great  work 
upon  tinman  physiology.  It  was  an  admirable  treat ise^-distinct  in  itselt^— exhaust- 
■ng  the  i^peeial  siibji'Cts  upon  which  it  treateiL'' — Philaiielplüa  Inquirer, 


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