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Full text of "General surgical pathology and therapeutics, in fifty lectures. A text-book for students and physicians"

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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 






,0,. 



^I^ mm°-^% 



TRANSLATOR'S PREFACE. 



DtTRDTa the past ten years the microscope has greatly ad- 
vanced onr knowledge of Pathology ; and it will perhaps he 
acknowledged that most progress in the study of Pathological 
Anatomy has been made in Germany. 

Prof. Theodor Billroth, hinwelf one of the most noted aa- 
thorities on Snrgical Pathology, lias in the present volume given 
us a complete resume of the existing state of knowledge in this 
branch of medical science. 

The book might perhaps have been entitled " Principles of 
Surgery," but this would hardly have indicated the specific man- 
ner in which these principles have been inculcated. 

Most of the views found in these lectures have been floating 
through the journala for several years past ; but, so far as the 
translator knows, they are not eo fully presented in any book in 
the English language. The only work in our language on the 
subject was published many years ago ; even the late editions 
are but little changed from the first ; moreover', the two works 
are, in most respects, entirely unlike. 

The fact of this publication going through four editions in 
Germany, and having been translated into French, Italian, Ru&- 
Bian, and Hungarian, should be some guarantee for its standing. 

Some few notes that have been inserted by the translator 
will be found enclosed in brackets [ ]. 

4Y WmT ThIBTT-FIE8T StBBET, JfEW TOKK, 

Dee^mher 1, 1870. 



,'^7990 



PREFACE TO THE FOURTH EDITIOS. 



AucoBT every time that it bae become my pleasant task to 
go over tliis booi in preparing a new edition, I have tboogbt, 
this time at least, tbere will not be much to alter ; uevertheleee, 
I always found much, very much to improve, to cut out or to 
add. In bo doing, I have always had the satisfaction of knowing 
that even in short periods the progress of science had been quite 
perceptible. We do not notice this much while swimming with 
the stream, but it becomes very evident when we have before us 
a book that is to a certain extent a photogram of the state of 
affairs two years since. The success that this edition meets 
with will show whether I have again succeeded in presenting 
my book in a shape to meet the requirements of physicians and 
students. 

The section on traumatic inflammation has been revised in 
accordance with recent advances. In the chapter on tumors, 
the part treating of carcinoma has been simplified, the term 
"connective-tissue cancer" being omitted, to prevent confusion. 

The liberality of the publisher has enabled me to increase 
the number of woodcuts by twenty-nine (Figs. 47, 53, 55, 58, 66, 
68, 69, 70, 74, 91, 98, 99, 103, 106, 107, 108, 109, 110, Ul, 113, 
123, 123, 124, 125, 126, 127, 128, 132, 133). 

De. TH. BILLROTH. 
VasvA, Nbwmber, 186fi. 



OOIS^TEKTS. 



LECTUBE L 



IXTBODCOTIOH. 



IMitiOD of Snigeiy to Internal Modicine. — Neoeuity of the PnotiBiiig PhysioUui 
being acquainted with both.^-Hiatoiioal fiemarlu. — Nature of the Stadj of Siu- 
geiy in the OermaD High-aohool, page 1 



CHAPTER I. 
snteLM mci8ED woxisds of the soft fasts. 

LECTURE U. 

If ode of Origin and Appearance of thedoWounda. — VarioiiB Fonns of IncUed Wounda. 
— Appearance during and immedistelv after their Oocurrenc«. — Pain, Bleeding. — 
Varieties of Hnmorrliage ; Arterial, Venoua. — Entrance of Air through Wounded 
Veins. — ParonchymatouB Hiemorrhage. — nsniorrliagio Diathesie. — Uteiiiorrbagt 
from the Pharynx and Beetum. — Constitutional Effects of 'Severe UsmoT- 
«■bago, p. IT 

LECTÜBE m. 

Treatment of Htemorrhage. — 1. Ligature and Mediate Ligature of Arteries. — S. Com- 
preesion by the Finger ; Choice of the Point for Compression of the Larger Art«- 
riea.— Tourniquet. — Acupreasure. — Bandaging.— Tampon. — 8. StfpUce. — General 
Treatment of Bodden Aiuemia. — Transfusion, . .... p. SO 

LECTUBE IV. 

Qaping of the Wound. — Union by Plaster. — Suture ; Interrupted Suture ; Twisted Su- 
ture. — External Changes perceptible in the United Wooiul. — Healing by Pint In- 
tention, p. 40 

LECTDBE V. 

The more Wnute Changes in Healing by the First Intention. — Dilatation of Vessels in 
the Viduity of the Wound. — Fluxion. — Different Views regarding the Causes of 
Flnzioii, p. 4S 

LECTÜBE VI. 

Changei in the Tissue during Healing by the Flret Intention.— Plasüc Inflltraüon.— 
Inflammatory New Formation.— Betrogresaion to the Cioatrix.- Anatomical Evi- 



Tin OONTKNTa 

denoes of Inflaamution. — CoDditions ncdei which HeftUng bj Fiiat Intention dow 
not oociur. — Union of Puts that have been eompletelj eepftrated, , , page 66 

LECTURE Vn. 

Cbangea peroeptible to the Naked Eye in Wonnda witli Lou of Sabetonoe.— Finer Pro- 
oeases in Healing with Granulation and Suppuration. — Pus. — Cioatriiation. — Dam- 
onstraÜDn of Frepaiations illnstrative of the Healing of Wounda, . . p. U 

LEOTUEE Vni. 

Oenersl BeacUon after I^jufj. — Sorgioal Pever. — Theories of the Fever. — Prognosis. — 
Treatment of Simple Wounds and of Wounded Persons. — Open TresUnent of 
Wounds, p. 81 

LECTDEE IX. 

Combination of Healing by First and Second Intention. — Union of Qraunlation Sur&cos. 
Healingnnder aScsb. — Qranulatiou Diseases. — The Cioatrix in Various Tissues; in 
UuBole; in Nerve; its Enobbf Proliferation; in Vessels. — Organization of the 
Thrombus.— Arterial Collateral Cironlation, p. 91 



CHAPTER II. 

80XB PECÜLIABITIES OF PÜNOTÜBED WOUNDS. 

LECTURE X. 

Afl a Rule, Punctured Wounds heal quickly by First Intention. — Ifeedle Punotures ; 
Needles remaining in the Body, tbeir Extraction. — Punctured Wounds of the Nerves. 
— Punctured Wounds of tlie Arteries : Aneurysma Traumatioum, Tarioosum, Variz 
Aneurysmaüeua. — Fnnotured Wounds of the Telus, Venesection, . . p. US 



CHAPTER III. 
aosTxmiosB of tsb boft pabts without wouitdb. 

LECTURE XL 

Canses of Contnsioiis. — Nervous Concossion. — Subcutaneous Rupture of Vessels. — Rup- 
ture of Arteries. — Soggillationa. — Ecchymoaes. — Eeabsorption, — Termination in 
Fibroiu Tumors, in Cysts, in Suppuration, and Putrefkotion.— Treatment, p. lU 

CHAPTER IT. 
aoNTUssD Aim LAoasATBD wounds of thb soft parts. 

LECTURE Xn. 

Mode of Üccurrenoe of theae Wounda ; their Appearanoe. — Slight Etemorrhage in Con- 
tused Wounds, — Early Secondary HBraorrhages, — Gangrene of the Edges of the 
Wound. — lufinenoes that effect the Blower or more Rapid Detaehment of the Dead 
Tissue. — IndicstiotiB for Primary Amputation. — Local Complications in Contused 
Wounds; Deoomposltlon, Putrefaction, Septio Inflammations. — Contusion of Ar- 
teries; Late Secondary Hnmorrhages, p. ISB 



OONTKKTS. ix 

LECTÜEZ TTTT. 

ProgreMive Snppnistion ■toiting from Coctnsed 'Wouitds. — Beoonduy Inflammatione 
of the Wonod: tbeir Csuaes; Loc&I Infeotion. — Febril« BeaoCion in Contused 
Wounds: Baoondarj Fever ; Suppuntive Fever; Chili; their Obiubi.— Treatment 
of ContuBsd WoimdH: IniEnertion, loe-blodders, Irrigatioc; Criüoism of these 
Methods . — Incisions . — Co on ter-openiiiga. — Dndoage. —Cataplasms. — Open Treat- 
ment of Wounds, — Prophylaxis against Seoondaiy Inflammations. — Internal Treat- 
ment of tbose severely Wounded. — Quinine. ^Ipium. — Lacerated Wounds ; Sub- 
cutaneonsBuptnreof Muaolaa and Tendons; Tearing out of Uusdes and Tendons ;_ 
Tearing out trf' Pieces of a Limb, page l-tö 



CHAPTER V. 

SIMPLE FBACTUSSa OF SOmCS. 

LECTDSE SIV. 

Caoses, Different Varieties of Fiaoturee. — Symptoms, Diagnoüs. — Course and External 
Symptoms.— Anatomy of Heating, Formation of Callus. — Souroe of the Inflamma- 
tory Osseous New Formation. — Ulatology, p. 1S7 

LECTDHE XV, 

Treatment of Simple Fractures.— Bedoction. — Time for applying the Di^ssLng, its 
Ctioiae. — Plaster of Paris and Starch Uressio)^, Splints, Permanent Extension.— 
Betaining the Limb in Position. — Indications for removing the Dressinge, p. 193 



CHAPTER yi. 

OPBK FRACTXmEa Ä2fD anPFUBATION OF BONE. 

Difference between Snbcutaneoua and Open Fractures in regard to Prognosis. —Vari- 
eties of Cases. — Indications for Primary Ampatation. — Seoondsry Amputation. — 
Course of the Cure. — Suppuration of Bone. — Necrosis of the Ends of Frag- 
ments, p. 191 

LECTÜEE XVI. 

Development of Osseous Oranulations. — Histology. — Detachment of the Sequeatrom. — 
Histology. — Osseous New Formation around the Detached Sequestrum. — Callus in 
Sappnrating Fractures. — Suppurative Periostitis and Osteomyelitis. — General Con- 
dition, — Fever. —Treatment ; Fenestrated, Closed, Sptit Dressings. — Antiphlogistic 
Bemedles. — Immersion. — Bules about Bone-epUntera. — Aiter-Treatment, . p. 197 

LECTDEE XVn. 

1. Betarded Formation of Callus and Development of Pseudarthrosis. — Causes often 
unknown. — Local Caoses. — Constitutional Causes. — Anatomical Conditions. — 
Treatment: internal, operative; Criticism of Methods. S. Obliquely-united 
Fractnres ; Bebrealdng, Bloody Operations. — Abnormal Development of Cal- 
lus, p. 207 



Z OOHTENT& 

CHAPTER TTI. 

ijrjvaiss or thb johttb, 

C<n)t(iaioa.—I>Ulortl(ni.— Opening of tha Joint, «nd Acuta Tnmiutio ATtiealar 
Inflainaiaäoii.— Varied of Covtm, »nd Beralto.— Treatment.— Anatomical 
ChangM, page S14 

LECTDSE X7IIL 
Simple Dialocation»; Trramatie, Congenital, Pathologioal LnzationB, Sublnxatioiu. — 
Ktiologj. — DitBcoltie* in BeduotiOD, Treatment; BednctioD, AfteivTreatment. — 
Habitual Lnxation*. — Old Lnxationa, Treatment. — Complicated Loiationa. — Con- 
genital LnxaÜona, p. 22S 



CHAPTER Till. 

ffVSBB T-W 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 

[iCCpipre BM ny 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 * ta üax 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 
prO OeS B, 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:?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 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 «(i M MtOTW'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 
pr catu re, 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 
^ h ad 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°^!rt EfJS!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 
h gpiD O J r h ages ; 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 infla m mation 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 B Uf geo na , 



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 
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 s