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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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STWOfiO, MUf. 94305 



Ulis book is theprtj^- 

COOPER MEDICAL CO..^. . . 

SAN rnANOiscc, cal. 

Olitf >" JH>* '■' }■•' rr l '* •til '-' ' 



GENERAL SURGICAL 



PATHOLOGY AND THERAPEUTICS, 



lit Jfiftg-orxc ^ccttrrcs. 



A TEXT-BOOK FOR FAVJiEyTS ^5PJ);j?ff J'Ä/CSf.VÄ 



BT 



Db. THEODOR ^ILLROTH, 

p&orEasDB or sraaiHT in tibhha. 



rHAl.-SLATED FKOH TUB FtlL'HTn tlKSllA.V KPITIO-V, Wnit TltK 8fECr.IL rVBXI^S/Oy OF TBS 
JL'IBOR, AXD ACr/StJ) /fiUV TUB SiailTH ElllnOX, BY 



CHARLES E. HACKLEY, A.M., M. D., 

phthciin to TUE vtw ToitK noRriTAu riLLoir or tbe rew tokh 

ACADEXT UF >EDtCItni, KTC., ETC. 




NEW YORK : 

D. APPLETON AND COMPANY, 

1, 3, AND S BOND STREET. 

1880. 



• : • 



Exmm, nccnrdlng lo Act of Ciincre», In tlip year 1>T:, hy t rumm E. II.iiki.lv. in (he 
OBIiN Ol Ihn LilimrlaD ot Coiij^ri e', ut WatblnEtoi). 



E:«TE1ltD. acoonlinfr In Act nf Concres«. In tliP .v«ir 1-Ta. Ity CH.VKLts E. llACLLrv. Iti tln' 
OlUn; of till' Lltinrluu or l'untnvM). M WaeliiDglua. 



i;:<TZBEii. afconJInB to Act of TongrcM. In Ihe year 1*79. !iy t-ninlra li, IIirKLrv. in lln' 
OtDcc uf Ihc Ubnrtui ur CoDtcrvtiü. M Wu»blii);ti>a. 






TEAXSUTOR'S PREFACE TO THE REVISED EDITION. 



Sbce tliU translation was revised from tlie sixth German 
edition in 1S74, two other German editions have been jinb- 
Ii;he«l. The present revision is made to correspond to the eighth 
German edition. In order to make urn of the stereotype plates 
»f the former edition as far as possible, some of the additions 
have been inserted in an appendix. Those are numbered, and 
are referred to in the text by corresponding numbers. 

Zister'a method of antiseptic, treatment is referred to in 
various places; and other new points that have come up within 
a few years are discussed. A cha2>ter has been written on ampu- 
tAtions and resections. In all there are seventy-four additional 
pages, with a number of new woodcuts. 

CHAS. E. HACKLET, M. D. 

New York, Detember, 1878. 



TRAKSLATOrS PREFACE. 



Dnuxo tlio poet t«n years tbo microacopo lios grcut]j ad- 
Tanced our knowledge of Pathology ; and it will perhaps b« 
Bcknowlodgdd tli&t most progres» in tlie stndy of Pathological 
Anitomj hm been rnndo in Gcrminy. 

Prof. Tlioodor BiUrotli, liimself one of the most noted aa- 
thorities on Sur^rical Patliologj, haa in the present Tolnmc gircn 
u« a complete ritunU of tlie existing Rtate of knowledge in this 
l>ranuh of medical scienee. 

The houk might perhaps have heco entitled " Principles of 
Sni^rj," but this woald hardly have indicated tho opecifio man* 
ner in whidi thefte principlos have been iiynilcated. 

Most of the views found in these lootnrcs have been floating 
tlirongh the jonrnals for several years past ; but, so far as the 
tranülator known, they are not ao fully presented in any book in 
the English laugmige. The only work ia our language on the 
Rtibject was published many years ago ; ovon the Into editionB 
are but little cliangcd fVom Üie fitttt; inoreovcr, tho two woHu 
are, in most reapocts, entffely unlike. 

Tho fnct of thi» publitSaddQ going through four ocHtiooB in 
Germany, and havii^been translated into l^Voncli, Italian, Kns- 
eiau, und Uungarian, «houjd be eoiu'e guarantee for its standing. 

8ome few notes that have bcoti inserted by the translator 
will be found enclosed in brackets [ ]. 



Kkw Ymk, ItrrvtArr 1, 1870. 



PREFACE TO THE EIGHTH GERMAN EDITION. 



This editioo aleo has been carefully revieed, and some addi- 
tions have been made to it. It is the hope of the author that 
the book will continue to be acceptable and beneficial to students 
of surgery. 

In addition to previous translations, there has been a new 
English one made under the ausinees of the New Sydenham 
Society, as weU as one into Japanese by Dr. Susum Sato. 

Til. BILLROTH. 



This book is the properti/ oj 
COOPER MEDICAt COLLEGE, 

SAN rAANOtSCO. CAL. 
oiiff M n»t to ftf iwnotve/ from the 

I ■ -I'lii litnun hif ouif fterifon or 
'■ '•' !■ iti.if ptvlext luhutfrer. 



AUTHOR'S PREFACE TO THE SIXTH EDITION. 



The steady advance of science, and the progress that wc our 
selves make as long as wo have the inclination and Btrengtii to 
Bwim with the stream, become most apparent when we are from 
time to time obliged to go over onr old work. On a similar 
occasion I have already expressed this thonght, but do not hesi- 
tate to repeat it hore; for this perception of progress is a great 
support to U8 in the many dark hours when, with the greatest 
zeal to serve our fellow-men, we feel oppressed by the impotence 
of our knowledge and ability. 

I have again done my best to raise this book to the present 
level of our knowledge, and have untiringly striven io improve 
its form and contents ; the section on Deformities has been en- 
tirely rewritten, old woodents have been replaced by better 
ones, and some new ones have been added ; prescriptions have 
been given in grammes. 

May this enlarged edition also bo well received, and arouse 
in the student a love of surgery ! 

TH. BILLROTH. 

VttNSA, NovemUr, 1872. 



PREFACE TO THE FOURTH EDITION. 



AiMOST every time that it has become mj pleasant task to 
go over this book in preparing a new edition, I have thought, 
this time at least, there will not be much to alter ; neverthelesB, 
I always found much, very much to improve, to cat oat or to 
add. In so 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, 
6S, 69, 70, 74, 91, 98, 99, 103, 106, 107, 108, 109, 110, 111, 112. 
122, 133, 124, 125, 126, 127, 123, 132, 133). 

Dn, TH. BILLROTH. 
ViKMSA, Ifovemler, 1609. 



OOIJrTEKTS. 



LECTUBE L 



IltlKODIIOTIOM. 



Relation of Salary to Internal Uedioiae.— NecMsitf of the TnOlaing Pbyaioiio 
being BoqiumUd with both.— HiBtorical Bemarbi.— Nature of the Study of Buf 
gerf in the Gennan Higb-wbool, , . . . . page 1 



CHAPTER I. 

SIXPLB INCISED WOUNDS OF THE SOFT PASTS. 

LECTOSE n. 

Mode of Origin »ndAppenrnnceorthedoWounda. — VariouB Forma of Incised Wounds. 
— Appesraace during and immodintoly after their Ooourrenoe, — Fiüa, Bleeding. — 
VarieUe« of IlffliBorrliaga ; Artarifll, Venous.— Entranoe of Air through Wounded 
Veins, — Paronchymatous Hamoirhage. — Hamorrhagio Diathesis. — Hamorrhags 
from the Pharynx and Eectuia. — Constitutional Effects of Severe Hnmor' 
rlioge, p. 17 

LECTURE IlL 

Treatment of Tlaimorrhagc. — 1. Ligature and Mediate Ligature of ArterieB, — 2. Com- 
pression by the Finger ; Choice of the Point for Compression of the Larger Arte- 
ries, — Tourniquet, — AcnpreHSure, — Bandaging. — Tampon. — B. Styptics, — Ocnerat 
Treatment of Sudden Aiuemia.—TrBnBfuriOD, . .... p. M 

LECTDEE IV. 

Gaping of the Wound. — Union by Plaster. — Suture ; Interrupted Sutnre ; Twisted Su- 
ture. — External Changes perceptible in the United Wound. — Healing by First !□• 
tentioD, p, U 

LECTÜBE V. 

The moro MJonts Changes In Healing by the First Intention.— Dilatation of Vessels in 
the Vicinity of the Wound,— Flnxlon.— Different Views regarding the Causes of 
Fluxion, p. 49 

LECTÜEE VI. 

Changes In the Tissue during Healing by the First Intention.— Plastic Inflltratlon.— 
Inflommntory New Formation.—Hetrogression to the CioaUix,— Anatomical Evi- 



X CONTENTS," 

dcnoes of Inflammation. — ConditioDnundcr wliioh Healing by Fint Intention does 
not occur.— Union of Ports tbit have been complutely Beftarotcd, . . page bS 

LECTUBE VII. 

Changes perceptible totlie Naked Eyo in Wounds with LosHof Subitance. — Finer Pro- 
ccsHca ID IlcalinK with Qranulation and Sup[iuration. — Pub. — Cicatrization.— Ob Ber- 
vations on ''luflninmution," — DeinonstriitioD of Preparations Uluatrative of the 
Healing of Wounds, p. TO 

LECTDEE VIH. 

General Reaction after Iiyury. — Surgical Fever. — TlicorieB of the Fever. — Prognosis.— 
Treatment of Simple Wounds and of Wounded PemoDS.—Burroving Wounds.- 
Open Treatment of Wounds. — LitUr't Method.— Coooobacteria Scptica, . p. Bä 

LECTURE IX. 

Combination of Healing b; First and Seoond Intention. — Onion of Granulation Surfaces. 
Healing under a Scsb. — Oranulation Diaeases. — The Cioatrii in Tarioua Tissues ; in 
Mnsole; in Nerve; its Enobbj Proliferation; 1» T«M«la.— Organization of the 
ThroDibas. — Arterial Collateral CiroulaÜou, . . • . . . . p. 09 



CHAPTER II. 

SOJfS PECULIARITIES OF PIMCTUBSD WOUNDS. 

LECTURE X. 

Aj a Bu'.e, Punctured Wounds heal quioklf by First Intention. — Kccdlc Punctures ; 
Needle« remaning in the Body, their Eitraction, — Punoturod Wounds of the Nerves. 
— Punctured Wounds of the Artcdes : Aneurvsma Tranmatioum, Varioodum, Vnrix 
AneurjamaticiM. — Punetnred Wounds of tba Veins, Venesection, . . p. IKO 



CHAPTER III. 

COXTUSIONS OF TBE SOFT PASTS WITBOUT W0UXD3. 

LECTUBE XI. 

Causes of Contusions. — Nervous Conoasslon. — Subcutaneous Bupture of Vessels. — Kup 
tor« of Arteries. — Snggillations. — Eochymoscs. — Heabaorption. — Termination in 
Fibrous Tumors, in Cyst«, in Suppuration, and PutrefiMtion. — Treatment, p. 141 

CHAPTER IV. 

COXTUSED AND LACERATED WOUTTDS OP TBE SOFT PARTS. 

LECTURE XIL 

Mode of Uccurrenc« of theso Wounds ; their Appearance. — Slight Htcmorrhago in Con- 
tused Wounde. — Early Secondatj lliemorrliages. — Gangrene of the Edges of tbo 
Wound. — Influences that effect the Slower or mora Rapid Detachment of t^e Dead 
Tissue. — Indioationa for Primary Amputation. — Local Complications in Contu--w.'d 
Wounds ; Ileoom position. Putrefaction, Septic Inflammations.- Contusion of Ar- 
teries; Late Secondary Haimorrhoiw, p. I'li' 



OOKTKNTa xi 

LECTHEE.XHL 

Progreuive SappuntioD BtorUng from Contiued Wounds. — Seooncüu? Inflammaüoiu 
of Um Wound: their Caiuci; Locil lufecuoo.— Febrile BeaoUoa in Contiued 
Wounds: Seoondu? Fever ; SoppuntlTO Fever; ChUl; their CaUBei.—Tre»tmcat 
of Contnied Wonnds : Immeralon, loe-bLidden, Inigatloti ; CriCituBm of these 
Methods.— Intnsions.—Coonter-opudngB.— Drainage,— CfttapIasniB. — Open Treat- 
ment of Wounds. — Prophftftxia against Seoondaijlnfl&mmaldons. — Intamai Treat- 
meat of those severelf Wounded. — Quinine. — Optnm. — Lacerated Wounds : Sut>- 
«nUneoos Bupture of Mosolea and Tendons ; Tearing out of Muscles and Tendons ; 
Tearing out of Pieoes of a Limb, page 164 



CHAPTER V. 

BOWLE FSACTUBE3 OF BÖSES. 

LECTDEE XIV. 

Ousel, IMfferent Varieties of Fractures. — Sjmptoma, Diagnosis. — Course and Extsmnl 
BTmptoms. — Anatomy of Healing, Formation of Callus. — Source of the Influmm»- 
toiy OaseoQji New Formation. — Uistolog;', p. ISB 

LECTURE XV. 

Treatment of Simple Fractures. — Beduction. — Time for applying the Dressing, its 
Cboioe.— Plaster of Pari* and Starch Dreseinga, Splints, Permanent Extension.— 
Betwning the Limb in Position.— lodicationB for removing the Dressings, p. SOI 



CHAPTER YI. 

OPSy FSACTUBES AA'D SXJPPimATIO'lf OF BOlfE. 

Difference between Subcutaneous and Open Fractures in regard to Prognosis. — Vari- 
eties of Cases. — IndioatioDS for Primary AmputaUon. — Seoondary Amputation. — 
Coarse of the Cnre. — Suppuration of Bone. — Kecroais of the Ends of Frag~ 
menta, p. 810 

LECTDBE XVL 

Development of OsscounOrannlst ions. — Flistology, — Detachment of the Sequestrum. — 
nistology. — Osseous New Formation around tiio Detached Sequestrum. — Callus in 
Suppurating Fractures. — SuppurativePerioalitis and Osteomyelitis. — General Con- 
dition.— Fever.— Trestment ; Fonoatrated, Closed, Split DreHsings.- Antiphlogis- 
tic Remedies. — Immersion.- iudr's Method. — Kules about Bone-Bplinters. — 
Afccr-TreatmcQt, . p. 218 

AFFSyüIX TO CHAPTESS r. AXD yi. 

LECTURE XVII. 

I. Retarded Formation of Callus and Development of PseudarthrOBiB.— Causes often 
unknown. — Local Causes. — Constitutional Causes. — Anatomical Conditions. — 
Treatment; internal, operative; Critioism of Methods. 2. OUiquelj-unitcd 
Fractures; Bebreaking, Bloody Operations. — Abnormal Development of Cal- 
lus, p. 226 



Til 



C0STEKT8. 



ClIAETER VII. 

tSJCRlXS Of TUK JOTSTS. 

CftntDtia«!.— PlMAttiM.— Umm^.— OfWKltif eT llw JoUUt «aJ Aeul« Tnumatto Ar- 
tlouUr lataBUiiallaa.— Varietf «t Cmma, uul KmuIu.— Trcaiiuial.— JUutomlMl 
Uk*R][*« !>««• >H 

LSCTOKB XVIll. 

SlmpI» DUIontloM; TraBBWtiis Coi«aiilWl, ?«tlii^|!o«l LuxaUona, SuUviMIob»^ 
etiology.— nifflwlti«« In BmIikcIoo, Tnuunati Bvdootioo, Afivr-TtcMoMnl^ 
Rtbltul T.aniUma.'Otd Laxuiow, Tr«aUiKU.-<oniplkal«d Lontlai».— <.'(»)- 
gtBlUl Lautl«!», P- M3 

CHAPTER VIII. 

eVXSBOT- W OtJSDM. 
LEGT ÜBE XUL 

nifltoriaiil Bfinsrbi.— Ii^uriM Chna Urga UImIIm.— Twimia FonMoT Bii]lrt-W««»da. 
— Tiaaaportatioa u4 Cua at tba VoQD<ka In the KickL— TniMuU.— ConpU- 
«Med OunriMt^nctHTM. P-3M 



COAPTEB IX. 
BCBXe AJTD FUoar-BiTxa. 

LRCTCBE XX. 

1. Bum« I Oiftd«, XlU«, l^«ata«nt.-^(uw(rohe.— 6trak« of Ll|tl>U>I"ir-- 
Vtm : 0ml«.— OMMnJ FtmjIdji, TnaRnaot.— OhllUiiiu, 



Froil- 

p. Ma 



CHAPTER X. 

JCtmt KOX-TKAVXATlU tStLAMHA nOS Of TOS SOIT FABTS. 

LECTTBE XXL 

tivMnI Xtktog; »f Aoot« loflMumOlot».— A«ut« Tatarnmadop i 1. Of ibo Cntli. 
«, Efjntpabtoailnlluunutlvn: t, Puniool«; •, CwViuuletAMlmuh TuauU Ua- 
llCM. 9. Onii» HaooM Udiubrano). 8. Of |]MCc1IaWTi*M*, Aeota JUNGatM«. 
4. Of tka Uudcs. 0. Of Ui« 8«n)aa Ucinbnii««, BbtaÜM «f iha Tandooa, mi-1 
ftnbonUiiMMi MiKon Bon« . . . p. iTT 



CHAfTER Xr. 
AC€Ts lyruuiJtäTioxs or ra* ao.vxs. piatiosTtcrx, axd joijm. 

LXOTUSE XXII. 

Anatooir-— AoBU PartAatllU KudOitMlinjretltii of tbaLoot Beoea; SjrRi|>tMiu, Tu^ 
taluUiwa iB BawlntlflB, Suppuntloa, K(«ma4a, PnapiMU, TnatacnL-Acule 
Oatftia In 8p«Bg7 Bodm.— Multlpl« Aont« OaUMHjrallÜa.— Awt« iBianmatlona 
af tba Jolau.— H7ilrof>« Aeutua ; Bynptoiu, TKaUnattt.— A«at« Supparatlv« ]&- 
ItMunatlaii* of J(»48U: Symptenti, Co«ne,TreatBiMU, AaaiMaf.— Amt« Anlculir 
RliMinatUn.— Artbriti*.— UiCaataUo lalacomalMii* af Joint« (QoiwrtbiMl, Pj- 
tal», Poarpond), p. »0 



APfSypiI TO CBAfTTltS t-Xt 
B»vle«.— OancTBl KaiiMriti *b«<ri Ami« laOftumBlian, . 



r. m 



CONTENTS. xiii 

CHAPTER XII. 

LECTÜBE XXni. 
i>t]r, Mobt Gan^Tene.—Im mediate CftUses.-— Procesa of Detachraont.—VariotleB of Gan- 
grene Bcoordinf; to tbe Remote Cdiuss.— 1. Lois of Vitaliij of the TUsae ttoia 
HeohanicAl or. Chemical Csubbe.— 2. Complete Arrest of the AfSuz and Efflux of 
Blood.— Inoarceratioa.—ConliiKied Preasure.—DeonbituB.— Great Tension of the 
Tiune.— S, Complete Arreit of tbe Bupplr of Arterial Blood. — QaDgrena Spon- 
taneft. — GangrenB Benilia. — Ergotism.— 4. Noma. — Gangreno in Various Blood- 
DiseMea. — Treatment, page 326 



CHAPTER XIII. 

ACCIDENTA-L TBAVMATIO AND INFlAJafATOBT DISEASES, ASfD POISONED 

WOUNDS. 

LBCTÜEE XXIV. 
L Local Diaeases which maf aooompanj Wounds and Other Points of Inflammation : 
1. Frogreaaive Pumlent and Purulent Putrid DiffiiBe Inflammaüon of CcIIuIbt 
Tiaaue. — S. Boapitol Gangrene. — R.Trauinatio Erysipelas. — 4, Lymphangitis, p. 3S^ 

LECTUHE XXV. 
S. Phlebitis; Thrombosis; Embolism. — Causes of VcaouHThromboHia; Various Meta- 
morphoses of the Thrombus. — Embolism. — liod Infarction, Emholio Motoatatic 
Abysses.— Treatment, p. SS3 

LECTDEE XXVI. 
IL — Qeneral Accidental Diseases which maj- accompany Wounds and Local Inflamma- 
tions. 1. Traumstio and Inflammatory Forar; 2. Soptio Fever and Septicemia; 
8. Suppurative Fever and Pynmia, p. SS2 

LECTURE XXVn. 

■L Tetanus; 6. Delirium Potatorum Traumati cum ; S. Delirium Nervosum and Mania. — 

Appendix to Chapter XIII. — Poisoned Wounds; Inacct-bites, Snake- bitea ; Infcc- 

tifjn from Diaaecting Wounds. — Glanders. — Carbuncle. — Discoaca from Moutba 

and Claws of Animals.— Uydroplio bis, p. 386 



CHAPTER XIV. 

ClinOSIC INFLAMMATION, ESPECIALLY OF TUE SOFT PARTS. 

LECTURE XXVIIL 
Anotimy; 1. Tliickening, Hypertrophy ; 2. Hypersecretion; 8. Suppuration, Cold 
Abscesses, Congeslivu Abscesses, FiBtulo!,Ulcerotion.—ResultB of Chronic Inflam- 
mation.— General Symptomatology. ^Course, p. 403 

LECTCRE XXIX. 
General Etiology of Chronic Inflammation.- External Continued Irritation.— Cou see in 
the Body. — Empirical Idea of Diathesca and Dyscrasite. — General Symptomatology 
and Treatment of Morbid DiiitliescB and Dyacraaite. 1. The Lymphatic Diathesis 
(Scrofula); 3. Tuberculous Dyscraaia (Tuberculosis) ; 8. The Arthritic Diathesis; 
4. Tbe Scorbutic Dyscrasia ; S. Syphilitic Dyscraaia, . . . .p. 410 



XIV 



COMEXT». 
LECTURE SXX, 



Loett TnMncBt of Cirotiio LiBaraBiolion: Siwl, CoRipreaatOD, Uohi Wanntli. B7- 
drofMiUilo Wrafia, ReactbcnUi, AnlipUogUlto«, DerWativu«, Fouuiitla, Ssloiu. 
HoxB, tbe Dot Uon vt' *i1> 



CflAPTEB XT. 

ULCEK3, 

T.ECTDBE XSXI. 

A(Mt»in}r.— Eztornal pMoUariiiM of VJten ; Form «nd ExUmt, Bu« and SoeMCicm, 

EdjpM, Put« aronnd.— X.AU1 TrtAbsont MMtdiag to tho LamI CoBditioii of the 

Ulen; FusgMU, C«Uo«i, PittTi<l, PhoKedcaic, UauMu Ulottn, Eliobff, CöMin- 

ned Irrit&tioD, Vwou CongwU«», D^mruUI Cmum, . . . , p. 4S4 



CHAPTER IVI. 
CB£oxic nrrLAMXATiox or t/ik pbhiostsusi. or tub jionji, asd 

LSCTDiiK xzxn. 

ChronJo r«tio*tlit» and C'rita Su[>«r*c'*lU.— S^nptMn*. — 0«t*«fl»7l««.— OnlMtpIulie, 
Snppuraliv« Fonsi.— Anatom j of C»rUi. — EUolo^f. — U>j[boi>üi, — CoKililiuUaD 
oTVariMia Fomu, , ' . . . . . , p. U^ 

UCTCBE XXXUL 

PrlmuT C«:itt>l, CUionio OililU, or CurioB.-^jriciito«!».— 0«lllii Intcim OaUopIna- 
lie«, SvppuratiiK, rBUfrota.— Abfocfs of Boon .— CwBMa«lh>m.M>«ÜÜ» villi C»>- 
•M* UaUsioffbo«*.— 'nib«rale*orBono.— DingoiMianrCaticB.— DialoaUJociofÜu 
Boo"t ifi«r Uwb Pufiol Dcatroelion.— CoogMliiHt AbMcaua.— fliotoef, p. tiS 

LECTURE XSXir. 

Proem of Cure tn Carlo« Hid OoagMtloti Ab«maf««.—I'r^MlL— Central ÜMlih la' 
Ofarouio lallaiBBitiau of Uio BoTW^Aoooadair Ljmplutia EaUripiiaeaU,^ 
Tr«a(nieDl af Cartaa u>d OncMtloi AbaMraw.— BaMctioia la Ui« Cooti- 
mHj, . . p. 4CS 

LECTOBE XIXV. 

NmmcU.— Ellologj.—Aiut«nlc*l CMidÜiMia la Total aad PartUl NeetMU.— Sfmp- 
toai* and DUjpiMU.'— TftatabanL — SwquMirotoiuf, ji. 4;t 

IXCimEE XXSTL 

beUtk.— Aamo«;.— «TniMMat.— KtMogr^TtMBumt— OtfMnulMia.— IlTpcni«* 
plir and Ativpb/ of Bou, |ik «tt 



CHAPTER XVir. 
eaaomo lyFLAJOfATio.v of rns joiiers. 

LEOTDBE XXJCVIL 

Oaaanl Bonirb on ttiaDi(tliiKtitnklfi|t CbanctnlttlMorth« OMaf F<-rnit.— J. tun- 
gvn and SnppunUTfl ArtuoUr tnBAiniaall««« (Tdbwt Albiu},BrRi[>loaii, Auto- 
mj, Carica Sloe«, Buppunttloo, Atonl« JPvnu.— Etlolofj^— Coum and Pmt- 
nwia, p. US 



COXTENTS. 



XT 



LECTURE XXXVIir, 
Treatment of Tumor Albus. — Operationa. — Reflection of tbe JointB.— Criticisms on tlio 
OperstloQS on the Different Joints, page ei4 

LECTURE XXSIX. 

A— Chronic Serous Synovitis.— Hydrops Artiooloruin Clironicus ; Anatomy, Symp. 

toms, Treatment.— Typical recurring Dropsies of the Knee.— Appendix : Clironie 

Dropsies of tlie Sheathe of the Tendons, Synovial Hernias of the Joints and Bub- 

cutaneou« Mucous Bnrsse, p. SS4 

LECTCEE XL. 
r.^^hronio Bheuraatio Inflammation of the Joints.- Arthritis Deformans. — Malum 
C>>i03 Senile.— Anntomy, Different Forms, Symptoms, Diafrnosis, Prognosis, 
Trentmenl. — Appendix I.: Foreign Bodies in the Joints; 1. Fibrinous Bodies; 
2. Cartilaifinous and Bony Bodies; Symp tomato logy. Operations.- Appendix II. : 
Neuroses of the Joints, p. 534 

LECTURE XLl. 

Anchyloses: Varietiea, A netoiny. Diagnosis, Treatment; Gradual Torcc J Extension; 
Operations with the Knife, p. B46 

CHAPTER XVIII. 

CO.\'GK\/TAl. DEFOBVITIES OF THE JOf.VTS DUE TO UnSCClAJt AXr> XES- 
rocs AFFECTIOya and cicatricial COXTBACTIOSS.—L0XAIiTHR0SE3. 

LECTURE XLII. 
1, Dffijrmities of Intra-utcrino Origin duo to DialurbonccB of Development of the 
Jrant.— TI. DeforuiitieH occurring ouly in Children and Young Persons, caused by 
Impaired (ärowth of the Joint. — III. Defomiitioa from Contructions, or Pumlysis 
of Single Muscles or Groups of Muscles.— IV. Limitation of Movements in the 
J'lints from Contraction of Fascle and Lij/aments. — V, Cicatricial Contractions.^ 
JTr^fi/nifn^— Extension by Apparatus, Straightening under Annstbesio. — Com- 
pression.— Tenotomy and Myotomy. — Division of the Fasci» and Articular Ligu- 
iiicnls.— Gymnastics nnd Electricity.- Artificial Muscles.— Supporting Appara- 
tus, p. 5S8 

CHAPTER XIX. 

VARICES AXD ANKCRISXS. 
LECTCKE XLIII. 
Pirf-vi: Various Forraii, Canscs, Various Localities where they occur,— Diagnosis. — 
Vcin-stnnes.— Vurix Fl stulffi.---TreBtment.— Varicose Lymphatics, Lymphorrhojn. 
—Anturiems ; luflnmraation of Arteries.— Aneurysma Cirsoideum. — Atheroma. — 
Various Forma of Aneurism.- Their Subsequent Changes.- Symptoms, Results, 
Etiolony, Diagnosis.- TWoinwnt .■ Compreasion, Ligation, Injection of Liquor 
Fetri, Extirpation, p. C7fl 

CHAPTER XX. 

TUMORS. 

LECTURE SLIV. 

Definition of the Term Tumor.— General Anatomical Bemerks; Polymorphism of 

Tissues.— Points of Origin of Tumors.— Limitation of the Development of Cells to 

Certain Types of Tissue. — Relation to the Generative Layers.- Mode of Growth. — 

Anatomical Metamori>hosis of Tumors; their External Appearances, , . p, d'Ji 



JIVI 



COK TENTS. 



UtCTUBE XLT. 

Bllo)<V7 <^ Tumara ; Kliunuuk todueaoe.— Sp«cifla Infootion.— Sp«cillo BckcdoD «I 
th» IfTiUWd TlMQta ; iu CauM u olwnjri ooiwUititioimL— laUraa] Irritatkuw ; 
UyjuAbtiu» M to the CbtnuMr and Uodo cf tha Irnuni Aclioa^-Outtraa and 
PKi^iw»bi8otitar7,Malüple, tofecUoiuTuDon.— DfKonuia.--Treitt«ieDt.^PriB> 
qipln af llw ClMatUcntioa of Tumoi«, ....... p»v* *<>& 

LCCrtTEE XLTl. 

I. fUfOmidii/ a, Soft; i, llaid fUwoaa.— Modo of Ooc w rrdnaa ; Opnvtiona; Xl^pHiuv; 
E«M«««Bt; OtimM-oMMOa.^. L^itmataj Ajmbaioji OminraM; Coutm. 3. 
CioMdreoMlaf OooamtiMi Opvnuion.— 4. Maoawta/ Fonai; Opaniln«, r- *1^ 

LECTOBB XLVn. 
S. UfauM.^-t. Vminbu ^T. An^otu : a, Plnxlfium ; h, Cftrtrnoaa.— Op«n>ttoiH, p. WT 

LBCrPKB XLVUL 

L SsrwMMfi.— •Anttamr:a,GnDiitMtoBS««etin; t,Si>iiidl*-«an»d8arMKia; e,GUiil- 
aallad8«noeu>; tf, 8uUM«Banea»; «; AlvMlarSvMoiat/.Pl^tMDMdSuMaB. 
— dUttl Jlfr«u>*aM.— DlafpMMia.— CftUfMb— ProffOMi*.— Uml« of lB(W«lian.— 
T«fognfi*f.—CmtanX 0(t««Mi«Miia. — IWoaUal 8ar««BiA,— SarMOu of tlM Ibm- 
■u, «r tba SaSraiy Olasda.— 9. £fi Hf *w>t ali Q. A n aloctf.— lUlaOpiui to I««MMaU. 
— TrMlnunt, ............ .p.HS 

LECTCkK XLLX 

». ApitlMMta.— It. J4««MaMl«.— 11 £V^ mJ Ofä»natv.—7oBiBa}u CrUa of tba 
BldB umI Umoi» Maabnaot,— Hoo]>luale Cj»u,—CjiU of tli« Tlijnid OUnd.— 
Orariaa Cjil*.— Slwtl-CT**«, t>- OB« 

LECTUKE h. 

IB CWcfMOMU.— IDstofleü Bcuikrfci.— QonenlDMcripUonorihaAtMtociiicalSmti- 
iifa.'MaUaianibaMa.— foim*.— Topofraptijr.— 1. glduaod Uooous Mcabmik*« 
«itb Pannaaa EpltheUam<— 1 lilllk UUnds.— a. Mueotu Olandi wltfc Cyliadtieal 
KpitbellBKi.^C imtbqrmai UUmU, 8«Ltu7 Qlaod*, and Pratau Qland».-^ 
ThjToLd QUmU uul Ovarlaa. — TrMiuMui.— Brtaf Bcauln altou Uia Diac* 
wwls, ... ... ...... ^ttH 



CHAPTER XXI. 
AUfCTATtaxx KXAHrirrz-tTtoxs. asd «e^scnoKS. 

LECTPRE LL 

Inipnriaouii <'( lite*a 4>pcnitii>na.— Ampul niioiu anil BxArUoulottma.— li>ll nation a.— 
Mkltt'iiU.— Attar-Trastnsat.— t*rri|[iuMi>.'-^oui«al Stnmp«.— Artifltitl LliaW.— 
Hi«:ar]i. — Ri'Miviian of ttaa Jalnia. — Ilinory. — to<H(»i^iu.— U«tli«dt.— Aftar- 
TnWmnni p. TW 

Amaipnt &<I<Ilil*Mfti}ailheEtff)uliOnnnan EJitioB, p. T19 

l«nmx. f . TM 



LIST OF WOODCUTS. 



1. DingTam of coanoctive tiittue, vlth CBpilluricH, . , . . . 

S. Diagram of iocidion, capillaries closed by blood-eliits, collateral iJistciition, 

3. Diajuram ruprcsentiDg tiie Hurfaco of the wound unllcd by iDflnmmatory nair 

(■irmBtlon, ..,,,.. 

3 a. VcHsels from mesentery of frog, ..... 
3 a. Development of vessels, ..... 
3 c. Vessels in vitraous body, ...... 

4. DiBftam of a wooed witb loss of substance, . 

5. Fus-ctlls from fresh pus, . , , . ■ , , 

6. Diagram of graoulation of fl woand, .... 
T. Fatty de^oiiemtion of oclls from griuiulati'>n-<, . 
7 A. Epitheliuni of tlie oomcaof ofrog, .... 
6. Corneal incUion tlireo days old, ..... 
9. iDciscd wound twenty-four hours old, .... 

1". Cicatrix nine days after an InciMon, .... 

11. Oranulation-IinEiue, ...... 

13. Youngcicatricial tiHsnc, ...... 

13. Horiinntal section through tho tongue of ado);, 

14. Same, ton days old, ....... 

15. Same, »ixtceii days old, ...... 

19. Granulat ion- vessels, ...... 

17. Seven-days-old wound in the lip of a dog, 

IT A. Micrococcus, ..,..., 

IS. Cicatrix from tho upper lip of a dog, .... 

li>. Euda of divided inuHcuiar Obres, ..... 

•2-\ Begcncrative proeeases in transversely-striated muscle, 

'-'1. Kci,><.'neration of nerves, ...... 



51. 
33. 
33. 



A, Nerves after division, ...... 

. Nodular nerve-terminations in an old stamp, 

Artery lif^tcd in the continuity, . . . ■ . 

Tnntver$e section of a f^sh thrombus, 

Tranitverse section of thrombus six days old, 

T«n-dayB-nld thrombus, ...... 

Completely-orgnuized thrombus, ..... 

Longitudinal section of (he ligated end of an artery, 

Piirtionof a transverse section of s vein, with organize J thrombus. 

Artcr.v, injected six weeks after ligation, , . 

Artery, injected thirty-flve nionth» after ligation. 

Artery, injected three months after ligation. 

Artery wounded on the side, with clot, .... 



51 
52 

M 
flu 
6>i 
67 
73 
75 
77 

rs 
rs 
ea 

83 
S3 
81 
S4 
So 

84 
87 
S7 
108 
113 
114 
115 

lis 

IIQ 
117 
119 
120 
121 
122 
1S3 
123 
lä-t 

la-i 

137 
1-27 
V'S 
135 



XVIII 



LIST OF WOODCCm 



U. Anearfun* trainoKtInim, ..... 

M. Varix kdcutUiiimIcu», ,.,... 

n. .\neuriauia T4rico«aa), ...... 

H. Granalixr and cj7«ullJna bninttoldiD, .... 

SSl DotMtiiiicDl of <la>d coDDMlivo tisMie Id «onlicicd «oinuU, . 

40. CcnlnlMxlnfatoni brmdiialuurjr, .... 

41. ErulMd nidiUo Infer, ...... 

411. Ann torn aM, wltli Mainila and clavioto, .... 

4). Longitoditial mmIoo «f ■ fniclnr« li>tir dty old, 

44. lKagran«fatoBfiludli)al*eeiinB«rarra«iur« niti-ciidafsoM, 

45. INaitnunvrakiii^tadinUicction of alhKliira iwcnlj-losr week* dil, 
4fi. FrMture. «Lth dUliMiatian, Aftur iwcBtjr.iGTcn dav«, 
47. Old anitEd obllqao tnetvt, ..... 
4a. L'>nKituiltn«iteetlontbiuitf[ht>i«< conical u)l..ti>nM, 
4Vl liifiamtiulorjr naw forualloB in liavcniau caunli, 
M Uiitfl^Ktiofi of )D0Mniiuloi7 iKOflaaia »n iW iuri'*t« of tl>» 1>«d« and in Ui* 

IliitvnUn canals, ......... 

Sil JUtUräll^-iDioctcJ citcmol calluit, flTe dn.T* old, 

n. ArtiS«l»Uf-uiJM(cd tnnivcnvatciloB, vlidaclajaotd, . 

n. Of«Uyiiig«alluaoDllMmuliwa ofa bollow UoBc, , 

SI. DcUohmcfit «f a FoporAeUl |>mcc of a flat lionc, 

U. J>«tMhiii<i»t of ■ ncvro*cd pordo« of boae, 

AS. FrMtuio of a lonx bono villi rxtcnial nouud, 

n, KevKmimottttmtiiiivtUacottomar, .... 

fla. Bollotaof vartouintj'ka, ...... 

n. TiMuaBB'abnUat'rorMii«, ..... 

60. Oiukat<4MtBn«<)rfkiiiuraiMlilbia, .... 

<n. TneMoflicIiliiia;, ...... 

•f. ConjuDBüvaalfeciHl «ilheaUrrb. . .... 

83. TiMiuc rrom a pNfnce ir.lHtr«t.»d frcm iDfiamtnalian, 
BL J*iinilerit tnfllt ration of Ihe cnlii ciMmmire tiitue, . '- 

CG. PnrvlcDl inflltratinn of tb« cclhilai ntarnbrati«^ . > 

flO. Vtiiulaof Ibe wallBor*tiabaM4>, .... 

90 X. Gro<nh «if funcu* from tli« oomca of a ralbiti 

VT. Vcnotti llirocphn«, ....... 

98. V*ver cur*« after «mfxitfttioQ of the arnii 

W. Fvrcregrrc atiet tciv<tioa ofcaliuua «riit, , 

V>. F<TGreurv«iii i-i7*ipclu, ..... 

"I. F«T« ttifr in »rf'tii'a'mlii, ...... 

1 1 A. Giaat mIU fron ttit>«ivVa in vartou» «ingca, 

71 s. Uinuio tulitrelM io tbe |>trltoa«aBi and oii ■ etiebral ute>7, 

71 1. Mimite KborclM an a ocTtliral arurr, 

M. CafaneoittslMroftha left. • ..... 

tL Ciranolatkiaaof aoMniDonnlocr, .... 

;4. Cariaa mintIIcuIii nf Aa tlWa, ..... 

73. Bactioit (if a placo ofcartaoa boo», .... 

73 A. Oalilii Bialarlttana, ...... 

7L DiMpFtaaranc« fYchalkj' aalla frnm peri|iborT ef bona, 

77. Sdarowd Ubla and ftfnur, ...... 

78. Prtai of catMsa d«(«iiataliaa In ibo fflnal eolntno, . 
n. I>t«ln(lion ftfthaTort'bTalertliitnn, .... 
80l Total DenDM« of iba diaph.viU of ■ bdlftw boM, 

SI. T«UlBMT«B>iiof ihodiitrliTaUofabotlowbeiMMitlidvUdiadMqBMtnnt, 4S4 
m Total BOoioaU oftke du[>lif «U of a LaIIow boo« aAtr nmo«a) DitttpUtUvm, 4S4 



tl3T OF W00DCÜT8. 



XIX 



83. ToUl neorosia of th« dUphysu of the ferauT, . 

81. Total UMTosu of the diaphyaia of the tibift, 

85. NecKsiä ofthö lower half of ÜspbjBiB of femur, 

8«. The bfiiiy eitracled fVom FiK. 86, . . . 

87. Diigram of ptkrliäl nccrosLa ofa hollow bone, . 

S3. Siagmn of Fig. ST in the luter atngL'», 

89. Tig. 88, Biter removal of tlie ji^quoilrmn, 

H. Scapala of a iirg, rcai^cttii with and without perioitcum, 

91, KacbitiomBlfofiDnliuniiof tholeg, 

«. WnmnnwUhflitensWu oateomalaoia, 

M. Section of Icnea-joint with fmiuou« ioflaiumAlirtn, 

M. DegemmtloBorcajtilftgein fungona inflammation, 

»5. Sab«]i«ndrBlc»iciortliutatragaluR, . 

96. Atooio ulceration of <!Ärtiluge tjom the knee-joint, 

»7. Diagram of the afdiliBrjgiili;(li(in, 

»3. Htraial pnottcsiocs of aynovial membrane, 

K. DegeaBratlon of the oortilage in utluiiiB deformani, 

liW. 0*twphylea inarlliriüsiiL'foroiaus, 

101. FungoUiinflsinmoticnodhi; elbowjoim, 

liH. Osteopiiytttf Jnjirtliiitis Juformaiis, 

lOS. MulnE>K'arti(^ulurt»diea, 

104. Band-like ftilheaioni In a rdit^tted elbow-joint, 

109. Adhesion of articular eurfacde of the elhow-joint, 

10«, ElMW-joititanctijilojieil by bouy bridges, . 

IW. Section of the »ljoulder-j''iiiIi 

108. Section of the sioulder-jt'iTJt, 

109. CnlrncEionof thefaSciBliitfl, . 
119. Cicatricial eontractiooB aft«r bami, . 
111. Cieatricialooiitractionfl after burna, 

113. SubFQtAacamljF-divLdflil tendon, 
118. Varices, ..... 

114. Cirsoid um^uriain of the scalp, 

115. Small fibroma, ..... 

116. From a myo-fibroms, . . . - . 
IIT. Vessels from s cutis fibroma, 
118. Neuroma, ..... 
US. FlIiTci-su'comBtnus neuromata, . 

110. Cartiing« tissue from cboodrouiHtii, . 
131. CboQdramaoftbe Sagen, 
12^. Odontomu df a back tootli, 

133. Bicclinii of anadoQtoma, 
124. Podunculated spongy exostosis, 
135. Ivary etoatosiit of tbeskuH, 
126, Section from an ivor; osteoma, 
1ST. OstiHvmaof tbeniUBUulnr attachments, . 
lii. Vi^tL^eljjyom a pklifurui angioma, . 
139. Jlosh-woft from acBvcmoui ftD^iom», . 

130. Tissue of ^Biiuhtion-BarMOia, 

131. Titaueor^lio-iBrcomn, .... 

132. Tissue of a splndlc-cellcd sarcoma, . 
183, Gi&ut-cella Trim a nnrcfmn, 

134, Gian^,eelled sarcoma with cjsts, 
18}. Cell-globules from a sarcoma, 
138. Muoana tiaane from a myxosarcoma, 



TAan 
485 
485 

486 
48T 
4BT 
488 
488 
489 
4V6 
601 
SOG 
608 
609 
612 
628 
631 
63S 
63T 
68T 
687 
643 
64T 
648 
648 
649 
649 
665 
666 
666 
670 
67T 
682 
619 
620 
691 
632 
622 
628 
680 
832 
632 
633 
634 
634 
635 
G39 
OW 
64(1 
S46 
64T 
648 
648 
649 
«19 



XX 



LIST OP WOODCUTS. 



no. 

18T. Huooun tUBun f^m ui adeDomyxoma, 

1S8. Alveolar Birooiiia from the deltoid muHle, . 

139. Alveolar aRrDoiiM fh)m the tibia, 

140. Central OBtcoMrcoma of the ulna, 

141. SectioDof Fig. 140, ..... 
14it. Cential osteoMTComa of the lower jaw, 

113. SectioD of Fig. 14S, ..... 

144. ■Comppitnticvitoruu of the thigh, 

145. Piirioatcal BDrcoma of tbo tibia, .... 

146. Section ofFig. 14Ö, ..... 
I4T. From uu lüujji-ji&rcDiiin of the female br«aat, . 

148. From Uiu curtioul lajcr of a liyporplastic Ijrmpliatic gland 
14». Sni'tioinof owart, ..... 

150. Frum a mufloua polypus, .... 
1Ö1. AdpinHuBcjftLi« thyroid, ..... 
15i. i.'riiii'iui:-ncilig cjiltliultul ciuicvr of the tip, 
1£S. yial epttUeiialouDceriurciiiU'chccki', 
IM. Ettfineiit« of an epithelial Cdri.'in<>iijii of the lip, 

166. From ancpitliäliul caDU«iof the hand, . 
ISS. V<<«H.~lafrumai3iTciuomaof the prnig, 
16T. Papillary form«ti(iiii.«r»villou* cancer, . 
158. UamoiarycaucGt.jidnout form, 
168. Soil maniroary csacer ..... 
lUO. From mauaiuiiry cancer, .... 

151. -LoDuoi^titi-'liiiuu frame-work of a cancer of hreast, 
IGS. Cancer of bniaat, tubular form, 
163. Cancer of tbu maniiun frnm ttoiitroi'hijdtiiwl, . 
IW, Vaioular net-work from a very young nodule, 
ISn. Vaaculnr net-work around points of •oftcning,. 
188. Onriii(.>Pliv(.Mi«i'Uü inflluaUuii, tic, . 

167. Citllular ittflUratioD offalt; tissui?, etc., 
IflB. Canacrofiliomui^uigluijdiiromuoie, 
16>. AdenoidcuDCcr ot'lliercctuni, .... 

189 a. Villousstiuomt, 

189 fl. Pummona, ....■■ 
1S9 o. From a ceictml tnmor, .... 
189». PlotirürmeaTPomn, ..... 
1S9 X. FroinacyllDdromaofthcorbit, . 



619 
6.'>1 
6.'>l 
do.'. 
856 
G.'>i1 
658 
6.-.7 

C58 
G>.0 

Gl» 
Grt: 
6T0 
67-i 
Cn<i 

657 

G^» 
C'SU 
6U5 
61'6 

esii 

6»T 

69H 
6U8 
6<Ki 
tC») 
TOl 
Ti)5 
I'll! 
ViW 

709 

7.->2 

754 

7.'.5 

7.'.r. 
756 



COOPER MEDICAL COLLEGE. 

tAN rilANOlSCO. CAL. 

and if itaf to ^ »v«mf»;W /nm the 
u 'der Uhiß -ptvlrjcl u-'.uUrt'^r. 



SURGICAL PATHOLOGY AND TnERAPEUXrCS. 



LECTURE I. 



INTlODUCnON. 



BaliÖait vf Bvrgürr U> lalcroa] Jledictiw.— KeMMity of tt« PtaaUkln^ Fliyriaiui 
btfnr nqtuistcd witli boUi.— HUtutkal Kemariu.— KUui« «f lUe Sl*d)' of Bar 
gtxj is UM Gwimii Uigti-aiibor'U. 

GKVTtBUBS ^ Tbe study of Burgery, which you begin with Uiia 
lecture, is now, in mosfc countries, justly regarded aa & ncocetäij for 
tho poutiatag phynoso. We couaider it a bapp^ advance that the 
ifiriaion of torgny from medioioe do longer exists, sb it dül fonnerly. 
Hie differeace between iotemal medioioc nnd surgery i» in fact only 
■ppareot ; the disüaction id artificial, founded though it bo on hidtor>-, 
Kod on tbo Iflx;^ and inorenRing litfrrnluro of gencnd medicine. lu 
tbecooneof this work your attention will often be called to the 
beqaeoOT with wliioh Burfrcry niutit consider tho goncral state of tbe 
body, to the anaJogy between the ilisonsi.'ä of tho external and inte^ 
oil part«} md to tho fiict that the whole dilTiTenoc depends on oar 
aeeiog bdbre as tiw ohaogcs of tissue that occur in surgical diseases, 
while we have to determine the aSectioos (A internal organs irom tba 
•ympCooi«. The actioa of the local distarfaaiKca on the body at largo 
Biait be understood by the Bu^eon, as well as by any one who pays 
especial attention to (lE.tca-Soa of th«! internal orgnua. Jn ahort, Ihf. 
fnyton can onij/ Judg« M/ely and comctljf 0/ thettat* o/ his p<üitsnt 
■eAoi ftciaatthü tame tunc aphtftician. Moreover, the pbyaicnan who 
|CO|)Oces rcfiMinf» to tn-it surgical prtticnt*, ar>d to aucnri solely to (he 
tnatment of intc'ni:i! 'Ii^'.-[is4%, must hart? some surgical knowUwIgp, or 
Im) win moke tho grofiseat blunders. Apart from the fact that Üio 
«Mtttiy physician does not always have a ooUeague at hand to wliwa 
he eta torn ori>r bia sqnrii'Jtl pntimta, the life of the pottctit often de> 
pettda on tbeeorrcct and mstnntaneoiis mrogniiioo of a siin^tml disease. 




ISTRODCCnoX 



MlicD blood spouU forcibly from a wound, or a foreign body 
entered the u-ind|)ipc, and the psticnt is threatened with suiTocaÜon, 
then Bui;^cat aid is rti|uirud, and quickly too, or tbc puticnt iüca. la 
otber cues, also, the physioED ignorant of sorgv-r}- nay do much liwmj 
by ttot reeognizinf,' the impMiaoco of a coso ; he may nUow a disMaaij 
to becotno iDcurable, and by lib dcfidvnt kncm-lodgcaiuscompcakabl«^ 
[njuiy, in a cnse n-liich tniglit bar« bocD rclicTed by early surgical | 
Lreattoent. H<>iico it is inexcusable fur a pbystciaa obstinately to 
Klitlc to the idea of only practising internal medicine ; still more inex- 
cuBciblc is it^ in this idea, to neglect the Atitdy of surgery : *' I nil! not 
operate, because in ordinary practise liiere is so little operating to be 
done, and I am not at all suited for an operator ! ** As if surgvry coii* 
etstcd only in operatiooB, I hope to gii-o you a better idea of ihij 
branch of modiclne tlian Is conveyed by the above remarb, which un- 
fortunately IB too popular. 

From the tact that aiirgoty hoe to deal chiefly iritb patent dla>^ 
eosas, it certainly baa an easier positioo in rt'gani to anatomical dia| 
Qoslii ; but do not regard this advantage too highlj;. Beaidea the faet J 
that surgical diseases also oflen lie deeply hidden, more ia demanded 
from a surgieol diagnoaU and progiKMis, and even in the treeltneot, tlinn 
front Üie tbeni|<euUo action of internal mcdiclna I do not deny tlutt 
in nuuiy respects inlemol mediane inay hold a higher rank, just on 
aeecnml of the dilficultiea it ha# (and often so brÜliantty oTorcomes) 
in localising and reoognizing disenae. Very fine operatioaof themind 
i$ often iwcessory to come lo a proper conclusion, from the comUnatton 
(>f symptoms, and the reaultö of the exuiuiiuiliu». Pliyaiciaos may 
point withprt<1« to (be anatonticol diagnosis ofdisoasesof the heart and 
lungs, where the carc-ful student suooeods In giving oa soeurate a de- 
flaiptioa of tho changes in the dt&cascd organ as :f he bad it riglii 
tmdor hü eyes. Bow wonderful it is to gain un oecumte ktwwledge 
of the morbid state of hidden organs, audi aa the kidneys, lirer, 
spleen, ioteetinea, brain, and spinal marrow, by tlie c ia m i n atioa of a 
patient and the combination of symptoms I Wliat a triaroph to dia^ 
nose diaeaaea of organs of which we do not know even the pliy^olo' 
gical function, 03 of the suina-rcnal cupsulcs ! This is some coitipeRsa< 
tion for the fact tltat, in inlcmal medicine, we must more frocpicnlJy 
adounrledge the impotence of our treatment than is the case in 
surg«ty, although, from the odvuicrs in anatomial diagnosis, we liare 
become more oortain of irhat we can do, and of what we cannot. 

Tho. irrilaLion of tho finer, cultivated portions of the mind in inters 
nal medicine !«, liowerer, ridily balanced by iJie greater oertaiuty and 
otitnieM of dinguoaitt and treatment iu surgery, so tliat tltc tm> 
hranehes of medical science aro exactly on a par. And it muttt not 



ISTRODÖCnOH. 



S 



beibrguttea tfant llieauat^niciU ilUigiicKti!) — I nicaa tlw rcroguitioi] of 
t^ pstLolofpoü diatigtis in tbe diaeMeJ orgau — in uiiljr uau means to 
the efi<l, u'bJcb is tin) euro of t)io disone^. 7?^0 tnie pr<Mfm»/or th« 
ftiy$icita are U> ßnd out tht catati of the morbiä proca», to pruff- 
■iiMft'oa/« tMcoune, fonduri U to afavorKiiM tcmtinatifm, or conirol 
if, and the»« are t^/ualty dij^cuit in fnlcmul and exttmal medicine. 
üdIj.' oce tiling tDore is required of the pmctical surgeon : lliis in, the 
kit of operaiiitg. Tti?, like evcrj- ait, liaa its knack; tLe r»ciii(jr of 
opcmting' S4>oo[u)wilj dcjvcnds on accurktc knovlodge of Bnnlonty, on 
pravttce, and on persoDul aptltiKlc. TliU npUttxle »my ulso be culü- 
rate«] hj ^KTfcvvmtj^ practice. Just rcmcmljcr liow IXtnosÜicncs su» 
Mcded i» acqtitiing fliicitcy in 6)>Cut:iiig. 

This knack, wUich is cfjtainlj iieccsAon-, has long separated sur 

[fTfiy frnm mcdicioo in tbc strict sense; wc may liistoricnlly follow 
this Bci»rfttkiD as it cooslantly became more practically felt, till in 
Ihia criitun- it ivos fmnlly recoguizfMl as iniprnctical and was a1)oU 
titled. Ttjc wonl " rliinirgt-ry " at once expresses that origioally it 
ns irgnnled as entirely iimnual, for it comes from x^lp and ^piyov, 
wbich litemlly mean "hand-wofl:," or, in tlie pleonnsm of llic middle 
spa, "haiiil-work ofchinirgfn'." 
LittJu OS it comes williio tlic »ope of Üiis work to glvcaconiplirtc 
sfcdcti of tbe bisuu;}- of surgery, it still seurns to mc inipfjrtanl lutd in- 
lemting to give yon a shart sketch of tbe cxtcmnl ami internal diy 
TckipcDCat of our M-ienc«, wlitch will eJipInJn to you »'nii' 
rioQST«gulAtini»a(reiMing the fio-cnll(f(l** mifdiiml Ntalf »till-' 
diAnmt ttates, A fuller history of surgery* can only be of use to jtm 
kennilrr, ulirü yoo alisU hnTC acquired some knowlfdije of the ralufi 
or woctblessncss of certain systems, methods, and operation«. Then, 
ihr hUtorioal devplopmpnt of ihe sciencp, cspadally as rvgnnls op- 
entt\-e surgery, yo«i will fii«l llie key for Eomo siupriamg and for 
MMne isolate vxpcricoce, also for much that is incomplete. Many 
things that may be Deoessary for tl»e oomprelienRion of the fiiihje<!lit, f 
shall roUte to you vhon speaking of the different diseases; nun. I 
ihall only present a few promincul points in the derckrptneat of txxt' 
rp »nd of its presont position. 

Among tliv people in fonnrr times, the nrtof boaling was inti- 
'jiiatcly A«tf>uml-<Ml with n-U}j:iou3 education. The nindooe, Arsbe, aad 
Bgyptions, as well ns the Greeks, considered the art of henh'ng as a 
nuuiifiAtaÜon niaJe by the gods to the priests, and then spread by tindi- 
ti'in. Philoloiri-*!» wer« not ngrei-d a,f to tlie age of the Sanscrit writ- 
tag» di»*nver*d not long sinco ; formerly tlieir origin was placed at 
1000-1400 K, c, now it Is coosiJcred certaiu tbat tbcy were ■wriltoji 
in the Grvt century of the Christian era. Tbc Agui-Vcdu (" Book of 



ßTRODUCTIOX. 



the Art of Lifo ") is tho most ttnportant Sanscrit work for mediane ; it 
is tike produoLioR of Susrutas, Ilveiy probnblj originated In the time 
of til« Rotnim Emperor Augustus. Tho Art of be»ling vas regarded 
u a wliolc, as is indicatt»! bjr tlio following-: " It E« only th« cDmbinii- 
tloQ of medicine and surgery tlut makes tlie oomplct« phj^ician. Tlio 
pb^'sioAD lacking knowledge of one of the«« branches is like a bird 
with only one wing.*' At that time suigierj' \ras without doubt by 
for the more advanced p«rt of tlio medical art, A large Duinl>cr of o]> 
entioiia and inalrumeutsare spoken of; etJil,it is Inily said " tlic he>t 
of nil instrumonia 18 tbchnnd;" tho treatment of wounds gireo is 
slnipto smI proper. Most surgical injuries were nlrcadjr kaovriu 

Among tho Greeks «11 medical knowledge at first centred In ^£11- 
eulapi»», a son of Apollo, and a scholiir of the Crntaur Cliiron. 
Vmny temples were built to ^sculapiiu, and the art of healing \jm 
haixled down hy tradition Uirougb the priests of theno leinples; the 
number of these temples induced various schools of vEseulapidcs, and, 
altlioiigli eveiy one entering tke temple as a priest bad to t^ke an 
natb, whicli has been handed down to our otvti limes (iilthcnigh uf late 
its geamncncss appcaw rather doubtful), ihm he would only teach 
tbe art of hoaliug to his sucoesaors, still, as appears &om various ct^ 
cumstances, even at that time llicrc were other phTsleianü 1>r-»idea ttie 
priest«. From one part of lhcoatli,o%-en,it isevident that then as now 
there were ph)*8iciniis wlio, as Kpeeiallst», confined IlicmBclTes to cer- 
tain operations ; (or it »aj-s : " Furthcnnore, I wlU never cut for stone, 
but will leave this opemlion to men of that occupatton." Of tlie 
iliffcn?i)t rarietJea of physicians we know nolhmg marc aemntc till 
the tiino of Jli/ipocratca ; be was one of the hut of tlie Asklepiadea. 
Bo was b<'>ni dCO B. d, on tlio island of Cos; lived partly in Athens, 
pattlv in ThessalL'in town», nml died STT R C at I^arissa. Wc might 
evpeet Utat medioiiie uonM l)0 considered scientiüeallf at this tiiof, 
when tho names of Pythagoms, Plato, and Aristotle, were shining in 
GreeJan ecienco ; and in fnet the worics of Hlppoeratüs, many of which 
are still preserred, arotme our aslunishmorit. Tlie cloar dasstcal do- 
seriptlon, the arrangement of the whole niatt^ri^d, thi^ ^'k^ regard for 
tlie bcaling art, Ibe sharp critical observations, that apiKac in the 
frorica of Hippocrates, and compel our admiration and respect for an- 
clriit Greece on tlila bmnch also, clearly oliovv that It is not a cose of 
blind 1>clicf in traditional n»c<Ucal dogmas, but that there was already 
a scientific and elaborately perfected medicine. In the Hip[>Qcmt>o 
scbools the art uf healing formed one wlitdc; moJicincand surgery 
were uniled,,but thcKi were various classes of roedioa] practitiooicrs 1 
besides tho Asklepiades there were other iKlueated pbysicianB, as well 
as moR) mochankally instructed medical assi-itanls, gymnasts, (luscks, 



ISTROUUCriOS. 5 

»nd irorkera of miradea. Th« pb^siciaiis took eobt^ars to tr&iD in Ute 
ut of ItMtling; And, ofloording to som« Kiiutrks of Xenophon, there 
vers ftlfio special anny pliysiciotis ; cspvcinlly ia tlic PcnÜHti wars, 
thcfy, together mtb the soothsayers and tlute-playe», had tlieif places 
near the royal tent. It may be readily understood tliat, at & time 
vrbcn so much vaa Umught of corporeal beauty, ua was the caoe 
among the Greeks, exteniat injuries irould claim »pccial attctitioa. 
HoDCe, amonj? pbyKicinns of tbe Hippocratio cm, fractures and Bprmns 
were paniculnrly st<idittl ; stjll, some screr« openitiona arc treated o{^ 
w» nlso nombcrs of instruincats nod other apparatuses, Theyaeem to 
bars bceii rur}' liiicku-iird n>^rdiiig; amputations; probnbly tbe 
Grcdifl preferred dying to prolonging life after they were nititilateil 
Tbe limb was oulj rentoved wlieo it was actually dead, gnngrettous. 

The teadiings of Hippocratea oould not at first be earned any fiu^ 
Iber, for lack uf knowledge of anatomy and phyuology. It ia true 
there was a fnint cfTort made in this direction in the scieiitilic seliools 
tif Alexandria, which äourielied for some centuries under the Ptole- 
mies, and by moans of which, after the vare of Alexander the Great, 
the Grecian R|)irit was nprend, at least temporarily, OTCr part of the 
Orient ; but Ibe AJesandrian physicians won lost theiDSotvcs in phil- 
nsopliieal syfttesii), and only advaneed the »cicnce of bealiog a little 
lijr a few anatomiral disoovcriea. In this sdiool the art of hculin^ 
iras at first divided into throe separat« parts — dietetics, intomnl mcdi- 
eiue, and surgery. Along with Greeiwn culture, their knowledge of 
tucdichic waa ahto Ixnught to Home. The fin>t Roman physiciuosircrc 
Gnrdaa »laircs; ilm tVeedxucii amoug* tliein were allowed to erect 
hatha; here, int, hartwrs and hathew lieeamo our nTol« and ool- 
loague^s and for a Icmg time thoy injur»! the rcj^iXTlabllily of tlte pro- 
feMiaa Id Itomc. Gradually the pliilosophicnlly-miuded took poae«*- 
ID or the writing of Hippoeratea and tlio ^Uexandrians, aiHl them* 
•Irea practisird mrdii.'itip, ivitliuut^however, adding to it muclftliat was 
ttcw. TTie great loek of origiual sotcntific produetinn is shewn in the 
cncyelopedial rerision of the most varied sdcntilic works. The most 
eel«t)Tat/>d wnrk of this nature is the " J^ Artihtt " of AuIm Com^ 
I'- ' ' (from 25-30 a c. io 45-50 /. i>., in the tJmc of the Em- 

!■ " nuA and Claucliu])). Kight hooks of this, ".ßö -VcrffcwMf," 

havo onme down to our time ; from theiie «e know the 8tate of mmll- 
rJiie and surgcrr at that Umc. Vnluablu as are these rellos fi^mi the 
RtHuau ages, they arc only, as we bare esi<l, a compendium, such aa 
tft oFbMi pul)Iis1ied at the pre&tmt day. It has even been denied tluit 
C^vn wu a jiractisiag pliyaJcion, but tliis is improbable ; from his 
irritinga wv muait,ata)l event», credit C(f/iru4witli using his own judg> 
ment Hie sm'enth and aghtli books, which treat on surgery, oould not 




8 



INTRODUCTIOX. 



have boen wrilteo so clnu-ly bj nay on« wbo had no pnoUcal knovl 
odgo of bia eubjeot. Hence no see that, eiace tho Üme of Hippo- 
cratet ftod Ibe Aloxandri» uhoot, surgery, cspeöallj the opcntiro 
part) liul Ruulo no great progreiui. Cebta spenlu of pliisLic opem» 
tionstof lieriiia, und jfives a motliod of smpuUtioii wliich is stilt oocu* 
uottoUy cmployoU. Odc part, from tlic Mvcntli book, where be *pcolu 
of the qutUficatJolu of tbo perfccL sui^^o, is quite celcbcatet), && it 
is charactcristi« of the spirit which reigns in the book ; I give it to 
you : " 11)0 Burgi'OQ sbouid bo yoMog, or at Icusl Uttle advnnccd in 
uge, with a bund nimUe, firm, und never trpinbling ; eqimlljr dexter- 
otu with both bands; vinioii, stuiq) und distloct; bold, anuicrciful, so 
that, BB bo vrisbcs to cure his paticut, lie may uot be movrd hy hla 
cries to hasten too much, or to out less than is necessary. In the 
aame vay ]et him do every thing as if he were not affücte«! by the 
cricB of Uic patient" 

Claudiua OaUnva (131-301 a. d.) mii»i be rcf^anlcd ns a phe- 
DometKm among tbo Ilomnn physicians; eigfaty-tiirec uiidoii1>t<?<ny 
genuine incdical writings of fais Iulvc come dovra to uSi G<üen rc- 
umed af[ft[n to tlic Hippocratio belief, tbttt ob«cr\-ntion must r<irm 
tlie (bundatioo of the »it of benling, and be sdvaiKCd anatomy grent* 
ly ; he mnde dissDotioos «htclly of asses, rarely of huuinu being«. 
(Saien^t (inatomy, as irell as the entire philosophical system Into 
wbieh he brought medicine, and wldofa seemed to him e\'eo more iro- 
portaiit Uinn olMtcrration itself, Ijks »ttHxl finn over a thottsand years. 
H« occupiesa very proouucut position iti the liietory of iiicdictue. He 
did Utile for surgeiy in partieuUr; iudcetl, be pnietiäcd it little, for in 
bis time llicre were special surgKnti», cilLer gymoasts, batlienf, or 
barbcis, and to unfortunately surgery was handed dornt by tnidilii.>[i 
as a meohanicid art, while intcmni medicine was, and long remaiixtl, 
in the hands of pbUosophic phynidanii ; the latter knew and imuh 
mented fiedy on the surgical writings of Hippocratft-, tho AtaeanJri- 
OfU, aod CeUfi», stilt they paid little altenlion to surgical prnclit«. 
As we are only gi\'ing a (&\ni «kcloli, wc migUt here skip scvenl «e»> 
tunes, or eren a Ibuusand ycar^, during wlüdi sundry made scarcdy 
any progm«, tt>deed retrograde«] oeensionolly. The Bynntin« era of 
the empire was particularly unfavorable to the ndvanee of science, 
there was only a short fljekerittg up of tlic Alexandria siJiooL £7ea 
the i»(i«t celehnted pbyRiolans of tho Inter lEoman timea,^n/yffM« (in 
the Uiird wnturj), Orihamus (320-403 a. d.), AScxattäer o/ TVallct 
(3SJM!05 A. t>.), J^vliu ofJEgina (6M), did relatively little for sur* 
gcry. Soiue adranoc bad bi,-<cn miido in the position and sfhularly afr 
tainnwDts of phyaidans; under Nero tliere was a grmnasium ; uoder 
Hadiiaa an athetueum, scientific institutions where medicine also was 



»TBODCCTIOS. 



tui^t; atul«r Trajnn, Uiere vna, a speöat medical sdiool. Milituy 
nSiUcal Bun-ioe was alteiuled tx> among^ tlie Romans, and ltii>rc vera 
■iwdsl court p1i)-aioiuis, ** nn:hi»tj^i pdJutiui,'^ witb tlic title of " per- 
feetJssimc" "c^nc»," or •* cornea aroliiBtrorum," jiist a«, «mong the 
Gennuis, ** nofrathe," " G«h«imratlie,'* "Luibantc," utc. Tliat, as a 
r«sulL of Ü10 fall of sdcocc io tlio ByxaoMno reign, the lut of hroling 
did Bot totally degcoentc, is duo to the Arabian«. The wonderful 
elevation that this people attained under Mohammed, after tlie renr 
OOft, aided in preserving adcncc The Hippocmttc knowledge of 
medicine, witli the later additions to it, paued to tJie Arsbiaaa 
thsoqgh tlie Alexandrian school, and its branclie» in the Orient, the 
sdiools of tlie Ncatoriaos; tfaey cherished it till Uicir {lowcr was de- 
moUahcil hy Cbnrles Martd, and returned it to Europe by yrt,y of 
Erpain, though Eomuwhiit diangml in fbnn. Jtftaset {650-932), Avi- 
emna (^0-1^37), AHucasu (f llOß), aad. Anetuoar i\ 1162), are the 
tnofit oelcbrate-i, and for surgery the most important, of Iho Arabian 
pliTsicinn)) whosy writing« hare boon preserved; the writiiig;3 of tho 
tall«r arc t[>e roost important for »urgery. OpcrattTC aurgory BufTcrd 
iniaitjy from the dread the Ambtans had of blood, nbicb was pnrtJy 
dtie to (lie luws of the Koran ; it etiusod the employment of the oo* 
lual cautery to au cs.tetit tliat we can hardly coniprelicud. T\ie di»- 
tmotioo of aurgical diseases and tJic certainty of dia^^oeis bad do- 
ddedly incrooaed. Soientifio inslitiitiana were intich otdtivnlod by the 
Axaliians; thennAtcelebnted was tho school of Conlora; there were 
al*e lKie[ntala in many places. The study of modicine was no longer 
efaiafiy privat«, but tnoat of the ntudents hod to complete their 
studies at v^imo ^^-ieiiltCio iiiKlitiitioii. Tliis also li^ul Its elTect on Uie 
Datäoosaf the West. BL*$idi'sS|»iin,Il«]yivu» the chief place wlieie the 
fcäeno« w«r* eultivatcil. In »outhom Italy thens wa« a rcry oele- 
linil«tl medical school at Salenu) ; it was probably founded in 803 
by Cliarlo« tlm Great, and was at ita zenith in tho tweUUi ccntiiiy ; 
aooordtng to the most recent idca^ this was not aa eodesiastical 
sclunl,hut aU the pu|ülB were of the laity. Thera were also female pu- 
plla,, whn were of a litenuy turn ; the best known among these waa 
Th/tula, Original obKrvotions wore not ins'lo there, or at least io a 
««ry «liglit extent, but the writings of the ancients wi>rc! adhert'd to. 
'Ott* achool is also inlert-iting from llic fact that it i» the 6rst cor- 
puratiou that we Aud baring the right to bestow tho titles " doctor " 
and •* mat-ister," 

i and Viv^ gradually took more interest in science, and 

loxi„ utcrsities; tlms universities were fouiMLed in Naples in 

VtM, En Paria and Padua in 1350, iu Pans in 1309, in Salntnanca in 
1343, la Prague in 1318, »nd they wore inrrated with tlic right of 



B 



INTRODCCT[OX. 



conferring academical tionont. rfailoAophy woa tlie gcteaoe to which 
moat stteocion wis p*id, oncl for a long time MecUoIoe preaerred her 
philosophical robo in the anircrsities; in some oucf thc^ mdhorcd to 
G&len'ti «j'stttii, in oUicrs to tho Ambinn or to now ine(ltoe>*pliili> 
ROplucal systems, aoil re^stcrcd sll their obserrations under these 
hatdt. Ti>is wu tho grcAt obstoclo to the progross of Iho natural 
aeienoes, a mental sUveiy, from which evon men of intellect could uut 
free thomsplrcs. The anatomy of Mondino dc j/uzzi (^Sli) differs 
\-ery Utile from tliat of GalcOf in epitc of the fact tliut tho aulhur 
bases it on disseetioo« he made of some human Ixidies. In surgery 
there wera no actusl advance« ; Jia$^rancAi (fl300), Outdo o/ CauiU 
aco (beginning of the fourt«cntU ccntiixy), Branca (middle of tlie 
Bftcontb centurr), an? n few of the noteworthy surgeons of thosu time». 
Before passing to tlie flourishing state of the natural sdences aod üf 
medicine in the aixtccnüi century, we muat review briefly the composi- 
tion of the medieol profession in the tiroes of which we hare been 
spenking, as this is important for the history. Fir^c, there were philo 
eophically educated pliysicluw either lay or monk, who had learned 
medicine in th« universities or other sdiools; E. c, tbey had studied 
tlie old writing8onatu.tomy,8urger^-, nndspudul medicine; llieyproo- 
tiscd, hut paid litUe attention to suigcry. Atiot)>cr acut of leamisji 
was in the cloisters ; Lhe Benedictines espeeially paid a great deal of 
attention to medioino and al«o pncüsed surgory, although Uie supc- 
riora disliked to sec thix, and occasiooalty special di^iensatioa tuul tc 
be obtained for an operation. IIk regular praclining physicians were 
•ometira«« located, smnetimea tmrelling. The fonnor were usually 
i>ducMted at wüentiäc scIkioIs and received {tcrmission to pmcti»e on 
cirtaln coiiditiun». In 1229, the emperor Frederick 11. iiubüsheJ a 
law tlut Die«« physicians should study logic (tliat is, philoeopliy xnd 
plillology) tlin« years, then medicine and surgvry Svc years, and tbm 
pnctisc for snmc time umlcr an oMcr physiciitn; bcforo recciriag 
penniaaioa to prootisG indcpcndcutly, or, as an ezamiocr lately said, 
ofphyiueians who had just received their dc^grcc, " till tlii^ wore k't 
loose on the public." Beides these located physicians, of whom n 
great part were ** doctor " or " master," tierowcrc nuiny " tiavefliug" 
docton^aeortof ^^ trarelling student "who wont through the mar1it>t- 
towns in n wsgon with a merry Andrew, and practised solely for 
UMHicy. Tliie genus of the so-called charlatans, which played air iin 
portant part in the poetry of the middle agi^s, and is still gleefully 
gre<-ted on the stage by tbc public, carried on a rascally trado in tlie 
uiiddlc ages ; tbey were u infomous as pipers, jugglers, or hangmen ; 
even now these travelling scholant arc not all dead ; although, in tbo 
Dhteteenth e^itury, they do not ply tlioir tnidc in the markot-[J«ce, but 



IKTBODCCIIOIC. 



ji Um (lnvrjng>«ooins OS fforlcers of niradoE, e^woiatly as Chiiccr-doo- 
tan, berb-doctors, somnxinbulista, etc. I<et us now Inquire ibe rela» 
ttoo, of those who practised »urgcry, to tbc aborc company. TTib 
bnmcli of mecUciDe wu occatiooally resorted to by altnoet all of the 
■bore; sUU tbcrc were special sorgcono, wbo united into gttilda niul 
fiannod boaonble societies ; they tx:ceiTcd iheir practical koowledg« 
Inst from a master, under wbosi they studied, and niboequeotly from 
books and edeatific iiisthutioiia. Surgical practice was c1ii«fly coaßiied 
to these peisODs, wbo were mostly located, but sometimes trarcUed 
■boiR ■« " hcmia doclo«," ** opamtoc« for atooe," " oculiste," etc. Wo 
shall become sotjuaiiited with some excellent muii among ttiese old mas- 
tcTT of our art. Bc«idca tbo aborc, surgery was also practised by the 
** hstbors,** and later by " barbers " also, as it was among the Kocnaao, 
■lid Ihey were permitted by law to attend to " minor RUfgery** e. jr., 
Üuy ooold cup, bleed, treat fracture», sprains, etc It will be reiidily 
ODdorttood that some strife would arise about the various nnd somo- 
titae» indtfßuit« privilege« of these different grades of physicians, 
especially in large cifcies, trhcro all classes of tlicm urorc collected. 
Tliis WMS porticulai'ly the oisc iii Paris. The surgknl society there, 
llw ■* Cüllöj^ do St, COme," daimed the same pririlegea as Encmbers 
of the medical faculty ; tbey were partjcularly dosiroiis for the Bacca- 
luBoato and Licentiate. I'hc ''Sodeiy of Barber« and BatJiers," 
•pun, wiftbel to praei iso any part of surgery, just like tJie membeia of 
tin Cotl^ de Sl CQme. To gall the surgeoos, tbc members of the Po- 
lity supported the claims of the b&rbcrs,aad,in spite of mutual tempo- 
my eompfomtses, t he strife coiitinued ; indeed, wo may say that it still 
OODttBDOS, wlirre there are pure surgeons (surgeons of the first class 
nz3<i ' '-' — ) and pure ph>*Bicians. It is oiily since alraut 1850 that 
t)i- ■'» was done away with in almost nil the Gorman atai(>>», 

and onitlrt^r L'liirurfp puri nur medici ptiri nere made, hut only phyai* 
Ciaim who practiecd mcdicJoc, eurgvry, and obstetrics. 

To finish the question of external rank, wo may notice that in Eng- 
kod alone there is still ■ tolerably well-marked diriding^ine be* 
twoct) surgeous and physldaaa, especJally in the cities, whlls in the 
ooootiy •* general practitioners " attend to both medical and surgienl 
rawns, and baTe an npothecary-abop eii'cn at the same time. 

In Qerm&ny, Switxcrland, and Fnuicc, circumstanoes often cause a 
pliyudaa to faaro more surgical than medical piactice ; but the mcd- 
i^ staff legally Dunsist« of pbysiciana and assistants or barber4ur> 
gcoos, who, after examination, arc licensed to oup, bleed, eta This 
anaaeemeot has finally gone into effect in the nnny also, where the 
■o-eaSod oompany surgeon, with the rank of »crgoant, formerly bad a 
^■efsble lime ander ibe battalion and regimental pliysicians. 



10 



LNTUODCaiOS, 



In BgaJu tuktog up Uie thread of the historical developmeut of 
Burgoiy, u we «at«r tbe -portod of " RintUBSnnoe " in tke nxtocntli 
oentu^, we must first ibiiik of Üie great clinnge whicli tlieo took place 
in HlnuMt all Bdcnocs aad. arts, on accouat of ih« Hofonnationf tlie 
disoDTei^ of priutüi^, aud tho awakeniog spirit of eriticiani. Ob«ei'< 
ratioQ of Nalurc began to rcnissunie iu jmiper position and gradually 
but slowly to free it«clf from Uio fetters of the kIiooU ; investigation 
ftftcr truth af^in assumed its claims to buiiig tho only truu wsy to 
kaonrledge — Üut üippocraüo spirit wna oguin awakened. It was 
chiefly tlie new investigationa, wo might almost say tJio nxliscorrry, 
of Bnatomy nnd the subsequent restless jwogrvsa of this limneli, that 
le\-eil»d tlie road. Veml (15 1 3-1564), Fblapia (1&:J;M 503), and J?w 
tacKio (tl5 19), were the founders of our present anatomy ; their osmea, 
like those of many others, arc known lo you from t.1ie appeltntions of 
certain parts of llio body. Tho <%-lebrat«}d Jiombattut TAeop^irastua 
Paraedmia (1403-1 r).*»!) was anKm^ the 6ist to criticise tlie prciiuling 
Galenical and Ambic aygtcnu, and to claim observation as ihn tiüA 
WMirea of m«dical knon'ledge. Finally, when WiUiam JTarrvtj 
(1579-1658) discoTnrr-d the circulation of the blood, nod v<<kS( (1581- 
1626) disoorored Uie lymplmtic Tceeds, tlio old soatomy and pbysiol- 
ogy were obUgud to gire place to modem sdeuce, which tbence grnd* 
ually prn^rcased to our times. Even then it was a long time before 
pnwtieal modldne escaped in tho aamo way from phQoMpfaio tliriil- 
dom. System was founded on system, and tbo tbcory of medtdas 
oonataoUy varied to eom*8pond to tbo prevailing pliiloaopfay, M'o may 
daim tltat it was not till pathological anatooiy mado it« great ad- 
VOBOes in ihd pc«S'>nt contury tlia.t pnu^lical medicine aotinin^d tlia 
Snn ■notoaiiooyhysi ological foiimiattou on wliieh the tvhulc structuro 
now moves, and which forms a strong protection against all philoeo|)b- 
Lcol medical systems. Eren this anatomical direction, boworcr, may be 
puslic^l too far and too cxclunivcly. Wc shall speak of tliis hnv^ftcr 

Xow %v'c will turti our attention to the scientific dcvcIopmcDt of 
htugttry from the sixtecntli ccnluiy to our timga. 

It is an interesting feature of that time that Ü>e wU-ance of pract.i> 
cal surj^ry depended more on the surgiad societies llioi) oo tbo 
learned prof'i^MSOTS of tlie iiniveraitiea. €n.irman surgeons had lo »ook 
their knowledge mostly in foreign universities^ but part of it thcj 
worked out for thcmsol res indopoodently : Htlnrich von P/(A»pruntU^ 
a Gterman friar (bom the beginning oCtbe fifteenth ceniurr), Jlieron- 
ymui JinintrKfeig (bom 1430), Hans v<m 6tr»dorf{sAxfui 1530), nnd 
F<iüt ITär/f (11576), Burgooos at Dawl, nro first uinong tlicso. Wo 
have writiaga of all of thina ; Feltx Würtz serma to me the most 
orighuil ot them; lie had a slinrp, critical mtnd. Fi^ry von Jfftttttn 



WTBODCCTIOK. 



II 



;35CI>-1634), oC B«Tne, and Ootffritd Punnan, of Halbcyrsiail and 
Breslau (about ISi'd), verv. men of ^cut axxiuirciueuts ; Uieir writ* 
tags «bow a high apprecintion for thdr ecicocc, tbcjr üiUjr rooognized 
tfac thIuc ami iitipcrativc ncoesatj of exact nnotomicnl kno«l«dge( 
and by tLcir wrilinga and prirale instntctioo hnparted it to tlieir 
scholars as mtxdi as possible. 

AnoDg tbo French mrgfoon« nf tb« sixteenth aod sorcDt^cnth oen- 
taeiea^ AnAroiu Pari (1513-1590) is moat prouiin«nt; origiDally only 
a barber, &nm liis gront scrrinrs, Iiv wok itintlu n iDcmbin- of the Si>- 
ciety of St, COmc; lie was von- aclivc oe an army eiirgcon, was often 
called fp)tii iMxiie OD onasultatioiu, and at last resided in Paris. Pari 
ailraaced aurgerj bj what wsa for tboeo times a very sltarp criUoisin 
of U«atBi(nt,*«spiiciaUy of the eoortnous ua« of problematical lumedic« \ 
ifloe of his rrvatUes, c g*., on llie treatment of g;iin-«bot wouniU, are 
perfectly cln&aica]: be rendered hima«If immortal by the iutroductjoa of 
it^uro for bleeding vcucU after amputation, i'ari^ as tho relbrmer 
trf Burgoy, may be placed by tlio sido of Vkiai, as rofemnerof anat^nny. 

Tile works of tho abore mdiriduals, besides some others mora or 
leM gifted, held Uioir place into tho acventeentb centui)-, and tt is 
only to the ei^t^^cnth that we Gn<l any important advance«. The 
atriA; belwtfvrt tlte members of the ÜLCiilty and those of the Onll4ge 
do Si. Cdmn still onntinucd in Paris; tho great celebrity of the Utter 
had more effect than the professots of surgery. Tbia wm finally prao- 
lically arloKiwIedged in !73l by tho foundatJon of an ** Acodctny of 
SiiTTrrr^'.'* which was in all respeota an analogue of the metUoiI livcully. 
This ioKLiltilioR «oon adnnccd to such a point that !t nilod tlio tut- 
prf of Europe almost a century ; uur wo» tliia an i£oIittod cuu£u ; it 
Ibnnrd part of the general French influeace, of that unircrsal mental 
doH^akm which the " gniade natioa " cannot even yet forget when 
Ccrmaa srtence hns forerer eclipsed French influenee, after tho coo« 
die«* of 1813-14. Tlie men who then stood at the licad of the 
moretaeot in eurgicul «aeooe were Ji»m Zouü Petit (1C|'4~1T68), 
Pitwre Jo*, Jkmxvit (174+-170r.), AVwc IVani^di /'m»/ (1754- 
Ift^), nul inaay others In Frame ; in lüily, Scarpa (Ii4S-163-2) wta 
ttw! raoist «i^tji^e, Ercnin the acvente^thceotuiy, surgery was hifirhly 
dcveh^xl in XTnglnnd, and in the eighteenth eonliiry it nltaiiiLvl great 
rmlnenoD und^r Perc'tval 3\>tt (1713-1768), William and John 
If ' ',»3), Penjamin P^ (174^1808), mitimt Cheaei- 

■f- ■')» -'Itoanrf^T Monro (1606-17Ö7), and others. 

Anodg tbeae was John Switer, that great gooitu, as oelebraled 
for anatomy n« suj^cry ; his work oa iuflammaticA and ivouoda 
ttiD forms tlto bositi of uiauy of our present views. 

In conipnriion with these, tho names of the German surgeons of 



\^,^ 



IS 



IXXnODCCTlOS. 



Üie eigliteeiith ceoUaj aro iiisiguificunt; moat of tltem brougbt thHi 
kiio«le(]{^ from Paris, ant] added little tbat was origiDal: Xorent 
Utitttr (1C83-1758), John mricH Silyutr (1:20-1796), and Chr. 
Ant. ThedtH (1719-1T97), are relatively tlie most lni|K)rtnrit. Ger* 
man Kor^cry only ubtatoed gre»ter emiaenoe witb tlit; cuimmcnt'fiDcnt 
of tlio prcMDt cADturj. Cart Ca^>ar von Stfbold (1736-1807), and 
August GoUhtb Uk/Uer {17'^~1S12), vrcre disüaguiahed men; lite 
formrr served as profcBBOr of Burgerj in WUrzInu^g, tbo latter in &It- 
tingcn ; Bomc of JiicAt«t'$ writings arc va1u&1>1« orea dow, cspcciaUy 
bis little book on rupture. 

On tlio tbrcahold of our century jOu sec professors of tuagery 
igaia ia tlic foreground, where tlioy subscquciitly uiiuitlamed tbeir 
poaitioo, because they aebiallj practi»«! surgery. A pmiiecessor of 
old Riehttr, as professor of surgery at Gottingcn, tlic celebrated At- 
bertlfaUer (1708-1777), at onoepbyaiolog^taod poot,one of tbe laat 
eoej'clopiedists, says, ** Ktel cliirurjrine rnthedra per scplcmdoeiin ati* 
mv mihi ooiKnedita fuit,et^iiioad«veribusdtfiulima8»dministniliöuM 
diirurgicas frequenter ostcudi, Don ttiincn unquum vivum liomiDem 
tncidoro sustimti, nimis no iiocercin vcritus." To u» tfaia seems 
•caiceljr credible, so great is the cluuige wrought by a Iiundred years. 
Rren nt tlio oommetxcnicnt of tbia century tlic French surgeons ro- 
roamc(Ialthghelm;Äoy»'(1757-1833),X«i^pa:A (1:76-1832), and pai». 
ticiilariy />«/my/rtfrt (1777-1830), and Jian T>ominiqvt Zarr^!/ (1776- 
184:3), WL-re almost mxU^putod Hutboriti«a m their line. Beaido Uieiu 
there aroe« in EngUnd tlic unimpcaeliable nuthority, Sir AatUjf Coop- 
er (1708-1841). lAtrrey, the constant eompanion of Napoleon t.lefl a 
largo number of works; you will bcreoflcr read his memoirs with 
greet ioterest. Jhipnytrcn was chiefly celebrated for his excellent 
clinieat lecturea Cooper's mooogmphu and lectures will fill yuu with 
uatonishment. Tranfllations of tlte writings of the above French aud 
Eiigli&li fturgwiu first uroused German surgery ; but soon the subject 
WM gone into most profoundly by original workers. I'he men who 
InduceU the German reroluttoii in surgery w(Te,nn)ongoitlieTS, Fwiom 
uon J:«m,of Vienna (1760-1899), JoAn .Vep. JiuM, of Ueriin {1775- 
1840), Fhilii^ voii Walther, of Munich (n82-18-l9), CaHFerxL von 
Grai^c, of Berlin (1787-1840), Cunr. JoA. Martin LangaAtck^ of 
GöttingCB (17:6-1850), Joh, Fri<^rich nuffenback (17W-1847), 
Cqfetan von Textor (1783-1800), of Wonburg. 

The nearer we approach thu middle of our century, the more tbo 
niggml Ifounds of tutionaltty diMppcar from tho domains of surgerjr. 
With increased means of commuoicatiuii, all advances in scieuce 
spread with brcathlcsa ha«to to all ports of the civilüecd world. Nuut* 
bcrloss tniting«, national and intcmatioDal medical congress««, and 



INTROOCOTIO.N. 



1» 



'petaonAl iabercourse, hive br&ugbt radioal oIui»g(» to the surgeona u 
well as to others. A f^eratioD of surgeons, upon whose works 
the profesnon loolu wiUi faonnr, iL])p«m to Lc now dring out ; I 
tnou men sucb u StarU«*/ (1701-1863), JLawrence (1783-1867), and 
BrcdU (1783-1863), in EnglamJ ; Bma (1780-1854), Bonnet (160&- 
1B68), i^roy (V!i^lS^\), Mahjaignt (1806-1865), C/viafe (tl867), 
Johtr« (1799-1868), and Vetpeau (179&-18Ö:). in Prance; Seutin 
1(1793-1862), in Belgium ; V-tlcntine Mott (17S5-1865), in Aracricn ; 
iTTuteT (1789-1863), Schuh (1804-1865), and ottt-rs, in Germany. 
)Ri our OWD generation at»o wo have sumn Xwsvi {m uioum, cspc> 
[]y the irrepanble death of the ^ft(>d, iiidcfittignlilc iiivcstigAtor 
O. Wiitr (1827-1867) ; of tlie exc^lU-ut Foa!n (-1SG7), one of tbo 
most solid of modem Frencli »urguons ; of Mtddridorpf (1824-1868), 
ithc oelebrntod inventor of galviino-cauttto <^)cration6. Among tli« 
A-it^ we miglit name many on whose shouldon rests the growing 
aeration of German mirgtxins, but the/ do not yet belong to his- 
''tory. But there is one point I muat not loavo unmeutioncd, that i», th« 
Introduction of paiiKjuelling remedies into surgm% Ttic niiieteetitii 
?tiHiry nijiy Iw [iroiid of the diacorery of tho practical iise of snlplui- 
K ether and chloroform as amesthetics in all sorts of operations. In 
1846 came from Boston the first uev.-! that Morton Uie dentist, at tho 
^ "11 of hb friend Jh. Jofkton, hiul, in extracting teeth, em« 

J . -i.-dations of BulphuHc ctlior, pu»bcd to couijilote aaa.>sthcäia, 

with perfect success. In 185!), SimpsoJi, professor of obsteirios in Ed- 
iabuq^i, instead of ether, introduced in surgical [>r»olice chlorofon», 
which acts still bcttvr, which, after various trials with otlicr mmilar 
sabetenoes, still piv»4^rrM its reptitntion. Tlianks ', in tlie name of 
humanity, n thuusaud tbanks to tlie^e meat 
Id continuatioD of my previous romnrka rvganling Gennan sur- 
ff I will simply add l)i»t at pn^sent it stands at least equal to that 
' other nation«, aod is perhaps even superior to that of Fianoo ac tbo 
preecnt time. To prrfect oiiraelve-s in the noietice of »urgviyf wc no 
need to visit Paria. But, of cvHirsc, it U nevertheless dcfiirable 
' «rery phyaician to enlarge bis experience and obaerration by viut- 
■ign lands. In tho tc-ii.*ntilio tu well as in the pnictioal part of 
f, aod of medicine gcncmlly, England ig now more advanced 
■ny otliCT ooaotiy. In America also groat advanci-s bare been 
tiraotical mirgcry. From the üraf; of UimttrXa the prr^cnt 
_-ijäfa surgery has about it something noble. Surgery owes 
It rei.'ohitjon in tho ninetoontb oentury to its attempt to unito 
sliual knowledge in ilaclf ; the surgeon who succeeds in t1ii»,and 
toasters the «ntiro mechanical side of Uie art, may feel that b« 
< attained the higbcst ideal in medioinc. 



14 



IN'TROßlXTlON. 



Before eateriug on our subject, I wiU idd a few remarks »bout 
Üie Btud/ of surgery as it is, or is said to be, pursued in our high- 
Mbookb 

In the fcMir yetn^ cnutsc of medical study which is custonury in 
GcnnnQ universities, I would «drlse you nut to begin surgery buforo 
tbc fi/tfa scmc8tr& Vou often desire to vecnpc the prcliminniy studios 
and plunge at once into tho practioul. It is tnu', thia is eomewUat 
less the caKC since courses on anatomr, microscopy, physiology, ohen> 
istiy, etc., liave been »tarted in the high-sdiools, wlicro you liave aomc 
practice J □crertholcs8> there ts still too mucit haste to enter the did 
KM, It is true, U is one vay of gaining expcrieiioe fmm the rery start; 
you cooadcr it more interesting thitn bolii»'iDg yourselves ut firitt 
with tlungs whose connection with practice you do not exactly un- 
derstand. But you forget tbnt a certain scbool of observation must 
begone tliruu^rh wttli, to enable us to make actually usuful what wc 
IcDow, II' any one just rclcaitcd from school elKHild at once enter 
the hospital Mg a student, ho would be in the same position a« a child 
entering the world to collect knowledge^ Of what use ore the ez> 
peticDOCa of the cliild for lua subseciucnt life among me»? How Inie 
it is 1>efoie we see th« true use of the most common ob^erratiom of 
daQy life ! Uence^ to wade throuf^ the entire derdopmcnt of modj* 
ctne in tliis emjüricol manner would be a long, tedious labor, and only 
a very giltod, industrious man would Icsni any thing in thia way. 
After liaring made aximerous errors, we must not place too great a 
value on " experience " and ** observation," if by tliesc terms we mean 
IH> OKue than the laity do. It id an art, a talent, a aaienoo, to abserre 
critically, and from our obttervntions to draw oorreot condnsions for 
our *" expcric-noc ; " this is the strong {Mint of tlie empiric ; tite laity 
know cxpericDoc and ohscrvatioo In the vulgur, not in tltc scicntifia 
aense, and they ralue the soiled ezperionoo of nn old shepheid as 
hig-h as, sometiiDes higher than, that of a physidan ; unfortunately, 
tlie pnbltD are aomctiuies riglit on thia point. Hut enoiiglit wben a 
pliygidaa or any one else displays his experienoc and observatioa bi>- 
ton you, loolc sharply to see whether he has any braira. 

In making th«ic remarks against pure empiriciam, we do not by 
any means intend to »ay that you must be theoretically acquainted 
with all medicine before st^idying it practically, but you should bring 
a certiUQ knowledge of thu fuodamcntul principles of natural sdcnoe 
with you into the clinic. It is abeolutely necessary to hare a general 
idea of what you arc to expect ; and you must know soioething of 
tbc tools before seeing tbem used, or diking them In your lionds. la 
other words, you altould know the outlines of general pathology atiJ 
ihcrapcuties, as well as of inatcrin modln, hcfoie going to the bod- 



ISTRODÜCTIOX. 



IB 



side of the patirnt Gonerxl sui;g;er7 U only one purt of goneisl 
psUraJc^', hcucc you aliimld sLud^- th« latter before entering the sur- 
pical clinic. FinC, joii shoiiM gain n oto-Ar iindcTEtandinj^ of normal 
lÜBtoIogy, at least of in general parta; putliological anatomy and 
Idatology should cotno with gcaetal surgvry, abont tlis SKU oemestra 

Geooral surgery, the subject of Ibe present leoturefl, is a part of 
general pathology, as we hare already Blat«>d ; hut it is nearer to 
practice than the latter. It cornpriBe« Uie study of iroundit, inflau»- 
mationa, aad tumon of the external porta of tb« body, or of those 
part« thai may be handled from without. Special or topognpfaEral 
■ui^pery oocupio« itacif vritb (Ik; eurgitral discaii^a of different jurts of 
tbe body» so that Urn moat diffcrcat tiuncs and orftans arc to be con- 
ndood aoeording to tbeir location ; for instance, while n-e here treat 
only of wounds, of tlicir moilc of rccorciy and imitini^nt in frenentl, 
qiectal curgery treat« of vrouoda of tiie head, breusi, and iibdonieo, 
paying tjwctal attention to the panidpntion of tlie skin, bones, 
■id vbooa. Wore it possible to pursue the fttudy of surgery for 
•ererat years in a large hospital, uid could careful cUniciü ooosid- 
OTtion of individual oasos bo oarrtcd on contiiiuottily vith tlio regular 
studies, it vrould probably be unnecessary to treat of special surgery 
in oepantc syntomatic lectures. But, siDoe there are many surgical dis- 
CMM that perhajw may not occur for year» even in a large bocpital, 
ImK which should bo known to tl« surgeon, the lectures on spedal 
auf ;gciy arc by no means supcrÖuous, if they are »bort and to the potoL 

During my student days T occasionally heard Ihe rcmnrfe : "Why 
should X go to listen to special surgery and pallwilogy? I con read 
thrm iDoro oonTcnicnily in my room." This may bo all true, but un- 
forltuulety it is rarely done, unices in the final eeraestres« irhea exam- 
ination Is approaching. This reasoning is false in another respect 
alao ;. tlie vftra cor. of th» tracbrr, a» old Lanf/enbeck, in Götliogen, 
uMd to say (and he bad a viVt V9x in ti>e be^t «ease of the word), 
tbo w1ngc<l word of tho tendier i«, or sliould be, more exciting and 
HTcctire than what b read, and the accumpan^'ing dcinonstTations 
of diagTuts, preparations, cxpcnmcats, cto, should render the lectures 
ßa pnclical surgery Bod moJii-iiio partictilitrly valuable for you. I 
attach great ratue to demonstration in medical instruction, for I knon- 
by c^perienoe that this kind of tcadiing is most cxeJtiDg and pei^ 
suuieoC 

Deaidfv these two iwls of lectures on general and special surgeni- 
you luTQ to practbo operations on the cudarer ; this you may postr 
polM to th« hut semeKtreit. I always like students to tako their 
cnnne in opcnttiuns iu tho sixth or seventh semestres, along with 
tbdr special surgery, so tltat I may ^yc them the opportunity of oo- 



le 



INTROnCCTTON. 



casiutiull^ operating, or evcu of amputating, under my direction. Il 
giTOS cxmngc in prautJw, if one bu during sludent-Ilf« perform«! op- 
eratious on the living subjeict. When jou liai'o followed Itie leelurw 
on ^gDoeral surgvrj', you taay eDt4>r Uie «urgical clinic, and liiere^ in 
the eorenili and eigfath sciDcstrcs, openly give an account of your 
Imoirledffs in Bpeohil casofl, and «^custom yonrsulvcs to collecting 
your idesA rapidly, leani to diatingtiisb tltc tnipartant from tbe unim* 
portout, and to leani generally in what pnotice really coosiata. You 
will thu» leom tbe potnta where your Imowledgoia doficieot, and may 
perfect youTselreB by perseraring atudy. ^Vhcn you have tbuB com- 
fdeted tlie legal time of your studios, pasaed yonr examination, and 
haro iucicoaed your medic«) knowledge by a few nootba or a year in 
Tarious largo liuspttals at boniR or abroad, you will be in cooditioD to 
apppeciato the suj:g)CttI cases turning up in practice: Dut, tf you viah 
to dorot« spcciiU attcution to surgvry and operating, you arc stilt 
tu from tho goal : then you must boooBw aoeuatomed to opcntit^ on 
the oadaTer, enter a surgical ward aa aosistant for a year or two, ua> 
iiringly study mooogmpfaa on surgical aubjoota, perberonngly write 
out cases, etc. — in ehort, follow out the praotkal school from the lowest 
step. You miL<a be fully acquainted with bofipital service, even witb 
(he duties of tlte nurac-s; in short, you should know practaoally eron 
tlifl most miDuto tbing« appertaining to tho care of patients, and 
should even perform thu duties yourselves occasionally, so that you 
uiay bo fully master of the entire medical scrrice intrusted to you. 

You see thcr« is much bo do and to loam: witb patience and pcn»o- 
veraoeo you wQl aocomplJsh it all ; but these virtues arc necessary to 
the study of medicine. 

"Studoot" oomcs &om "to study;" hence you rouei study taiih- 
fully; the teacher indicates to you vrhut be considers the most impor 
taut; be may stimulate you in various directions; what be give* you 
aa podtive may, it i& true, be osrried borne in black and vbite, hai, to 
cause this positive knowledge to li\-e in you and beoome your mental 
property, you rnntiL depend on your own wrntal efforts, which furra tlte 
true " study." 

^Vheoyou conduct yourself as a passive rooeplaclc, you tiisy, it 
is true, acquire tho nam« of a v«ry " I»amed iwrson,** but, if you du 
not awake your Imowleidgc into lifi-, you will never txxomo a good 
" practising physician." Lei what you see enter your miod fully, 
warm you up^ ami so occupy your attention that you must think of it 
frequently, then tbe tme pleasure ami Bp)m*i.':iiition of this mminl 
labor will fill yon. Cti^fA«, in a tetter to Schiller, aptly says : '* Heat- 
ui«, oomfort, and interest In the aOiiira of life, nre the oulv realltiei j 
■n dse is vanity and disappointmcat.'* 



I 



CUiVPTER I. 
ST]\IPLE IXCISED WOUXDS OF THE SOFT PAliTSi 



LECTUBE II. 

ICo^of OrlgUBndApfMAnaceoftboM'Voaiuls.— VftrioBi FomuorlcxitMdWMOid*, 
— jlpINUWM« daring ud Imiacdiatoljr tfter tli«ii Oecumn««.— Puln, BtMdlDff'-' 
VariHiM of UamnRhaK« ; Anttial, Viooaa.— Eatnmoe at Alf ihroogli Voundod 
Vi/^M.—TutnfA'paatov» Batnarrha^a. — HniBMTbifila DlttbMt*. — llBinimliiga 
fton ik* PbufRS and lUtCDiB.— CMUtlilua»iMl ESbou of Sortn Usroorrluf & 

Tub proper iTeatment of vrounds b to l>e r^gmrded ox Üio most 
toiportaat re«iuimncnt for tbe suig<non, not only on aooouot of tho 
Inqoencjr of tUis variety of injury, but bccauso vre so oftea iuteu- 
liooally malte them in operating, cren when operating for something 
tliB« it not )l«eU dangerous to life; Heaoc we are aoswenible for tlie 
bcalti^; of tb« wuuod, lo »b grcnt an extent lu it is |Xttxible bj expe- 
rtcwfl to Jttd^ of the danger of nn injtiry. Let u» «jtnmcnoo with 
mtäaMl wcmDiK 

Injnrio oiumxI by sharp knives, scissoni, sabrca, cleavers, hatcbcle, 
tAA^ r p p waent pure !ncIäL>d wotinds. Such vroumls are usually reoog- 
ntsiUe by the regular sharp bordere, wbore ve see the smootb^ut 
■mfiwe of tlie unchungod tiüsuc ; should tlio instmuHtnla be blunt, by 
very fttfüd motion they mnj still cause quite a smooth iociscd wound, 
wUk b^ slowly entering the tissue they would gire the edges of the 
tromd a mgf^l npt>eamnoe ; oocasionatly, tho rariely of the injury 
does not boconte cridcnt till the n-ound is heating, for wounds made 
«-ith sharp tngtruinents he«! more readily ami quickly (for reasons to 
be urivcn benwflt.T) than thoec caused by tlio slow entrance of dull 
kaii-««, »dasora, eXc; 

K«n>lr a perfeclly blunt body makes a wound exactly like an incised 
uue. ITiia may occur fttmi the »kiu Uring torn tlirougb by fnmo ap* 
plied tbrougb a blunt objcot, at a |>oint where it lies over the bono. 
That yoa will not unfrequonlly sec »cslp-wounds resembling inciifed 



18 



SIMPLE IKCISED WO0SDS OF TflE SOFT lUBTS. 



crounda, allliuugli ihvy way liav« been due to b blow (mm a tiluol body, 
or from striking tlic lead against a stone, beam, rtc. ; Bunilar smnnih 
wounds of Itic tkia also occur on the Land, c&po«iaU^ on tbe voUt tar- 
face. Sharp augles of baoe ma; so divide the skin from within that 
it will loolc M if cut throiigii, as, for inNtancn, wliffn one falls rm 
tlic av&t of iiic libia, and it divides tlic skin ttvm witbin uutvrard. 
A« may be rondily uiwlerstood, sharp splintoni of bone pcifomling tbe 
skin may also make n-ounds vriüx sniootb surfaces. Lastly, tb« 0]M<n- 
injj of csit of a buUcl-«ound, i. c, of the canal which represents tbc 
pHBsage of a buQct, tnnj sometimes bo a sharp slil. 

The knowledge of those poönts is important, tor a judge may ask. 
you if ft wound lias be<>n caused by tiiis or tbat instrument, in this or 
that manner, pränta whvcb ma}' greatly affoot tlie bearings in a oriuj- 
iinl Knit. 

Hitherto wi: hart! wtly ooitsidcred wounda mude with a blow or 
Atrok«. But, by n»[>eBtod cut« on a wound, tbe «Igcs may »«qui» a 
backed app«amuoo, and thus th« rM^uiremvuta for recovery may be 
wiy much changwl. For the present, we leave such wounds out nf 
oonsidention ; their mode of icooTcry and ticutmeut is just Iho eaine 
as Uiat in contused wound&, unless they can be urtifiotally omrrrlfd 
into Mm]>te incisrtl ^rounds bv piiring ofi* the |aggcd edges. Tfce 
various directions iti which the cutting itislTiuneot entert tbe body 
pcnL'rally makes liltle diff^n-nce, unlt-ss the direction be so ohliqae 
that wnne of the soft parts bj« detudied in tbe form of a more or less 
thick fhtp Tn tbosRjt^f>^ounds, the width of tiic bridge, uniling Ibe 
batf-iM>pflrated portion with the bo<^ly, ia important, booausa on Üxla 
drpenil» the qiicslion as to whether circulation of blood can continue 
in tliis Dap, or if it liua ccaHoi), and tlio detaclied portion ä to bo rr- 
gnrded as dcnd. Fhip-wounda arc chiefly due to ruta, but may abo 
nriae fitm tearing ; ihor «re \ety freijiieut in the head, where jiart o^ 
tbe scalp is torn oiF by a Lard blow. In other cases a ]X>rlioD of the 
•oft parts may be entirely cut ont ; then we have a wound W/A foM oj 

Ity pi'iiffryitiny xrvutuh we mean those by which one ot the v ■ 
gnrat cavitira of the body or a j^°t is opened; they are most :.-. 
qiiiiitly dtic to stabs or guiMitiot Injuriea, and may lie ocini}>licntcd by 
wouTKhi <if the viaocru or bonc«L ßy tbo j; ' "linal 

and (ffa^ron^ wounds woof course mean tfa(K" ' I<>i>g 

or diagonal axes of tho trunk, head, or extremities. l>iagoniil or Inngv 
tudlnal wmmda of the muncles, tendon«, vessels, or ooriree, arr ulcvursc 
those dividing tbcM< jtarts loniritiidinatly or diagonally. The ^mp* 
t^msin thn person wounded, induced mote or loss directly by tli« 
wound, are, first, pain ; then, bletJlnff simI yajiing of tbc wound. 



gviinoiis— PAIS. 



IB 



As all tliA tissues. Dot excepting' tbe epithelial and epidcnnoitl, 
m supplied <«-)tJi scusoiy nonrcs, injury at once anises pain, 

TLU pain rarics gceatly wiUi ibc oorvfr«upply of tlio woundcil 
pwt^ and with the sensitiveness of the patient to paiiu The nirwt 
KBsitive poru are tlia fingen, llps^ tongue, nipple^, external gL-uititls, 
and about tlia anus. Doubtless, escli of you knovra from KXjirncncu 
the charicter of the p»in from x wound, ns of the fingr^r. The <li*Tsion 
of tltL* skill is tliu miuit painful part; injiirjr of the miucJe« and ten- 
tlooa IB tar less so ; injury of the bono la alvraya very painful, as jou mu./ 
find from any ooe that has recovered ttoat a firaclure; it has lüso boca 
banded donn to ua from tlic Limes when amputalioiut vtpt^ raitdo with* 
out dtlorofarm, that aawin;; the bono was the nioHt p.iiufiil ]Kirt of the 
operation. The mucous tucmbrnuc oi the intestine», on being irri- 
tät«d in variou« ways, show« very little sensittvcitess, »8 lui« beou occa- 
aioiully üb3t!rved on man and hennt; the niginul portion of the ulo 
rvs also is almoH inacnaitive to mechanical and chcmieal initatioa; 
oocasionally, it may tte touched with the hut iron, na is <1i>D(> in Irmt- 
isg certain diseases of tliia part, without ita being felt by the patient. 
It appears that the nerves reiguirin^ a. specillo in-iLatioii, its Ibu 
nerves of special sonse, are aronmpnniod hy few if any sensory 
fibres. The relation of the sensory uer\"es of touch to the scaUent 
aem» in the slcin cannot be regarded as decided, or whether there 
bo any drcidod differcnco between thein. In the lifl^fi nml ton^o, we 
hnre «enwry and senlient nerve» ctose together,.«» tluit in t>oÜi parts, 
bcsitle:! the apcaHo scnac i>ccutiiir to the organ, pain may rImo b<; pcr^ 
«elrad. The whit« tubalanoo of the bmiji, although containing ninny 
BUfve^ is without feeling, as may be sewn bi ninny severe iiijuriee of 
Uw bead. The dimion of nerre-lrunks ia the Bcrcrust of all inju* 
rii& Some of you oiay renicuibcr the pain from rupture of a dental 
nem on extiaetion of a tooth. Severing of thiek ncrre-tninka must 
cauae overpowering pains. Sensitiveness to |Kitri appear» peeutiar to 
imlividuals. Dut you must not confouml this with TariouJi eAhibilions 
nfpoin, and with the pstychical power of 8nppretsiHg,or at Icnat limiting, 
liua otllibithMi ; tJia lalt<r depeiida on Ihc strvogth of will, as well ]is 
oQ Ibe (•■ "i(, of the inilividunl. Vivacious persona diapluy tboü 

pain, a? iii';ir other feelings, mora tlian plilegmatic ponoQi, 

Uo«t peraan» maintain t1iat crying, aa well as the tnstinctirc powerful 
tvtmuii of all the niuRcli.'B, cspeji^ally of tlio nuiHSciern, gritting the 
teotli, eiCL, renih<rs the pnin more endurable. PersoiuUy, I have not 
benn able Ui verify ttit« slüleiuent, und I think It mn^t he a mUtntco 
of dl0 paUenta. Strong will in the paliont oiny do much tn suppress 
tbecbow of pain. I well remember o woman in the Oüttingen dinie, 
wWn I was a student» who, without chlorofonn, had tho nhoK' uppei 



'* '■•' 



so 



SIHPLB INCISED nOUNDS OF THE SOFT PARTS. 



Jaw renioTed for a maJignant tnmor, and, during tbU diHicutl and 
pkinful optiratioD, she did Dot one« cry out, alUtougb «overal branches 
of th« trifacial nerve wore divided. Women gtmerally stand aulTrr- 
in|^ ti«ttvr and more {»atiiintly llian men. But the necessary exercise 
of psychicAt strviifTtli not uiifrvqueutly causes subsequent EairiLin);, ur 
czoaaairc pliy^ticiil and [».ychical mlnxation, of longer or sborter du- 
ration. Tou will certainly meet persons who, without anjr cserciM 
of will, «how so little pain from »cvcrc injury that wc can only bc- 
licv« that they reAJly re^^l pain less acutely tliuii others ; I hare ob- 
served this most in fisbby sailors, iu u-bom all the seqnol» of the 
injury arc also i^ncrslly very insignificant. 

Tlie quicker the wound is nmde, and the sharper ihn knife, tbo 
l»<ia the [win ; hence, in larg« atid small npt^rutious, it has aliraya 
sc«nie«l, ami very correctly too, for tbc advantage of the patient, 
that tbe incisioDS should be made with certainty and rapidity, par- 
licularly In dividing the ükin. 

Tlie fcfting III til« wound, iiniuediatcly after its reception, » B 
poouliar burning. It can scarcely bu tvrmud any thing but ibc fed- 
iug of beiqg wound«»! ; there aro a number of provincialif^ms fur il — 
in Northern Germany, for instance, they say "the wound smarts, " 
Only when a ner?e ia compressed by something in the wound, twisted 
or irritated in some way, ther« are severe neuralgic patns tmtncdi- 
ately after the injury; if tb««v do not soon cease sponlaiieously, or 
after cxamitijitiun of ibc wound and removal of the local cau-ie, if 
poesiblf, they should b« arrested by the exhibition of »omo internal 
ramody ; oiborwiae, they vill induce and keep up n atate of cxüta- 
ment In the ]«licnc that may iiicTCase to msniacjil delirium. 

2b acuül Uk p'xin in Operations^ we itnw always use aoa^het- 
ics; this subject will be treated of in the course on operations. 
Recuutly ether has come more into use on account of the number of 
deaths from chloroform. I now use a com[M>silion of 3 pans chlon}- 
fomi, 2 sulphuric ether, and 1 absolnte alcohol, which seems lew 
dangerous [hiin chlorufunn alone, Iti KnglaiKl, for aooie ^ean, 
Spencer WelU^ among others, has used and reoommet»d«>d bJohlorid« 
of RMtliyline, elaiming that it sets as quickly as, and is loH dan- 
l^rous than, chloroform. Local aHaiätAeties, which have fur their 
object tc-mporary blunting of the pain in tho part to be operated 
on, by application of a mixture of ico and saltpetrfi, or salt, haro 
be«n again alMndoncd, or rather they have never been genemllr 
received. licccntly ibese attempts hare ag*in ao(|uirfd a izoneral 
Ütcrest, aatt seemed that a suituble mutbod of localanjVAtbrsta liadmt 
last boon found. An English physician, It{fh<tr<f4on, constnidcd ■ 
small apparatus, by which a alream of pure ether [or, better, rhigt^ 



I 



3Y MTTOMS -H.EMORRH AGE. 



SI 



line] Bpray is fur a time blown af'oioBt ottc sput in the skin, and 
Euch cold is hen* iiiiluced llutt uU scnentioii is lout. After proooriiig 
■Dme at this elber (livdramylätlier) from EngUnd, I wm» Kaüsfied of 
Ha perfect action. lu a few aeeomits 1b<; skin booomes ohalkj white« 
utd itbsolui«ly witbOTtt sensation ; but the effect hnrdly eswnds 
ibnni^ R modenitelj tliick oittts; um!, if tlie etiier be still blown 
Meinst tbo cut sur&co, tbu frozen tiiwucs cunDot be cUalinguinhcd 
irota e«ch otlicr, &n>l iho knife, being ooated vrith i<!0, vill no lon^^er 
cut. Henoc, evcu In this moro ]Mirfect form, local annathveia can 
ool^ bo used adraQtagcoualv in a few minor ojicrations. My foroM^r 
dr^d, tliat healing of tfac wound would be essO'StiaUy interfered witli 
b^ tills Crvezing of the part, has been shown by esperieooe to bo 
grouudlno. Far quelling the pnin, and as a hypnotio, imraediatoly 
■Rev exteuslre injuries or operations, there is nothing belter than a 
qimrlfirof a grain of innriate or acetate of moqihia; this quictfl the 
paUenI, and, even if it does not make him »lei>p, he fe«l5 less pain 
from bit wound. Quit« recently hydrate of chloral ( 3 s»~ 3 5i >» ^'^ 
m ghas of water) lias been used ; its iiaieotio aotioa was discovered 
bj- lAebrtiehy lS^i9. It» cffi^rt is cMscutially hypnotic, but veiy imcct^ 
laiti ; it MDDOt aupploat chloroform, bat is a decided acquisition to 
our materia mcdioo. Locally, for the relief of pain, wo employ oold 
m th« fdiape of (»Id oocnpretsea, or bladders Riled with toe, applied 
Co the wouud. We shall refer to this under the troatmcat of wounds. 
Lastly, we may gxva hypodenni« injection». If, Mnlh a very fine 
^rrloge, furuifthed wilL a Unce^haped, sharp csuula, which may b« 
Ünvai rv'odily through tlie skin, wo inject a solution of |-4 t>f & |?raia- 
of acetat« or muriat« of morphia, this remedy will cxcroise iis nnr- 
cMia cSbot at first tneally on the nerves it oomes in contact wilh, and 
Ibcn DO tiio brain, OS tlic solution is altnorbed and enters the blood. 
Of 1*1», thi« mode of employing morpliia has been exoeedingly popo- 
Ur; tramcliniuly after an operation, or severe injury, such an injno- 
tkm is ^rim, and the pain is at onoc arrested. 



In » pun» iniüsed or punctunsd wound, hamorrhage is n second im« 
«UalA symptom ; its extent depends on tlic number, size, and Taricty 
vf the dtvided Teascla. At present vre shall only speak of luemonhage 
fhwi ti«eit<*K pm*ion.<e!y normal, and ili^tinfruiiili ra[nUaiy, pareocliynia- 
tooB, arterial, »ivl reiiuus bit'intirrhage», which must be considered scp* 
anlely. 

As is well known, the different patu of the body vary ffrwlly in 
naoohirity, especially in the number and size of tlie capitiark«. In 
Ifnta ofeiiual size tlie skin baa fewer and timuller cnpillariea than most 



23 



sniPLE isasju) WOUSÜS of the soft paets. 



mucmis membrnDe« ; it niso has niore elastic liusuo and mindM, bf 
v:\iitli {m we may fe«l and lee iu Uie cold and soKialli-d gooac-flcal») 
the vcii»:U urc moru readily compresaed tliaa thej* arc iu Uio mucou« 
tncmbrsncs, vbieb arc puor in clulic niui mtisoular tissiN} ; hoiico simpla 
skia-wouadfi 1)1e«l It-ss titau those in iducous membraticA. Usmoi^ 
rtiap» from tbc capillftrica ak-iiu ccaac spontauoausly i( Üio tissue be 
b««ltb5, because the oponiogs of the vcssola ore eompfessed by con- 
tracüon of tbe vounded tissue. In diseased parts, whicli do oot ooo* 
tract, even bietnorrhaj^ fmm dilated capillaries may be very cooatdcr- 
able. 

l-ixetnorrhagc from the arterU* U readily reoogiüzod, oa Uw ooo 
lund, bucuuse ttic blood liowa in a sLroaiu, whiub aunietimca dearly 
ftbow« the rhj-tbmical oontractioiu of the heart ; on the other, by the 
bright-rcd oulor of tho bloud. If thcru bu iitipiLtrsJ rcepiratiuu, ihift 
brtgtit-rvd color nwy cbat^o to a darii hue ; thus, iti opcnttioiu on tJio 
Deck, porfonnod to prcwut thrciitciiiiig tiiiSbcatiou, atid in doej) aiinw- 
thoaia, tlork or almual black liluod \uny üpurt Aom tbe uu^t'ua tlw 
amount of blood cacapiag depends on the diameter of llie totally« 
divided artery, or oo tlie sue of the opeoiog ia itd wall. Vou ioui4 
iiot, however, believe that tlte atream of blood oorrespoiids exactly lo 
tliv aize of tJio artery ; it ia usiiiilly inuoti smalk'r, for tbe calibr« of 
tho artery gcuendly ooutruol« ut tbe putut o{ dirisioaj only Ibe 
lai;ger arteries, such us tbo aorta, carotids, femoral, axillary, etc, have 
ao tiule muscular fibre that they contract, in their ciroumftfTPnoo at 
loastf to a eouoely perceptible extent. In very small orturics, lliia oua- 
trainion td the cut Tf«.iel lias suoli an eStict thai, fron the iitrroaetMl 
trictiun, tbe bloud llows from them mtbuut 8|jurtiHg or pulsating' ; in* 
deud, lo -very small artorios, this friction niny bo so dceidud that the 
blood flov« «ritli difficulty and very slowly, and soon coagnlatcs, eo 
that tbo hionnxrliugis is urrestod Bpuutiinumisly. The smallor tbo 
tUamctur of the ntturics bc-oumca, Irum diminution of the amount of 
bloud ia the body, tbe more readily botmorrbago will l>c arrested spon- 
toneoualy, while otiierwtfie it would hare to bo arresU'd ortifieially. 
Hereafter, yoit will often bare occasion to neo in Ü>e clinic bow frvcly 
tbe blood spurti at the Doinmcuoenont of an operation, and bow much 
lew it will be toward the end, even when wc ait bu-g<?r veneU iban 
wore at Grat dividuL Titus decrease of the total volume of blood may 
oanao spoutauoous arrest of bemorrlugc ; Ihs weaker eootraotioafl oC 
the hrart have also soioe iiiflueuou in this. ludtiMl, in internal luamnr 
rhagea that vru cannot reach directly, wc employ rapid abstraction oT 
biood from the arm (renesocuoo) as a bannoat&tic ; in stub oasee the 
artiScial eJEoitcmciit of ansmia is not unfrer^ucntly tho only mmody 
tre hare for iuterual lueniorrluige, paradoxical as tlib may teem lo 



SYHPTOMÄ-ILEMO RBEAOB. 



33 



tat the fine gloDcci Hwfnoirliiigc« from iacised vrouuilit of Uie 
iitrga uterie* of tin trunk, nack, sod extremities, nre alwa^v bo oon> 
sUlcmblo tluii tlii-y absaluU-ly rotjiiirc txi bo lurcstcd, luileaa ilia open« 
ings in their n-nlls be very &mnll. But, wbeii tlic tvnnüial branoli of 
aa ar1«fj is ruptured without a, wound of tlio skin, tlw htcmoniui^ 
tuftjr bo arrestod bj' pressure on tlic BUtTOuadlng soft parts ; sudi in- 
juriea subecqueDtty indue« oUier diaogcs, to wbich y«ur «dvutiun 
will bo oalled under otber circumatsnces. 

Hsmcarliage bota the veins is characterized b^ the stendj- fioir of 
dask blood. This ia especial!/ Uue of amall and middle-ntzL-d veins. 
Iliese hiDnorrbagea ara rarely very profuse, ra tlint, in or<U-r to obtaia 
a xafioient quantity on telling blu<xl fnjin lIid subcutauwMis veins uf 
the arm at tliu bend of thu vlbovr, vtc must «^wtruot tho Bow of blood 
to iho htmrt. If this were not done, blood would only flow from this 
vein at llie time of puncture, further bicmorrhage would ocase sponto* 
Qaoaaly, unless kept up by muacular contractions. This is cliieJiy be- 
ttUM the thin whIU of the reius collapse, instead of gaping, as the 
arteries do vrbcn divided. Blood doe» not rca<lily (low back froo) tho 
ceotial end of ttie ruin, oa aooouut of tlie ?alvea ; we micly have any 
thiag to do with Uic volrelou reixifl of tbe portal Bystero. 

Biemonliago from the large venous tnmks is always a daogeroua 
symptom. Bleeding from Ilic axillai^^, femoral, subclavian or inter» 
aal jti^ular, is usually quicidy fatal, unleaa aid arrive inunvdiattily; 
«■Miada of the vena anouynin may be regarded a« ab»)lule!y niorfail. 
Tti« blood does not flow continuously {rvaa these large veins, but tliH 
tow is greatly influenred by the rcHpiration. In opcrotions about 
Ute neek I have frequently »uea pttliunts live »Act Uicir iatcmul ju^c* 
■lar Tein had been wounded ; during inspimtiou the ve«ee1 coUaptuxl 
ID that H ought have been regnrded as a oonncctive tissue string; 
duriDg expiration tlic black blood gushed up aa froca & well, or »till 
Bum like the bubbling up of tbe water from s deep spring. 

In these veiiu near the heart, besides the rapid loss of blood, tltcm 
il aaotlier clement that greatly increases the danger; this is tho «n- 
Anmof «[Z" <f i> in$otJi4 vtins and Atari, as ooc^a&ionally tiilces place xvilh 
t gurgling udiAe, on d^-ep iu.«pir:iliiMi, when the blood rushes towanl 
ibo keari ; tbi« may cuu^c iastoiit dealli, tliougb iK>t rtec^ssarily. I 
cannot now enter moiv explicitly into tliis very remarkable pbenom' 
niOB, whose pbystolo^eal eflvct has not, us it seems to me, been saU 
lilactonly expli^Ded ; yoa will again bavc your atteaUoo called to 
da* Biib^-t by the books and lectnn^ na open.üve suigery. I shall 
wmlf mentioa that, on opening oiw of tlie large veins of llic neck or 
Ibo axilluT win, there may be a perceptible gurf{Ung sound; tlic 
fatiaat instantly loses oonsciotuaoss, and eon rarely be restored to 




u 



SIMPLE IXCI^D WOUXDS OF THE SOFT TARTS. 



life hy tnstautnncous re34»rt to arU6oiAl r«9pirtk1ion, dc. Deatb is 
[»obabljr causeJ by *.lio entrmnoe of air-bubbles, wliid) preu forwud 
into Uie nicdiuui-^zetl pulmoniirjr arteries, nixl ure there arrested, and 
prevent furtlicr access of Uootl to tUc pulmooary tcucIs. 

I hsTC üover m«t aoj tiling of tliv kind, aUhougti I have s«en air 
(.'Qtcr the itit<.-nial jugular rein, and frothy blood ihca escape ; tbia 
hod DO pcrccptiUe cEToct on Uie state of the p&ticnU Diflereni am- 
inals appear to be gusceptible, to various extent«, to the eotimnee of 
air into tlie vesseb ; if we throw only a little air into the jugular rein 
of m ralAiit it dies ; vrhile we loay aometimes throw sei'cnü Byringc- 
fula into dogs without obeen-ing any eBeots, 

Besides the above varieties of bsmorriiage, we dlKtioguish the M^ 
called paroieÄymatou« fi(tm»rrUaye, which ia somotimes lacorrcctly 
idontlGed with capillary- hcmofrltage. In the normal iiaaoe of ao 
otherwise hnltby body, paienohyniatoua hraDorrhages do sot eooM 
from the cnpillarus, bat fiom m large number of amall arteries «id 
veinfl, which from some cauM do not retract into the tissue sad eon- 
tratrt, and are not «mnpre&sed by the tissue itsclC Bleeding from the 
oorpus cttvcmoaum penis is an cxaoijile of such parenchymatous lumi- 
orthages, whidi also oocur from the female genitals and in the peA- 
neal and anal regioBS, as well as from the toi^e awl »poogy bOMS. 
These pareochymatous Iucnx>nbagea ore e^ecially (ncqucot fimn 
diseased tissue ; they also occur aAcr injuries and opcratÜHU, as ^»■ 
caUed BMondary hsmotrhag«» ; but we shall spoak of these hi>re- 
■Aer. 

One other point we must refvr to here : tbis b, that there are per 
sons who bleed so freely from a small, insignificant wound, that Ibey 
may die of luemorrhagc from a acratoh of the skin, or after oxtiactlon 
of a tooth. This oonstitutiocuit djaeaae ta callod a h/xmorvh^^ dla- 
thetit; people aflected n^th it arc called hcem<^UeH. The caoae of 
this disease is probably abnormal thinness of the arterial «alb ; ibia b 
coDgenitalin most oases, but may pcobabty result gradually from Buorbid 
degeneratioa and atrophy of tbevnscolartmk«. This frightful malady 
b usually hereditary in «CTtatn families, espedally among the males, tbe 
females being less liable to it. In these persons haemorrbage u caused 
not only by wounds, but light presturo mayindooosubciitaneotu bleed* 
il^, qxHitancfOus hnntiorrbsges, as from the gastric or njslm! mucuti» 
DMrnbraiic, which may cvra prove &taL It ia out exactly ia huge 
wounds where medical aid b eallcd at oooe or vtxj soon, but more 
pttitioubriy in slight wounds, that cootinued basmorriiages occur in 
sucb persons which arc difliculc to arrest, partly, as wo above fitntcd, oe 
sooount of sUght contractility or total bd: of muscular tissae io tb« 
vessels, portly on deficient power of ooogubtioQ In the bluod. It b 




STKFTOHS— BJIUORRBAGB. 



95 



rue, the latter [loiiil has not been proved from the blood (bat escaped, 
for in the csm-s where attentioa was directed to this point the blood 
Aoved like that ot a hvalttiv person. 

I flliall aIao cn)l jour nlUriilion to some pcouliimtiat iii hicmorrhngcs 
fraa ««rtAiD locAliti««, espcd&Ily from tho*« ia the phartfnx^ posterior 
uami, and rwcf urn, «Itliougli, alrictlj' spenkiD^, this cooieH in thv tlonmin 
pf Bpediil rmrgaj. Wounds of the phamyx or pofiteriur nnrcs^ made 
ihroiiffb the open mouth by aocidcnt, arc nue, but, m a result oi cod- 
eUtutionsl tli&ease, wo loa/ hare very s«vere spontaneous hn-morrha^ 
trum thcic p<ui«, or tliese maj ruult from operations^ fur vte Dot un* 
Emjiimtly linrc to nse knives »nd ecipsor* here, or to tour out tumora 
with fixeepa. The blüod does not alHajs (.'seupfi from iLe mouth and 
noM:, but It maj- run down the pharynx Into the Ösophagus without 
biio^ pcToeiTed. The genenl eSects of rapid lo«s of blood conic on 
nqildlr, which wc shall soon describe more n>inutt-Iy, but ws ara 
tnutble to disoorcr tlic source of the bleeding*, which maj be behind 
tho aoft palnle. TIm! patient soon vomits, and at onco throws up largo 
quaoUiies of blood; when this ceases there is another pause, and the 
poll 1 1^ alao the. Burgeon^ thinks tbe bsemorrliage ha« oen^il, 

till < ' A a vomited, and tho patient gtov» gtill weaker. If the 

•ngcoo does not roopguixc tboiesymptotus aad apply proper remedii^s, 
the patient may bleed to death. I remember one ca«e where «cveral 
physicians gare various remedies for vomiting of Uoud nnd gnatria 
hnBorrfaage after a little iqiemtion in the throat, and the source of 
tlte bleeding was finally recognized by an ezpcrietioc«! old surgoou, 
who arrested it by local applications, and thus sarcd the life of the 
patient, 

Tbe same tiling may happen in hzmorrhage from the rectum. 
Frotn an inlemsl wound the blood flows into the rectum, which is ca- 
pable of CQomious distention ; tlie patient has a sudden desire to stool, 
ind eTScuates largo qiuiiitities of bltXHl. This may )» repenttxl sev* 
cral tiai>^ till the rectum, irrituted by the expansion, cither contmcta 
ukI thns arrest« the hiemorrhage, or till it is finally cb€<cked artificially. 

A rmpid uxces»Te loes of blood indueea ohangpra in IIks whole body, 
»hich ore soon ptTccptiWe. Tlie faw^rspri-ially the lips, becomes pnle, 
the latter blui&li, tlie pulse is »»isUer, and ut ttrsl leas frequent. The 
bodily tempnmturo sinks most pcreopübly in tlw extrcmilic«; the pa< 
tteol, esper^inlty wlien .sitting up, h subject tu rainting-spells, dizziness, 
lauaea, or evi.-a voiiiitii);.', hia eyes oio dazzled, and bo has noiM^s in tho 
iMK, t^try ihinfT appears to whiri amund; he colleota his strength to 
Inild himwir up, he boooraes unconscious, and finally falls over. These 
■Tnptntns of synoope we refer to rapid amentia of the brain. In a 
luritoatal posture this soon passea off. Persoui often fiitl into tliis 



H 



SIMI-LK INCISED WOUNDS Ot THE SOFT PARTS. 



Btato from very slight Iom of blood, oocuioniilly inoTC from luaihhij; 
•nd ftvcni<Ki to th« floiriog blood Utim from weakness, A single 
fiiinting of litis kind is ao muiuiure of tbo amount oE bkwd lost; tbe 
patient aood recovers his fbrocs. 

Should the bsemorrlia^G contloucs the foUowing spnptotus appear 
■oooer or later: the oountenanoc grows paler atid waxy, the lips 
|Mle blue, tbo cjres dull, tbe bodily tenipcratiire » loirer, tbo pulse 
Binall, thready, and v&y frequent, rcspirution iiicomfitctc, the )>iit!<!nt 
fiiints (rcqnciitiy, ooDslantlygrow!) more ftx'Mc nud anxious; at Innihe 
fanaias urnxmscious, and the»! is tw-itching of tbo arms and 1^8, which 
Is renewed by the «lightest irritatioa,B8 by the point of a needle, etc. ; 
Ihi9 Stat« mny p>a3s into dc>utli. Great dyspoeeu, lack af oxyg«i, isoiie 
of tbe wont signii, but even here we should not be»itate ; we can oflpn 
do aoractbing- even after appareot death. Young women especially 
cao bear cnormoos loss of blood without immediate danger to life ; you 
will :i ' ' haro occaaon to witness tbia in the obstetriad cliinc. 
Chi!' Id persona can )eA5tbe«r loss of bloml; in young diJldren 

the resulU of the appUmtion of a le^cli arc often evident for years by 
a Vf?ry psUid look and iucrvnsed excitability. In very old persoosgrest 
loss of blooii, if not imincdiatfJy fatal, may induoo obstinate ootlApec, 
which tt^or days or weeks passe« on to death ; this is probably because 
the loK of bliv>d ia irainediately supplied by Benitn, and io old pwrnm 
tlie fonnalion of blood-eorpuscles goes on slowly; the grcatl^wlihit^d 
blood prOTBS inaufficicDt to nourish the tissues, whose nulxitioa is at 
any mte very diiggi^ 

WLen the patient comes to himself after scTerc hirmorrluigr-, he 
bos excessive thirst, aa if the body were dried up, the resecls of ihc 
intestinal canal greedily tako up the quantities of water drunk; in 
strong, healthy persons, tlie cellular cunstittieiits of ibe bl<K>d are 
quickly replaced, it is true wc do not cxaetly know from what auutee ; 
after a few days, in a person otherwise healthy, wo can pcrceire few 
signs of the prerious atuenua ; soon, too, his strength has 
bom tbo exhaustion. 



LECTURE HI. 

TnobMntarnaunorTknii«.— I. I.Ienntp nntj U«>Ilftt«<LI|tBtanor AKvrio«.— Tonl'm.- 
1. Comprewionli; iliu Pioitrr; Clioict »f ttie roimtbr Coaiprauionaftli« Ijmh« 
Artvriu. — Tniirabiiwt. — Amytmmn.— Ksadiyliif .— Tanpon. — S. Bt^iiUca.«- ' 
Gaaofkl TrtMiiivnt oTSadda Aa—tla— Twasflirioii. 

Obxiixm EH : Vou now know the different varieties uf haemorrhage. 
Now, urbal tneann have we for arresting n luorc or less severe bleeding? 



TftKATUENT OF E^UORRB AGE— 1.10 ATDER 



S7 



Tlic numlxcT is 'great, altbougli ire use but fen* of titem— only those 
tliAt ftrc tlic inoAt certain. Here you bare i field of «irgica) operation 
wberp quick and ("prtain nitl is require*!, eo thai, the result must be 
imEailiog. SuU, the cmplojincnt of these remedies require» practice; 
cool-blooded quiet, ftl>8olut« certainty, aud preaenoc of mind, are tbe 
fint miuiiätes in daagi3roiis lia*EaoR4iBge. In such ctrminttancos n 
«orgeoQ Ru>7 aIiow of what metal he is made. 

Hiemutatii» am divided iuto Üircc chief clasaca : 1, Closure of 
tKe rosael by tying it — ligation. 2. Compression. 3. Tho remedies 
that cnuse npid congidation of blood, styptics (from aix^bi, tooonttsct). 
1. The ligature may be applied ia tliree ways, nz., ns liiiature of 
the iM>Iat«d bleeding rcssels, as mediate ligature of Oie latter vitli 
tho sunoanding soft parts, or as ligntinn in the continuily, L e., liga- 
tion of the vessel at some distaucc (rom the wound. 

Thetc varieties of ligfttton apply almost exclusively to arrest of 
artrrial htemorrlinge. Venous fatemorrhages rarely require ligation — it 
is otdy oocasionally indicated in tho large venous trunks ; irr avoid It 
«beaerer we can, as ita results may be dangerous. We shall here- 
aiu>r inquire in what tliig danger oonRttts, and at prestrnt speak tmij 
of the ligation of arteries. 

Let us sui^so the simplest cose; a small artery spurts from a 
: you first sdxe the artciy, as much isolated as possible, bost 
iTersely, between tbe bmncbes of a eli(biig forceps; tbon faelcn 
Ute slide, and tliu bleeding is stopped. The sliding forceps arc best 
made of German silver, 66 it rusts less readily than iron. There sro 
amay diffident varieties of these forcepA, ivhicb are all so lurongvd that 
«ben cIcKicd tttey remain üxed in that jKtsition; tkc mecltanisni accom- 
{dialaniif thiik dooure varies greatly; the more simple it is, the better. 
It is IniereetiDg to follow llic phases of development of this instru- 
ment siuo- the ihys of An^rOK Pare, before it attained its preeeiit 
(Maple cijnipli.'ti^iiea» Of late small spring rjumps arc not nofiv- 
^amUy employed to eompreas the bleeding arteries ■ these are very 
«nrieiwhle, if strongly made. Bedidfti thpse pincettes, we may also 
oc smnll emrcd »harp hooka {BromßtMra arieryfaook) to dniw out 
llie artery, but this Is not so good a ■way, for of eourws the blood 
«tiuld mniinuc to spurt during tho subBCC|UL>nt ligation. 
Having »cized the artery Bccurdy, the next thing b to close it 
fvnDan«nliy; this i» done by the ligature, But satisfy yoiirüelf fir#t 
iJal you have not included a nerve ivith it, for the coineideut ligation 
d% nervo nwy not only Induce cootinucd eovcre pain, but even dnn* 
(tfooe general nervous oflccliona. For luting arteries we use sitk 
Ifanad of various thickness, aoconllng to the nze of tho arteij ; it must 
bt good, strrwtg »ilk, so that it shall not break when firmly tied ; and it 





»6 



SIIIPLE LVCISBH WOüyPS OF TBE SOFT P.IBTÄ 



«hould not r«*dily «bsorb fluids. Have tho forceps, whtdi lian^ir fi 
tlie eud uf llic »rlvrv, Ijt'ld up, ttieu from beluiv pint« thi? silk HfouiiJ 
tho artery, making linst asimplakaot aD<l tying It tigbllj Justin froi 
of tbe forc«p», thcu tic a scooDd knot. Now looaos the forceps ; U i 
ligKtnrti i« nfr)illyfip{>li>'<l, t)ii> hK-t'iiing tnttst boam>«WNl. The tiph 
rniiigof the ktiut must be uccouiplishiMl by pushing IIk* silk furuunJan 
Btrctcbiog it witb tbo poiata of botii fiogcre. If tbo ailk be good^two 
Bimple bnuts, one over the other, will suffice. When the ligature 
firmly applied, cut one end off gliorl anU lead the otb«r otit of t 
wuuttd the sliortost way. In from 6 to 10 daya tho^o can usuulljr he 
removMl. Whon yoa propo«e to close llio wound entirely, it ia boat 
to use catgut mado pliable by soaking in oil ; the knots and loops 
are gmdunlly abflorbml. and only rarely thrown off by nupfiuration. 

It is not always possible to lake up tbc spurting artery aud ligatc 
it by it«elf ; ucnwJooally it contracts so strongly into tbe tisene, ea- 
pedally into tbc muadcs or dense cellular tissue, that ita isolation is 
impracticaUlo. Under such circumstances It b difficult to ooiiijiletc tlie 
UpUioa securely; we are very apt to include the blades of the fofoqw 
in iIk ligature, as it is difljcult to push the ligature far enough 
ward- Such cases are proper ones for mediate ligation. AlWr ha' 
ing piitl«! forward ibe ble<Hiing part with forocps or a hook, pass 
ain'ed needle, held iu a uccdlcbolder, around tbc tuiay, then lie 
ligature so as to encirclo tlio entire end of tbe artery ; tie the loiots 
ti^btlr, SS sbove dirooted ; tbua, while closing the mouth of tbe nrlcry, 
you will enclose some of tlie Burrounding tis&ue. Mediate ligalioii is 
only to bo regarded as an exceptional proceeding, for tbe ligatetl ttss' 
dies or the ligature suppurates through reiy »lowly, to that Iho 
ration of the latter is uincb iiopc^Ied ; uf course we must gusrU 
including any riaihlo Dcnc-trunk near the artery in the ligature In 
pcrcutuneous loediuie ligation of Middeidorpf^ we proceed e%*cii ttn 
summarily ; we paü» a strongly-cun'cd large needle through tlie iläii, 
under and acniss tti« blccdliig artery, and again out through tli« skin ; 
the thread in lie<l, and, besides oompresetngullicr parts, oompivasostlia 
artery ; the Ihrvad remains two or three days. I do not reoomnioiid tlii 
method; it should only be employed in cases of necessity, and sk 
prorisioniil hiemoetatic. 

Whenever tbe bleeding artery can be seen in the wound, tbe biem 
orrbage is to be arrested by b'gaturc ; but, in those case« where tbe 
srtoti« of tbe periosteum or bone spurt out blood, tignturc is unpoft- 
sible, and other methods, sueli as compression, come into play. 

If you have to deal with large bleeding Arterie«, the prooeodiug ts 
just the sanie, only you must bo doubly careful id isolating tbe 
•ft«ry: seise tbe bleeding eod and scrape back the surrounding 



JIIU 

rhM 
,wo 

:4 



«ps 








TREATVBNT OF OfUOBRIUOB— COHTBESSlOJf. 



30 



tissuo with & snuitl scalpel, then ligate carefully- nnd accuratolj; in 
atost catei, when ^u Imrc the central and peripheral ends expoftcd in 
the wouimI, ynu sltoultl ligato lK>t}i, for tlic ituasbomoecs in tlio art4;rial 
system are so free ttiat, if the pcripbemi enil docs not bleed nt once, 
it may do «o laUr. 

The irotind frum nhich a copious h.'Vtnorrliaj;^ ooincii may be wry 
«mall, M n punctiir«! or frtm-iOiot wound. From your anatonucal \.y 
koowlndge you ehould know what lar^ re«sel loay be injured hy such 
A «roond. If, from iha free harmorrbugn or ita frequent rcctiircncc 
aft«r oompKssion, you an) eatisGed Ihat ligation la the only oerlnin 
remedy for the bleeding:, you hare the fbtlowiDg alteiDatires: either 
enlarge th«^ estüting nound by careful, clean Inciuoos, and sock for 
the resKi in the vound while tlic artery is compressed above, and 
QgBt« tlie divided ends of tl>o artery ; or t-lse, wliile you havu the 
btecding Teasel compressed ia tbc wound, you sock tlie ocDtral part of 
tlioTeeael »boTCthc wound, and then ligatci» the continuity. Both op- 
erstioos demand accurate anntomicsl kiiuwlodge of the positions of tlie f/^ 
arteries, and practice. Mliich of these two operations you ahall choose 
depend» on bow you can soooebt prudently attain your object, and 
on which of them will require the smaller new wounnl It you think 
you ^m expose the artery in the wound without enlarging it imicli, 
ohooee Üüa method as the more certain ; but if you eonaidcr thiK very 
difficult, if at the Bt*»t of the wmind the arterj- He* deep undor mtuolGB 
and fascia, especially in very musoubir or fat persons, make a regular 
bgalioT) of the artery above (toward the heart from) tbo wound. 

I sh&U not bcrc disensa the points chosen after years of trial, on 
tieal and praeticnl groumla, for the lifption of nrterie&. In op- 
mirgery, In iho t«xt-hooks on surgical anatomy, and especially 
iti tbo opcralivo course, you will be inatmoted on this point, and muM 
att^n practice in oertainly finding, neatly exposing, and carefully 
ligutinj;, the artery, m doin^ whteli, you cannot accustom yourself to 
too much pifliuitry and technicality. 

Althoujjh the value of the llgnluro h recognized by all surgeona 
\nl the preaent day, still attemptd have been constantly made to find 
impler kiil>stiiii<<'s which should bo just as snfe. Some have con- 
isidered it (unjustly, as it seems to me) a great evil to leave in tbe 
oimd a &ilb thread and a portion of ligalcd vewcl lo die and be- 
come putrid. I pass orer the attempts and proposals marie for allow- 
ing tbe ligature to heal in the cicatrix, and merely mention torsion 
tif the blet^ling- artery as a moile of closing' the ve'*»t-l meehftnically 
till its walla grow together. The blecdinj» vessel ia eeisod with 
■trang, ftcuurately-closing forceps drawn furwnrd hiilf an inch, and 
twisted on its axia five or six tinu» ; I usually draw it out or far sa 



80 



SUirLE 15CI?EI> WOÜXDB OF TUE ßOFT PABJS. 



ponibi«, «nd tvtst till it brculn off. In this wnj- I Iiito twisted VM- 
sels from tlie Bmilloet stie to tliat of the bnicliiul, «o u to securely 
arrest llic bleeding. If bnmclica Icaro ifae Artci; just above the 
bl«ei3ing^^poJnt^ it will not be morablc enougb to mak« Ute tonioo 
securelv ; ticocc I have never tried torsion for the feoionl ; but other 
ntr^cons have done so sucoossfully. 

3> Cofstjwwwjon, — IVessur« on tbo hieoiling voss«! with the finder 
is such a simpl«, apparent method of aircstiug hannorrhage, if we 
may call it a method, that it is etraDgc the laitj do not resort to it at 
once; nny person thai has seea one m tiro operations would inatJnc- 
tlvcly hold hi& ftnget- «n the btecdiag Tesse) ; slQl bow rarely people 
do thb io a case of accidentnl wmmd t Thoy ptrcfcr resorting to all 
Hfte of homo rcmcdiea ; spidor-wcba, hair, urine^ and all sorta of filth, 
ue stoeared over the vrtninil, or else they run for some obi woman 
who can arrest the bleeding b/ tnagkb And no one around thinks of 
comprcesing tbo wouni 

Methodical oompreaston may be made for one of two purpoMC, oi 
pror>W3Ral or pcrmaocat, 

Pfovüional oomprcssion, which U used till vre can dctemÜDe 
how tlic bleeding nay be beat arrest«*d permaDently, may either be 
made hj preying the blcrding vckscI in tlic wound against a bone, if 
possible, or by preiMiog the central part of the arlerj' against the 
bone at some distnnee from tlio wound ■ the former, as we hare al- 
ready stated, is to be done when wd prapoae to ligate the tnmk ; the 
latter, when we wish to tie tlic blp«ling end of the aitery, or to ex- 
amiM the wound more carefully. 

Where »ttall we compress tlic artery, nod how aliall we do It most 
efleciually? To compreaa the right carotid, you would pla« your* 
Bolf behind the patient, and Iny the tips of the »eoond, third, and 
fourth fingers of tlio right luind along the anlcrior bonier nf the 
BtcfDO-dcido-mastoidcus muscle, nboat the middle of Uie neck, and 
press ßrmly ngninst the spine, while you pass the thumb around the 
neck, and with the left band bend the (»tient's head grnlly to the 
wouodi-d «do and «omewlutt hnck^rard. You Bhotild distiiit-tly feci 
the pulsation of the carotid artery. Firm pteasure here is quite pain- 
fill Ä)r the patient, for the vagus nerve is unavoidably oompresaed, and 
tlie teosioa of the parts Deocssarily acts on the larynx and trachea. 
From the free anastomoses of the two can>lid5, tbc effect of comprc* 
sion of one of them, in arre«ting bh'cding from nn artn^- of tliL* heiul 
or fiiee, is not generally very great, and perfect compression of both 
vf«seU requires so much space, that wo must generally be aatbficd 
with dimtntshtng the volume of the arteries by ineomptele eompres* 
sion. CoropressioQ of both carotids is always a very painful and lev 



TBEATlCEyr OF HXUOERBACE— COMPBBSSIQK. 



titying opetation for the patlcn^ espcmlly on acoouat of tlie strong 
•Moodaiy pressure made oii the luryax and tracbca ; henoe it U tarol? 
emplpjed. 

Coraprcc^ion of tbo tnbdaolan artery ma}' be more frcqacntlj li"- 
(juiivd, esjiecisUy in Roaads of Üiis artery in Mohrenfieim'a fo«sa luid 
ia Iho nxUUu Iii tbis operation also jrou i»a; best stand behind tbe 
l«eutab<iat or bali^lUng pmient ; wttb your I«ft haod iuciiuc Lbckcod 
of tJte patient tovrard the wounded (rigbt) side, nntl pttsli }-our right 
thumb firnJy IjdiiiKl tbe niit»T Imrrler of tlie clnviL-ular {>urtioa of tbe 
iduted fitcmo-clvido-nuutoid muscle, ao that yinj miiv Grwlj compress 
t!te artery ngüiist the first rib, nt tlic point »here it ps«ii(» forward 
birtwtt-u the soaleitL nuisdes. Uere also picssurt* is pninful, from Uta 
iiabilUy of tlio brachial plexus of ocrrcs to be ijicludcd in tlio com- 
pieasion; still, by employing sulBcicnt forop, ve may i-omplutoly ocnn» 
prcH tbe artery so as to arrc»t pulaattoo of the raJiaL But tlie thumb 
fiooa grows Liiod aud loscd sciiGation ; h«ncQ Tanous aids bare been de- 
vised — instnunents by nliicli tlie comiiression may bo made rertainly. 
Oite of tbo moat convenient means is a abort thick key whose vranls 
ara Mfapgicd in a liandkerdiief and the Iiandle held iinnly in the palni 
of the hand ; you pince the waKl« of the key over the artery, and 
rompnsa it firmly against tlto Srst rib; But tliis canDiM>t fully ivplsoi 
oooipreeBtoa b]r liic finger of a Kkillcd aseistaat, for witb tlin iasbnniMiat 
ytn of ootme canooC fed if tbe artery slides away from tlie preasure. 

From its poiJtioQ tljo bracMat artery may of oourse be readily 
dOmpreascti ; in doiiiu' tliit>, you place yourself oo tlieouterside of the 
Mn« take the ann in your rt^ht band, so as to lay the ««cond, third, 
and fourth Cngt-n olun^ tbe inner side of the bctly of llto bieepe, about 
the mkldlo of Üjl- ami ur a littlu above it, euirouod the rest of tbe 
ami witb tbe tliuuib, and }>ro^ agaiust tbe humorua with llie Gogcra ; 
tfaa obIv diJUoulty here i». to avoid simultaneous oompression of tho 
mofiao Dnrw, wluch at tliis pohit almost covers tbe artery. By com- 
picaing tbo bimobial artery, wc may readily arrest Üie radinl pube^ 
mail we may employ Uiis cunipres^ion witli great adrantage if we de- 
sife to Ug&lo either the radial ur ubuir artery on account uf wouada, 
ur to aaputate at the furvorm or tlio lower port of tbe «roL 

In kannorrhugvii from the arteries of the lower extremities wo eoitv 
IKvaa x\\p ftiiioral artery at ila commencement, that is, immediately 
bei 'i-^i ligament. Here, wbcro it lies just in the middle bo 

tvi.:. : .. -uLiemilum pubis and anterior inferior crest of tbe ilcitm, 
tbe utay should lie pn»sed against tlie lioiinntal branch of tbe pubis. 
Tbe pationt should be rccunibeut; compresjski» should be made witfa 
libe tbambi and is easy, because at this point tbo artery is snpcrilciaL 
Aa hr down as tbo lower third of tbo thigh, the fomural artery may 



3S 



SlUPLB INCISED WOCNDS OF THE SOFT PARTS. 



bo comprosted »gaiast tlie femur, but thU can on)/ be dooe oerUJaiy 
by Ü1C fingvr ta v«ry tliio i>e»otis j b moat OMee we employ for Üiü 
pufpoM a spodftl compress called a iouniiquct. 

By A lournl^uet vre mean an »ppaiutiu 1>y wliicli we preu an 
clongnlod oral peoe of wood or luatlior, « pad, against an artcrr, anJ 
this a^ia»t the booe, by mcaos of a twi»tln|f, acrowing, or buckUog 
mtK-liKnism. SJnoe a long oompr«ftsioii of tbs braciiial or femoral ar- 
teries 19 wry fati^ing, wo may adrantn^oously call it to aid In oom- 
prcssing tlieA« arleriea. Tbe form of iostrument that we now employ 
U the icrow tourniquet of Jean XoMi* T^YiV. The pad, wbicli is mov^ 
able on u band, ia In bo applied exactly orer Uie putufc owreiqtondii]^ 
to tile actciy, and opposit« tlic screw, under wbiob a few folds of Uoüu 
arc to be placed, to jirovcut too great pressure ou tbo skin. Then 
buddo tJie baad around tbc cxtit.-mity, »ud by nioaiis of the screw ami 
band draw the pad tighter till tbo subjacent art«ry coaxes to pulsate. 
In an amputation-wound, if we do noi at onoe sea tbo mnutb of tbe 
■rt«ry, wc may loosen the screw slightly and permit a llttlß blood to 
escMpe Crom tbe artery, wbicb at once shows its posiUoo ; then screw 
up Ü10 tourniquet at onoe, and ligate the artery. This is llic great nd- 
vuntagc of tbe screw. Vrltcn the apparatus fs well imidc nod careful- 
ly aj^Iicd, it is of exooUcot sortice. It is true, tbo band aronod tbe 
limb unavoidably compresses the veins, especially tbe «uboutiiocous 
veins ; ncvertbeteffi, o» aocount of the pod, it acts clilefly on tbe »rltrry. 
With a piece of brond bandage and a round block of wood, or a loDer 
of bandage and a short stiele, you may rcndily iraprorise soch a toui^ 
niquet; still, if this improvised apparatus dues not secure tbe artery 
very Gmily and sccurtdy, I &bauld advise more certain modes of com» 
pression, of which I sball apeak inimcdiatcly. Tbo facibty of olteok- 
ing even oonsidervble hoiraorrhagcs by means of tbe tourniquet, mfgbt 
dtJude us into leaving it on for a long wbile, untu tlie bleedfa^ 
etojipcd of itself, und wu slicmld thus eacape tbe trouble of ligaUof. 
This would be a great enor. If tbe toamiquet remains on half an 
hour, tbe extremity bcrlow tt grows blue, swells, loses lensatioo, aad 
circulation in the )mrt ntiiy lie entirely nrrcated, and it will die ; 
chrcugh your whole life yuu would blame yuursnif fur lueli an etnir, 
which might greatly ondangnr the life of your jwtienl. 

nence, application of tbo tourniquet is only admissible as a pro- 
viiiontil hn-inostatio. Il is nlrr.oxt inipractieable to ooropress a large 
lutery with llio fingLT till tJic lutiutn-rhitgo sbiill be certainly arrested 
spontaneoDsly. Still, coses may arise whore oorapreealon with tUr 
finger is the only certain mode of arresting bleediug from smaller ar- 
teries, as in bmmorrhage» from tlic n?ctum or deep in tlio pharjmx, 
wben other means Imr« foiled; hero, compmaion with tbe tingci 



TatATltOT Uf ÜjEMOSRfiAtiE-COMPRBeSIOX. 



39 



must aomeümes be contjnuod hxtf an lioiir to no hour, or longor, für 
li^tKPU of ilio intcninl UJac in tbc furaicr case, and of the carotul in 
th« Utter, &ro lu daBgcrous M thoy are uncertain for & permanent ai^ 
not of the bleeding.' 

Quito reoeotly tbe genial »irgeo» and obstetrician, Simfnon, of &!• 
iiibu^, wbom yoa alrea'ly know as the introducer of chloroform, 
liat reoominentUMl a nicUnxI whioh I cannot recognizi> as a porfijct aut^ 
alituto for ligation, btit wliicli is in tniuij cases of practical use; Itila 
is tbe ooroprc«ion of the Weeding nrtcry hy a needle — acupmsuri, 
Aouprossure muif bo mnde in viiriuns ways. Fiv inEtitu.'», iu an »m- 
ptitatioo-flup, joa introditcc a long iiiscct, or scwing-acedio, nearly 
vertically tlirou^ tbe skin and 9ofl parts to witbiu onoKjuorter or 
oneJiatf an inch of tiio nrtcry- ; turn the neodle horiisontalty, bring its 
point close over or uiidcr the artrry, and at atxHit the same dblaooc 
fruia tho artery you puab it into tiiu soft parts, nod jiilm it out throu^ 
tbe ticin nearly v»rücally, so that tbe artery shall be oompcessed be- 
Iweeo lie nt>«dle and the soft parta, or, sUtl better, against a booe. 
Sbmild this coiuin-rssioQ not act perfectly, as it M-nuld rarely be likely 
to in \arga arteries, if the first needle vaa »pplivd above the artery, 
pasa a secood one below it, and ao compress the artery between Uie 
two tteudles, or else press tfie artery agniost tbe needle by means of 
• wire loop. In ainputati^tris I prefer acupressure by torsion; I pa»s 
tbe oeodle transvcreuly thrvugli ihc artery, vbich is drawn fonvard, 
aod wilb tbe needle toako a half or whole rotation in tbo diioctioa of 
the radius of tlie suiCtee of the flap, until the bleeding is arreated, 
and tlten insert tbe point of tbe acedle into tbe soft partii. TIx; 
noeiBea may be rcmored aft«r forty-ei^ht bntiri, ivithouc reiietnd of 
Llc«diiig. Tbe oiten^ive experience of KngUsb aurgeous io tbc suc- 
cess ol this bold operation first gave me coungo to try it, and I must 
ickiunriedgQ that in several amputations, even of t\tc tiiigh, I bare 
•era no objection to it. I cannot <Luite believe tUiit acupressure will 
tU^ether displaoe ligation, as Simpson prophesied. In this opera- 
tion, to wbicb I bnve resorted in nwst of my amputations for several 
yean, I employ long golden needles with large heads, because other 
inctalt rast eaiily, and silver i» too aoft, and platinum too expensive. 
Quite recently Vim BruH» luis applied small ligature rods, with 
•diich too]M of silk are applied around and retained aguiiiät Uic 
•rtery.previ'iusly drawn out. These, like acupressuienccdlcs, arc ro- 
OWTcd after forty-<>igtit hours. I have just tiled this procedure with 
peHeei success on the femoral artery in Im amputation of Üio tliigh. 

la Tcaou« bamorrbage, or bleeding fiou) numerous small arteries, 
espsoall/ in so-called ])ar«iiehyn>atous Inemorrliage, a r^ular tampon 
nut be npplicd, by meaus of baudages, compresses, and charpie. 



st 



SniFLE IKCKCU VTODXDS OF TOE SOFT PARTS. 



Kyoa liftve « hmnnrrtmg« from the wtd or ^cg, tJial vuu n-iKli to 
UTCst hy coinprcssiun — il^ for instaaoe, luge qiumutit's oif blood are 
being pouicd out from a dikted diMoecd Tciii, or if (liera be blccdiug 
froiJi nuuierouä «mall url4.>riL>s — ^^ou ttay *|>p1y a bondage finuly fnim 
thi! lon-er to tbc upper port of tlie extremity, having preriouiJy covered 
ibe wouod vritb & conprcsa «ad charpio, and after applying sewnil 
ihielciicftiM» (>f lioen along tht> eoiuse of the obief art«i7 of th« extivmit^. 
Flut ibe liiHer pnqxise you may also fiiipUiy tbc gnidual<^ itmipretts, 
wbtcb 3*011 will leam Lo make in llio coimo ou bnudagca. To ÜiIm, 
trhicb is «tied TAeden'« drcMing, it is well to ndd a uplinl^ to ke«p 
the extremity perfectly quiet, for tbe bleeding is readily renewed by 
musoilar cnatractiaru. llie»e grnduitted compresses, carefully ■na<lef 
ore parlicxdaply scn-ieooblc on Ibo bsttlc-Beld, in guQ-«hot and puniy 
ttirt-i) wounds; by tbeir aid we may arrest bfemojrhage irom tbc rndt- 
al, ulnar, anterior and posterior tibial, and even from the bmebbt and 
femonJ artori«». IntbeforrDeror9mal!orartflrie»,hy b-aving Ibcdr«.-«- 
iikguii BIX or eigfit days, uo may arrc«t ttie bleeiliug pennnnuntly, 
but in tlto latter it only aot& «a a pToriaiooal tueoiOBtacio ; it mast be 
follow«! by ligntion, if u^ n-i»li to hi at all sure of aroidiog a teoar> 
nmse of the bleeding. M'e loay also employ eompreffidon in biDinoP' 
rliagrs from tbc tborux, ob in cose of pumncbymatous hicmorrliage 
aller rftmoral of a diM«sc4 breAst; 'heit we lo&ydre&s the wound with 
eomprosscs and chiirpic, and retain tbem in position by bandagee 
oroiind llie tborax. But., for sucb u biAndage to be cfficaeious, it must 
be Tcry nnnoying to the patient ; on tbc whole, it is better to ligatn 
the Ueedit^ arteries, even if there should be many of tbem ; by ao 
dotngf botli you and your patients will be betluT off, for you uiU nut 
be worried and disturbed by tbe secondary haemorrhage» follovrittg 
tiMM opomlion« as a result of basly ligation and iusufiicicut coniprv»- 
sion. 

lo «noio part» of tlio Imdy you eunnot employ corapresses, as in 
bkedibg from iho reetuin, vugiiio, or iHMtcrior oarca. Here llie tOO^ 
fon (ftom Umpofx, plug) is scn-ioeable. There are many rarietioe of 
tampons, n^wcially fur hirmoTrhitgo from tbe ragioa or rectum. One 
of the simplest ia aa follow«: Take a fuurcotnered pitMx: of litioiL, 
abuut a foot square ; placing tbe niidtUe of this orer two, tlire«, or five 
fingen of your right band, pa88 it into the nigiita or rcetum, and fill 
the space left by tbe removal of your hand with lu nuieh cbikrpio aa 
you can get iii, »o that tbc ragioa or rectum will be fully distended 
from within, and tbns strong pressure te nuule on its wiills ; wlieo fbo 
hjetoutrluigc is iirrrstcfl, leave the tampon in till the next day, or longer 
if neoesaary, ihvn rcmore it by gentle traction on tbe linco, which 



« 




TREATMENT OK n^MORRQAdK-STTPTICS. 



35 



uasMfortbediaipio. Toumuy ulBOlnJLkcaba1Iofella^I)tco^ 
• linen hj WTDppin^ a utrinjif oniund il, uid Icavo a long Rtrin^ liangiog 
out hy whidi to muove il ; »s Mich a tanip») mar be cillir.>r loo Iiirgc 
OT too «mall, I pruftT the fint method^ in wliii;li we Duty iJll tltc Imca 
Bie to tlic uxtoiit we d»sire. 

If tbo bleeding come from tl>c portio ragiiuilis uteri, after an 
operation, for iaetaoce, s morv ccrtaia tray its to hold back the poste- 
rior wall ivitli & Lirg« Sims's speculum, Uius briiig'inj; ihe portjo VBff- 
oalis into ticw, and prtss a tampon iinnly a^inst tha bleeding port; 
for it roquirce aa incredible quaotity of cbarplo to fill tlie vagina of » 
«oninn vbn has borno many cliJldreu, 60 tliut no blood cuo piUK 
llirougb, and il causes great pain. 

la prufuW bleeding from tbe 0000« wliicb moatly coioea from tlie 

riot pnrt of the infc-iior meatu», and not un(m]URnt)y from tbo 

eriorly-sitnntal cavernous tissue of tbe kiwer turbiuut(!(] boui*, 

phi^^üig tbo itofiu Eroni tlte truiit pruvc-a incfficaciuiis und usrlcss; tbc 

bV^oding continue«, and the blood cither passes into tbe pharynx or 

Iflmra out c^ tbe otluT nostril, aa tbe patient pTVBSes tbe Teluni pen> 

' dBlam palati against the wall nf the pharynx, and shuts off* Uie uppiT 

I part of tbe ptiar}*ngeal ca\ity. Hence, ne must be prejMred to plug 

|lb« [KiKtefior Bares ; we may dnthiaby theai<lorJ7e/'/uo*j boud«], Tliis 

fm> ' '. ' invcuicnt instrument coiisista of a canuin about sii incbca 

^uUfi ' -'-ly ciincU at oite eud; in tlio cauuln is a steel spring of 

il«r length, with a perforated buttou-lioad al oue end. You 

jforeliaud a tliick plug large cnoi^b to till the poslci'ior nares, 

IrikI liavo A tbrcud attadied to it. (7 ou way luuke thid plug by Iny- 

injj thn^n<)9 nf olinrni'" «iiift by silt« and tying them 1 ighlly to^llier in 

lÜM tniiliHe Willi a nilk threail.)- Vou apply llii» plufi- by jKissing iLu 

lont, with ruttnctcd apriug, through the inferior Daasl meatus, 

! fiBsliing the spring furwanl (ill it apponm bolow the velum in ibo 

iDmitb. Piias llip thread altaclicd to the plug tlirougb the eye in the 

lirad «if tlic! spriiijr, tie it there, and draw both canuU aud spring mit 

Lof tbe noec ', tbe thread attached to tbe latter and the plug fast to this 

liuEBl <(>now, and if you draw tightly on the thread llw! plug is pr«Med 

■lare»; if ibe Iileedinjr be now arn-ÄU'd, a» it uau- 

1 xhoulfl nut Ik." Inoff oiioiigli for it^ end to rea^ 

J the tnyax) was not too small, you cut loos« tbe tbnutd, leave the plug 

I'hi tin the noKt day, tlicn witbdmw it by the Uircad left banging from 

Ike mouth i tbiA is usually eacily done, as the plug is generally covered 

niih miaoiu and i« eontu>quei)tly smuoth. As Ibis instrument is not 

ilwan at hand, wg may um; an elastic cat]ict<T or a tluii slip of wbate- 

UiiE for tbc same purpooc, inlrodiioing it through tbe nose, seining it 



JO 



^-lUPLR IKCISF.D WOUS'DS OF TDK SOFT rJRTS. 



with the Soger bcltiad Ibo tlOuui, &iid liringing Üie cod out of the 
moutli to tio llio thrend to it. Bat the emptojmcnt of tLis substitute 
rcquircB more dexterity thiui is neccsnary for BtUoc's sound. 

3. Stjff/fics are remedies which ad partly by causing cootisctloa 
of t)>e tiAsiio, partly by inducing rajMd and firm congiilaticMi. TIio oinii* 
her of roincdioft recommended \» imm«nsc ; wc shnll only mention those 
that liavB a proved rcputatioa uodor cortitiit circuriistatM^ea. 

CoH not only irritatrs the arteries and veins to contract, but also 
innlcrs the other sofi parts contra«:! and Ihiis ooniprcss tlie reesule ; the 
eufTcnt of Mood is gradually more obstructed, and may cren stagiwto 
«Dtirely, when tltc part is ixinip1nt4>1y fitnrn. It »oems lo me, liowerer, 
tliat ibo recoinuicadntion of cold iia a hmnoetatic la oftra carried too 
fiw; I ndvixc I'oti not to rely oi* it too mut'li. Cold may bo employed 
»s futlowi : firsl^ ve may aquirt. iconater agninst the blemlrng vrotmd, 
or into the Taginn, rectum, into the bladder through a ratlieler, into 
the nose or mouth — here the nitxh&nieal irrilation or a ntmnj^ atrcutn 
of watoT in added to that of the mid ; or you mny lay [tiei'p« af ice on 
til« wound, or itilroduce tlicm Into the cavtti««, or have tliem swallovrcci 
fo gastric or pulnionaty bfemorrhage; or, Innly, ynu may fill a blad^lcr 
with ice ami apply to the wound, to 1« left oii for hour« or diiys. 

llie ah«<tiuU 'fniet to I>c obserred in all lunuorrhagus and thti dim- 
inution in size of the arteries as s. rccolt of the bleeding that has 
alretwiy oocuirred, may often have more effort in ampsting iho hrpnoor- 
riiage than ioc ha», while it rcecires all the credit. I n ill rint dit>»uiide 
you fixim using cold in moderut« pareocliymatous hteiuurrhiiges, but 
do not expect too mueh from it in bloe^Ung from ]argo nHerion, »ml 
do not waste too much time over it, for tiras^ hkx>d — blocd ta Ufa, 

Hie same is true of the common local remedies, vinegar, solatioa 
'>f altim, ete., vrhieh aleo contract the tisueti and thus eomprpss tho 
vcs&els ; tfiey are very good for arreetiag eapiUury hmmorrhagR» &rna 
the nnoc, but you mu.><i not expert any tiling wonderful fmoi litem. 

The ftot iron, femiin eandena, oaustiomn actuate, aeL> by chnrrinfi 
the ends of tlie vrAselm uihI tlio bloo<l, and tlii5 Mcape of ttiu blood ii 
arrested liy Uic n'^ulting firm slough. You only need to bold n rod of 
iron with n n-ooden handle at one end, uimI at tlic otlicr n Rmall iron 
bead heated to a white hent, cIow! to llie bleeiUug spot, to form u blaclc 
crust instantly ; indeed], the tissut; occauoonlly blsaes iip even from tlw 
ndiattxl heat A red-hot iron pressed on the bleeding »pot hoa the 
«ame effect, Imt is apt to cling to Utc reuniting eschar and pull it ufl 
again. Hiis iron md (cnulery imn) ia usually heated to the proper 
dogrec in a furnace with bellows. Under some drcumstnoocs tlio bol 
iron may Im* rery oonveolent for arreBting bRmorrhago; formerly, bo- 




TREaTMS.VT of HfMORRH^GE. 



87 



tigntiou MTis known, it wn» (br most wlcbrntrd ttjptic. The 

Lmliittn siir^-oiis »siuill; hca.t«<l tlictr iitnpuUliiig knlrea reU hot, n 

vwlitifj; ibat oven J^aitrieiua JHhtantie fxtollL'd, allboiigh he pre- 

burning the bleeding srirrica si^pnnitr]^ with fine-poiuted cau- 

ID wliid) he must hiivu liiul an euvisble expcrtaeso. 

QuilR mcpiitlv ri siriiilnr nu^tliod ha» been itivi^itod, njirm'lr, llw 

^VKi o( pIntiniiiM lie«.ted by I lie gnlvaiiicbatlrnf. Tliiu is Ihi; (^(i-call»hi 

fotvano-cauetie ioUodiiccd inlü Gcnnaiiy by Jlidd^idorjif, irhich oiay 

sometiniffft be f-mployed with idvnnliige. Af, you may rvsdily under- 

stund, in practice we have not »Iwiiys at band nn iron properly shaprd 

i'T arrrjitiag haemorriiagc, nurb as you BGo in Ibo surgical cliuioi. 

>üffniUuA, the moat talented German operator of this century, who 

p-ut St the urae time o most original man, on«% lacking otber me»»«;, 

■ ■■in» \yooT (Iwflllng, nrrost4Hl a IwmDirtinpi fulluwiiig tJie 

ii of n tvimor from the ba<.-k, by means of the tongs wbleh be 

in llw KtOTP. A kuilting-nifdl«*, stitek in a pica» of wood or a 

'^torit, und heatnl at the lump, nmy answer the purpose of the hut iron. 

A teiiicdy vrliich not ooty equals, but occasiooally surpasses, the 

it imo in it* effieets, is liQilor J'trri ifufiiiehtorati ; this fonns with 

ftbe blt>od »ucb « Ictitlicry, odlKir:»! iMagnhini, tliat it act* excellently 

' • Btyptick To apply it, you pre^FS a piece of cliarpic, inoisttrucd with 

, fiimly apaiiipt tin." wtmnd ; «fl*'r bsrinfj wniib«! off the blooil witli a 

IkiM il iben! fruin two to live iniiiuten; you will ibuB be uUc 

' «rest vjuitc fre^ arterial hn-morrbage. If the first application does 

ot wrvcrd, try it n srcond or ibird tiini?; this reinccij will rarely Wl 

i; but it mikes a Klouglt, l)rhind wluch there is often sanious sup 

tniii nii»<-<l with gafl-|)ubbl>>.s ; lience we should not employ thia 

Rfwdlrnaly. 

TliB applieatlon ot punk «nd blotling-pajier to blccdlug wounds Is 

'THicily; the punk ntirkx fast to the blwxl and the woimd, 

^ \ic not cxccfisivo ; in hn>inorri»gM at nil fn-e it is uwIpjs 

twithuut nimilluneuus compression ; occaajonally it is very elBcaoious, 

Kid I» U|fhly praised by some surgeons. Dry ciiaqjic presse«! finnly 

w tite wound bns the »uinc effeet, according to my experience.* 

Otiier luMiifistatie« are oil o/ tnrj>fntme and aqua Jiiiiefli, in 
[«hldi the creosote is chiefly efficacious; concerning the former alone 
Hun I «ny cx|>erienoe, and I rccommnud it strongly ; whoa I studied 
«11, it wraa also specially recommended by my [»receptor, 
1 uiK^I It once u illi such s< riking benefit in a doubtful case 
tlntl liAro & Qortain dcrotJon for it. It is, lioweior, an beruio rcmetly, 
BOt only because application of turpcnttncKiil to a wound induces 
mrtn pain, but aUo Vteeause it cxcitt^s soren) inäanmuittou in the 
noaaä anil ltd vlrinttf. I will rolutc the ens« where I employed it 



i8 



SIIIPLB UfCISED WOCKt« OF THE SOfT PAKTS. 



A. young, feeble woman Buffered, ftfler confinoment for many montlu, 
from «n extoosire suj^ration behind tho right breast, betwoen tho 
m&Bunar)* ^snd wkI tlic fucia of tiie pectoral muHole; numcroua iain- 
Bions tud already tx^en made through tbfl hrcHSt, and abuut iiB ciroum- 
rerenco,to give free aoceNS totlie pus which fbnnrd iamcli quantities; 
but tbv i^K-iiin^ GUOQ closed ugaiii, aiiO new oucs luid to be nmdc, as 
the wound did not hcnl from Ix-low. From one such iucision, whiott I 
nude quite extonsiro, sevoro bmoorrhage resultod, blood welled up 
bont tJic depUi of tbo abscess, und 1 vrns unable to Hod tlm bkediug 
«i^etael; it flowed continuously, as if from n spring. First, I filtod the 
dtvity ivilb chorpie and applied a bandagf; tbe blood soon oozo:! 
through Ulis dressing; I removed it nnd ii)jecl«d ioe-water into tbo 
various openings ; the bleeding moderated. 1 agoia made fimi oomprcA- 
sion, uiid the liatnorrliagc pecnied arn>Klo(L I had scarcely rcaohed my 
room in the hospital wWu 1 U'lu cutlod by ttie nunw, bocuuae tJie bkwid -^ 
again ooMd through the dri.^«siDg ; the patient had fainted, was p^H 
ss a c90cpG(>,aud tbu pulsu was very huulU. The bandage bad toVP 
removed at once. I now thruat pieces of icc through the diffcrcot 
openings into tho canty under tho breast ; stUJ the bteediug wu» not 
■trestetL The patient went fram oue fiiiuting-lit into anotlier, the l>i<d 
Bowed witli blond and ioc-irntcr, tho patient lay unconwioui, with cold 
limbs Bud uptam«d tryesy the auracs constantly trying to resuacilate the 
patient by liokliiig aninioniA to the ikwc, and rubbing the fbrahcad with 
Cologne water. At the coiuinenccnieQt of my suigicjil life, unoceu»* 
toned to quiet and presence of mind lu such sccdofi, cau«eil by my owo 
set, 1 altnll never forget this situstiofL I thought it wcmld be nbK>- 
lutely necessary to ampuute the breast at oaee, to fiixl nud ligato tho 
bleeding artery, but delennined to make one more: attempt witti oil 
of turp«ntine, I soaked a few WAds in this subttAncc, ifitrotlucod 
tbem into tl»e woun<1, nnd the bleedfaig was instantly arretted. Tlie 
pattt'nt Kxm revived ; tlic turpentine, which was left in tweiiiT-Toar 
hours, oauBed intense reaction in tho abeccss canty, whose wnlJB bo- 
ame detadied. Subsequent active granulation induced in three weeks 
a euro which had for montlis been patiently and perscveringly aottght 
in rain by physicänn and patient. I iwnnot expliun to you bow bleed- 
Ing is aiTtsted by oil of turpentine and crcofotc ; they do not cause 
psrticnlarly firm coagulation of the blood; probably the intense irrita* 
üua ihey indiux) excites a peculiarly cnorgctio oontrnoÜon of the di- 
vided capillarieii, 

Vou will rarely see »typlics employed in tl« emgical clinic ; they 
arc rather favorites of ibo practising physician, who is not accustomed 
to ligntc arteries. Whore wc can ligsto or cüwipre5S, we aUoidd not 



TBAKSFCSIOH OF BLOOD. 



39 



stjrirtks. I» parencIijiniitoM» bleeding from the face, nctk, or 

Fperinemn, vre vmj wsoit to »tjptic« with advniitnp«, if it aiKkoa no 

tUSenvoce vhctlicr \ho u-oitntl suj>punitcs euljsc<(|ucntly ; but, if the 

aorrliagc be couBidcrablc, and Btjrptics fsU, subsequent ligntioa ia 

mora difficult, as tbo wo<und is often terribl/ «ncatcd up bjr the 

'previous i^lkntioos. 

Inmrgeryym liarc nothing to expect from the internal admmi»- 

rtntioa of remedies reoouuueoded oa styptica. Absolute quiet, kccpinj; 

f eool, niurotics, purgatii-es, mnj oacaMoaaMy be of great BBSistaone in 

!.cnugv«tive luemonhngfr», but tlicir adinri ii inr too slow for Uie blec<N 

btg that wo tuivc to deal nith ia surgery. 

"Hi© general debility (««d pro^BC hiemorrhage ■will, of couise^ 
[be most cfi'i*ctually combuted bjr turesting the bleeding; but, while 
[idotqg this, you muy have tlic) aAsiitiantfl, not otlit^nriso employed, try 
|(o tesiuatat« tUt^ patient by sniclling-Aalts, sprinkling vith water, 
I Ml Vou fthuiili) not yourself join in the«e at templet, till the ble«d- 
lag Is Blojipcd ; Ihcii you may give winir, rum, or brandy, irunn oolTcei 
or soup; cover the pnticnt up warmly; let himtnkcn few dropfof spir- 
its of cth(*r or ncfrttcetliitr, and smell nmmunia, oto, I ha%'e ne%t.T Iiiul a 
INtli-nl bleeil to death under my hatHb, hut hare met two cases wbcro 
Hie patients died, two and 6ve hour« aRer «xtonslre operation«, 
u-tth d_i-«<]Min>« and iipa n mod i c oontraetions, apparently as a re^ultof 
the gn-it l(i«s of blood; these oasea dcetded me, under ßiniilar ctr- 
l^omstanceev to inject the blood of a healthy person into the veins of 
bleetling one. Tins operation, whieli is eallcd tmiMfuaion^ ia 
atideat; it originated in the middle of the seventeenth cen- 
tury. After tlie worid had been for a time astooished ut its boldness, 
it was laid aside and derided, but, toward the end of the IogC contury, 
\h wiu Rgaio drawn from tlie shade of oblivion by Engiish physicians, es» 
I ivdolly the uljatutridans. After I>i(^enbach had made some atlemptä 
to iiitru<ln'-e tr^nsfufion into Germany without stiooess, .J/är^ 
nfi» has of late 0>0 credit of again calling attentioD to it as a mode 
Mviti^ Ufe, while J^num has cxhauetiTcly treated the subject in 
r pbysiolngicAl cxperimcnls. Statielics sTiow that the opcratioti wm 
fimimhle in the great majority of cases, and was x-ery easy to ppp> 
farm. Altliougb formerly lamb's blood was auccessfuUy injected into 
miD*» veins, it is best rod roost natural to choose tdood from » youBf, 
bmltfaj, und strong human being. The instruments required are a 
blfr, Ibrceps. seisson, n fine eanula, and a 4-6 oz. ghisa syringe to 
ft it We o|)cu tbo vein of a healthy, strong young man, in Uie man* 
Mr kotvafU^r to be deseribed, and receiro first about four ounce« of 
ibe bkwd in a rather liigh bowl, standing in a liosin full of blood-wurm 
ntm; the blood, Sowing into th« bowl, is beaten with a twirling; 




40 



SIUFLE LVCISCD WOUXDS OP TOE SOFT PABTa 



Blick, tut the rihrine is separatcil. While this is being done, the most 
peropptible siihcuUn^ous reio at Uie bend ot tltc vlbuw of tbe patient 
is to be exposed bjr on indsion Uirough the skin ; then two ^ilk UircntU 
arc to bo passed under it, the lower one is drawn on wiUwut 
cIuKing it, so tlmt no blood may escape by the subsequent fine oblique 
inctsioTi tnfldc in tlie vein by the sciasors. The cjinula is paused up 
into tlic now gaping opcuiuiif in tbe %'ein, and the upper thread ia 
croned over it without being tiod ; «omc blood should escape thniu^h 
the caoula, so ua to Gil it and drive out tJie utr. Meanwhile, the iia> 
sittant bos oomplctcd tlic rcncscction nud filtered the whipped blood 
tliroiigh n fiiio oluth ; tlien tbu pruviously-wanned syrin^ ia to be 
filled with Uic blood, in rerted luid the air forced out, pkecd (Lnnly in the 
cftnula» and tlie blood injected very blowly. Experienra bas tangltl 
tbnt it It not admable to inject mom than four to eight ouni-oa of 
blood, and that this Is eoougb to recall life. M'e sliould werer «iDpty 
the ^J'rillI^■ entirely, und ocase at once if the patient hua dyspnixa. 
'Ntlieti the injection it completed, ve romoro the ligatures nnd cannla, 
and treat the wound as after rencscction. There has been mueh dis- 
pute, as to whether or not it is necessary to remove the fibrine ftv.m 
the blood to be injected. Panum'tt esperiments have clearly pivred that 
fibrine is not necessaiy in resuscitation by transfusion, and that, even 
vrith tlie greatest oaic^ it inay act injuriously by dottiog. TV actirc 
clemcnt in this operatioa npp«ars to be tho introdtiction of blood-eor- 
pusoles as bearers of oxygeu. Possibly, Iraiisfuskwi has a still wider 
fiiturc; at all events, it might be worth while to try it in cxccuirc 
omemifl, resultiug from other, somotimcs unknown, causes, even al- 
though, uc^ionliug to Panuni's excellent observations, the blood itself 
does not nouriali, but is only tbe bearer and forwsnlcr of nourish- 
meat. The experimeals made by Seuddi/ety during tho IsaI Itulina 
War, CHI tltc wounded who had beeoine nnsenUc Crom profuse suppiirs- 
lion, had no brilliant ri»u1t«, it is true, but furtlier trials iJiould be 
mode of ihis operation, which with proper care is oot daogcrouiL 

Ilueter Itad studied transfusion tno«t Ihorougbly of late ; be rer- 
onunBiids injecting beaten and ßltered venous blood into ao artery 
(such as the radiiil or |K>sterior tibial) in a peripheral direction, just 
as was one« done hv Von Qratf*'. A« Huet^r bas demonstrated ihnt 
this arterial transfusion is eaner [h»n tlin venous, it deserves the 
preference, bccDusc by it wo avoid the dangier of pulmnimrr emboli. 
No abnormAl symptoms occurred whore //w^-iyroprnted on the bands 
and feet ; but \ doubt if it would often be posftiblo to introdaee a 
eauula into these amall arteriös iu a patient bicedbig to death ; in 
stich a case we should bare to choose Uie brachial artery. 

Tbe enormous increase of bodily temperature, the occurrence of 



GAfiSQ OF THE WOUND. 



43 



bltvxly uriae, and olLor »vmptoms, following tlita operation, show 
thAt it Ima a vegr decided influence on the physiological action oflbe 
oi:gaii)Sni, As Ihta operation has always been performed in Tain bj 
mjTBolf and my aiisistantji, I am much luss in faror of it tfaiui formerly, 
when I only knew it from llie acooimt« of otti«r«. 

I cannot tor« enter on the Ireatraont of tliB later results of con* 
aitieiuble humorrbagcs ; it will bo evident to you tbat, ta gcooral,tbc 
ebfooio effeeu, the deficient formation of new blood, must be com- 
bsted by strcnffthcoing' and nourishing' diet and medicines. 



LECTURE IV. 



■liUif «r the Waand.— Union by PUsUir.-^^iituni ; Iiitcrni|>tod Sctura ; T« !>il«l 9a- 
iiu«.— Ezttro&t Cbuiiet porvojittble in ths Doited VoaikL— Iluftliii)[ bjr Fin'i lu- 
uniiva. 

After entirely arreating tbo hacmoirbagc from a vi-ound, clcnniDg 
ita »urfftpc willi cold water, and xnÜKfyinj^ youraelf of it« depth, and 
of tbo cbanictcr of the parts dividL*d, in doing- which you must notio« 
wbether a joint, or one of tlic cavities of the body, haa been opciiod, 
■ bige nerve divided, or a bone exposed or injured, etc, you will 
torn your atlpntion I« tlic Ihinl Ä_>iiiptrini in the frej-li wound, lliat is, 
ita gaping. On divi»oa aluu, fuscia, and nerves vriU svp:ir»ti;, partly 
from their own einstiejty, partly bocaiwe they are altaeliod to Ü»© mua- 
olca, which, frrrtn tlivir contrartility, aluink logetber immediately 
after bcinff divided, and whose cut sorfaccs, oonH^fjucntly, especially 
io ttniiirvcrH; woimds, arc more or less scpaiated. 

At first we ^atl conuder only those tDcised wounda where there hog 
been no lai« of substance, Hut only a simple division of the »oft parts. 
For Boeh a wound tn heal qaieklr, it ia deflintblc that Ihe two edges 
ahould be Imtiughl exactly togctlier, us Ihoy wem bcfooi the injury; 
Io aocompUsh tliis, we make use of strips of adhesive plaatcr or of 
raturM. 

In wounds where tlie cutis is sraroely divided, as so ofteu happens 
ia thr oomtnon indsrd wounds of the fingers, wc may use ialngbitat- 
/lAwr«** with advantage. It consists of a solution of ichlhyoooUa is 
wal«r, mixed Willi a little spirits of wine, painted over a thin, firm 
•ilk «ufT or I I' hack is often painted with tincture of benwin, 

wliiiih giv«^ I , r a pleaaaut odor. As the plaatcr readily \(\->% 




.m^ 



«ü 



SlHFt£ lüaSED WOCXDS OV THE SOFT TABTS. 



ms under mo!si cainprosiK«, It is o{itea adriaable to pBiiit it mth col- 
lodiou, after it ha» dnc<1. 

OoUodion U a solution of f^un-cottoii in n mixture nf ptlirr niul 
Oleobal. If thb fluid l>c paiaUnl orcr tlic plu&ter kiiÜ ilm ekiii iiniiKKli* 
ntdy Bitjaccut, tlie etlicr quitddy oraponitcSt find « Ena meubniw ia- 
soIubl4> ill \('iiter rpniains, often puckcriog up tliu nkin. A furtlicr 
therapeutic use mzj* be im<le of iIiih mnlnictilc nction of oollndicin, 
hf puutinf;; it on tbti)iiflnin(.\liikin, either diiocUjr, or, etill belter, after 
COTering' tlie part with a thin, eoarw^mofthcd ontton-doth (gauKo); 
this causes moderate, even prL-More. 'Wlicn j-o« i»f collodion to 
fiiatcu the [faster, avoid upplvinjr it directly lo the wound; tlül TKA 
only oatBiea unncceesaij pniii, hut m.ij sl&o indium inflammntioa and 
suppuration of the wound, wbirh should be particularly avoided. 

If the cutis bo divided, and tbci pliutcr mitflt nwat any covddam- 
t^e tcosiou iu keepinfif tbc! cd^s of tlu^ wound together, ichlhyoooUa- 
plantor proves insufficient, ai»d dhrMog ptagter nui»t be employed. 
Of this vre luivo two nirietius, be^idüs innumerable modiEcalioiu, frutu 
allCfnpts to make it cbcnpcr imd better. Emplastrtim Adtio^lrutn, 
emplostrum diachylon coinjKisituiu, our common adhesive pbütt'r, oun« 
MBts of oliro-oii, litbiiTgc-, resin, and turpontjue. While it \s fluid 
firom beat it U painted on linen,anditiägeoeraUy u4ed in fttri)>e, which 
an) laid over the wound, and hold its edges togelhor. Wbon frosb, 
this plaster adheres exotdUmtiy, but loosens after a time, If moist com* 
presses be »ppliod over iU Very sonsitirQ skins are izrilatod by this 
jilaBter if it iafrciiucatly applied; then wc may resort lotbo other adh» 
sivc plaster, the emptastrum ctruMot (omplastnitn luUMwivum tUbutn), 
wbicti is prepared from oUre-oil, litharge, aiid white lead, «itli hot 
wntor. This ]da8tof adheres liM fimtly, but luu tlic itdvuBta^ of 
SDivatiiig ibe lip« of the wound Ivss than tlic yellow plaster. A mix- 
tim; of >:(|uhI pnrts of tbn two pkstcrs lessens the objccttons aod oom- 
bines ibo adinintages. 

In UrgB wounds wo now avoid tbe use of adbemvo plasti>r more 
than formcHy, and in ita place employ llie «uttav more comnaoly. 
Wlicti we wish to unite wounds by the suttiro, wo gwienlly obocao 
between two varietieii, tbc iittcrnipted (suluni no(lo«a) nml dip twisted 
suture (sutura eircutni-olula). There is some tnttb in tbe aaoition 
that, by the ialroduation of a forei^ body, suvh as a tiitMd or ueedln, 
we toaintaln constant trritatioii in ibe edges of the wound, hut this 
GWinot equal the great adrantnge obtalDed by tlio ocrtainly of ad- 
justtncal of tlie edge« of (be wound by means of iiitaras. Hencv, 
except adhcedve plaster, attnoitt all substitutes for tbe «ature, In whicb 
sAcicot and tnodöra lur^ry has exhausted itself, afto- bL-ing fuhiun- 



CKIOS Of WOUNDS-SnOfiES. 

■Uo t-ir a lln»>, hare been Uiruwn aside. The iiiitnrc Itu Dot yet 
bem l^n^|Jp(y1, nnd prolwlily tivtct will be, any iiKire Üiiiii Hf^ntioo. 

Tbcrc lint ocrtain parta of Lfac body, a» tlie scalp, luiiida, und foot, 
whüre ve try to avoid sutures, bocauso tbcrc ccrtaia inti&intnnbory 
pnwe-ssps, which have ottea beeii nacribod to tbe suturu, readily assuitu* 
M thugnous chamctcr; biit I think tlicre is a good Had of prejudice 
in thin. Wounds of the hcit<l are esp«cially proa« to okusü itiäunma- 
tJotu of tbe skin and submUinROiis tissue; extcm^ivc statJHtics luve 
iwroc ahofrn whether tili» Icridciicy ia particuliiriy increased by tlic 
irritktion fmrn sutures. There uro many articles of laith lutntlod 
tloirrt fn)ni pro«>ptor to pupil, from one text-book to SDotbi>r; many 
of theni an! n aurt of Hippocratio tnulitious, full of practical truth ; lo 
thcM I p«y full respect ; others aro baaed on aocidental oljecrvations 
and oonaequent judgtnents ; among tbe latter, I clasa ths fibje<'tir)n to 
sutnm in scalp-wounds, Reviewing my own cxpericDCP, I lumcmbcr 
iDOra «aecs of inllauuiiatioD Ibllowing wounds where no eulureawcre 
iatroduoed ihaa wb<>re they ware. It \s very imjurCant, hon-e?er, at 
once to reootpiize iidliuiunatioos beginning in Uie head, and to cemove 
lb« sutures. Tbe amuunt of gnping and the funna of the wound (c g., 
m dap-wiyund or not) «t or.co «bow the necessity for suture«. Ono 
woald iM!irer tnko luiy unnecessary trouble in intruduciug sutures, un- 
la« urged by rx^^äS of surgical suui\ ; but where, for the reasons above 
gitpnt, »dhejtive pUater will not unsver, wc should employ sucures. 

For Ifat! {nlemipted suture we use surgical nccdica and ailk thread 
or wiir. Siiri/i<yil ruxtlffs differ torn onltaary ones, in having a lanoc* 
«haptxt, ground point, which pierce« the akin more readily than tbe 
roand point of n sennng^no'Hlle ; tboy nte also of Komowhat softer 
■terl than EnglEhb scwiafp-ueedlc^ so tluit they do not spring so 
tnucb. Tbtür tbtcknesa and leuglb vary greatly, according as wo 
wi^ to njiply «. strong Uiread deeply where the edges of tlie wound 
are tcnw, or uuly to use u fine tlircwl tu bring tlie edges together eJC- 
aotly. All needles should, bowcixr, buvc a good-siced cyC^ so that wo 
may sot, like a tnilor, lo«c timo in Uireodiit^' lliirni, hut do so remlily 
and quhJiIy. The needle may be eithor straight or curved. Tbo 
oorre should vary with the locality where wc vith to sew; for in- 
•tjiticr, Tcry fine, ■trongly-cin-ved needles are required for sewing about 
tbe iaiirr ciinlhuie of the eye; large, slmngly-eurved needles are 
orcdrr] for sewing up a periniL'um, nipturud during likbor, ete, I'he 
curratiu« may citlier be iu the whole needle or only at the pointed 
end ; fur ili9lMn«>, fur certain operations, it is sbaiwd like a fish-hook ; 
tbo vuiit'ty tfl wry great. For sewing sueh wounds as usually present 
UieotiL'IvcB in pmctioe, you need only a few &ae aud ooarsc straigbt 
and nmoaily-eurved noodles. 



«4 



BDtFLG INCISED WOCNDS OF THE: 80FT VIKTS. 



Hk tlircad is UBuallr of silk, vliose ooarseoess oorrcapoads to iba 
BJae of tlic neodlo. Fonnorl/ I nlwajn sewed iritb tbe red Gcmwn 
>ill^ which bui long been used for tttU purpose ; but in EngUod I 
found a sori of iiud^-ed, siroiigly-twiated siik, vrbk-h, eroo wlien very 
6X1^ i$ to «Iron; thilt, with thread a» fioo as a hair, we may Bew op 
wounda u)d draw lliem tflgvtlier. Morvoror, thi« silk loibilte« tto ütÜo 
moisture that it may lie for days ia the wound without swclling' or if 
ritatiug. Now 1 use only this so-called Cliincse silk. Another mate- 
rial for sutures baa beea ]aU>ly used iu Jt^ighind aod America, viz^ 
tilver or iron vrira. It must 1» renr fiue and soft; tbeiron wire for this 
puipoM is well Dnuealcd, The trial of this material was £rst iiHluc«d 
by the long-kitowa fact titat, when metal« wctc introdiioed under tbe 
bÜu or any when) in the body, tlie}' usnally excited no wippiimtinn, 
but the ]>art(> often healed ot^cr them. Bencc, it wiu thought that 
iho inflamnutinos often oocurnng at the point« of suture might be 
aroided by using uiutal instead of the anitnal subataooa rilk. lo 
tratJi, it cunnut be denied that this stippiirnlion b less apt to occur 
brom metal than from silk thread, still expcrimenls of Simon have 
shown that the suppuration from sutures depends greatly on the tliiclc- 
ncas oftlic thn;nd Froni uiy own exiwrieuoe I cau adinn tliat Hue 
silk threads cause as little suppuration along tho counc of tlie suture, 
and may heal in, just as well as metid ones. 

We come now to the appltcaiioii of the iiitrmiptud tuturc. Yoa 
do it aa follows : with a toothed forceps you lirst seize oite lip of the 
wound ; pass tlic noodle through the skin, about two line« fi-om tbo 
edge, as di-ep as the suIx-utAneou« tissue, and bring it out through the 
wound ; now ecloc the other lip of the wound with tlic forceps and 
pierce it from tho wound up toward tlto ekin, exactly opposlto tbe 
first point of entrance, then draw the thread through and cut it nfl^ 
leariug botli sidps ]t>ng enougti to tic readily in a knot Now make 
A dimple, or, if tlio teiiaion of the borders of iko wound be groat, is 
surgeon's knot, nud draw it tight, sudng that tlic cdg«s of tbu wound 
ore in exact apposition ; tliL'u make a second knot, and cut off both 
threads, close to the knot, so that no loug cads of Üircad nvay gut ia 
the wound. 

Should you desire to use wire, you thread it as you do the ailk oo 
the nettle, draw a short portioa through the eye and bond it« tliea 
make the itutun^ as nborc de»mlK»<J. >Vh©n the xrirc is vcnr «oft, wc 
ean tie a knot with it nioiily, just ss with a silk thnwd; still, tho 
wholo of ttiis maupulatiou is much less pleasant with wtro than with 
«ilk thread, and on okwiog the knot tho horder of tfao skin Is readOjr 
displaced, or there uvay be twists, that render the hold less secura ; 



UNIOX OF WOUXDSL 



«a 



thk U t-apecially apt to luippcn with oar Gfcrman wire, n-bioii liu no( 
yet «ttained tlie »ofUies« of tin? English. The plpasantnst wirwi src 
tboso 111*1« of A niixUirc of gold »nd silver and of p]a1inuni, of »rliich 
rwy fini*, pliaMc, »tid, a.t the «am« time, fina wiremajr benuidc. [Vcrj 
nlov wire is inulo of k'sd, aod it is supposed by some to bo an idran- 
tO{^ that this viU break if the junta slioiild swell cxccssivdy.] Still, 
ivtv ridiculous it would be to try to :sub«litutc these expensive artidea 
for nrdinarr silk, hy wbidi millions of woundg Lave been Iicalod (excel- 
lently, and will be ia fuiure ! I pass over the maay newly-recoinme tid- 
ed modes of ttitctäog the wire by knots or twiating'; they sliow tliat 
even thow who adrocule im^lallic sutun^s Iiav« found rohw trouble in 
fajtoming the knot. I first muke a simple knot, draw it together, 
make tw-a or three aliort twiat«, and cut off tlie enib close to the 
twiatod port. Wtro cuta the edges of the votind, ju«t as sUk does, if 
Übe raj fincw * 

I hare rart-Iy found the little ohjcctiona to silk sutuifs sufficii-ntljr 
umoytDg to make oic replace them by weUl suturcH. 13c^iiiiora 
gttDflnlly orr in making sut urea too tight; thU coustricta the edges 
of thft wotind. Wien they swell, as tlsey mostly do, this onnBtriclion 
Ü iwniy enough to kill tlio tissue at once, but caiiHO» inflammation 
Willi redneaa and suppuntinn nbout th« puncture, which may spread 
Kod impede healing of ibo wound if tlie sutures be not removed in tinxt. 

Stimif^t needles may bo Iteet iiitrodtir<>d with tlio fiogen; but 
cttnrvd needle», csjjecially when tltey are sumll or tbc wound deeply 
Hoated, an) iiitittduced better and more oortaioly by means of a nttdt^ 
Afdder. Tbero aro uumbers of tlit-sc; I am iu the habit of a^ing 
Jifi^rtJiacf^*, It consiata of a forrcps witU slrart, thick blades, be- 
tween wUcli wo hold the iiccdlo firtnly and seeiitely, and iutruduoe it 
ibnm^U the skin in the direotion of its cun'atiue. Ulis perfectly aim* 
pie loatn T'T almoAt all caacs, and in good bands ia 8ii> 

piTil I' I fnr security in holding and introducing the 

oaedle, Complirated iw^lrumenU are «rspeeialiy fiuitetl fur unglcilful 
«nrgcoos, sbt« Ifi^hibaefif m the un[Mu-uJlelvd iutroductiuu to his Ope- 
rative Surgery ; Dtvttho iiigtniment, l>uL the hand <^ the surgeon, should 
oporat«. Fractk» and habit render Litis or ttiat instrurocut indispeti- 
B^dib Tlina eome God il complicated and inoonvctiicnt to seize tlie 
Up! <if the wound with foreepa, as I taught you, although (his Is bet- 
ter than holding tlieui with the linger« ; fiv me, tlie latter n'uuld be 
TTty iooou re nielli. In ibiä matter nuy one iiuiy do as his liiiliils and 
iocUnatkm lead iiim. Wien I liaTC to sew eome deep part — aa t^ 
tdom, nsiLum, or vagina — I always use needles with handles. 

Of ooitrac the number of sutures to be applied drjicada on thp 
6 



to 



SUPLE ISCiaSD WOUNDS OF THE SOFT PAKTSl 



lon{j;th of the irouud ; ^eucmllj suloroa hiUf-ui-iDcb ajunrt sufficn, but 
where perfirat apposition aikI small cicatrioos are vrry desirable*, na in 
wounds of the face, they must be closer, and ehould ^temata betweea 
oOMse ooee at a di&tanco from the cdgo of tUe wound, :ir>1 fine 
&o«1o5iDg but a small portaon of the edge. 

Tlw pecoad variety of »iiture, twitted or hareltp nturt^ is made 
passing o long pin vriih a laDoe^iapetl point thröugli tlic- flaps oT the 
wouimI, and pftuing s strong oottoa or silk thread around ft, rs I now 
«bow }-<]u. You take the thread in both hands, ky it panllcl to and 
imnK>diatc1y over tho po, tbat is, transversely to the wound, pass it 
iiiidt-T (h« two ends of tlic pin from above, nod draiv on it, &0 AS to 
nppro&iinnte the edges of tliß wound exantiy (tills is the MXalled 
yiJUour) ; t»w you chnngc the thrends to the other hands, and. «*ith 
tho right thread in tho left bund, posts urouud tbc left end of the pin 
from above downward, and, with tho left tlirvad in trie right hand, do 
tJie same fur tlic right cud of the pin ; you cfaangt? the threads agftia 
and muhe four to six similar, so-called iigure of eight lums; theo tie 
n douUe knot and cut the ends cilT doae; then cut off Uic ends of the 
pin to »proper Icngtli, so ilint tliey may not press on Jhe skin, bat not 
90 »hurt ad to prereul their being nudily withdran-n subsequently. 

Tbcrc arc a great number of other 8utw«s, whleh ht tlio most 
ftxt are only of historical interest, and which we here poM over; 
■omc poatllnr fonns of suture will be ireat4>d in special ani;geiy-, under 
wounds of tlic diflerent port«, as in wounds of tho intestine 

Wlicro are tl)e advantage of lUo twisted over the mtemipted 
suture ? and when do you employ it ? Tliese iodkations may be r^ 
ttuced to two ffwtors, so tlutt you will ooitflidor tlie iiitemiptod sntinr 
us tlie simpler and more oomiixin. llio twifltcd suture isprefemhlo — 
1. When the ilaps of the wound nrs \vry tense ; i. Wboo the aklo- 
fbips to bo united are very thin sad without support — in ohorl, vrhen 
the lipq of the wound have a teodecoy to roll in. Tbe needle, temah»- 
ing in pcwiUm in both cases, rendcts tho suture more secure anil firm} 
the needle ser%'cs as a sort of subculatrentis splint for the edges of the 
skin ; they arc supported by it, and are also held more seounly by the 
(bids of tbrcad on iho oul«)(le. In many c«»o.<i, in applying sutures in 
tbo face, the interrupted and twi3t«.-d aulures are applied alternately ; 
the Ultcr ecrre as supports and to resist tcnuon, tbo fcrroer to in- 
duce more exact union of tbo edyet of tht isvtiftdL 

^ybcn tho bleeding- has boon stopped aud the wound united, all 
has been done that b at first necessary. Now let ns obswr« whs* 
takes plaee in tbe dosed wound. 






I 
I 



I 




xrsioy OP wodxdr 



4T 



UM) \ 

Kttut 1 




■mraotUalfllT aft<>r h^ing uniieA^ ^^^t* «J^a of the wound 4re gcaef 
nlljr wliiti^, from tlip jwvssurc pxprrispl hv the sutures a« tl»py com- 
press the capUlnries ; rarely tlie borders of the woanil iiru dark Uuc ; 
thif olwfty« iodicat<!S great impe<Unioiit to tlio return o( blood throu^ 
tho veins, dap to s Io«s of part of tlie blood'VOMcls. It is evident 
'that the coaimiinicntion between nrterics and T«.-ms lanr be; pjoatly 
iflturbcd b^ the dirUion of n Iftrgc number of Cftpillnrio«, so thnt at 
point in tbo bocder of tlie wound the vi« a tergo of the venous 
tlfCkin shall be iitsuflidcnt. Od tlic irtinle, this datk-blt» color of the 
ftapM of the «round is rare; it eith^ir (Usapptrars spontancotislj or a 
Mnflll portion of the lip of the wouml dies, a symptom to wliicb wo 
ahall nrtuni when speaking of coiiUitied woiin<l», in which it b qiut<-r 
COBUnOD. 

Kvuu aflcr S few hours you God the bordi>rs of th<.> woiuid alightly 
oUcn and orcanonallir bright red; thi« rcdncHi nnd swelling sro 
CD sb«eat (especially where the epidermts is thick), hut oooisicMinlly^ 
rdtng to the extent and depth of the wound and teiimnn of the 
1^ it Bjweads from two or tlirce lineSf or 1o as many inches, around 
the iroaad j tbu usual so'cullcd local reiiotion about the vounil tukua 
pbee (n this rjxw.'o. TIio wound pain« slightly, cupceially on lieing 
toadnd. All this may be boat seen in children and women with 
ddieato skin. About wouniU of the fitcci especially of tUo eyelids, 
mti often Dotiee extensive oedema in twenty-four hours; this Ev- 
illy t^rrißcs tho friends, but is usually free from danger. 
In n considctultic ntnnbcr of cn»e9, if the sutures be not \<yn tightly 
tho edges of the wound appear unchanged not only At ttie 
ime, but till the euro is eomplote. But often enough tho wonnd 
ibe cardinal symptoms of inflummatiun ; puin, rcdneiiSt swl-11- 
; uui increased heat, of which you nmy s«li»fy yourself by placing 
your finger on the parts about the wound, thvn y>n a diBlurit part of 
the body. The process going on at the wound, and coding in the 
union of ita edges^ ootnea under the combination of morphological and 
Armial melamorpboeps comprispd hy the name inßunimation, and, 
in the case under cousEdcnlioti, would be termed trtiumati': inßtuii' 
«otfon, that is, an inflaoimation caused by an injury {rfMV^ut). 

As a rule, these local symptoms hav» reached their hfig4it fn 
tmnty-ftjur hiHirs; if by that time tbey hare nut exccpdud the above 
iMBds, \ ' r' tbo procTfs as taking a normal course It U a 

•wi«f/'< ..' '.]f traamatic inßammation^that, in apure/orm^ 

ilUttrictlji Ninttfd to tht hortltr» of the woun^, and doei not ertend 
"lAnl ipeatai cauM, It is not imiisu&l (or tht-dc symptoms to remain 
tt iki Mme height the sooond or oren the third dsy ; but by the third 
■ MA day, the rodocas, swelling, pftin, and increased Lemperulurc, 





48 



SIMTLE ISaSED W0UND6 OF TUE SOfT TAKIS 



should li&ve dis&p))ear(.i(l mostly or eiitirvlj-. If llie symptoou »till 
iDorcsae the aeoond, third, *od foartb lUys, or if »onic of tbcm, oi se-' 
TOrepÜD, And great Bwellhtg, recur at this <iiiK>, or if Owy ri.*main Kt 
the suae point to tlie Alth or sixtli day, it is a sif^n tiist the ooune 
diflen in some wn; from the noniiul. This will be especially eridrnt 
bma ttic g«uei«i condition oT the patient. Tbß xvhold body nwels to 
BR irtilstiun of oQO pftit of it, not in ■ poroeptiblo manner, in snuül 
wotincU, it is true. We elial] rcfcrto tJiis geoenl reacUo« at the close 
of tliia ckaptcr. At prescul, wo eball oonsUter excJusirely tbo ooodi- 
tion of till? wounded juut. 

The third day, often indeed on the »ooood, yon may carefitlty m- 
move tbc pins of the twisted suture, provided you hare also «pplic-d 
iDlemipt«! «iitiircs ; tliig i« best done by »eizinii; the «ppiUe with 
Di^enlach's nCL-dloholder, uid rotiitiii^ it gently, while fixing tlio 
Iwtated thread« with one fiof^r. The tiireads U6iuiUy rcmnia u a 
sort of damp on the n-uund, to which they am attauAed liy dried 
blood • they subseciuetitly looseii HpontAoeoudy ; by forcibly datod^ 
ing the thread, you would uuncccasitrily str&in tho wound, nod posai- 
My tear apart the freshly-united edges. If at this time we carefuUy 
feel the edgvü of the wound — if the tedema has »ulwdiled— we find tlii^in 
rullicr firmer thiio parts around ; tliis state ot firm inJUtration sooner 
or later dtsappeariL 

\V1icn you huve applied many Etitcbes, you may remove sooie of 
tlion, Uuit hure little to bold, on tlio third day ; other», on tlie fourth 
and fifth. At the teo&oly-stretchcd parts of tho aUu it a wl41 to lenve 
a few.thmads for ei^t days or more, or oven louve them tfll llioy eut 
tlirougb tlie llnps of the wound, pruviJed it can do any giMxl to bold 
toother tbuedgis of the wound, whidi may be gaping opco. Sxrald 
tbo inllammutJOB quickly exceed the normal amount, wo most moore 
Uic sutures earlier, so that tbcy may not increase the irrltutloD ; not 
UD&eqoontly blood, tbat is decomposing or mixed wHIi pus, at tJie 
boUoni of tbe wound, is the cause of tlie uiinsiin) irnution. 

InieatOTiag the internipterl suture, jnu should Lake iha follmting' 
preoautioQS : out tho tlireud on one side of tbo knot, wbcic you can 
moBtrendilyintrodnoe tlio thin blade of the scissors wilboui ' j 

the woowl ; then seiice tlio tbnead at tLu knot with a di.>. < < 

OC[M, und draw it out toward the »tfir where it was dirided, sa a» not 
to aopamt« tbo edges of the wound by the tractioa. 

Suuld you tbink that, after removing tlie suture, the uulon ol tiw 
wound is still too weak to prevent it^ gupiti^'', you may, by npplyjof 
strips of icbthyooolls-plfeilcr trausvcraely over the wound, between tba 
points wltere the sutures were, and fastening t)ie ends (not the port 



PSlOy OF WOCKLS. 



49 



erect tlie wound) wi(b coDixlion, give support eaoui^li to prevent ton- 
Biou of llie tliijHi of llwt wouDc], suth an uiutToidaU^ «^ws in c^inngcs 
of cxprr:«sinn ia llic fncc^ 

lo from six to cigtit <UyB, most airople luciusl vound^ hiire adhered 
Kmilv eouugli to require no furtlier support; in(K>>Dtl, tn tiinnj' cases, 
tlila I« the case hy ilie secoiul or roiirtb dttj. If, iii thu coime »f tlie 
Collowing day», (he drf blood aixnit the -vroimd bu carefully wa&hed 
off, the youtif^ citiitrix npponn as a Sn« rt-ol strip«, a scarcely mlblQ 
fine line. This proct-M of heuling is called heatimj ti'jßrut intfittion. 

Ia the iX)ur«c of (ho suhsctjuont montbfl, thn ctcatfix loecs ilA ml- 
nesB and hanlniss, and finally becomes perceptibly whiter titan, and u 
•oftay, the ulna ; to (Imt for jesn il m»y be recognized a» » fiiiu whilo 
Ihte, Il often <liMi>peiire almost enlirvly After some yt^ars. Soidc of 
yno, who left the unir^mty t<rith many still i-isiblo etcatnces no tho 
taw^ may hojte thit ttivy iritl bo scarcely vixthle in sir or eight yetoif 
when the PhilUUnc visago wUt become you less tlun it docs the stu* 
dent. T^mpont mutantur et oos luutamur in iltis. 



LECTURE V. 



n« owl« SCntit« Chui^ta In Ilulloff hf Ih« Finrt lBtDnlif-iii.—Da( lotion «fVeutU Is 
Xbt VMaltjr of tk« W»BaJ. — naxloo.— IHEnrent Vieira Mgwdiiig tba C«B4M vt 



Ckxtlckks : TouBiv now aoquniutcd with the ch.tn«i*s, riaibtc to 
tbe lukcd eye, that tuke place in the u'ouiul uhile il ia hciiliug; let 
IS now tty to see what occurs in the tissues from the time of nouud- 
Ing till the focmation of tlic cicatrix. For a long time, attempts have 
l.>e«n nude to study ami Icnow theso changes mora thoroughly, by 
making- woumls In aniuialu, and examining them at the difTcrent 
na^p» ; but it is only tlie most exact microscopic examination of the 
liiif. and the direct obserration of Ih« clungea after wounding, that 
hare ctuibUid us to p[ive u dv^-ription of the proces« of healing. I 
ifaaU attempt to girc you a brief rMiimi of tliu result of these invc^ti- 
gatnn^ «tüdi, until recently, I have made my special study. 

The intereatiDg results ihi» arrived at hare in a great measure 
bn>ugbt it about that by " inflamnialioQ " we now tucan generally tlia 
Mcica of changes which we p«rcoi\*« on mioroscöpic oxnniinatioo. Of 
bCe «c are accustomed to consider these morphological proousses as 



50 



SniPLC LSCISED WOCM)e OF TUE SOFT PABT& 



tho Msential part of tlie mflammation, and to terra titeir occurrcnco 
and tvpical course tliu " iuflanimatorj procASS." I irould not iveu)c<^ 
Toor interest in thcsu tbiiipt sL iLc oiii»ct ; but tLc prcTsilio^ tctuk-n« 
oies render it necessary for m« to call your Attention to the fact that 
(as in all OT;^Dio growth, and in each tTaasfomiutian of the tissue* 
of tl>e body) form is alH~ayü Urn product of chemical or plijalrnl 
pcm'cr inhcrvtit in tlii: inatcrinJ supplied ; th« inflatntiiutorr, like 
every other physiological procew, is cbemicopbyuologicsl ', Oiis u'o 
nerer sec, crcn with the best inicro«co5)eB ; we mewljr perceive the 
tesu]ts of it« actioo. Tbc£C remit», destruction and new formation of 
tissue, hiivc sometliing peculiar in ihfir lypical course j hat tlicy van* 
ti» widely a)t life und death; the tissue may die suddenly or not for 
ycant; of Ivro neoplasia of tbc saino stmoture, one may form in a (ch* 
dsy«, the other may require months; very dilTcrent oauscit may induce 
very eiriiilar ttew formation». Hut I drviul coiifming you, if I ent«r 
further iDto the difficulties always arisiag when wo epcnk of inflam- 
mation in ^encntl. So let me go at once into detail ; and we will 
hereafter reium to the general question of inflammation. 

Ttic cbangea aflx^r injury of tho difTrrenl tissues am particularly 
E«en in the vesscU, in tie injure«! tissue il9«lf, and in its DerTM. The 
'indueaee of the latter on the jiroeei» is, however, so obscure, that wp 
iJiall nut con«der it. Wc »hall nl once dismiss as unanswerable th»j 
question, wLctlier the finest nutrtcttt (vasomotor) Dcmt'S» wliich koo 
theuisulrea in (be different tisäuee (fur the question can only arise ooa> 
rvming these), have any direct infiiicnre on the chaogoil occurrinj]: hi 
tbc tisdues, and in the Teesels themselves ; and the rather so, aa ibe 
end« of the nerves have only l»ecn certainly recognixeil in a few pan» 
of the body, while fur other jiari« it is entirely unkiiuuii bow tbe ou* 
trieut nerves act, and what relation they have to (ho capillary vcBstds, 
You will have already bad your attention called to the Imaginoble pos- 
sibilities and probabÜitieü on this point, in the leduros on physkjogy 
and gvnemi patbolog'y. ITcncT, if wc say but Uttlc about tlic ncnva 
in what follows, it is because we know UttJc of their action in tbii 
special prooesK, not because wc wish to deny tbojr influpnee. 

Let us first oonüdcr tbe aimplect ti&sue; lei us suppose a Torlltal 
section, tbrot^h tbc eoonective tissue, with a closed eapilhuy sygbcm 
nt the eur^uie of the skiu, magnified 300-400 times. Hei« you hare 
a diagram of such a system. 

i«t there be on tDdsion down throu^ the tisstio ; the eapitlarics 
lileod, the bleeding soon ceases, the wmuid is aoouralely itnltcd. Now 
what takes place* 

Tlie Uood coagulates in the capillaries a« far as tbe next braiMbea, 



UNIOH OF W0CKD8. 



81 



, r nott points of iatenootioa of tlie ciipillarj* net-wofk. Pomcco- 

HiliUoil bkiot] usually' remalna nbo between ttic flujis of ibc wouoil; 



F», 1. 



-■ 7, 



n 



o 



o 



■O 




DUtfiMi atttmimeare IInob, wltb «aplltarh*. XwnUod 090-1)0. 

w Ihtc DtuiUud UM in Fig. 3, so M to have th« sliiiplu&t |K»siblc rep* 
nwgiUUnu of üie fliuitgi^ Of Uic cImmieU (or the circulation in our 
tDafniiL, Mtoe liai'n become iiujiuuaJile j tbu blooj must acconimoJate 
Hirif to the nxiAtin^ by-path»— i>f coarse tbia takes ^«cc under a 
homer ■rtcrio.l pn^SBure than pn.'vioii»ly ; this pressure is gtviitop the 
pala tbe obstructioQ to the circulation, and Ute less nuinprous iIir 
bffribi (of th« «xalli'd cUlatural ctrcuiaUon). The result of tliis 
inaw M OJ picamrc i» tlio diotcntion of tho vcäsoIb (which, however, ia 
■waOfunKji greaivr Ui:m coiiUl be rcprwüiitoil in the iliA^TAin), lieiicq 
'^ raiiu^s» abinit the M-oumL, aiid to some extent alao the »vrellin^. 
Onttbe Uttor iüao bus aiiolhcr <;«uso; the more tb« capillary walls 
ndoModed, the tliinnur they beoooie; if under tbe otdinary prouf 
iiff,«{Üi normnl thickness of Üicir wnlts, th«-y pennit Mood plasma 
In put u> itourijli tlio tissues, uo\r under increased pressure, mor« 
fiUiini ikui nonnal will pass through tlie walla, wbieb sRtur:iiea 



SUiTLS CCaSKD WOl'XIS OF TUE &}n FAKTS. 







Dl^m «r lKUt«>ii.-CartBu1n (hMod kjr hkia4«la(. Collueial <l*t(mU<w. Mv 

tt»c iüjiiivtl tiKtK^ nnd «rhicli th« Utltr «iKOrbe by ils power of 
»vcelhng. 

Tliis ü n brief erplnnatioa of tltc pvrccpliblo rltaiip^A in llto 
bordcfs of tlie wound, ibo redness and iDoreued be«t cauMd hy tht: 
rapid dorelopiiicnt of tbe cdUtcrBl «nrculaUoii, by irUiefa more blood 
flow» through the veoaelfl nearer the surface ; tlie avolling ia oauscd 
by tlie ilUlcalinn of Uie veaseU and sweUuij^ of Um( tiuues, wbieb 
again induoi>a »li^it ounpreision of the nerves, uml tliia eadi« acnsa 

Thi«, aa it eevms to nKr, Tory simple inochnnic«! oipUnalioo, wouM 
bo muoli more Tuluabl«, if it fully BxplaitK.'d tlie wholp aubaetiDcnt 
counkf, and could be applied to uU inflitmtnalioiiB, wliii-li anr Dot uf 
Irauiuatio or m«<liatüeäl ori^n. But thia ia not tbe ome. NwtUct 
Ae gnat vascular dirtonüon that oomrc somo time aller iujurj, thai 
■Itowa itaclf in extensive nxIneM around llie wtiund, nor Uw cJipHliuy 
dlltttatioo that exift« ftom the first in idiopathic ioflaminatiaos, van bo 
referred to purely nneolianical eauae«. 






0XIOK OF WOUNDS-IRRITATIOK. 



53 



If Uie distiirbnnoe of circulfttion Uirougb Übe inci&iaD be not nt- 
t«osiTc, it paaaea off Tcty rapiillj ; theso eo^xllcd pa*tim hypfrofmia» 
mrc DOt esACÜy tuß&ranuttioDa ; theLr extent accanitcly corrcspoucU to 
tbe inMihanical cnnditioivi, wltile ia regular inflfliiimntionii tli« redaess 
ofteo (•xtdids Cu- bnyond ilic polat where tJie circulatioa \a taediatii- 
Mlly impairetL We Jo nut call it inßammation till irritatioa of tbo 
Ü1WM acx90ni[iiiiii(>§, or in fiict «rises from, l)ie capiUiiry distvuliun. 
Stiob tmtatiooa, causing ililBtAtion of tbo npillaries, are numerous; 
we «bkll bcr« ^pcak only of ibc tncciianicnl otx-s. You now ec« loy 
onuiar coiijuDcUva of il puru bluiiJi wbilc, liko thst of uny iinrmsl eya. 
KüW I rub mj cyo till it weeps, and tbc conjuncttvo bcoome» rcddisb ; 
perUflps witb tbe Dskcd eye yoa luay mo «ome of tbe larger re«»eb 
— with a tens yxiu will also see tbe finer Tes^els, full of blood. After 
fire minutes at moat, the rodnen hnn entirely disippc-nri-d. tx>o1c st 
ai) ere wbere a small insect has accidvutiilly goltuti uiidc-r tbo lid, as 
•0 oAmi bappetts • tbe peison rubs, tbe eye woops and booomcs quite 
red ; if tlie insect be removed, in half an hour you will probably «ee 
notbing aoticcabic about tbe oyc. Here you bare tbe simplest obsor- 
Tation how vcweb dilate on irritation, and empty aj^oiA soon after 
ill« oessatkiD of the iiritation. Wbat is the immediiite cmam of this 
fl^nptomf Why do not tbe vesseU cootract instead of dilatiag? 
TbosD questions are as difficidt to answer as tbo obsttrvation is easy 
to Duilic^and to repeat innufiierable times, witb the same result. Tbe 
tm^ itself IiM been kuown as long as mun has obscnrcd; tbo old say* 
w^ *' ubi slirauliis ibi aOlusus " refers lo tliis. The increased flow of 
Uood is tbe attswer of tlic vascular part to the irritation. 

Of Ute, the proctrsa inducing thtA rcilnrs« is railed active A;f- 
pteawaia or attivt eon^eiUon, Virf^hoxe too!» up llie old uanic, arvi 
mailc ^'JltixioH and eotig«ation " again p»>pubir. 

M»y your ktMiwIedgo of general pathology, j-on will now 
\-- 'it it is di.'-.tr«ble to give a tbeoretieal explauaüon of 

Symptoms which, tbroi^rb all time, bare fonnod ottc of the most iin- 
poctwit objects of conRideration in metliciiie, pariicubirly as tbe pm- 
'.tM* of iuilamnutioo i« atwiiys consiilcretl a.« closely allied to this ae- 
Itv« congcstirm, or indeed eveu njn^iilered as always a sequent of tbo 
tatUr. Atüeif Cooprr, a cclcbnil«! English surgeon, whose worlr» 
ftM wQ] rend witb pleasure, when you take up tbe study of mono- 
a tltorri^iglily pnotieal siu-gwHi, begins bis lecturc>>< on sur- 
tho fnlbiwiitg words: "The suhj«?H of tliis pv«»ning's Ira> 
Itti« ts irritAtioa ; whiob, being the foundation of surgical saence, you 
nist DarefuUy study, and elnaHy nndsnrtand, before yoa ean expect to 
know the prinnplea of yoi«- pi-ofession, (t I>c qunlifted to pntctiso it 
orc^tably to yourielveti, or with adratltago to tho«c who may place 
ibenselv«» under rour oare.'* 




64 



SUPLE IXCISED WODXDS OF TBE SOFT PAXTi. 



This will slioir ;oa what part llie qucstioiu to<by under oon* 
ftidcmtion, which jou tnigbt regard as a auperHaoiia ezerdse of tbe 
miod and ima^stion, haro played at various times; you vill bere- 
after learn, fmoi die history of Ric<liciiic, that entiro systeius of medi- 
cmc, of the (ntaitcBt proo^cal importsDcc, arc based on bypothne* 
that n-crc formed tot the cipUnatioD of tliis ejinptoin io tho vewdsp 
uf this irritability and of irriUbility of tlic tiasuea generally. 

litis is not the place to cntrr inio a cliorough hislrtriral roniidcm- 
tioa of this queslioD ; I will only call to uiiud a iew h,\'[>othe«cs which 
have been advanced lately, under the olready-exuttinf; knowledge of 
the vcucb and parta visible to tlic nakdl cyo, ootiocniing tbe oooio^ 
rmoo of vofioular dilatattoa from irritation. 

From histolu^y and pliyaiology, you know that, until tlioy pass 
into capUliLric«, the* artcnvs and Teins bavu transverse aod loogiiudi- 
nal muscular fibrae in tlicir walls, and that in general these are more 
•«.•anty in veins than in nrleries, although this vari^ greatly. JCow, 
although it may lie rciy difGcjlt to make direct obsen'ntiont of iho 
oBeciof irritAtion on tiKvo »mnlleflt arteriesand veins, it iRvcryaimplQ 
to sec it.« efTpct in the intestine, where we hare essentially (lie aamc 
couditioiut, namely, a tub« prorided with longitudinal and transrerse 
muBculur (ilirt-s. Hut, irritate tbe intestine aajou may, you will iit^rtT 
indu«) dtlatatioa at the cotistrictcd part, but only & shortenitig or eco- 
striotioo and a oonscquont tuotioa of tlic ontitents of the intestine, 
whose jupiiiily will depood'on the fretjuentry of tlie rrpclilion of the 
<-oDLnict)<:>iis. DmK can dilatatiou of th« caplllariea be induced by mdi 
increased rapidity of motion of the vessel« ond hlood ? Certainly not. 
In the general patboki£:y of Xofw, tin* peWhnited modU-al ]>}iiloM)phiiT 
of GOttiujrcn, you liud swiie remtirka whiub nru so upt, and, like all the 
ehaptJT» fin thisauhjert, wi «ell »how tlie brilUiint genii» iiud critlml 
acQiiK-n uf the writer, that I shall make iisu of hi» eiprt-uIunK. Hi* 
flays : " Patholoj^sts wbo seek to explain oongrstion by incmaicd coo- 
traetion of the iirterit^'s, assume tlii> thimkless Ia&U of (ho Dnnaidna; 
tliey caiutnt Bh«w iht stopper that prevents tli<" eseaiJe uf the Uood 
that is pumpol in with so much difficulty. OvcrTuloess rceulte if 
more is introdiiivd and the same amount escapi^s, or if the 
quantity is introduced but less escapes. If we supixiseu porti' 
reMcl to coatract laory* actively and rapidly, it will buvc as little tvif 
dcaay Ifi indueo iucrensod afllux or diminiabed eCTIux of blixid aa iho 
atain{>{ng of a person in a rirer would to rr^lnte the omotmt of 
wat*sr.** 

This refuted hypothoai.«, of the dilatation of tbo oa]>illariea dd^nd- 
ia^ on oioro rapid and energetic contract ion of the artoriesi, was at 
loBSt based on known o1>»ej-vations ; hut ZoUe'a caplnnatiim, on tbo 
oootnuy. Is 80 fiir froui nil analogy, T might almost my bo niL-tti]>livsi- 



ÜNIOS OF WOUSDS— IRRITATIOS. 



5S 



€smlf ihikt v^c cannot attaoh any value to It. JmUb asserts that there is 

10 obJQotion to th(! euppoaition tiiat eajHlIari«« an affooted diffisrcatl/ 

mrteries hy imtatton ; by nerrous infiueDoe Üiej may expend ao* 

t«Tclx on inritatjoa, by tbcir molecule» »eparotitig. But this riew ia 

ptm) hypotbeois, wbioh not only has no aaalogy, but is crca opposed 

I reoent obeervittiotia. It ia well known Oial, with tbe microcKOpe, 

am follow tU(> cirüulntiou in tliv »m»ll(-r arteries and vcine^as wvll 

in the CBpiUnri(>9 of the web in tlie ftxit, iu th« mesrotery and 

of the in^j or iu t)ie ffiu{; of n but ; but tlie ioimedtate ciffect 

c»f a nnld cbcmicsl or mcdianicul uritniit dous not at once shovr in tlic 

«MptlUric«, bat fint in contraction of the smaller arterio«, otx-n^ionally 

i of tbe veins ; tbis is vi-ry evaneHCffot, of scarcely a B«.'onil'a dura- 

indued, it often escapes obsoiraUoD, and wo then suppose that 

. md gnde arc too slight for us to nwasurc. This brief 

is Ibllowed by the dilatation, nhose immedinte eause is 

tUict eifo ofl inicroe(»pir&l obaervalion. We shall soon »Be Uiai 

Ü iiisuQiciciit, that tbe fluxioo is the result of paralysis of tbe Tea* 

:U, active as the sjnnptotii HjipennL Even tlie recent iTry interest 

^obscrrations of GolnUir, who had llie kiniliiess to show me that 

tUancs ofthc nJcUUitiDg'tacmbraDC of tbe üog contract tnu» 

ly, as tbfl result of Strang doctrioal shocks, did. not appear to me, 

1 no Ihlnktnjf tbn matter ovnr, to apply perfectly to the qnection of 

'fluxion. 

VltvJtMe nppc^r» to (hiub that the imialion, which is certainly tho 
jioiDediat« cause of tlttt cotitnietion, is followed by quick fatigue of 
the mnai'leB of the vrasuU ; thai attar a, tcUmic oontnwtioa tlicio is a 
leUxation, just as in irritntcfl nen-es and muscles — a view which 
Bay Sod some support in a ooinmunicatk»» from J>uboi»-Jt<^ymotni 
JbofA the iwiiiful t(:tanus of the miiaclc? of tbe rcssela in the head as 
t eauf« of he«ulaeh(> on ooe side, so-c^tUnd liemietania, since tliLt sup- 
pnsoil ti>tanui) of the ntittelc4 of the vefwels, induced by strr>n^ exvite- 
msDiof tbe oervii-al portion of the syinpnthetic, was certainly followed 
hy their rcUxatii^n and great <ü»tcntion of the Tesaels, nnil shortly Ijy 
^^□plotns of eCTvbml eongestiuo. 

I tIow (by which a relasnliiMi or tcmpomr^' paralysis of 
I TDMol« and a consequent decrease of their rcslstanoo 
la die prossiins of th« blood woidd, it is true, be explained iis a so> 
((nent of their ooatraclJuii), wc must not forjfei that it is by no means 
(vored that the muscles of the vessel», once irritated SLd excited to 
mpid ctHi tract ion, are iiidwd pamlywd, while in otber muscles this 
hti^pie luitullt' oceurs only after repeated imtatioo. It ts neocsssry 
utittvnly to amume tliat the muscles of the vessels xetf readily bo- 
eomo Cktijined, wtiiefa Is direetly refuted by experiment. Prom physi* 



^K. 



M 



SIMPLE »OtSED WOirXDS OF THE SOFT FARTS. 



ologj jou know tbat Claude Sernard lina proved that tho contTsi> 
Uons ftad diktalions of tbo arteries of tLo bead aro under Lbe iaflu- 
enoe of the oemcnl portion of tlie sytnpatlietio nerve, as I bnv« aU 
veaAj iDdlcttted, If uc irritate tlie upper ocr\ical ganglioa (if this 
nerve, th« arteries ooutiact j if wc divido tlic ocrve, there ia dil»t«üon 
(pnmlfsis) of the arteries and ci>|ült»ri<>s. Tlii« experiment of ini' 
Utlng the muscles of tne vessels may be uflvQ rrpemUM], viüiout their 
becoauDg quickly latigucd, ualces the elccüical ciurcat bo too atioag; ; 
hcnoe wo might itnnginc thst there is litllo probsbility in the ItrpotJt- 
csis of inunediate £iligue after n single irritation. Sehiff, howevpr, 
like I^olMf Bssuines that active dilatation of the rcswls is pr#sible ; lie 
thiiika that this neeesnarily folloirs fioni certUD cxpcritnenis ; but 
thi> is perfect]/ iiteoiuprehcnsible Co me, for tliere nrc no muscles that 
oould actively dilute U>e vessels. 

If the veins alone contracted on being irritated, filling of the cap- 
illaries would duiiblluss follow the obstructio», and there would then 
be no difit-Tcnc« between venous (passive) hypcnrmia ami fluxum. 
But this suppo«itioD i« quite untenable; it is perfectly iDcomprcbensi- 
ble that the veins aluue should contract cm inllamtnatory irritation. 
Tliat tbe veins contract on niedianical irritation, you may sec in the 
femoral vein of an amputated thtgrh, to which VircÄote has called 
parliciilar attention, iiml this irritability last« vi'on kmger iu the walls 
of the vein than in the nrrvcs. 

Jlenle already advanced the view that tlie »ymptain of distention 
of the vessels from irritation was directly caused by paralysis of their 
whUb; when Lotz€, in opposition to this, says that it is not suppcNnblo 
Üiat thfrre should be paialysis of the muscles in a man who ia cxo^ 
sively imtated and boa his muBclcs tense and bis &ce glowing, liis 
objection is uot perfectly tenable. Kordoes the other obJectioD of 
the usually acute £<f(M appear to me correct when he says, ** What 
ihal] we think of paleness, of the contmetion of U>e vesa^ tJiat refloUa 
from fright niid terror? Docs that look as if due to great muscular 
action, if redness in nnj^r and shame is induced by paruly»ia f " J My 
this prove« nolliing. Fright may throw tlie musdes into a tolanio 
fltate, which is usually quickly followed by fatigue of the tnusclrs of 
tlio Tcs&cis ; imniodiatcly after s great fright, we gcncruUy fei:l the 
blood pour into tlie ebocks, as soon ns we begin to breathe and re- 
cover ftom tbe shock; wo eoon gnm- red again, at first indeed redder 
thaD we often like; not un frequently ilie juiliiig bom fright ia oAcn 
orerlooked, awl only t1.c siieeoeding rednoss perceived. 

Still, apart from tliese objections, Itow can we imagine the paralyx» 
big aetiod of an irritated nerve ? Wc actually kiK>w inicb plieomnctui 
from physiology ; the obstruction of the heart's action by tnitatioa of 



nxIOX OF WOUNDS— IIUlITAnON. 



fi? 



I 



the T^gas ocTTtf, of tbo roorentoDts of ib« iateatine« from irritatioD of 
the splaocbnto oerrc, etc. Here s vaso-raotor oerve-ft/stem in siip- 
posed whicb arrects tlie contract ioii of the muscles; coiiJd itat sach a 
TWKHDOtor öcrvT>«jr»i«m ulao be supposed for the rcsscJa — ncrrcs, 
trritatioQ of wliidi lessotw tlie tone of ih« masd^ of tho vessels and 
thus rcoden tbc walls less cnpulilc of naisting tbo pressore of blood f 
Tbe doctxioo about vaso-taotor ucrrcs is so dÜBcolt to cxjdaiD, thai 
eren n brief exposition of tb« probable possibilities of tbo proces* 
would lew] us too Clt ; benco I must content xajielt witli barJnj^ called 
»tUiition to Üui aoalogous physiological proocoaea. Virc/iow and 
MattU a{frco to tbe view tbnt t)io Hymptoms of fluxion arc duo to 
panl/sis aiUm vl-smIs, altbougb they refer this paralj-sis to dilTeroot 
ctxma ; on tbo wbole, most crcdvnoo is attached to tbo view tbat tbo 
vraades of tbe vessels, libo those of the heart, are partly under the 
f'^ft'TfTt'*' of Bytnpathelic, parOy of cerebrospinal nerrt^s, and Uiat tlie 
fionncrcause tbe rbylfaniical (automatic) oonlractions of tbo vessels^aod 
tb« latter a«t as rcguUtox? or obstructors of these ooatraotioiUL Iiri- 
tatioa of tbe sympathotio filaments would increase the oootnictiotM 
nt tliB VDOscbt, dividing' them wonld result iu paralysis of tbc mus* 
■d« of tbe reascla and tbcir consequent dilatation ; but the latter 
tnigbl also be caused by irritation uf tbo oerebro-spinal obstructive 
Dem«, 

Tbe diaoovcry by Aeby, JSlrtrtA, awl Auerbacfif thai tbe blood- 
eapUUr»«« are enlircly composed of ooll», might escito new hypotheses 
«boat the irritability of tbu capillary oelU and their inßuenct» on dils- 
tatkm and contraction of the capillaries, altliouj^b even tbts woubl 
not »ol?e tlic iiK'cliamciil difficulty which opposce the idea of an active 
vas(*iilnr diliitation. Jn the action of local irritation and entiivly 
locsl dilatatiuQ of the vcasela we liave the cltoicc of considering' that 
irritation of the nerve* of the vessels (er of tl« Hvinj* cell-substance 
oftba capillary wnlU) diro>elly disturl» ttioir fuuctiun, or that this dis- 
tmfaaaoe ia due tu rnllex irritation.* 

Voa haire ivow material enough for m*>ditution. Xone of tho 
byptMfaeif« advanced can claim to fully cxplaia the s^-mptoms of 
ftuaion^ altliuiii>h somo of thtin pcrhajM cnntain tbc germ fur future 
perfi'ct development. Still the recojfnition of Ibis truth, the dia- 
tioctinia of brpotbeses from obsen'alirjD, is useful ; it does not limit 
ifae onward progrea» of experiment, but conslanUy r«%niinatcs iU 
Cbnjiralubit« ycurselr^rs that it is permitted to you and the coming 
gvomation lo drar up ihi^ point. 

Wo shall now leave this question, and tlie next liour shall again 
nrtnra to tbc fIcM of certain obacrration, to study tho effC'Ct of the 
wuuDdfaig on the tissue itaelH 



5« 



SmCLB INC1E£D WOUNDS OF TOE SOFT P^T& 



LECTURE VI. 

CtuuiKM M tlic TivuA during Ittal'mK tyf tbo Flnt InUntton.-'rUalic tnSltnttso. — 
InÜHiuiutoiT' Utrt FanttMitra. — SeUoffmeoioa to ill« OcBtrtc— AtMtoadcal Evt- 
denoM of InillMiiiMiti».— Cotjdi tiona unier vliieli Ilcallns bf Fmt iBtectioB doo* 
Dol occur.— •Dnion or Fort* tliat liave beta oontplel«!/ Mrparalcil 



Tbk dilatation of Uic ca|VilUrip5 and Uic exudntioa of blood^st-nmi 
that ii&iully acoofapftiued it, wbicb w« hare found as Die first effect of 
the tround, and vbicb ü most re«idilr seen in Uie living timie, oa 
above mentionecl^ cnnnot of course hy itself Ciiuxe two lliips tbat arc 
brou^t iu ujiposition to uiijtu orgunicallv^-chnogvs must IaIeq place 
on tlip stirfai'<^'S of the ^foiumI, Iiy whioli the lütter are to n certain ex- 
Ipiitdbsolvediind melted into ciicb otbvr; juatiui^'ou render two cods 
nf sraliog'Wox »oft by heat, to EiuiLca tbcm togctbrr, so here the sab- 
stance itself must bcoomo tJio mc^ns of union, in order that it shoold 
be firm and intimate. In fact, tliis is the Goal result of tbe bealbig 
process, both in the noft parts and in the bnnc. 

Let us keep in mind the nboro diagram (Fi^. 3), and luppoee Uiat 
onl^ OonoecCire tiastie and vessels have been woimcled, and that ihcdr 
reunion is tbc question for consideration. As yoii atrondr knovr, ont>- 
ncolivc tissue oonüsts of coUular elcincuts and Clamcutarv iiili-rcvUiibu 
subabinee. The cellular elements are partly the stable, ^^^c/, Inn^- 
Ictiovra carmfciivc^mu« roi/nwcZtx, L e., Hat, niieltiated cell«, nith lung 
proceoaea, which adhere to the conneetivc-tissue bfindloBj partly Ibo 
vyinäeriny crfU di»oovercd by JifrX-Hntjha>">^ri^ whif* nr« id^^ntl««] 
with whitt-Woo«! and lym|jb cells, in fonn, «[kjcii-*, and vitJil pccidiar» 
itics, are ptobably formed for tbc n>ost part m the lymphalio (Haods, 
thiDugfa the lymphatii.'s enter tbe blood, from the capillaries and veiuti, 
oocasiooally wunder into tho surrounding tissue (ss diM-overed t*y 
■SfnV^/"), there become fixed tissue-relln, or agmn (as observed by 
Jitring) enter the Irmphatte or blood vessels, or undcrgfu melainor- 
pbotn not yet dincorered. 

If wc cMitiiiiie Uie IJssue of tlie flops of the «"oimd a ffvr hour» 
after the 'nj>irj*, we «hall find it fkdl of wamlering cell«, Thf*^ in- 
cnasa enorrooittily from hour to hour; they infilliat« the filmnia tttsoc^ 
already softifucd by »wcUiny, and even wonder from one flap of thtf 
wound to Ibo other. During this ccU-activity, and probably pi ac- 
count of it, tlffi connect! vo-t issue intercellular sabetancc ^u ' 

ohanges to a houiogeueoua gelatinous suljstanc«!, which gnulujdly j^ 

ponn OS the celht inorcatm, posaibly bcinj; consiinicd by them; so tlint 
there is a line wIicd the fui^ioet of the wo>iiid in Apposition conti«! 



rUäTlC D.TILTRATIOX. 



fffi 



ohnost entirely of cells, hcW togetlier hy ii rcry slight quantity trf 
prJaÜnuiui iiitraroMliale sabatiDPe (which 8nbs«iucntlj- becomes finnor 
and fin&lly fibrous). 

In th« akctdi belair (Ptg. 3), u sequc) to the abovo diagnin, j-oa 



ria.1 



^^^ 










>o 



■i-^\*A 






O 



03 



^ 










o^ 



O ¥1 



o 



PO 



» 



alfi< rhn aDirira nf (lif ■rnond anlMI tw ItilUmnutoi? niiiH dirniilna. 
B. pli*lltlulllli»ll<MiBriluiia, Manned ait-iw. 

B woljoa o( ibo woaod now iinitcil by nßwljr-fonncd tiMnc, which 
umw (pp nil Wff tilinll trnn iitßtitninaiori/ ttrtc ß>rinntion or primär*/ 
«edutitf f C*3n«'. TTrcAffWculls it. >^unuklioii lissui-, lütuyUtteft gunu- 
liKaet. "nKi iiifluHitiiatoiy new formation results from an earlier st»t« 
ii tItiA the »till filAiQeutary connectirc Itssu« is iaIilLntwl with iniiu- 
■«■hl« «tanilcrUig' cells, a state which mny readily rctura to ihc nor- 
»-; tosooellfl. 1\ääe.\Ageoie<:2Utla.fmfiaüicinßlfi-a- 

AV, , :.: ' Ague fiSielftlinnor than in wslery A/«mafotM r*r>;f/tra- 

tfM^b «hnost olwajr» at 90tno distance from the odgo of ilic wtmnil, 
Ulhit in nnjr stjrh spuomcn of » recent wounJ we iway follow the 
iRKlojiawint uf llic iiitlsnaiiiAtory new fonnati>^n frnm ibn plastic 
/flnuubr) iBliltmtion^ if wc mukc inloroscojHQil exaiinnatioiis from the 





1 espMft4ArMwr bMn. m* 
• wrnti ud WiMdrtDC isla Ik* 
■ ■ ■ ■ ■ ■: »latlw«. 

In Uip great oittjority of coses th«rc will b« at l»wt a »light Ujcr 
of ooKgulati'il bltxMl bctiretM] th4> flaps of the woand ; this nUoextvadi 
anraewbnt into tbc iutcraLin-» of the tteaue of tlie lliips of llie wound. 
'litis blixxl-vlot uiuy aofDGtitiies iiitcrn^ro wilh the hcAÜDf^, aa u-hen, 
from its sice or other ouiiiea, it docomiioeeB or turiu to |)i[x ; l>ut it majr 
also hraomc oicAtric-i&l tiasue suJ piTff.-ctJ.v «iisuiipMnr with tiu! ol-w 
formation in thr Hnps of thf> vroun<i ; tbi« must take pUc-o for union 
by llie first intention to occur. Wo shall herciifler epcnk of tlio 
obiinRL>(i ihftt take plncr iti th«.- dotted blood duhnj^ this prooc&s. 

We must no« &ttoiul to lb« c|ii«stioo, Whence come the innumon- 
IjIo WAndorin^ opII« thst indltmte all infUmed tissues immodiatftly nftor 




fLASTIC INTILTIUTION. 



01 




m 



T imtatioo, as they Lvre do tlicf1n[>s of the wound? Of late, this 
acfttJon hasnvcivini Uio following wundi-rful esplauntinti, Tvliicli ten 
euB ago would li&ve bc«D coitstdered u tb« fancy of ft mudmnn. 
'oAfiAcifn nude Ike following remarkable obficn-atton: be introduced 
fiDply-powdered anilin blue into tlie Ijrnph-fiao in tlur bnck of a frcg, 
on irritated the animal's cdniea with cau&lie, and fonnd that nnmbora 
tramlertng cella (lyinpb-pus cells) contuining anUin jn'udually col* 
U.^ at the eatilprieed point; bcncta the concliuion, <t( an irrilatcJ 
itu trhil* btood-corpiucifs \rfu,thrj'r<^m tite re»«tU into tfir tisxue ,• 
Khite b/ootf'corpusciif cvu»tUutt, tite i/ifi'iiniutUor*/ rrllttlar in- 
i4>n. Cohnhtim th«n coatiiTDcd, by direct obflervutioa on the 
int*ry of a linng frog, the dUcovDry already nuidn hy Strirlvr on 
tbe iiirtitdtiiig iiwiitibrane that had ju»t been removtM), that under 
mc circtin)»tunocft tit« vrhit« blood-CuUa wmtder tbrougb tbv walls 
r the vvweU into tbe tiitsiic», nnd sbowod nlso that tbis ocouriyMl to 
B Blill grcatvr extent in dilali-d enpitlftrit-a and veins. 

Altboupli it WUB aftonranl sbown that an Eng^l^ll eipt-rimcntcr, 
uff. fi'aU'-r, had H?vi?rHl years previously made sinitiar olMOM'ntions 
ibc meaeamy of tlie t«a<I nnd tbe frog'« tongue, tbo works of 
rnian obserrera, StricitTy Von R^<-klin-ghati«en, nnd Cofmheim, 
quit« indo|icndßf)t of hia, and Cchnhtim bus the undivideij 
nor of baring oorreclly tntprpreted his obBt'n'ationH on inlbim* 
(ion, «hich liave constantly ndvnn«^ 1o the prescul lime, iitii] 
of having presented tbem in a fumi to gniitly uUcct ull niudum 
patholitj;*', 

Jt Udiflirult for you, gentlemen, to imagine the immmAe itnpresaioa 

tDkdo on all bialology by tbc&c novr disoorories, which 1 have just 

«1 to you as simple fat-ta, beonusc you are not aoquaintcd with 

ler point of riew from «bifli tb« origin of intiiiinniatnry npw 

lations, and that of eainplkaled or|;^nnuH^^I grovrtlis, wn« r^gtrdcdi 

Din pwvious obserrat ion, our idoa of th^ affair wa« about as follows : 

t waa (uppoKtxI tliat the cells of tlio conniHnive lisaue, of u-lncb only 

oftv »aiii'iy, llie fixed, was l<nown, increased greatly by dirinion as a 

xwiX of irritatioQ, and cvUular inlillnttion tbii^ re5u)t<ML Imagine 

jWBwhfi haele a («w years, in a lime when nothing was known of the 

»'tis! '■ 'rJiw of yoiiop eells, ortbetrannelioid and Imromotor ao- 

tv.i -ily knew how to dodoco the eoiirsf of tbe pathological 

|immM Grom various stage» of the diseased Ijut not dead tiftsne*, as is 

Mill ilw cane in th« normally-developing layer ; then you will readily 

faiäMftt,tu\ that itn-as derided without bcHitationthal tJiowlU lying 

P*i ' !■ in th« inflamed tiiisuc weru formed out of one au- 

"•''-- ...i. ibifl waa a great ulvance, wbicb was only possible after 

•** otwthrow of the ff&teratio (Fqunwca ; for, not long before, the 




62 



S'lVFLE INCITED WOtTNDS OP TOE SOFT PARTSL 



dci-ctopmcnt tif cells and tistiie from lympb, coa^ulatod bloocl, and 
fibrinc, was firmly U>1icv(Hl in. The finitu1)titirratk>nBOn c<-11-divuton 
ssnresiill of abnormal irritaliun were rnadi? on cartlliig^ W Jledfim in 
Bngtand ; tlicn followed the olMicrvalions of Virc/to^c and //ifwon in- 
Aatnod corn<». In both cases it was sd^o that tStnr caatorization iritli 
nitrate i>f sUi-er, or aftnr intrniluction of a «vtun, tliu tissue wa« filled 
with young cell»; in ihu original tissuL-^clls, biscuit -sbapcd, then 
double nuclei wore seen, from whiuh a divisioD wna decided on ; young 
celU were »een {grouped togetbt>r, and tht'ir origin from the ti&suc^wllB 
seen>ed indubitably. ITence arose ilie idea thai inflamination was a 
process in tliv tissue!«, tv})ji:)i,entin.-1v i<idop«iidt.-nt of th« vc8«cls,irM 
assodatcil with a rft[>ic) liixuriimt |>ivilifi>rat loo of tiMU0>r«]l8, and pttf- 
ttal soCteaiag and dittintogration of Ibe in («reell ular liasue. Vifu 
Jt<cX!Uiigh<tusffi^a disßoycry of the two varictica of cells found in ooa- 
ticctiv*' tLuuo, as wpII as his discovorj- of the varit^d ni»reni«DlB of 
piia-ctflta, might w^ll bavc given rise to the question w)it>( hnr thr pro 
IIIcrBtaon uf tli« cclla, on irritntiug Ibc titisu«, btaried from Ihu fixed 
or movable connwlivp-tisaue corpujclo«, hut failed to do »o. Uut 
DOW obst.>rvat ion \» piled nn obKcrvatiun ; and we ar« dnvon 1^ the 
supposition tfuU aU */ounff crlls tehtch in inßammaUork tee ßnil uf- 
Hormaüy in the titstie are fpand«rtnff white hhod^ettt*. 

Obaoiver» who hare rpocntlv inmost igntf») this point do not all 
agree; aome atill ascribo to the stabile evils of tb« conni-ctivc liKsue 
■ part in tho inflamniatory process. Strielrr, in bis lat«al pubUca- 
ttoos, nuiiiitains that, on irritation, tb(^ atnbile lissnc-ocIU are fillod 
with ittMiplasma, increase bv so^nentation, and aid in ihr fonnatioD 
of pus : but he doc« not deny the wandering oT white bluod-celU. 
Cohnhtiin^ Kry, Et>ei-t/i, and others hare dcnicrl lli<> con'cotnrss of 
Strieker'» obBervatioia, or rather of his interpretaUonB. Obserra- 
tionfl nn this point art- ra tcdioi» that we cannnt wonder at tlio deUy 
in cluciilstiitg a question apparentljr so simple. 

Of oountp, fmni the vbHciir errors to wltieh we arc IJabln In tnlvr' 
pppting-theaiffnificanceofwhat has been observwl, weslioald bcTcry 
cartful about announoiug f^iiorul piinviples. In regard to tba in* 
Haniuiatory changes in eonnectivo tissue, however, as far as nijr obser- 
vation and criticism extend, [ would maintain tlte above Ktat^nw&ta. 

In cartilage alnnc, nothing has been obMn*od diOerent frmn fur- 
inor appearances. A« the hyaline cartilage-substance hnit no eanals 
passable for colU, so far an we at pipftent know, tht>re is lillti> Mt 
Kxcept to suppose Chat the ioorMusc of cells in the carlilage-caritiea 
after irritalion ryault* from diviBion of the protoplasm of the earliUge- 
oells; of this I shall herenfter show you preparations ; still hya^Da 
cartilag« haa never yet been watched for days In n living and Im- 



PLAffTIC nfFILTBÄTIOy. 



m 




Stat«, had conscqu«-nt)y ibU obg«rv*tioa must give place to 
tie studies an liring corinecliv«- tUisUL-. 

But in hjratinc cartilngo ibf^ro is no siioh acute suppuration or 
ifiltntiun of pus as in connectivc tia^uc. I vrill aRsin rcp«»t that I 
unly cun&i(ier r rtmnvntiiin and prolifcruiinn of coiiucclive tisKu» mid 
oomtral evils ns iiii|>r')biihle in titose cases wlier« thu pruloplasm liaa 
i;d entirely nicUiiiurphoAvfl cvcu to tbc imclcua, ttiit Ib, th« gta- 
connective tiasua ind coniesl granules of grown «uinials whose 
itikM resembl« tbofle of man. It has ncvoi been doubted tbat pro- 
■m, when it ozlsts aa auch in cells, tbat is, in growing tissues of 
tnd itMliriduitU, may incivase and divide up; inattonlion to the»; 
lints niiy have givvm ritte to wme of the dinWcnres in the riewg 
nh»vr- HlikUri). The sauio is trn« of epithelial tissues ; it hii» nuvcr 
been niaintainod that llio ci>lla of fully-dovcloped epithelial tiseuo, 
^^b'^ dldincntii of the bair, naiU, epidermis, and upper lujror of Ost 
^Bpltheltum, onuld b« nmovatMl by irritation, whilü it in not daniod 
^H' »at iucrc«$o of the young eluuiuiits of Ibvso ti»su«9 ie fl 

^r|i -- xml ne««8»ity for llipir growth ; here th« only <lilf<>renoe ia 

tbat gronrtii of these epitliclial tissuoa continues during life, while 
it of oonnoctirc tissues only goes on to a certain agt, and hcnc«, 
(ter oesMtion of the growth, wandering cells are the uuly young 
»I» found in thme tisxue«. 
If it he nnw catuhli^ied buyoiid doubt that most of tbc young 
whi«h infiltrate the inflnmeil ttesuc nnd somelintOB escape from 
as pus, as wu sluiU horvafter sec, are white blood-cells, or briefly 
fiiff ctiU. then two iinestinna arte«' ; Why do so many cells 
wa&iluinto inSamed tissit«? How do sueh auinhors of them get 
itu tbo lilrjod, ami whence do they come ? Thero are difTorcnt 
us to the moijc of escipe of wamlcrtng cells through the walls 

My views ar« lu follows: Tlie lirst change that we see in inflamed 

u/f% during life ia dilatation of the vesiieU ; the immediate result 

this is inv-n.-ner>I traoaudalion anri a colk-ulion of white blood-CclU 

nag the periphery of the vefuel. Then the wall «f the vewel i« 

Klmlly auTlened by khui; unrjiptain^ chemical procois that goes 

fim in erery inflammatioit, so that by their active nrnvomcnla tlie 

«ti^te hloo(lH:ell« gradually enter and finally pas« through it. Ilcncc 

ditstation of tbo retsels, accumulation of white cells along the walls 

U tb: marls, and softening of tlm walls, seem to me to be Üie 

nqmtviDeuta for extensive emigration of cells. Cohnheim and 

AiDtMf kare laicly announeed the same opioioB. Wltencc come the 

Mm«OK number of wliit«; blood-ijella tbat escape in intlainmntiun is 

«tWy » physiological question, TTie lymphatic glimd» and the 



04 



SIMPLE INCISED WOUNDS OF TBE SOFT PARIS. 



spleen are the organs winch vo first ^u«pf>rt ; and, atlhmi^h it can* 
not be provu^ that uuiuctuus nuw lymph-cvlli» aro [«nuird n» the 
othem esfAp«', it is very proboblp, espi'i-iiilly ms tre know from HIni> 
cal «xiit-rioitce that [he Ivnipliatic glitiicl» in the viijinily of an inflam* 
malion almMt alwajrs ewoll la spito of oarcful temrch, I bar« been 
unable to discover imy thing about th« TnoTjiholnfTict) pr., '<!» 

cell-formntion, but Koosider it very probable that IvmpI _;i. 

niitn from »pmuting of Ih« nets of tiin Ijrmpb-flinosAe in Uie fiUntl». 

I must mention one other point, which is, that in indammal inured 
blood-oorpt»«Ie.i also not imfroquenllv pasjt through the nalU i)f tlip 
vessels; according to C'o/i7iAcmiV CKperinient«^ this is grcatl,r influ- 
enced by the incrcAiO'I intmra&cular pT4'Miun>. 

Aocurdiiig to Arnolt/, not only red but while bloo«l-cclU escape 
from ihc walls uf the voswU ut jioinls wlu-re llic capillary i-easeU 
Icai'c small opeuiogs (stigoiala, &loiUHla) ; it ii> said to bu iui>re c»- 
peoially the cement of the cells of the enpUlary vesseb thai cweDs on 
inflaming, and become» ao yieUliiig that Ane slrenins of bkiDd^ortiiil 
flow tliruu^t iheao vessvls into the intcrstii-cs of tliu usHnea. 

J^'t iiH novr rt^lum lo our wound, and «ec whni br^-omea of the tts- 
ftuc iulitliaied wilb celU, of tlieiiiQiiiiimatorv nevr fonuiitioa ; bowtlte 
cicatrix develops from it wbilutlie opU-in6itration cxtPitdualowlr aitd 
»luggUhly at .'>onM»<lislAn<'" fi'om thcMTiund. TIio crlUir t ■* 

of the wound, wliicti alrcudy adhere louiwly, (rriirliinlly ai^« ■ _ ii- 

dte ahapc ; tbc intercellular iisBue then bc*cume» firmer, tbc «phiill»- 
cells cliang« to fixeJ conucctivc-ti6«uc cells, and fitiaDy lh<' .vounf 
[•icalrieial tifsuo aaxumi-K mon- nnd more the funn of normal, fibroua 
connective tiwue ; that is, thn white bloncl-eolti beooine fix«! coniwo- 
Ure-tLMu« cells, as prubabl}* lakes place oven iu the omWyo. Bore^ 
again, wo an.- met by various quvstions. TIic newly-fonned adbuiift«, 
Iiit<'rliicing li;tsi»c soon iHrcomrw firni, i^pfciiilly i» I"' *■>* 

iutoutioo; errit after ttreiity-four hours we 6nd it» i "t>- 

Btatice qoite stiff and fibrinous am) iha borders of ihu wmmil am mlao 
mom or 1p*h inliltrativl with llii» »tifl'subfitaiiri'; it !■ ' ' :\t 

Innk'ninf^ of the intcrcrihilur cuniiertivr wilminnce, .i»- 

uiled si^nim and «^flrnod (^onneellrc tinni«, that eiplninii wbj lb« 
union Is so lirni, even tlie thin] day, thai the tlnps u( tbi' wouckI tiiild 
logotbor witbout sutures, for witliuut such connectEve »ubMlancr llic> 
yaoDg cellular tissue ctudd not he »o c->liffi;iii, Tl' n- 

nective-iisguc substance (Kig. 8) is most probably tiii i>. 

slsta (if the tcansudation coining from the vessels imdrr ibe inAuonor 
of tl>e exiravasaieJ hloof]-*- 1 : ' itoshlblv n' ' ' i'l^ 

cellft. From iJic *>xcellrnt ■ is of ,■!/. is 

known tliat most exudations coutain tbc ai>ciiUt*d ribrogvaotv »ub> 



UULIKG Br VIBST IN'TE.VTIO.N. 



0£ 



vtiiofa forms fihrine as we know it in llic coagutatod eut4>, hy 
nning vritli tltn ai>ro-i)1utiosul>atanc<;ortlie blood anil olbertU- 
sac«. Very accurate proportions of fibrogenoua aud fibTtno-plMtic 
futwtanof iin* ra)iiin>il tn fonii Oliriii« ; ihcsu favoraUu it^juiremtmU 
«ociir la mnnj iiiOamtuutiiHis. Schiitidt ooiuidcrs it probable tlint 
all firm SI>rt>u9 tiuue U foftaod and Riaint-aine<l by Ui» tibrqgfiiHnis 
•tiiMtaoc« fh>ni tlio blood being procipilnt^^d in ft rartain mannor 
SNHtod tb« tiuuiT-cfllK becau»o thej' contain a fibrinoplaslic sub- 
in; in a fimi eliApr. Under ibia )lvpollli'^i» w*: must auppono a 
riSo cvil-aolion, wincit would riiiiso the voAgulaüng product to al- 
anine ihe fonu of muscular sLriiB iu ou« place arid in another of con- 
ire lis.tiJL'. In our case iJiis ia a very probable riew, for wo see 
icotuJ-r conncc'tivo tlaauo ffraduully form from the interccllalar 
«oaguUlod libriiu*. It ia Intc the atnaunt nf inti-rppllular xiibstoncc 
in ill« new formation is not groat, but there is liitlc doubt tliat the 
«»all itp*oea btitvrc«n the oclla are iilloij by it. A ahort time eubec- 
qiii " ' r cicatricial tissue appnara still to oonsUl cIÜl'Hv of 

»pi . iy pp*iw<l togieihvr (Fly. 9); hut thfn the «piudle- 

oetla diaiiiii&b j^ri-u'ly by Battt.*nia);, luauy uru evim dvslrorod, uud we 
hsr« now D filnmctitni'y conncctiro-tissuo substancP', «rbicli U to be 
DtiuaidiTeil partly as a proiluct of secretion, partly as metiimorphoiied 
in-Dli»pUani of lUr Hpitidli'i-eliji; tho cieutricial tiutiio finally rvmoins 
stabl« ill tills «tutfl, T/iitracAy who qiiitc ruccnUy ha* aj^iiii carefully 
atoilitfJ Ibtf healing of wouiidn, maintains tlinl tho apparanlly fibri- 
noi " - aubstancu ia not 6briue, but only mctuinorpbosed 

CC'U' 

1 will not d'^ny that thrw may bo an immediate union of tho ftoft- 
I on-' ' '. i-f tW wound, altliouj^h it must be very rate. Quiu; 
rf i Dr. Giue^nfMuef tnaki; a new «erii-s of accumtc (ib&er- 

v«ti>w«nn tie:diii;^ by tho finit iiiti^-ntiun with especial reference Co 
7/iiCr»cA'a viuns. fie oould Uüt coatirm the UitLnr*« obfiervationH, but 
bev ** wvf «A GUttH^iiU, arrived at result» wtiicli in the main oorre- 
api' '>rp vif'WSjWiiich I arrirrd at from my o>Tn studies. 

it tui« bi-^cuiut* of tlwj dosed ends of the wss^'l»? 
Hit; bloott-dul in tbem U ruabaorbcd or organised ; the walla of tlic 
TeaaeU ' ■ ' ■* ' ' .whicli coininuolcato wilb the vascular loop» of 
(be o|»[> ihe wound, and witli each other. In this way, 

bawcn.T, nnly i.lir- rather »canty union of the opposing va.scular loops, 
«faich i«at ßntäliglit, i^ntcomplbhcd ; tlic&o Mere aUcady formod by 
eateoaiva tortutwit ics and wimling» of tliu ve8ael)>, which had lno|i- 
!((;r (IiL- injury (Fij;». 15-U). Thii« bi not the 
',.iIU of this inten^slin;; dcviJuiimcuL of tlio VUA- 
onlar loof« ; Uidr decclopmeni is noi due solely to dilatation, but very 




BIUPLG ISOläKD W0I7KDS OP THE BOFT TJi&T3. 



'^■■' niudi to iiitvnitUial growth of 

tlio wklts of the vogsel«. The 
original, fonriurlj« sis ting vascu- 
lar union is ibus replaced b;r a 
nen-ly-fonned vascular net-vork 
ifliicb u at fir»t fiu- richer. 

Quite rci-TiiUy Arnold has 
moat cnrofullr 8Lu<]io(J tlio pro' 
ce»8 of ihf dcrelopnieut o( ves- 
riclt^ and has accu it gu on in the 
taib or tii<Ipv)«3 (Fig. 3 u) 

Although ilie heart uaä Inrger 
reaaeU of the cialirjro wom to 
originate from appoiot«il ccll- 
'gToups of the luidiUe gi'riniual 
layer, b^ the peripheral part» 
formiiij; the wall of Uio vua««.'! 
anri tho (xtitral purts the UImxI' 
ci'lU, IuUt this (lot^ nut acvja lo 
occur ; at least, obsorvuliatui luadc 
on this point by liokitantk*/ and 
(>tlu>rs do oot f>4>ein to Iium 
t4t{oDd[DUGlim''dciict*. Aci. < 
to ArnoUi^« invosti^tions, off- 
alwuts frcnn the vi's&cis liiivDi to 
be tlie only mode of devclojtlucnL 
of vcasd» io the embr^^o. 

I fonnoHy tJionght that Iborp 
miist bn another modo of growth 
for vessels in tlir fnmiHlion »f 
granuliitioiia anj iu soio« tioo- 
pliusia^ nninijy, a tubular (uraia- 
tiun b<r U/ing togi-thi-r &pilKlk- 
cclix, an al a, b, aud c, iu fig. 
3 f ; this I call«] ** secondary " 
formal ion of vessel» (*' primary-" 
1 upptit^ to the dcvalupmcul taf 
tlio boart and larger rwaeU in 
tho middle genu<layer). llie 
development of vcMeU by »ff- 
sh.x>ta I called "ttrtiary." But, 
ainoc recent invpsLi){alions, I 
TiM moTM »r Uf ktwMbin «r Um* vMMin RIM rcudUy agiec that the nio<l« I 
MiSlÄ''Iito;^i;S~' •"'""-* term«! " secondary " powUly did 



HEALING BT VIBST IXTRNTIOS. 



R7 



>t eust^sml that the fine plasma string (tlio offshoot) and the Gne tube, 
whicfa the eprodlc-celJs gruwirig out of the young advcntitia Iny, 
ly hare nsoHjied my noti»>. But t will act neglect to mcutioii that 
Wrrffc-A, supported by recent obson'ationA, hiui rep«at««i his fonocr 
aaef^rtioos (wluch then «««med to mo improbable) that io tho youog 
inOaiamatucy Dcoptask them b a tiet-work of tubps, contii>cted with 
the blood-Tcescls liy sti^intii, which is houodcd tncrvly by the tissue- 
odU, Dot by sfieciji) walls ; tlits itgroc« very well trith the recent ob- 
■ttoos on capillaries ill iDHauieil ti&sueo. According to this, there 
ltd be bkxxl-Tesitels in this tissoe which are not drcular cnnala, 
but irregtilor intercellular fwasages, ]>erbaps merely bouuded byspjii- 

Fis-ba 



iHM<'<W)>talaia«rll>M«)HMlr»fMNi>tar*ia)f- HwiUmI ibont 000. AttttAmeU 

Avarrnnllof tlirrestoraliouof circulation through the young cica- 
(rii, the cirCTxlatorj- diatHrbiinw» «auscd by tliu injury- are removed, 
Uc radavsB Btid fiirr<t]iu(.'or thu borders of Ihc wound diKap])enr ; from 
•ie Biuncroua nawla, the dcatrix appears a» n 6iie red stripe. Now 



98 



SniPLB INCISED WOtrXDS OF THE SOFT PAHT6. 



the consolidation of the «calrix ninsit takefJ&ne: thin ia Rcootnplislied, 
oa the OQ« liaiid, hy the [»rtial dituipp(«niitoe of the iiitwiyfonncil 
VOSM-Ix, vbosc ««11» fnll togr;thcr, and tiicy tius become solid, fine, 
oontMiTCtlrc-tiMiic siringe ; on the other hand, hy ito intorceUular 8ub- 
Btanoo becoming firtnpr and containing lesa WBt«r, aa nbovR mentiooed, 
the cells afl&iune the flat fonn of connectire-tiasue corpiMclcs, nr disap- 
|>03r; pos&ihij' Bonie of them reiiuiio as vraaderiag ccU», «nd return 
nguiu iuto tlto lymphulics »r blood-vessoU. To ttiis condwiMtlon nod 
^itrophjr is duo the great cuntrnctUe power of tlw daitricnid ussuoi, 
Ur means of which large, broad cicatrices may occuioaally be roducol 
to half thdr original size. 

At the firat glatioe, it might appt-nr to you oontnidictoTy, that ou 
uppBrcDtlj exDessive oa{)iIlAry iict^work ahould bo formed iu the youi^ 
Hontri X, uid slinuld HubscqucnUy be for iho most pari obliterated. Wa 
ca&ciol explain tiiiä aj^Mivtit excess, still there are pletny of aiwlogic* 
in embryonal devcIoptiKtit ; I only need to remind you that thvn: ia > 
period in (eetal dcrclopmont when, even in tho vitreous body, thMm b 
s CApillarj' ncUivork, which, as you know, disappom, leaving »carcdff 
a traec. 

Nut to fatigue you with so-called theoretical subjects, I leave tliis 
field foe a short time, at>d, before leai-itig healing by tlie Grst iuten- 
Iko, «8 a point fully understood, I sliall moke a few temarlts on iW 
«■QSOu thnt may prercnt this mode of healing, even when llie llap« of 
the wdttiid are in appmition. 

Hc-aliug by liist iiiu-ntion does not take plaoc : 1. Wlico tho edges 
of th« woiiod are brouglit togotltcr by plasters, or sutures, but tUoir 
IcDkion OF tendency to separate again is very great. Coder thoM 
nrcumstaoocs, dtbcr tho plasters do not keep tJi« winind accorataljr 
cloecd, or tho suturos cut tltrotigh tho lla|>s ; pcrliape alsu the inuivn 
of the tissues obstructs tlie Sow of blood in tbc oiipillarifs, and tliu« < 
distuitu tlic cell dOTelopment nnd funnation. now gix-al this tendon 
inufft Ik!, And what means wc have for ndivritig it, you can uuly leuru 
in tho cliiiiu. 

2. A further obstnictioii to healing U, a largo aionant of blood 
poured out botwcoa the edges of the wound ; this inlerfrxr-s with tlie 
proeeae of he«liog, pertly as a fomgn body, und partly, if it dcoom- 
poses, by the influence of the proceu of deooroposilioa. 

9. Other foreign bAlics, as sand, dirt, alkaline urine, ficoe«, ota. 
fclfto retard the heeling, partly mechanically, partly cUc<ni<siIly. HctiMf 
tli«ae subalnncm should be carefully rofooved before uniting the wound. 
la wounds of the urinaiy bladder, it is nob usual to aU.cm\A the ckw- 
ute of the skin-woundj the unoc would force its way into th« fub- 
rutaneou« oeltidar li&sue, or into t lie poritoueal sac^ and cxoit« t^rriUi* 



< 



DRALWö BV riBST ISTESTION'. 



99 



[jnjary, fli'ri'-, under some ciniiiiiätuiicjcs, it would Ik a decided Taiilt 
unite th« n-ounil, nlthough of Ut« tL« vich-s on tliU purLicular point 
dilTcf Miw-wliat froiu dio«o of former dayB. 

4. lAntlvi fratn a ooatuMon, wbosc effect on Uio flaps of Uio wound 

wo nur foil to obocrvc, th«ro tnsj bare b«cD «a extcn&iro disturtwDCC 

of drculatloo ami destriKitx») of mimito tit<sue, wlncli has imluwd t)if 

dead] of ocrUm part« or of tbo n-lioln üurfaco nf tim woimtl. 

Iiea, M then is no oell-fonuutiou in the e<tg<es of tbc wound, but oitlj 

rbpre the tiaaue is still living*, \ro have small tags of tlic lU'stroyed 

tJafrue lyings« foreign botlifs between the e<lges of tbe iruiiud ; tlwee 

mult prcrcfit besliag bj first intctitii^n. If this mortilicittkin attack 

onir minulo pftrtides, tltcs« lua/ j>o««ibly quickly luidcrgo uwloontar 

Pdisint«^rBtJon and absorption ; this may txxiir not uiifreqac!»tly. We 

retail spoale more cxtcn&ivrly of this tnorliGcaltoa of the tis8u<!, and of 

fits tletadimefit from the boalthy parts, when treating; of oontusiooB. 

ExpAricnw, BrUing from many obsemtions in Juilging of nouudiK] 

aurfiK:<!5, will hereafter enable jou in njoal cases to eay ■n-ho(hcr heal 

log by first intcolion may be expected or not, and joti will also loam 

-n-hen it mny he uaeful, even in doubtful cases, to try to aid this trnion 

Jiy applying rlrearings. 

Vou will occnstonully hear of wonderful ciues where parts of th« 

dy, cmnpletoly sepanited, hnii-c again become iniitiMl. This appears 

' he actually the case I have never had the opixirtunity of making 

any obacmtiona on such cases ; still, even in Into days, very trust- 

l»y men have asserted that they have seen small portions of skin 

tmitc after being removed from tlie Gngcrs by a blow or ciil, 

lly tt-placetl and fastened on with adbcsive p1ii8U.T. Fur« 

itiwded Bgninftt tbc pogsibillty of this healing, but miKt now 

. H, alau ou theoretical grounds, after it has beootne imaginablo 

' 'lienvoTCincnls of the celk, the detached portions, if not 

'_. «ooo be restored to life again by tlie entrance of w«n- 

li-riog cells. That we maysuocBSsfully tiansplanta twig.cutfromonw 

into another one, ii< well known ; but, as the circulation in pUnta 

Oiit W ptimping, but the Mp niiu »imply by cellular force, the onal- 

not very close; it was more rcumrkiible, it \s true, that a cock*a 

I could be tiansplanted to hia cocnb, but between biida and men 

ibe diffenmccs in the fonnatire process iiro also very great, and any 

trmuifer of ohservatioiut is tnudiiiissiMe in practice. 

When treating of tbe i-iaitrintUon of wounda i\-ith loss of aul>- 

MaoM^ve »bull inrestigat* tbc diiworery of Äwerrfm tiiat we may 

mne qiidermis to grow on grajiulaling surfaces.* 



70 



bIMPLE IXCISEO WOUNDS OV TUB SOFT PABT& 



LKOTURE Vn. 



CImii(m pncMitlhls t« t]i« Kakod Zf« In Wmtads «lU I<om at Subauooa.— Fiaar Pro* 
MMca In Ucalinii vltli ttraaubiion tod 8upt>anUon. — Pn«.— Ctntrivtioa,— Ob» 
urralio«» on " InflitmnAlion." — DciuAailntMkvf PrapbratiAafiUnatntirscf tfa* 
HMling of Wmuidi. ~ 

It aov rcinsina for us to inquire vrlwt liecomes of the woitoil, il^ 
BDdcr llio above circtimelanocs, it docs Dot heal hy first iatentioD. 
Then, ss the flaps gape, we httvo an open wouniJ beCore lu ; anil 
tbe drcunutuicus «ro the stuQC us if tbc gaping wotuvl bad not bocti 
dosed, or as if a plate had been cut out, as in a wound with loss of 
sulistaacc. Accurate olwcmilioii of such wounfls, wliich an; usualljr 
oorered wilb some umrritatiDg body, sa iritk h fold of linca dipped in 
oil, with oiled or dtj obarjiie, oto., shows the following change»— itf wa 
examine it dailv, this in not neceMiarj', it In truR, anil in»y even he in« 
Juriousl »der twciitj-four lioiin, you lind the borders uf tlia wouiid 
•U^Uy reddened, somcirliat swollen, and scnKitivc to the touch ; the 
samo symptoms as in closed wounds. Aa in healing by fimt ioten- 
tioo, these s^iuptoms may bo very insgniGcant or eutirdy ahftcot, as 
in oM, rdlaied, flabby gkin, also in strong skia with thick cpidcruiiL 
We obaerre thRse Symptoms best in the skia of he»lthy children. An 
extensive and increadng redness, svrelling, and put» about the wouDd, 
malie ua vuapect an abnormal course; just as, with Ibe same Symptom* 
in a wound healing by first intention, various itidividual circumstaaiiBC 
arc to be coaaidcccd, and tbc ribmtiom from tbo nonnal to tbe abaar» 
mal are so numerous, that the dividing line is often difficult to dela>>- 
miae. After the fiist twenty-four hours, the surfiii^e of tha wound hua 
dtaoged but little ; all over it you can atill recognize th« tinuea quite 
diatindly, altbough they have n peculiar gelntiaous, grayUh api>ear- 
anee; you aluo find a oonstilendile number of yellowish or gmj-iab-rpJ 
amnll partide« over tbe surface; on dose cxaiiiinulion, ruu fiml ibcM 
to be smal] fragment« of dead tissui*, vrliioh still H<Uii-t(% bowrvr^r, l^ie 
seeond day, you may already notioe a trace of r<?ddii>h-ycIlow, thin 
fluid over the wountl, the tissui>9 appear more roguUrly grurish ird 
and gelatinous, and thoir bnumlaiics become tnore iixlintincL Tbo 
third day, the secretion from tbe wound is piu« yellnw, »ofiio"t>iit 
thicker, most of the yellow dead particl^^s »ni detached and flow oIT 
with tlie secretion ; ihe sur&ee of Uie wound bcoooMS mmv orcn and 
regularly red — it t^fanM off^ as we tny technically. If you bad not 
boand up tbe wmind (u stump from amputation, for hKlanon), ami had 
reodved in a baain the Kcrction that funned, the first and second ilay 
you wouW Sod it bloody, browiusli red, theo of a gclatUioaa dirty giay. 



I 

'I 

I 



nCALINQ BY GRiSTLATlONa 



tbeo ilirty yellow : at tho poiute wlier« the »ocrctian flows fmm Oia 

«rotud, 6bnne not unEre4tuentIj stiScru in drops, IT ^'ou exatDiiic can> 

Atllx f^ * ^-""i «""i ^« ^""^ f^'V» J'<J" will 800 nmnerou» r«l nod 

atecs RFUcely as Urge as & millct'sccd, projecting from tlio tissue 

— Bizull granules, ffranttlatio/ia, flishy wart». Tiy the fuuitb or stxtli 

dm.y lliese haTegreatlydeveIoped,an<l gradually juiniuloiifitio.^mnu- . 

Ixf-, fcri][^t-n)d!nii&oo-->thc jTranuTofi/iyaNr/iire,' at tlie sunm time, the 

fluid floH-iiig firont ihij suriuco beoocoea thicker, puru ycUow, and 

of careamy caasiateac& ; thüt fluid is /nw, and, when of the quality here 

cla«csnbed, it U good pus, ptu hoaum et Uuidahile oi old authors. 

Of this normal courso there aj« nuiiiy ^-orictics, which chiufly de- 

p gn d on tlie parts tnjorod, and iKa mode of injary ; if latg« «hrcds of 

tms:Biae from the surisoe of the woand die, the wound is longer in dean- 

it»^ «ffiaodtbcii you tnaysometinwasee Uie wLite^adlierciit sliredsof 

^iBmtA tiiBaea still dlugin^f for days to the fturfii«e, most of which i» ol- 

nc ■ <3 J granulating. Tendons and fasci» are jiaitioularly apt to 1ioy«i 

t ^ao ä-« * arculatioo «o impaJroJ, even by slmplo incised wounds, that they 

<Xi<^ -to an unexpected extent from the cut stirfaco, while there is little 

I r>M i M of looM oelluhu- tissue or moscle. "Hiis is undoubtedly due partly 

ti^ ^Lt&öcni Toscnihuity of the tendinous parts, partly to theJf Bmi- 

T<c^w,»bicb does not ponnit rapid collateral dilatation of Ibe vessels ; th« 

w ijua ■- if tmo in injuries of bone, especinlly of the cortiuil subslanoo, 

"^wKa^Ksi; there Is often death of the injured bont^urfucc, that requlrrs 

la loEif; time Ibr detachment. Other obetaclcs to active derelopment 

>f ^y nulaljofi» arc coustitutiooal cxmditjoos; for infitanoe, in ve«y 

dchUItatod persons, or badly-aouriahed children, the develop« 

^*Ät o( gratndatioDS will not only bo \ciy alow, but they will look very 

».1^ tnd flabby. HereaAer, at tlie close of this chapter, I -will give 

aihixt review of those anomalies of granulation whtdi are daily 

'^■'^•xiTeocrs in large wounds, and, to a certain rxtent, may be regarded 

»• xa43nnij ^t »t l«Mt ourtomaiy. 

Uut, lo cetum to the observation of the nonnally-dercloping layer 

*" ^Snnulallona., with the continued socretiou of pus, you perceive 

y^'^'fc- Ibe gnutulalHHis become morn and mora derated, and sooner or 

' iltain Uic levi-r of the skin, and not unfroqucnlly rise above it. 

'^ this protxas of growth, the individual granulm become thicker, 

'^^^ mots ooofluenl, so tliat tliey can hardly ix^ rcoognizod as separate 

jl^^»!»; but the entire surfoi-e sisumes a ffl sissy, gelatiuons sppearaiMXx 

* I >iiiiiiiillj thn granuliLtioos reraain fcir a long time at this stage, 

** '^^t WD hare to use varioua remedies to restrain the proliferating 

'''*'^*JiäMm within hounds thnt nrc requisite for recovery; on the 

P"*^pheTy, partifulorly, the grunuhitiuu should not rise above thf 

'■^ of the skin, for the cicatrization has to oommenoe at this point. 



>ld 




J 



TS SlltrLK I.VCISED VVOt'KDS OF mc SOFT VJlKTS. 

Hic roUowin^ mctaaiorphoecs now gradusUy occur: »he entire sw&oe 
rontrncts mon- nnd niori?, becomes Bumllcr ; on tho bon)«', between skin 
and graiiulattou!*, the secretion of pus dimtnUIics; firat, a dn', ivd 
bonier, utxnit bi>lf a. line brood, forms and adrancc« toward the centre 
of the wound, ind, m U |)rogrcs8C9 nnd traverses the grnnuhr surfncw, 
it ü followüd dotielj bv a bluisb-wbitc border, wtuc^ passoe iuto nai^ 
nml epidomiai l^oaG two &<.-ams result ft^m the duvclofxnent of 
epidermic, whirh atlviiuec« from thi« jjcriphory t'^itrard tbo oentre ; 
cicatriiation 1x>g)iis; the voting cicatrical border advnnces lutlf • IEdp 
nr u line daily ; riimll/, it corers tbe calire granulxtioo »uriacc Tbe 
young cicatrix then look« quite red, and ia tJiua Eharplj defined irrm 
tlia bcaltfaj skin; it f«eU firm, more eo tliuu tbu oul>8> and a Ktill 
r«y intitnatcl; connected with the subjacent parts^ In tlie oourae 
of aonic months, it gradually grows paler, softer, more nunvb)^ and 
Aually wliitc ; in the coursu of moulha aud ycurs, it grawfl still mmller, 
but oftca rentotas whiter than the cutis all tlirougti life. l*bo 
ctioog oontinctioa in th« doatrix ol^ca causes traction on tlio ncigb- 
borinjf part», an effect that is oeeauonally desirable, but sometltnea 
Tvry iinweloomti, as, for iiiBtAuoe, when such a (Beatrix on tbc obeeic 
dmwa the lower eyelid down, causing cctropioo. 

Tou will oecasiuually aco it assorted tbat the eicalrizatiua ol a 
granulating aurfaoe may »nnictimes begin fixira several patohe« of 
Ofmleniiis foriuing in it« mtdaL Thia a ouly true of ooaes wboro pcx^ 
tlons of cutis with rcte XUlpi^ii have n^umncd in tHo miiUt of UiQ 
wound, H8 may readily lukppen in gniigrvuous wounds, as the oaoitta 
ageut may ]»cuctiate uncquidiy deep. Under »uoh ciroumataooes, epi* 
dermis again forme from some rcmatmng portion of tho impÜlarr 
lay«r, thiit bn« th« alightcst poenible oorering of cvWs. of the rate ^InJ- 
pigbii ; at tbeao points we bare tlie same ctroumatajioca u when «o 
bare raised a vesicle ou the sicin by cantbaridei), inducing by tbe rspiil 
exudntktn an elevation of tli« epide-rmift liomtliu muooua byrr iif 
the ekin ; this is followed by no gnuiulalions, if you do not coutiuue 
to irritate tbe suriaoc, but bomy epidermis u^a forms at oo^ ot-cr 
the nniooua layer. But, if thera be no snob n-mnant of rote Malpigbii, 
wo never bare these islands in the cicatrix, tltc formatittQ of (TiWlennls 
only take« plaoo gradually, from the periphery of liie winu«! towanl 
tbeccDtre^ I lMilJvrelbt8sofinnly,tbatItliinksuigeona, whasay tfaoy 
hare sccu otherwise, mu!<t be miistuWcn En aome way. 

Tbe transplantation of cpidcrmia after ^ti4n^% netbod also ap- 
peal« to nio to favor the view that c^pithelium is only davel(^)ed from 
epithelium. 

After having considered the external conditions of the wound, the 
dovolopQumt of granulntiona, of pus, and of tlie eieatrix, wo lauat 



DILATA.TION OF THE VESSELS. 



73 



' turn again to tbe more minute changes b;r vhic^ tb««e external 
>tuinn »re iuduced. 

It trill Ix' Himplrst for us, ngun, to ntprpftpiit n rcliitii-d^ simple 
CK]nlUr}- nt-t>work in the ccnnordive tissue: suppoAe a cresccntic [>n;cv 
to be Cut oni of it from mbove ; fust, there will be lileodiug Iroiii the voa* 
•els, «rhich will tw ihtckUnI liy t!ie fonnntton of clots as for «a the 
next hIBlll^hes. Tlicn, thun* niuHt be tlltsLntioD of tlie rcssuls about 
tho wound, vhicfa is duo portly to fluxion, portl/ to lucrcaacd pros»- 
upe ; an increased transuilatioii of blwxl scnim, or an oxodation, is 
kIso aneoesnmr result of ttic capillary dilatation, from causca above 
^rra; Ibo tninsudcd scrutn oonioiiis eome filiro^noua subetanoe, 
whiuli, by tha inllaeocvi of tbe ncvrlj-fonned oells in the ituMt super- 
Gcial Ujrm^ coagiilatos to fibrine, while tlio Mruui, luixed with blood 
I olT. The Taeculor nct-vork would assume tbe following 



VM.i. 



#^ 



V 



€^:, ,c^ ^1 ,, 



t«f m«imid,«1Ui1awcf nlMMnea. TunlMdIlai«llan.M*cnillT<] «v-NOUMta. 



Ia noet casr^ fiorn insußiciuut supply of blood-plafim at the eur- 
bBt<4 lliis wmin«1, muro or let» particW of tiüxuo will <lie; u the 
ttopfngt) of rcMeU must, of course, dwrply aflcct llie iitilrition of tin- 
IDE* tut rrry raKitbr, and, where the tixsuvs «re vt-ry eüff, dilatation 



u 



aiSrPLE ÜCCISED W0ITSD3 OF TUB «OFT PAWA 



v) 



of UK vtsecl» wilt be interfered with. Let us suppose that tbc upper 
lajer, tbndcd in tltc dia^^ram, is dead from tlio clicmgcs in Ibe eiiwubi- 
tiOQ. Viliat will now take pince iti the liiunie iU«I[? Esaentiallyf 
ÜIO same cbanges n» iu iW uiitlod oilgcs of a wound; wandcving 
of white-blood evils tbrougb tbu walla of tbc Tcssela, tbeir ooUectioii 
in (be liii«ue wil.li tbo socoodary itction th^- jnditoe ; jtlBslio iiifiltni> 
ttoii, and inflamnuitory new formation. But, Hiuee tliere U no oppos- 
ing wounded surfnee, witb wbich tbn new üwuc can coalesce, then to 
be quiekljr tninsfaRDcd to connective tissue, tlio eoUft, e-scnping from 
tbe TGsscla, remain at ilrat on tbe xiufnce of tbe wouud ; tlio exuded 
fibrinous nialeriid oil the Btirfiice of tbe wound bcoomca soft and 
g«ltttiaoua; at the same tiiiw, tb« inßltmted tiasue of tbe suiftoe of 
tbe woaod usumc« the same peculiarities ; tbe soft oonnective tianie, 
into wblob tbc youog Tetaels eborily grow, even if only present iu 
anaU qoantitici), Eiolds together tl>e ocLÜ or tbe inflammatory new for- 
nation, wbteli con»tAotly increase in number, tlte ffranuiation jAutM 
is thus formnl ; tbia is, therefore, n biffblyn»s<;ular iuflamuuitory new 
formatier. At Srst, it grows ooustantly, the direction of it« growtb 
is from the bottom of tlie wound toward tb« iiurfciec; tbo tissue is, 
boncTcr, of ditTcrcnt consifitcnoe in tbc Tuxious layers, its snjierEciid 
Mir&use «specially is soft, aiKt mott euperficuUy of fluid ootislsteDce, 
fur beru tbu intt^-nvlluhir eubslnnc« bewiiM's not only gelntiitous, but 
fluid; this uppermost tliin fluid hiycr, wblcb is ooujilantty flowing 
and bein^ oonstootly rcocwcd from tbc in^nulation ttseoo by Dcll-«xu- 
dation, is^u« {Fig. (>). 

Ileuci', pus is ßuiil, M it were mclled, dissolved infbuuroatoiy new 
fbrmutiuQ. Wlicrc pus is present in qiiuntily it luu^L have coaie frxm 
KKOC st^rt of gmnulalion tiHsuo or from Bomo olber bigbly-vuonkr 
and usually biglily-cellular source ; ibis source need doI klwnyii be u 
Burfitce, as tn the prcsvat crk-, but may lie deep iu tlir tissue nud fonti 
a cavity; tbc centre of an iiinnnimalory new roritnilion ai^ywWfc Iu 
ibe tifisue may brealc down into puE ; then we bsra an ainaeeea. 

We slinll frequently bare oocaaioo to speak of this n-rlaii - •■ -"is 
and grttuulatioiis to caob other; bold fast U> tbe idea of^' 
bciug tU»ua (not granulös), and of pus Wing fluid 
formatioo, and you will hereafter readily undersland lu&ny procc^f-s 
espocially ebrooie iuflamuuitione, wbo«c ruriiible appi-ikraoeeyan would 
otiwnin&e Gnd iuwiiiprwbcnsible. 

Let us now sny a few wards about pus tt«;l£ If left standing in 
a reoael, it sopnratca hilo an upper, thin, dear layer, nud a lower yel- 
low one ; the funner ts fluid intercellular substance, tbe latter cODlalns 
chiefly puSKXirpusclcs. On simple micitMicopio examiaatiou those are 
roand, finely puttctated glubulc», of tbe sise of wlJlc-blood cor 



I 



Inliniiuiiat'ji^- 



QRAKITLATIUN TlSSiE. 



76 



Üiey (notun throe or Ibur dark Quold, irbiolk become quite distinct 
on addition of acetic acid, Wcaiisn it dissolrea tlii: putlc granules of 
ibe protoplasm, cr at l«ast stri^Us them so tbat i\tcy beooiue Imnspar- 
etit. Tbe Qudci aro not Hotuble in aoctio acid ; the entire globale ia 
raulrljr dusolvcd in alkidies. 



r». D. 






» 



Pw-c*Ua r»»arm»kuii* ii>«eiiWc<l MBttmB« a.dMit wlihaatMMItlm; AithKaniaewnaaltoi 
mUklim or H«Ue Mill: e;v»loi» foran that Hvlag put-cell« auiimo In UHlrkuirlMld 

At a iini) 6 wc si6c the pusHxdls aa ihcy usually appear vhen vra 
cover a diup of pus trith a thin glasü, and without any addition ex- 
smino it uader Uio microecope. Ttie abore-mcntkncd obaorraLioti» 
of Von Jtaktinyhauten bavosliowit that only the dead celk have this 
round sbapp ; tT we obaerve tlie pus-cells to the moiet rliamb«- on a 
wwiiwd ohjixt-tahlc (aixx>rd!n^ to JUT, lichuUse\ wu ncc tlio amwhoid 
moveeient of tlicso ocils most beautifully. Theso moTcmctita, which 
only go on slowly and slug^sJiiy at blood-heat, become more rapid 
■t a Ugbcr temperature, 84>d less so at a limcr. Tlic nurtilier of pus- 
cells in pus is 90 ({icitt, that in a drop of pure pus, uudcr the tuiovi- 
scope, the fluid liKeroollular sulitttaiico \s not at all poru-iv-ed. Chemi- 
cal cxatnlualkm of puH is dÜGcult, fint, because tbe ooipuaclea can* 
oat be compMcly separated fr<xn tlio fluid; also, beoaosa tbe large 
qtauititiM of pus oblatnnble for ciiemical exarainatioa had already 
DceB a lonj^ titn« in the Ixxly, ami may have changfid mmphologicaUly 
and cbemicaily ; atiil luelly, becauHe cliiolly protein Biibetanoc« are cou- 
tazoed is piu, wboie perfe>n »eparalion hitlterlo has nofc always bevQ 
poadbl«. If ve let ptw fmm a wound staod in a glam, the clear, 
brighb-ydlow serum tuuuUy occupies more spooo than the thick, struw- 
yeUo« ftxUmenl, whit^h omtAins iho pU8-«orpu«cle9. Pus contains 

tootoeltlecn jwrts of finu ooiiHlituunts, chiefly chloride of sodium; 

Ü>«a«hy ooostiliicata are about the same as those of hlood-ecrum. 

Rnvnt e-'vnmirmtii^ng of )>U3 bare ehowa that myosin, paraglobuliri, 

{ntafjoD, tilty acids, leueio, and tyrosin, are constant constituents. 
Pia n^lerti-d In llie body does not readily undergo add feiroenta- 
*"!; pure Ertab alkaline pua soon becomes sour, however, if it is 
ltftflt«ndin^ (br a time even in a corennd glass. 

hex '1- titro to tlic fcmnulatton layer, where we have htill 

U nnp)>' . . to coufriUcr, namely, the numerous TOSSCU, which 



SIMl'LE LVCISED WOCSDS OF TUE SOFT P.VRtS. 



'i 



it* red ap))eiannc(>. Tbe extenKire vascalnr loops that most 
fonn on tbe surfnc« of lUe wouikI, «ad wlticli iu tbe tUiigniu (¥\g. 6) 
arc U>o snull »nd too Fütt, oommcnor, wilb tlie growth of the Bturmind- 
ing gnuiulali<iii Ussiie, to ekit^t« nnd become ntoro toruui»; tow* 
iinl the rouiili or GfiU day new TcsacU dcvcli^ aa fine blcrat cApil- 
(aiy commtinicstkin, as in lioaling by fint int^^nLion, nm) ihe tiunic b 
»oaa tr&vereed by an esoesaive aumbcr of ifsafls, v*lik4i haTe so 
inucli elTect on tL« appearanoc of the entire graoulatiiK) Burikce that 
it is hardly r»o^zabIe on the cadaver, where the fulnüss of ih» rea- 
seU i» wanting, or is &t loast less marked than during life, and tbe 
tissue oouM-qucnlly apjienr» pule, rchtxed, titnl much 1<\<)S thirk. Ilie 
qucsLion ttriMs, WUca«c conic these remarloiblc, small, gradually-«»- 
llucnt rt>d nodulo«, ivbicb aru risible to tbe naked eye? Vi^y does 
not tlic smiucc look c^ uu ? XudouJ. tliia ka froquoaÜj the oiae ; lb« 
graault» are by no nwimns always distinctly defined ; but it is not Oftsy 
to explain tbe oause of their form. It is iisualty BKSumcd that tbe 
granules arc to be regarded as imitations of the cutancoi» papiUir; 
but, independeab of the £ftCt that it is incotnprcfacnsiblc why such 
8t|W!turGS should be imitatiMl in nnucle and bone, and that tlio gmi>> 
ules are usually ten tiioes aa large an the culaueous papilliv, this {s 
DO real cxiylaaalJMJ. The appcanunxt of the giaaidt-s, doubtli^ss, de- 
pends on the srrangr>m4.nit of tlio tuscuIbt luojw into tufts, on certain 
boundariev between the diilcrcnt groups of r<-&se1». Ilenoo we otlgbt 
fiuppoee Umt llie raacular loops aoqiute tliia fonn «ithuut Icnovrn 
caiwe. Still, it seems to me aatiunl to compare ibcQi to tli» dtcom* 
»orib»l capillnry district«, already fonnt'd In tbe nonuul liümiM, of 
wliirh «c have numerous examples, capoöally in the skin and m tiit. 
To« know tiiat «Try sweat and sebaceous glaod, e^-ery hAir-follide 
aui) fat-lubule, has its nearly-closed capillary net-work, and, by the 
rnlargemrnt of suHi rapillaiy nct-woHiA, the peculiar rJo«i<'d x'axtäar 
fnniia of tlie granule« n)ighl nris^:. In fiii.-t, in tltu cutDucuus Bud 
laliy tissuß you will find the individual fletiby gruwllt«, jwrtiouhirly 
nli^ply »nd clearly (]ofinc-<l, while tliia ts nioro ran-ly ihc caas to 
muscle, where thcH boutidt-d cajnlliiry dl«(ricta do not occur. It ean 
only be (htetdcd by »rtiftcial injections of frv^li grauulaliuns, wlidhcr 
tills explanation b cjirrcct; till then, it rrmuins simply an aiti>ni|it 
to refer tbis pathological new fontintion to tionnal aimloinicxl eo^ 
dItioDs, 

Tbe following akctcli, in which, oa account of the groat cnlai^> 
moDt, and tlic »uiall injured district, nothing can bo seen of llir graai>- 
lar layer, may serve you a» a dinnram of the deve]<»pia.inl oftbegrwj- 
ulalion tissue n-ilh iu rcssek, and of its rehition to pus and to tbe 
subjacent matrii, aa it boa developed fitm Fig. 4. 




KKäl'LTS OK UR.UiCLAT!OX 



77 



If the grotrtb of the gratiulntiuns was not arrested at some point, 

iCon»t&ntJ^r-jrrtiwui^ gnuiulaliuti (untor would he tnrm«il. Fortu- 

ilrJy, tili» ii Qe«er oc very nr«lj- ttie 0*6«. Yuu ainnidy know, from 

^Jm rep r<«e nut lion of tiie exlpmid oouilitiontt, that whuu tlic gnuiula- 

ckina liarcT mu'tiril lliu luxul üf tliu cuiif, or erco awDcr, thuy oeose 

-^o grow arid or« coated nitli c]»ilonnis, und retrograde to a cicatrix. 

The following changes occur in ibv tissue : At first, !ii thi> gmnuln- 

-kxi tiAStif , u in the edges of the wound m healing bj- the first inten- 

ion, tlicTT aru uunieruus cvUtt which are destroyed. Net only tlie 

■lillüiiH of pus-«clla on tht> surrA«;', Iwt aUo C'4U in the doptht of Iho 

jolmtloii tiasue, disappear by disintegmticn and n--iibsurplioii ; it is 

L^reijprohHbl«^ that cells from tUe granulation tissue may pnssbaßk mi- 

iato the reetek» oa wo shall sec when treating of tbc organi- 

llou of tbruinboae« of the vewek. A* the cells retrograde, lino fat- 

inules gndually form in them, not only in the ronnd bat alao in 

apindle-abapcd ones; such cells, which src coinpcsod of very Eoe 




rarrUoadif. tiidl>itnLtttibibepa>^rni Is Uic Ij^mc nivic Kcnralelr iron Itiafnva- 



Ifl i^IUPLE INCISED WOUNDS OF IDE fiOFT PABTS. 

fat-globtiles, are generally called j;rd»u/(ir<y/f»(K(Sfiicbeiuelleo}; tbey^ ! 
often occur in the granulalionSjOS above dosoribed. Whi>n tbe gnu* 
nlation lisanc is thus dimmblied by ntrophr and escape of the cells, 
and at iho same time tbo non formation of cells ccaees, something im- 

Tw. T. 



<S' 



Mlj iTn»>ii11iiii ■ti.int nm» iiMiblliiini Unnublloa-fvlU. MasnMwdtboMIMaUnMMi. 

portaiit must happen, that is, the gmdunl consolirlntinn nf thA ^olat* 
■IIOU8 intercellulnr tissue to striated conneotivo tijtsu«, which » 
brooffht about bjr the steadily increasing loss of water, that is carried 
off by the T<.'ss«U uiid Craporated frooi tbe surfac«; tben the remaic- 
iag LvlU at once aa&ume the shape of tbe onlinaty ootinectiFe-tissuQ 






S. ZpHbdUl otU« IWim In^» rant»«, thwmrtoi nni rtaou « i W *!«* qf ■ Iom nf mhilMW. B.I 

corpuscles. According to the view of other obserrera, the original 
iulercclIutarsubHtance entirely disappears, and tt« plaoo U supplied by 
ihe protoplasm of inanuUtion ells, which transforms into fibrouctis* 
BUG. ^Vitb these change» which take plaoo from tlic periphery tow- 
ard tbe ceDtre, the secretion of pus on the sorface cease« ; at the very 



1 



BESÜLTB ÜF üKAKCLATlUN. 



SDOe of tlie \routi<] oo the oatlenaui!; nrntmlution ttflsue 
'l|>idannls forms nod quickly «>paraLc!i into lian) epidcTniic and muoous 
kjers ; occonling to J. Arnold, llils fonnatioii talcM place by Uie di* 
riüon of* ptotoplum, nt Erst entirely amorpbous, in the imaie<lii>(« 
ricinity of the exislin^ bonlLT of cpidormis. Lastly, the superfluous 
c-apillaries must ha obtitenitcd ; few of them remaia to keep up llie 
circulatioa tltroiigh tUo öcatnx. With their oblitcmlion th« tisäuc be- 
come« «Iric, tAuj^bcr, oootmcts more and mon*, and often the ctoatrix 
^opsnot aciquiiw it» peminnent fnrra »nd coii-siatence for yean. 

The whole process, liku uU tht-,-« mode« of hc-aling', contsiiu much 
. is very remarkable, lUthwigli reocnt !n7c«tigatioiis hare cxplaiaod 
of ^le more minuto morphologioal changes. The possibility, 
I necessity, undf^r otherwise normal oircnmstancra, of arriving 
^t a tjpicnl (eraüoation, ia the c^icf characteristic of tliose nevr forma- 
tliat ara induced by an inlhininiatory prooeKs. If this natural 
< of healing doos not tiihe pluo«, ü Is because either constitn- 
^ tSonal or local conditioiui indirectly or directly intcrfcn:, or because tbe 
^«^^ attacked ia so iniportant to lifo, tlie disturlianco to the catira 
Ltnly m acrei«, that there Is death of the organ, or of the individual, 
' (l»at tbe fuoctiooal disturbance of the fonnßr causes U>Q death of 
latter. Kverr new fbcmation, due to inflitinination, always has tbe 
imcJency to resch a certain point, to retrograde, and pu&s into a sta* 
onxary ntatc, while other new fonnatjona have no sach nntural tcrmi- 
l-ion, but Usually coittlnue to ^row. 
ÜNlIeteat as healing by the Gmt and seormd intciittoiis nppnars, at 
fitstglanco, the morphoIo^nU change» in tlic i'umwe are in liotit 
a a ea Om Mm« ; jou only need to diri<lo Fig. 3 at <z, to hare the Bome 
(lii-ttzreas fn Fig, fi. OlMemilion teadtea In tlic simplest manner that 
llie» U artnally so ; tf a woinid nhnost licaled by tirat int^-nlion, but 
(ka 5«! oookoUdaied, be torn open, we have a graDukUog wound 
nSi<*)iK)OD8uppurat«e. Vou «ill herean«r be fi-ctiuently convinced 
' \ his in pmctioB. 

Tba above process of healing by immcdjutc adhesion and by gran- 1 
itioa we have t«rmM) tratunatic inflammation, and have found it 
itical with some otbrr forms of inflammation \ it has also Ifccii 
'lUtcd Uul n marked ti-vuUunty of tnumatic iuflamnuiliou is, that in 
it, wHfcoiit KHUC further cnusi*, tliu irritation in the tissue does tiot 
bU«di] buyooil llie tnitn<?<Iiatä vicinity of the injurj'. I beg you 
tsvMly to rumember this limitation. As wc know noihinK' ac- 
onat^lr about the rfiemical cliangcfl and oorT&«clion« in the in- 
fiuDed tiHUR, while we do know ihe morphological pfocesscs wry 
lennkly, we naturally attend most to the latter if we wish to dc* 
Ctetad generalise the term '*in6ammation." I will briefly take up 



eo 



OrMPLE I^CCISED WOCNDS OF THE SOFT PAUT& 



y 

the previous viüwa on tbis sulijcet (p. 48). TiiflutiimHtion " i« a 
modiBculion of tlii* uorrnal ph^iuloj^ical procvsM-'s in tlic dilTcrent 
tissues of tbc body, a "dlsturbaacc of uuiritioa" ( VircAotc) irbose 
histopo^Jtio results yau now kiiuw and uf irliose duslnictivc, ilcleieri* 
ous actions you will licicaflcr bear. Anj part of the budv was laid 
to be " iiiRamrd " Hben it was bot and red ; os it ta tbi-n gcüciallj 
swollen nnd painful also, tliis name is applied to processes wliere the 
nbnve sj-mptotna occur. Tlie word inSatnmatioa orifrinatcd when 
ibiirti ^vQte no true patliologico-anatomical ideas ; eren tbe oldeut ub- 
Rorvcrtt understood that aomntliing unosual vraa goin^ on in the 
tissues, that tliey wore much lie-atcd (i"»</fam»K<öJo),and from tli« 6r»t 
tbis proocu bu btieu regarik-d as au tiiteaae iitoreuae of lliu vital 
proocsics. As they could not uncIßRctnnd the process itself any l>ft- 
ler tbiw vre do, ibc/ coDsIdünil ibe M-mptoms and tlie rüsults of tlui 
prooess, just as we do; eo that Ooubls ofiuii anise if it were proper 
to spoalc of {nflammntioD when oo« or other ^mptom was absent ur 
not well nuirked, just as it is to-day. Wt;. now know ilial iaDsmmaiian 
is not an rxistenco outside of tJie body, which inak<» its way into 
some pnrt and there grows, anil must be expelled Uke Beelic'bub, .1 
and we know why " tuiuor, rubor, calor, dolor,** are oaused by hi- 
fianunatioo, but although any one u&ually ract^nizcs au acute inflam- 
mation as Ruch and designit«* it correctly, it still remains diflieult n» 
well oliniailly as annfoinico-palhologically to give an exnt;t di'Giiitioii 
of "inflammatioD," ^Wre is no dilficulty !u disting^inUing »u oak 
from an nss ; but, if you attempt to ^ncnilize and give a sharp defi- 
nition between plants attd animals, you will have the greater ililHcully 
the more yon know of tbc drtails of botany and wjoloffj-. The Wi 
**in6ammation" is in use, and so accurately designates thosn 
oesses to which it was finl applied, that it would be useless to Ixy 
root it out. By it wc understand the abovc^lesi 1 ' * 'ion 

of prooesscs in llio tisaucfl^ which i» the present m 

purely meclianieul irritatiim (wound) actinjp only aooe. tlow m 
bypencmla, exiidatton, «ikI new formation of tiasnc is require«! Wfc«« 
we can term llieproccM inflammatio» cannot be stolcil alMotutviy. 
It seems to be ngrecd by surgeon« and nniUomists to deaignaie as 
" inftuaimatory " tbe pnrei*/ reyencratite proeftiit*^ that la, the o 
plastic tissues, wbicb directly or indirectly replace tbo low of 
Gtaiiec. If wo eousidor thw [inxJOM in the uKHleni ' " ' ' , i,i«t, 
it cannot be accurately defint-tl frum the inflammHl' >, '""JQ 

be occasioaally. From a purely ctiiiieal potat of ^"iflw, Uic dbltn« 
is easiiT, as we often meet esses without any of the four eanllnal 
symptoms on the edges of the wound ; and still the diflercnco b» 
tweea a slight icdneas, swelling, and scositirencsfi of Ihc boMora 




PRßPARATIOS'3 snOWIN'fl HEAI.ISO Of TTOÜNM. gj 



f made a 

L«o«Ulc 





Ute wouiij to «ri intense, pTogressing' in(bniinatiot] over the entire 
«SDctcd portion of llio Ixxly i« ooly one of dcgrco. Custom boa here 
made a distinctJou; when a wound hoals wilhout nay symptoms of i 
ctl reaction wc do not call it iofl^mnuition of ttic wound, bull 
i»))ply tin» term whoa the Symptome of ioBimmattoD arc verf( 
^{irQittinent tX the part injured. 

I deemed it noocssaiy to spoak to you of tlieae genera) ooniuclor* 
ions on iulLimniatiou, 90 that you uiifjfht early Ivum souie of tbo 
ties of the subject. lu these lectures iL will always be mj o)^ 
Jeol to ex])lain to you, as clearly as is now possible, the anstomioo 
^ysiologi«»! disturbances, and at the sarao time to show you liisto- 
ly the origin of tliaoliaiool descriptions and exprcitslons now 
ma This is the only way we oan truly ground our knowledge ; 
lUt unJcntaodinj; this you would alwa3-s be fvi-liu^ around tbo 
o of »yniptomii, and by clinging to certain ones fsll Into In* 
intUe dog'initism, which in i country doctor tlw world calls "nar- 
row-miitdcdncsa," in the emintmt city pliysioion "io&IUbtlity." As 
the great mnjoriiy of men are stupid in ptiysioal matters, you are 
sore cren willi thu hittor {tcculisritics of Httiiiniii;r ^^st prsctical 
lucoeu, but you must tbcn renounce all idea of opprcotating or ad- 
vancing the progress and dovelopmenl of soctoty. 

It is not tlie object of these lectures to ahowyou on preparations, step 
fay slep, tbo niMpholo^cal microscopical changes in wounded tissue — 
jtrti will see these, in the pmelical lessons on pathological histology — 
but I will show you a fi:w points, so that you may not think that tiie pro 
um I of which I hnvo spoken can only l>e demonstrated otx disf^ranis. 
Y 'iltmtion fif tissuR, after irritation by an incision, is best 

I Been : nus*. Four days »gn I nude an JnciMon, with a Isooe* 

»bsped Icuife, in tbo ooitie« of n rabbit j yesterday the incision was 
Mfilila as a fine line with milky cloudiness. I killed the animal care- 
ytdly,iiut out tbtf oomoa, and let it swell in pyroli^ncous acid, till this 
■nmiujf ; Iht-o mada a scclioo through the wound, noil cluarcd it up 
»Uh glycerine. 
I Xow, st a d {^g. 8), you may see the connecting subsiaoces be- 
tvoen the cd^es of tlio wound, in which thrrc has been a conBidmble 
eoU«rtion of cells, betWL>cn the I«meIl;B of the cornea, where the cor- 
neal rorpuscUfii lie. These cells are not so endcot in the method em< 
plfiycd BH iu that wliero cnrmine ia used, still ilic intcxitieitiatc sub- 
^ jtttta cc between the edges of the wound i» rery diatiaet. jVs you see, 
Hf^BhrisIs almost entirely of cells ; the cells alone would not, tiowever, 
PiHHir tbe union suOicicnily fini), if they wcru not glued togvUier by 
[ a- SbriDMis ocmont. The young cells prolwbly come out of the edges 
t of tliewound fmm the fis«uKS U-lweeu t)icooni«al 1amell»,snd prolv 
«bt| Jo not originate in the coiUK-ctivc substanoe between tlic edges 




8'2 



SIMPLE ntCISED WorXDS or TUK SOFT PARTS, 



(if tlic vroiind ; o» the contrary, tlie latter is GnnJIj fonnefl from tbent 
Let mu Kioarii iucidvotaily, tliese fine corneal oiualnc«8 aulioeciuent- 
\y cieax up, so ns to Icnvc scarcetj* a traoe. All tlic celU that ytxi 
bore see iu the pre|MnUion come from Üie vnsculur loops of tlie coo* 
junotiTa ; Uic oonniil »ttiiliitc cuniual celts an; not vitüblu bvre. I have 
chosen ibis «iHtcioieD bccaiisä the inlonnodinte sutistanoc u broad and 
very rieb in oella. In very small incisions, made in tbv comm wiib a 
very shaqt knife, tbc intcimK>Uiitc eubstaaco » so alight, that it is scoo 
with diUJoulty ; thon, too, the ohangoa on the cdg«« of uns wound UQ 
EÜ^bter than here, and so slig'ht a scar is not vjeibi« to ibe naked eje. 
Ucrc (Fig> 0) you bare & tmurcnc section through n tv 

rm. s. 



nV^ 



/. 



OonxBl twlataatliiv« AQa«U; «a, ihvvillliMMbdaanWIvMa tW tvroaldMuf Uictacl* 
Um. BI«cnUea an dUmMen. 

hour old, Freshly-united wound in the cheek of a doj^. Tlie htcisloo is 
well inarkÄJ at o o / tlie edges of tlic woimd aro ac]«i8l«l by a Jatk, 
iaternKdJAlA aub«taiice, which oonsists partly of white cells, portly of 
jed oorpusclos — the latinr belong to the blood, esciipwl bGlneon the 
edgto of tbu wound, ufler the injuiy ; the ooimectivotisäUR fissures 
CTDWcd by tbc n-ouu^l, in which tbc c->nntfctivc-tie6UQ celts li»^ bm 
altesdy lillthl vitb mimprous nowly-furmc«! ctOb, and these oells bav^ 
already pusho] into the cstmnuatcd blood between tbc edges of tbc 
wound. Tlic prrpantion has been treated with acctk acJd, benoe jrou 
nolonj^ see the alriation of the oonnoctive tissue?, but sec tlie young 
cells mofe distinctlj'. tjcx>k particularly at crrtuiii strings, rich in 
cells, thnt citctKl fiT>m the wound toward bolh »idea (i 6 Ä) ; tlitite 
arc bloo4l-T4^ss«l8 in whoAC shf^ath« matiy rella are infdlrated ; thia Is 
aji^nrLMtly becaoM here many wbit«-blood c«IU bare passed tfarougb 



64 



SIJII'LK ISCISGD W0ÜKD8 OF TI!B SOFT PAUr*. 



Ftiio sections cannot be made of granulatioa tissue, just tnkeu 
fioui a wouikI ; it b {^ocrull^' a very diflSoult subject fur lino prcpan- 
tit*na^ If you boiflen tbe granulation tiasua in alcoliol, onlor itie seo 
tion ivith caruiinc, then cle-ar it up witli glycerine, jcm bare a Bpixt 
mra like Fig. 11. 

n«. 11. 



OnnhlUa Ihiw. Ui«nldc<)X»Jiaiacvr«. 

"Hu: Uiwuc appcATB tu cuimifit stiMy ufccIU auil rc&sola, yrith tery 
tUin walls ; tbc wholo tiesue U slininken by tho alcohol, »o tbat wa 
bore see nothii^ of tlie muorius iutercellubr substanm wliioh \t al- 
xnxyi presenlf even If only In amull quiuitilics, in licatlbr, fn?ah granu- 
taüoos. 

"We 80C tlic tissue of tlio yotiug cicalrtx particularly uell hi Ibe 
following prcpamtiuu (Vig. 12), Trhicb was taken from a broad 
trix, following grvnulatiou and suppuratioa, iQ tlio back of • 
about fo ur or fiv e weeks after the injury. 



^^m 






PREPARATlOüi; SBOWEMO OEAUN'O OP WOÜKDS. 



85 



Tb« preparation hss b€.'<!0 tioated vHh iici»tic add, lo show the up- 
roogvnBcut uf tlic coiii)cctive>t3SiQe c<^1Ul, lliut Iiut« fontuNl rroin llie 
f:Tauiulation tüsnc; a a a areporlly oliUter&teü, {«rily still pcrmenlile 
blnod-reescls ; the coniiei^tive-tiäüue cells iire still relatively Inrf^c, mo- 
cidf nt, nnd di»tinct1v sjiiiulle-fJmjied, »tili tlie inlt-rrt-Hular miltMiiti<^e U 
riclity ilL'Tclijped. 

To Ktudy Uic «tat« of the blood-Tcwo-l* in lite iround, u-c niiwt 
make lojeclions ; tliia ik quit« difficult, atxl quick success otteu dcjK-iids 
DD s lucfay chance. 

no.». 



m 






'Pä, 






^m 



'-v 



$\ 



A( 



m 



t 



'W 



ti. 



3- 



..^ ... :^;..;ii>na'tAkcti>ia4iidtiailt'Elai;, lurir-tlultl tiounaRcr tlia 
■•M Al«m*ton ; afto r n'Bwod»«r— « d, le umt*dlua tnhMann benreen 
'^ (aoartMias of at>iQiniiaf7-lookIiis aiU)ort*<i niBUtlklan<l«lmn- 
'IIa« hM pwied Ihmagli iira hrtn cf mmcle crMrtnt cadi aUiar. 
.'■ TTlfh diUtatleinln Imili bordcn *f tl>Q «mm»] } ««sancnclugclomgkr 



On this subject we liare llic recent works of M'yVTodio^ and 
7Siim(Jiy whoM results in tlio main o^rcc partly vritU cnic aooibcr, 
[Hitlr witji my Invcslfgationa on tiiia subject Wyaodzoß', who op- 
"tUxt on dog** tongue«, giTes a series of rcprcsentatioiu of the con- 





J w*ni la fl« 1lp el ■ «nf. BmII^ by ttv Inrt iDimirn, U'^cilnn et Us 

da ; ibcfee cnse itnmtxlüifcly nt tbo yoinig cii^trix ; tlieir <la not 
r<Brm tn tfif! cüstrüc till the fibrillar conncctirc-tissue bundles fonn. 
lie grmnuUüon tiasae also bafl no lymiJiatic resiwls; frheTc the in- 




88 



fflVPLE INCISED WODSOS OF TUE SOFT PJRT3. 



iltunmnlury new Contmlioo, wbcrc the prunaiy ccllukr dHsu« fiamu, Üie 
Ijwpli-rcuvls ftrc ntoetl/ closed, pai-tl^- hy fibroua coaguUtioDS, parUjr 
by OOM' cell foniwliiius. These observatioi« have also been confining 1 
quite rooeuUy hy Xö«:/, of St Petersburg, hj cxamJaaUonB of Inw 
laatjcaUj' inflamed testiclct). 



LECTURE VIII. 



OmmtbI BaactioD aflor ln|nty. -Ci i r|iMl F«vcr.— Tli«ori<« of tb« F« vcr. — Progaotfi.— 
TrmliiMiit of tjimpl» WmiiiIi aoA of Wgwulcd Pcn«iu.— 0)>en Tnatnmit of 
Vouu4«, 

GKKTtxUEN : You now know tb« oxteniiU wid iiitf^nuil minute 
processes in llic beaUngof wounds, so far iw ii is pnuiblo to follow 
tbeiu vrith our pnäcot oücroscopca. 

CX Üw wowitUd person weliavo not yH »pok'^ii. Tf yo« have erit- 
icaitly exatnlai^l lib oomliüon, you will lutvu iiotkWl cliunget«, wrliioh 
luu^' not bo cxpUinud by ocU-knuvrlcdgi; (mit Zvllcnircixliuil), and 
prrbtip» UKyl nt »11. 

PuMÜily even Hie lint daj* tlie patient ma^ bave been restless 
towunl crcniu^; Iio may liaro fiilthot, tliimty, witli no appctiUi, ftome 
bcadache, wakvful at uig'bt, and dull itie next rnoraing. These sab- 
jective Bymptoms increase till the eveDing oXter tbe next day. If wo 
bxl tlto pulse, we lind it ini>re freqiictit titnii nimiuil, Uic radial urtory 
is t«nscr and fuller than bofore; tlie sidn in bot and dry; vre find the 
bodily ten)|5erlaur« elevated ; the tong«» is ooatt.>d and ivadilj bocomoa 
Ury. You nircudy know wliui ails the ]mtical — liu liaa furtr. Tea, lie 
has Fever; but what is fever? whence conio« it? what coiuuwliiiti is 
therebetween tliediflereiit remarkable I'ubje^^'tivM and objective Symp- 
toms? Hut do not ask any more quo^tioos, fur I can »uartx-ly answer 
those already propo«ed. 

By tlic name "fever" we dMignate tlto coinhiiiatiori of -i mj'iinns 

which, iu a ihuusand diifcfent ahapes, almost always aeo()h1jk(lllil^ iy 

' Uuninatory di»(visoa, and is generally appnrcntly diio to tljom. Wo 

yf know its duration and uoursu iu vaniMu diseafius ; Btill, its imture !s tutt 

fully undcrrttood, although it is bettor known than funucrly. 

Tlie different fever »ymptonis appear with very variabl ■ 
TSro of these s^-mptoma are the most constant, Tit, the n- i 

^/pulae and bodtly temperature; wc can meanure liotb of tboni, the brat 
bjrwunting, the latter by the thermometer. The frequoocy of *ho 
beart'a Itcat depends on many tilings, espedally on p8yehical e^cit»- 
taentof all sortd; it sliou's slight difTc^reiiceji in bitting, lying« atanding, 



SÜBClCiL FKVEB. 



8d 




I 

I 

I r 

^^ vrauJi 



m 



wnXking. lieiux, tlicre urc niiinjr tblnga to Kbidi we nioiit ittt«t)<1, if vre ''' f 
would an4il error. IJowcv«r, w« may avoid tLcso luütokus, uud fur 
(«tituric« ttie (Jr«<[iiciii.y ot tiie pulse has been used as a tncaaiine of *" 
lever. Exatniiiatioo of tlic pulse also &bow8 otlier tbings importaat to ' ' " 
bo koown : tb« amount of ibo blood, tension of Uie artcrie«» iiregu* .'. — - 
larit/ of the beait*beat, etc ; and it Rhi>ul<l not l>e neglected even now 'f^ '. 
that wc have other modfts of incasuremciit of tlie fever. Th« otlior, ' ' " 
and IB flotne respectfi c«rtaiulj Uitter, inodo of incasurin«; Uie ainouut 
and duration of tlie fever is dctcrniiiialion of the bodily tompcraturo 
irilb cftTefuIl^-pre]ured tlii-nrionicters, wliuac tcu\i«i are diridtxl, ucourd- 
ing to Cdtiu», in one bunUrcd decrees, und t-acb dcj{rcc lu ten parts. 
The itttroductiuu of tbit; mode of mciisurcmciit into practic« is due to 
Vtm Stir«naprung^ Trauhe^ and Wunderlich ; it lias tbe advantag« of 
gtaptücally presenting tbe mcaauroincutE, wliicb ore usual!/ tnwle al 
9 A. M. and 6 F. IL, ua curves, and making tliem at on« easily read. 

A scries of obscrvntinos of fci'er in tbe narmal course of wmind» 

IS the following points: tnuitnalio fever occa^knially begins iiiinie- 

'ly after an iiijuiy, more fm^uently not tilt tlie acoond, tJiin), rr 

b day. Tlie Utgbest teiiijienittire atuini^d, altbougb mrely, U 

Itrt.ß'F.-lOS.fi'i tut a nilu it dues not riö« inwrli «kivc 102'-i03°.£.' 

ämfile traumatic lever doe« not usually tiint orer a treelc ; in TonA 

caiUA !l ouly couliitue« from tno to ^w days ; in many e:iKtii it is vn- 

iirely abaorit^ na in iiioet of tbe sinall eupcfUctal iiicUcd u-uund» of 

which we spoke above. Traumatic fever depends tnlircly on the stale 

of tbo wound ; it is generally of a remitting type; tbe decline may 

tuLe pliux' mpidly nr slowly, 

Frotn Ibeae obserrations we sboulJ n&turally au]>po»c lUc fwer 
would be tbe biglicr tlio more «erere the injurj'. If tbe injury be loo 
iD8t£nifio8nt^iJieru is either no fever or tlielncrcase of temperature Isao 
t and evanescent as to esedpA our mode« of measurement. It ba* 
tbuii^lit Lli:ii, a flealoof injuries migbt becoastructed,noccNrdtngto 
which tbe fever would laat a longer or shorter time, aud he more cr 
lett iateiu«, iu proportion to the length and breadth of the wound, 

THb couclu^un )b only approximaLely corrcet, after niBl<Iii^ very 
eanekliuabk: limitnlions. Some persous become fc^-crish oiler Tt-ry 
«U^rbtlojuries ; otlicrs do not, even after Kcvcr« one«. Tbe cause of tlus 
dmcroneo in tlie nccnrreooe of traumatic fever depends partly oti 
her tlir wound beals witli more or less inflammatory symptoms, 
y 4>u uukiioM-u iiißuences. "We cannot avoid tbe auppositloo that 
(lurvly indindualciroiimslntiees bare some influence: wcseethnl, from 
eimlUr injuries, one jiersoii will be more disposed to fever llian an- 
other. 

Dvfiirv going on to examine bow the »tntc of tbe wound is related 




&0 



RrMPLR I.VCISBD WOrXDfl OF THE SOFT TARTa 



to tbe general condition, we must examine tlie latter a little more 
carefully. The rooüt prominent nnd phyaiologicaltj- the mott romork* 
■hie 8jrnij>toni of llic fever is Uic olevaiiou of tlw tcmporatiirc of the 
Llood, Biid (lie cunacqueut iucrcoso of Uic bodily t^nnpcntnru. All 
tlte modern tbconc« of fever turn oD Ute cxplaoatioa of this sjmptoni. 
There is do ground for euppoeiug that in fever any abtMiIutely new 
dement must be added to tbe requiremeat« acting for tlic preservation 
of ft ooostant temperature ia tlio body, but it is probable Ibat the fcrer 
temperature ia caused by some change of the aormiil rcfjuiremeota of 
temperature, which vary readily villi circumstaDce«. Wben you re- 
member that men and aoimaU in the varied temperatures of nimmCr 
and winter, in hot ami cold ciinutcs, have about the »amo t«m]icf«tuf« 
of tbs blood, you irill see tbat the couditioos of pnxluctioa and giniig 
oir of beat are euscepti1>le of pre&t modification, and tbat witliia thew 
oooditioQS there may very posaibly bo abnormitifa of tbe resultiiig 
bodily temperature. It ig evident a priori that an increase of Ixidily 
tctnpcraturc may depeud cither oii dlmioutioa of the amuunt of lieat 
^rcD oSj the productioo remaining the same, or on in<TCa«ed produe- 
tion, the toss of heat lomaiuiug tlie same (other relutioria of them 
factors to each other arc possible, but I shall poM over them, to avoid 
coofusing you on this difficult qacstion). Tbe deeisioD of this cardinal 
questioQ does not seem possible nt prr-xent; it would be possible by 
dotenulning and comparing the «juiuitity of lieiit produced la feror 
fwd ia Donnal conditions, by the ao-oallcd calorimctncal cxpcrimcats 
on nwo aud largo warm-blooded animals; iMit liitiicrto then have bem 
great difficulties in llie way of these experiments Xi^ermetttgr and 
Xayden haro invented mcthoda of calorimetiy, that seem to mo oop- 
rect ; but tlic metliods and coodusioas of Xii^ernuiattr have 
energetically combated hy Senator. Ileooe, in regard to the 
qnwtiotkS, we aro still, to a great extent, thrown on probability 
bypotheüa. 'Äs tbe proditetkm of heat depends cUieily on oxidatinn 
of the oonstitueiita of llic body, incmaw; nf the latter would neeos^arily 
be followed by increaAO of tbe former if the loss of beat »uiaiuel ÜWj 
same. Now, since the amount of urea is mgardcd chiefly as the 
of the buniin^ up of tlic nitrc^nous Ixjdles, and us ibeatiiouiit of» 
excreted in fe^'er ia uaunlly increased, and the weight of tbe bodfa 
rapidly docrciiHo«, as np|)cnTS from the experiments of O, IFeder, Uäntr* 
meiatcr, Schneider^ and Zej/ilen, ibis, with the abov«4Deulii>ned 
metric experiments, ia conridcrcd strong proof tbnt in fcntr the i 
sumption is greatly tiicreaEcd, and that oonsetpiontJy more warmth is 
.Veally produced Uian in the normal state, more than can be disposed 
'^ of by the body in »he same time. Traaie givca aiKillier view of tb 
ocomrcnoc of fevci^heat : he Ohscrts that erery ferer begfns with enc^ 



Bi:.K7ATI0.V OF TB11PBRATÜRE IN INTLAUHATrON'. 



91 



oootractioD o£ the cutaaoous TcsecJs, especially of the smallei 
artorioe^uid lliat thus the ^ving off of heat lo the air is docroaeed, and 
mors liieat colleut«! in the body^ wilhout its actnalljr producing more. 
Although tliis bjrpotbcäs ia adranord by its author with vcmdori'ul 
abilitj nod Kcutcoesa, and is apparcnUy supported by the work of 
(Senator, I, with most piitbologislK, cannot agree with it, espedally aa 
the prcmiaee, tlie coutniotioii of the cutaneous Tessels, can only be ao- 1 
koowledgvd in the casct bcpnin^ n-ith chill; bvt this diill is by no 
laeau a ooiMtant aymptom in the foror. Beacc, iti what follon'», we 
shall start bam tl>c point that in fever there is increased production 
of beat. Then arises the question, How do^'S inflamniation griKTitlly, 
and ttaumatic inQanunatioo particuluily, (rtTed the increase of budtly 
toaqjeratore ? This question is anüwcred in vnrious way« : 

1. At the point of iaflamuatioo, ns a rmult of the lirely intcrchan^ 

of lissue, beat ts produced ; the blood flawing through the inflamed 

port is vrunned monr, and dislribules Uie abnormal amountof brat here 

acquired, to the whole body. That tbo iiifiamed part is warmer UutD 

th« nou-inflatncd is readily proved, cspGciully in sujierficiBl port«, as in 

the akin, but thi& docs not prove that more warmth is produced Len 

thkD is UfiUiU, but to probably simply due to the circulation of more blood 

through the dilated m[üUaries ■ if the inflamed part he not warmer than 

t&e blood Sowing to it, it is not probnble that it nbould produce heat 

The tavestigstions on this point are numoioufi und coiilrodictor^-. Tbc 

llienaomctrical mwisurerncntii of 0. TP^Äwand Ifu/tfJ>midt hare given 

Tirious results; t^itally the temperature hi the wound and in the reo- 

tum (which ha» about the wnimth of arterial bloo4l) were equal ; oocb- 

nmdly the former was higher than the Inttor, sometimes the reverse j 

i^tbe diöerrncp was never great, not being more than a few tenths of a 

^He^rcfl lo any cose. Recently 0. Wcher Itas hit on a new method of 

^Keaflutement, the tbcrmoeleetria : by hia v^ry difficult inrt.>st!gationfl 

^BIm ijuestioa seemed to be derided thnt the inflamed part is always 

irmnoer titan tlie arterial blood ; indeed, Ihut the venous blood coming 

/ram the sent of inflnmmution is warmer tlian the artc-rinl blood gtung tr 

it. Quite tvcently theso inveetigutions were rrpeat4>d lu Konigtiberjt 

^^ff IT. Jacoh^on, M. Btrnharvlt^ and G. lawUrn, with the final n; 

^^ult of showiiif:^ t>o increase of warmth in the inflamed part. From the 

cc30U*dietioa of the results of obscr\-ation it is impossible to form a 

^on tliiü point. Kevertfacless it seemH certain tltat in tlic in* 

t there is not enough heat produced to derate the tcmpcnu 

*\Tre of all the blood in the body several degrees. 

S, Tlie irritation induced by tlic inflammation on the nen'cs of tlie 
mflamed part might be supposed as advancing to the centres of the 
TaioiDOtor (nutrient) nerves; the cxeitenient of the centres of llies« 



y 




92 



RIVPLB PJCIflED W0CSD3 OF THE gOFI VAKtS. 



nen'es irould induce increaac of Uie ifcncrut cluingc of tissue Bud oaa- 
MqiKMit in««tfc of the production of wMmtli, Tlii» bypotlie«ie, which 
is !:a[>[)orle«l Itj Bome fnct«, such sg tho grrat diffoivnce in febrile irri- 
ubility, «nd whieb I fonnprlj tnaiataiocd, no longer appeora to mn 
tenable ; it is opposcO hy tlio cxpcriinontal re&earcbes of Breuer and 
C'Arobaty n-hicfa prove tliat fever occurred even when alt tho Qflrvea 
ivcre divided, bj which there coiiM he aii; conduction from tlie peiipb* 
*rtl in juPT to the norve-cen tres ; the recent invcat tgutioos oFZ<y{£m alM 
oppns« tliia hypothesis, since they prove tliat tJicre w »0 constaot ro- 
Intlon between the to»i of nitrogenous materiell, or oonaumption, and 
development of warmth. 

3. Simw, from the natuK of the procc»«, Id the inflamed part sonm 
of tbe ti^ue is destroyed, while aome Dew Ussue io formed, it h not 

/improbable that some of the product» of thi^ destruction cater the 
blood, pMrtly tbrougii tho blootl-vesiols, partly through the lyiapb- 
TGSBcls; such material acts as n fonuent. excites diange in llio blood, 
fts a oooscqucnce of which tJte cotiie amount of blood may be wanned. 
VTe might also admit a more oomplkatod mode of developiDeilt of 
warmth, which, by including the dcttous aystcm, might in some re* 
ft apects bemorcscrTtccablctbcoroUcally; the blood changed by taking 
up the product uf irritatioti might prove irritant to the oeotrcs of Uie 
rascHDOtor nerrcs, and thuü induce increased prodaotion of irarmLb. 
Tho dcci&ion between tbetic ^iCTercnt hypothesee ja diffieult ; they are 
all about «qiiitlly jiiittifinble, and all have the commoo &ctor of polll»- 
tion of tlie bloud by niateri»] from the scat of inflammatloo or tbo 
woimd, which is recognized as having an cSect on the production. 
of beat; theee subetarieca must linvo tiic effüct of exciting feror 
(n /lyroffenous action). Tbia waa to be proved. It has been proved 
by eTperiments of O. Wr£er and myscU^ which I con ootico only 
briefly here. Ig most open wouuda, espooially iu contused wounds, 
throds of lisxue are always decomposed ; to many idiopathic iBflain' 
mattons, the cirvulntion is arrested at different point.«^ iu tho inflamed 
tissue, and tlierc ia pnrtial decompo!>ition of thenc dead pcotion*. 
Decomposing tisaue, then, was an object to be examined In mgard 
^to its pymgenoos bcUod. If you inject filtered iubiaiooa of this 
ibstancc iiilo Ibe blood of animal«, they hare htgh fercr, and not 
tmfrequently die uiih Symptoms of d'-!iility, of v'min'klenoe, with ooto- 
ddent bloody dinrrlitra, Tlic nmo effect ia intluecd by fresh pus in- 
jected into the blood ; a weaker cßcct followi the enplojmtent of jtdee 
and pus Herum pre^sin] out of the inflamed part, but the s^vrPtloR 
from che wound taken during thi^ first forty-ei^it hour» i« e^p'-ciBlly 
active. (lonec the produnts of decomposition, a« well »>• ihob) of 
new fomiiition, have a pyrog«.>uous action in the bluod. Tbeae prod- 
ucta arc of a «"ery complicated and variable nature ; some of tke 



ru ' 



FTBOGEXOUS lUTEBIALä 



83 



adepenclontly 



» 



substances in Ibcai liavc be< 

heir fcver-cixcilinjf iiiialitios: vre may irulw« fever by liijoct- 
ing Icucin, BuJpliurcttvU hydrogvn, Bulpbidcs of «mtnunium aud car> 
bon, ftni] oth^r abvmical mibslanm'S n>«tjltii>g from the (loooiiifKuiitiuti 
of tisMie, or evca by inJL-ctäng wutur ; decomposing vcgctobic mutter 
«Iso bu a fever-exciting effect. Ilcnc« there ar« on spcciBc fcvci^ 
«soitiag BnbstAooes, bat tlio number of pyrogeiiuus mutoriuli; is in- 
numeroble. 

[ may Intro mention Ibftt tbti bail-suurllln^ aubiitinc^rd dt;veIopi>(l 
bjr liio decomprwIHon of tho ttssm's ore pntlwlily the K^aat dangi-njiist. 
I intfntiunallv distiaguiidi tlio products of decomposition in acut« 
inflsmmstions, which arc usunlly odoriees «t 6rst (wbo&c activity as 
poiaoas wv first learned by expcnment), from those of decomposing 
dwad bodi««, wtiich generally smetl had nt once, although their pyro-- 
genous aclion is uiinilar. If sx woundi-d pntioiit Has fever, it i» for f 
ne « jiroof that tbore is dvcompotition going on ia hi* wound, and \ 
thai tb» products have puaed into thu blood, wbctbcr the vounil j 
ataclU or not. 

Aitcr tilt! prrogcnous elTtict of the producta of inHamniation and 
d<«onipo«itir>n hnd bcnn nbsfilutply confirmed, it remained to ho proTPd 
that ihiB material could be taken from the tissue into the blood, and 
(u be shown how this t«jok place. Fur t)i!<i ptirpoHt^; it vr&s injected 
into the sabvutaocous ccUulaC-lUiuc, where it tpread around in the / 
nMinhiw of the tissue ; tho elÜ-ct, as to fever, waa tliv sanio aa wlien the 
iojeotioa was made directly into tlit: blond; hence tho pyrogcnoi»^' 
malcml is abwrbed frooi the cellular tUsue. Here there is another 
obsrrration to be nudo: after a time, at the point where decomposing 
fluid or frvah ptis bos hi';«u injected, there is severe and not unfrequcatly 
atfnäiy progn^wMTo inllamiiuition. For instance, I inji^tcd half an 
oBoee of decomptMing fluid into the thigh of ii horse ; in twenty-four 
bomm ibe whole log was swollen, hot, and painful, and the nninial very 
ferenafa. I did the same thing with the mme result, with fresh (not 
doeoopiMing) al»ceM pus, in a dog. Thia action of pus and putrefy- 
ing' BMlter in exciting local inltiimniation I call phlnf/agenous. All 
yr og M iKwa aubstancea are not at the Baraetintc phlogogcnous ; some 
tnarc so than others, and, especially in the putrefying Quids, it 
a great deal of difference wlvther the poisonoi» power, which 
V do not know aoeumli-ly, is present in gieater or lens cjuantilies. 

Jl ia not certainly det«nniiUTd whelbLT the pyrogcnous materials 

nler llw blood through tho U'niph or blood-vessels; they may vary in 

••r-ci, S »mil points are in favor of tbe reabsorption taking 

iL'tly thioufrli the lymphatic*.' 

Tbere is still something to be said about th« co«/« of tlie fev^r 



91 



SIMl'LE IKCISED WOUNDS OF TOE SOFT PAfiTS. 



■rtificislty induced in aaimsb. The fuvcr befpna very eoon, often 
«Ton io AO hour After tb« injection ; kftcr two hours th«ro ia Always 
considt^fablo vipvaiion uf tviup<-r»tun-: fur iiiKtanvi?, in a ilo^ whose 
tcmpcrsturo in the rectum woa 103^ F., two huun aft«r an iajmtiüii of 
pus it miy tw 105", and four hours after the injection 107°. It i» im- 
material whether ifa« substance be injected din><>tly into tlie bluud or 
into tbf! ce.tluUr tissue. The fercr ma^' n>iu;itn nt itA height from uao 
to twelve hour«, or even longer. The defcrretcencc may be cither 
gradually or by crisi«. If wn miiko new injections, the fover incvenacs 
again ; by rc]>eatvd injooliuiw uf putrefyiug niat«iri»l we may kill the 
Wg«sl animal in a fen- day». Wfacthor uu niiimal ahull die from a 
single exporitnent, depends on the antuunt and poi»onoua qualities of 
the injected materia) in relation to the sizo of the animal. A medittm- 
fttaed dc^, after the injertion of a M-nipln of filtered decomposing Suit), 
may bo Ecrerish for a few hour» ami l>a perfectly well after twdve 
houn. Hence the poimjii may be eliminated liy the rhange of ÜasoA, 
and the dlsturlianccs induced by ita prcscnco in the blood may «gain 
subside. 

I will now temiinatc thew observations, »nd only hope I may have 
made thiH important subject, to which we shall frequ«ntly rrtam, 
oomprobcnsiblo to you. I feci convinced that traumatio fever, like 
any inflammatory fercr, CRsentially depends on a poisoned state of 
the l>loo<l, and may be induced by various materials passing from tlie 
«cat of tnÖumrantion into tbu blood. In the accidental tmnmAtic 
diseases wc ehal) again take op this question. 



( 



N'ow a few words aboat tlie prognosis and treatment of suppurvt* 
iiig wounds. 

Tlii>/>ro^no«t« of simple incised wounds of the soft parts de{>ends 
chiHIy on tlia physiological importance of the wounded pari, botli as 
regards Its importanco in the body und as regards the disturhanoe of 
ftinetion in the part itsdf. Vou will readily understand lliat injuries 
of the medulla oblongata, of the honrt, and of Ivgo arterial trunks 
lying deep rn the cavities of the iKKly, should be nbsolbldy fataL 
lujurics of the brain heal mn-ly; the same is tnie of injuries of (be 
spizuU medulla — they alninot always induce »xteasive pamlyxia and 
prore (ttal bj Torious »eoondary diseases. Injuries of targe ncrrut» 
trunks result in paralysis of the part of t he bodr lying below tli« suit 
of injury. Openings into the cavities of the body are alway« nry 
serious wounds; should they be aocompanied by injury of the Itmg', 
intestines, liver, spleen, kidney, or bladder, (he danger Increan«; 
mnny of these injun^5 are sixsolutely fatal. Opening of tho huf« 
joinla is qIki an injury which not otdy often im])airg the functton uf 



TBBATltEÄT OP SIHPLB ISCISED WöüSDS. 



95 



i^ 



th» joint, bat is often daogerou« to lir^ fiom Ua eecomlnry L'Svcts, 
Kiu>rri>l t^ircuimlancet, tlie cuustitutiou aod temperanit^ut uf Uia pa-^ 
ticut, huTu altiu n certain influence OD tbc course of euro. Anotber 
Eoorco of danger is the accemoej diaoaees which subecqueiitlr ariM.*, 
and of which utifortuiiately there «re many j of these wo sliiill hero- 
after »peak in a separate obapter. You niu&t for th« time boitig ooti- 
toot youn«lv«j| with (bos« indioatioas, whose furlbcr elucidation 
foraia a vciy oonsifleruhlo part of clinical aurjfery. 

yr<r maj givp the trrtitmcnC of simple iiiriseij wounds very briefly. 

Wa hare alrradjr s[iokeii of the uiittiug of wcunda without Iom of 
»ubiitaiioe, and the proper time for removing the sutures, aitd tliut ta 
about all that «e cao regard as directly afTeating the proccas of beal* 
ing. Still, an in all mliooal ihcrupeutics, hcru it is moat important: 
1. To prevent injurious illHuence» that may inlgrfi-rc with the nor- *-' 
mal course ; 2. Carefully to watch tho occurrence of deviations from 
tlic CMcnuü, and to combat ihcm at the right cioio, if possible. 

Hwe, first of all, limit ourselves to local treatnient, we have no 
remedy for decidedly shortening the process of healing by first inteit* 
tirio or by suppuration, aay to liulf lis time or leas. NevcrtbeJess, 
most nouiido require certain care, aUliough innumerable EÜghiwouttda 
lii!«l without being seen by a surgeon. TItc 6rEt rc<|uireDicnt for 
noRDa) healing ia absolute rest of the injured piut, especially if the 
wound baa extended through the tdcin iulu the niuaole». Hence-, iu 
wouuds at all deep, it is very neceasary that tho patient should not 
«fliy kc«^ hja chamlKT, but that he should remain in bed for a lime, 
ft« U ia uvidetit tliat tJte movement of injured parts, e^tpccially of in- 
jated muado, muat interfere with llie process of healing. Tlie eeo- 
ood important point is cleanlinc!» of the wound and its vicinity, 
KoniK*rly it «as always ccinsidered necessary to cover the wound, and 
In apply dresaiuga in all cases. Of lal« T have grown doubtful if this 
be indeed accessary ; indeed, I would go so far as to assert that in 
■nuty oaa» it is well not to apply uny dressings. In woundn that 
liave been sewed up, it has ofteu bofn obsen-ed thiit it does no harm 
l«i leave them uncovered. If we wish to cover njturetl wounde, on 
uoDttDt of pain, rt^dneas, and swelling, or booaus« thoy are in a part 
' ly upon whieh the patient must lie, we may apply various 
i ; reusing ; we may »mcar the edge» of the wound with pure, 

fioo oil, best with almood-oil, and lay on a fold of linen dipped in oil, 
*« liiL'h should bo cltauged daily, Uli the sutures are removed ; or cUc 
11.' luay apply a Ijn«! oomprcse three or four liiyers thick, and the 
fi nr of the wound, wet with water, and eover it with oil-silk, gritta- 
percba abeeCiog, or parchment -paper, aixl make a few loose ttirns of 
a bftodage over iL 



■jUta 



9ö 



SIMPLE [XCISED WOVXDS OP THB SOFT PAKTS. 



For some tim« past I bave used &» ttift iiimMdlale earning of 
recent wouiida mcrelj a moisU-ned tbia abtct of gutlu-porclia, over 
Ulis a mMst compress ; ftnd to jvrcvont tb« Utter I'roia drying, I 
oofcr il iTitb some wutvrproof sLufT, »ucb as gtaxed paper, guiu* 
perdia, or oiled sUk, and then cover with ptuDt_y of iliy wadding' (do- 
|H-ived of fat and made bibulous by cooking in lye). Thi* drcMii^ 
may bi> removed witliout wetting or giving paiR ; it is u> bv »taiood 
in place by a baodag« or atUicsire plaster. For moistening ibe 
cumpreues asd tbc blicct of guttn-ptTcha, ^rbicb lies directly on tbe 
wound, VC fTcnerally employ liquids wliicb arreat the derompnaitjon 
of tbe secretion from tlic wound and prevent its »rocUiog bidly, thai 
is, which are antiseptics and deodoniut», and al the same time may 
destroy any inTectious matters clinging to the dresüngs. In my 
vlinic, for this purpose we employ saturated solution of chloride of 
lime, aqua plumhi, solutions of oarboUc acid, carlwlate of soda, &t»d 
eulphats of soda (10 per cent.). I have not noticed any dodded 
diltereuce in their »fTet^t, and on the score of peoootoy use eohlliotl 
of chliwidfi of lime for onlinary dressing«. 

The fn]i:|UVt)oy with which the dressings of a simple wound Hhoolü 
ha renewed depends on the amount uf secretion. As a goneral rule, 
dariDg the first four days the dressing above described sliauld b« 
removed at least twice daily ; if during the Fmt and second days 
IIm «ecretioa escapes in a few hours, the diessi&g should t» changed 
«t onoo. In doing this wo no longier need to use a syringf% and to 
oarefully work off tho charpie from tho wound, wbile ibc patient 
fluOurs tortures; should it ever be oeofessary to inject fistulous 
wound», of whioh we shall hereafter apeak, we may lis« either ■ Km- 
pie syringe or an ^march's dotielir, which consists of a cylindrical 
vessel id ccDtiniolres high and I'Z io diameter, trith a short tube in- 
serted at its bottom, on to which a rul>bM tube with a tioule is 
applied; when this vessel is h«hl up by an attwidanl, it art« as a 
syrioge. It b gcnenily enough to wipe off the wound with a lilth* 
wadding when changing tho diesaing, and it is not nooeasftry to 
remove evcrj- trace of pus. 

In many caacs this dressing nay be continued for weeksi, lieinj; 
after a time applied only ooco daily, aud then every two or tlircc 
days; ejcntrimtion proos on and tho wound heals wilhvat doiag any 
thing ni'jn>. 

Nuvcrtbclcss, indcpetidont nf oerlaio diseases of the gnnulntiniU', 
of which we shnll speak more particularly hereafter, it frw|ueutly 
liappens tiiiit undt^r a continuance of the Esme Irxntmenl the heal« 
ing is arrv-slcd; for days the process of cicatrization does not md* 
vane«, and the granuUtbg 8ur£kce asdumoa a flabby appt>«r«nc>P. 



TBEaTMEXT of SJUPLK tNCISBD WOCSDS. 



Mich circumatsiices it is aJviublc to duDgo tho dr«s£mg, ta 
ritata the gnmulalitig surface hy now romcdi««. Thes^ t«mpormry 
azTUSts of improvement occur in almost «very large wound. Under 
jtb cinnuniftARoes you may ur<li.-r fumoiitations of wami cnmomile- 
M ; sercrai compresses may be dipped in the warm tpo, wrung oot, 
nd fjroni time to time applied fresh to t1i(> wound ; or you may prv- 
cribc lotions of li.-ad-water, Vott may alt!o paint t bo wound from time 
tim« vith a »olution of bttrutc of itilvcr (two to 6vo graiiie to tlie 
ponre ot water). If thf wound-surfat'it l>u tio longer lnrgi>, vou nuy 
lally make u»e of »iilvea ; tlicnc should be »prrnd thinly over oliarpic 
or lincii ; the most suitable are tb« baülioon-ointmeot (oorapound 
nÖD cerate, coaftisting- nf oil, wax, resin, «upt, and turpentine) nnd 
a nlrt^ of nitrate uf «ilvcr (one grain to u. drachm of any salvo, with 
tbc addition of Peruvian baUam). If the cicatrisation bo already far 
adrsneod, we »»y employ zino-sitlvc (ijno. oxide 3 j» «nf?. «q- «WO 
* J), or let the dry cliarpie adhere, »nd havo the laxt portion of tho 
wound bcal undr-r tltc »cob. * 

A veiy peculiar and occasionally a vorj efficient metlioJ of bast- 

•idt^ oiimtr]2]ition of gfanuUUng wounds liu been iutroduced by 

JtmtnUn. He found that a »mall portion of cutis taken from Ihu 

of tbc body with coocaro scüaors, and Eastoncd with the raw 

face oo the grunulntions by tncn-ns of adiiofiive plasters, not only 

radbunmt, but tho Ininsplantud «.'pidurmis liegins tu grow 

I the centre of a so-called cicatricial i5Und, whence the skin- 

u^'er of the wound advancca just as it docs from the margins. 

tbe clinic we have often rosorleil to this artificial skinning over 

wouods with epidennts, and rarely ineffectually. The effect is 

perceived whe-ii we remove the plaster on the third day »nd find s 

anr<nla .-tround tho trnnsplant<>d piece ; this gradiiallygrow»,and 

tbe sixtb or eighth day Li followed by a bluieh-wliito border, just 

loicktrtEatioa at the edges ef the wntmd. I dn not underestimate 

lelioat value of this prueoedinf^, but it ia evi^u more intereetjng 

n»c from ttiR addition it forma to our knowledge of natural biBtory. 

Ii-Tv we have thi? most striking pnmf not only of the independence 

cell life in the l!»ues nf »ran, but slill mure of the readily-excited 

(live pnwcr of the ''pi thulium, which is here arous«) by a change 

nutrient niateriii]. while tho portion of the papillary layer of 

tbe rati« tnuiHpUntcd ui tbe same timo docs not grow, 

Thirts^h, Miniii'^h, nnd Mensfi have made Al«crvations showing 

lOi^ht hour« or perhaps longer after death, epidermis maybe 

uHy transplanted. Tlie finnr detaiU of the histological 

Ci in tho«c transplantaiioDff bavo been carefully studied by 

Rnrnii», uiid «lill ranrc so by Amtihilt. Clfrtty has shown that 



Ldttt,' 



i/ 



9d 



SIMPLE LSCISED WOUNDS OF THE SOFT PAXT& 



muoous itipinbnine from tho mouth (vith flnt epitWIium) nnd trom 
Ute nose (with cjlirulrical ciliuted oi>itlicliuiii) luay be succdkfull^ 
grafted on wounilft. [Is this, perhaps, one ciuse for tinimal« licking 
iheir wounds?] The epithelium of these membranes proterres iii 
character but a sburt tiai<T, tbon it is trauaformcd iuto cpidrruita. 

[March 6, 1871, Or B. Hoieartl presented, at the mcotinjr of th« 
New York County Medical Society,« case in which, »ri^rskiit-grarttng, 
oicatrizutioii had progressed for a lime, tht*n soomud to be arrested ; 
whereupon he grafted small portion» of the biceps »hukU aud tbua 
indttued n continuanoo of the cicatrixalioa. The question wof raiaKl 
whether the reuvwcd activity was not due to the previous »H-iu-gntt- 
iag. Or. IStcin stated tliat iic had nrouecH these old ulcers by qirin- 
kling epidermis bmIo* ovor their surfaco.j 

ftegiuding ooQBtitutional trealmciit, wo can nepomplish amrccly 
any thing with intpfmil reiiiedieG in prevvntingor cutting »bort ihr sub- 
sequent fever. Still, oertain dietetic rules are ncooaaary. AAvr Um 
injury tlH? palient should nut overIoa<> liis stomach, but, aa lung u 
he has fowr, must lire on low diet. This be usually doe* spoDlana- 
Dualy, OB fcvur patieots rarely have soy appetite ; but, oven »fl«r 
Bubfiidence of the fcvpr, the patient should not live too higb, bot 
' 'bnW (tat as much as he can dig«si while lying in bed or confined to 
bis chamber, when' ho has do excrctsc If the fcTcr Im: htgl^ and 
tbe patient desires some change of drink from culd water, wiikh ti 
gcnemllv prercrred by fe%'cr patients, you may order acid driitki, •* 
lemonade or xomn meilirinal substance; tbe patients ao- < ' >od 

of the ordinary lemonsdi;; they bear pbosptioric or uuti i i ■ I in 
water with Imit-juioe, raapberrr -vinegar in water, apple boOcd in 
water, toast-water (infuBton of toasted bread with sntiie letDon-juIco 
and sugar) ; »oiuo patients prefer almond-niiiinlogo, nalcr-tcc dia- 
solved !u water, oatmeal pruel, barley-water, etc. We «my giv« thn 
taste of tbe patient full play ; but it is well for you to attend lu sueli 
ihings younwlf. The physician should know »s much about the cel- 
lar and kitchen as about tlie apoth«Cftry-sh<^]>, and it is erou well for 
him to Imve tbe reputatiuu of being a gourmand. 




BEALÜ(6 BT nR8T AMD BEOOND LVTEXTtON. 



LECTURE IK: 



eo 



(;«inbliwÜt«rfU««liiwbyr.m«idS<»M.JImi.niioo.-trnl<iB(ifOrotiul«tongttrf«e« 
— ll««UQrtia<lct*8Mh.— QraaialMioD Di»«M«».-Tiie Clo«riKin «Brioai TU«»t» ■ 
hl Und«; taX«»»; iu kniAbj- [-rolifmiion ; U \'o*Mli.-ÜTifuii«Mioi»<,r lU 
TbraBbm.— Arterial «oUoMfal CinMluloo. 

To-DAT I hnvo first Miti|>Iy to add a tcvi words «bout oerlain de- 
vbtiofui from tb« ordinary c-niirw of bcftliDK, wliich occur m fre- 
quentljr ttmt tbo/ must vi-rjf ofteo be ooumcd as Dormal; «t &U 
«««DC«, w »ory freiuctit. 

Il b not ut all uiifrcquont for tbe two /orma at healing qIjovc ile- 
acribod, by first »ad econnd iiit#iitioii, to cfwnbine in the aauw wound. 
For imtuncc, you uuitc a wouud wtii[)l(!tclr,and maysomwiinus oh- 
»*.f«r tliat at soma yl^cr-* tbt-ru ic healing by iht first in Ion lion, wbilu 
at othor«, aftor ronwival of tli« suture«, th« wound g»p*s, and subM- 
qusntJy lii-aJs by aupiiurau'ou. 

But it a much more «omroon for a lar^c and deep wound to beat 
*u|)rrfioiBllr, and to supjmmte for somo time from th« dccpt;r pari. 
If the entire awljico of tli« wound bo hi-allhy, the cause of tlie in- 
conipletc IwalinK is cither that it was imperfectly ooapted at tlie 
fint dr<43ins, ur that bluod «od exudation OBcapod iKtufc» tlm 
edge*, which r>ot only do not ixMjr^late firmly enough to keep u]> 
iJm adbvnoti, but ono ereo dccoinpos* and 8«t up an Inflammation 
mkuk may spread npidly and cauee severe general disturbances. 
Tlipaa important results of sucli wounds compel u« spociatly to atixly 
llivir mvehanical rainditiona and cbemicnl cfiaiigpa ; from tbe first 
ÜMjy ant innre or Ir»» compli-tc ./frfH/wi« tcaunJs. 

It inay bo readily «ecn that where Ibe skin baa boon dividodi as 

for lb»- remoTid of a dwply-wtuiited tumor or a portion of diseased 

V>oe, a cavity Im left if tl»e »kin i» sewed up, wbich will rumaiu filled 

with air and blood, unless tbe bleeding has been completely arrested, 

the wmind well eleiinsed, and It» «djre« brought well in contact. ]i» 

COM« where different tissueg are wounded, and ecmtruct iiiiequully, 

aa tn A wound going down to Ihe bnne, the surfi«»s would be very 

I 't be accurately apposed if the od^en of the sUin were 

! Ejtpericnce teaches that in such cases Urge wounded 

r 1^' < . inren if loQiely apprDsimate<l, may be readily separated by 

*cvu((il«rr lurmorrhaKes or fluid exudations, which often doconijiuae 

("Whil« tbe slcin ahoro them is cocnplctcly united. Then tbe ptrta 

>and the wound awxll and beeome painful, and high fever eumes 

I will out here üftcribe tboae dangerous slates, septic phleg* 

and blood-poisouiug, which m»j arise, but merely say that we 



100 



SIMPLE INCISED WOUSDS OF THE SOFT PABTSL 



m*y oftrii prcv4tiit tlie devdopiuuut of Lbi;au prucvsitut by corljr evuo- 
uBtion of tiio ilecompwiog' m«t1«r. It U not ihn tuero presenee of 
blood between the tissues that causes tbae alTeciiuns, fur that ofieo 
ooours in Mrero contusions without wounds ami tii<Jii<\-a at b«d re- 
sults ; it i$ tbo decompoRition of the blood, iwd tho pooulinrly phlogo- 
g(>nou9 nnd jiyrogciious pro|tertirfi of iUv first exudalio», whifh 
c&UHü the ilaiiger. Ht'i»'«, in Irt^xling' llirsu wotinda, wu mtwt cske 
caret first, to prcvoot colloction of blood and scctciion in tbo «rmmd* 
und Eßrondlv, in (^aEP this has not 8u<;oci>dcd, to pro^ent deoomposH 
tion of iheso fluids, so that they tuny re&t ijutctly until absOTtwd, as 
tlie.V wouM if the »kin had not ))crn injur(.>d. 

Of cotir««, if thcro be no blood or s<>crction in tlio wound, they 
(WDimt dc«i>mpoxp ; hence it U nio\l iinjiortant to prevent their eol- 
loclioD. This would bo most simply prrvc»li>d by not closinjf up 
d6«p wound«, but filling ihcm with charpic, waddiofTi or similar bib- 
ulous insterial, after carefully arresting the iuetnorrhagp ; this dreas- 
iag must be rrnpwcd 119 oftoii as it becomes aaturatctL This tnetliod 
was uM.-d for yours, and was considered satisfactory, as no other way 
was Itiiowii ; stiil, as wn now know Ix'ttpr nietlioil)i, wo think tl>o 
Teaotiun wsB oonaidcrabli.', akhougb luss than accompanied tho irri- 
talive treatment of tlio tuiddl« a^s ; inftitntoationB spreading from 
tbo wound wore frequent, and wero rpfom>d to individual poculiari- 
ties, then to general ititliK>iioe» of the atmonplRTe or to hospiul air. 
H is only within the last twenty years that (ho pritpricty of the 
above treatment has been questioned, and new ways, based on differ- 
ent hypotheses, have been souglil. This led to two oppoaite metli- 
ods; ODD entirely without dressings (open ireatweiit of wound*), 
lllo other aocurat« clostire and air-tight dressing (method byoccitt* 
sion). In the open trealment of wouodf, which eaii only be usod 
with fseility in woiiikIs of tlicr cxlreimti(.-s, ihi; part is so ^dAccd that 
the secretion may How readily into n vessel placed beneatlu Tba 
first two days this secrolioo is of a dark blood-color and tbia ; frooi 
the tltinl to the fifth day it becooies light brownitih, then yellow, aud 
soon in the vessel tbo pua-aeruni separates frotn tlic lumpy lakcB of 
pu&Kfells; at the ordinary t«mp«raturo of the room this e«Qrotion 
does not begin to smell badly in twenty-four bourn, unless ooasider- 
aUcquantilieHofdccomjKiaiiigdead shreds of tissue lie in the wounds 
and pass off wiiti the Bi*cretion. This frwHlom from smell tnuxt 
strike any one wIk» has smelt dra&sings tliat have been removed from 
a wound after heine applied twenty-four hours. The bodily lem- 
^ratnre to which this eecretion iit snbjeeted whilf in the Hressing ii 
doubtless the cause of its more rapid deeoniponition. Should ooe 
•I prf (»*{ suppoee that with suc^ a dressing collection of Iheaecrctioti 






I 




OPS» TBEATMEKT OK WOUXD& 



101 



wiLb Its evil ipsults would be imposubl«, lio will soon find pnoti- 
callj that tbc object of tlic ujicii trvatRicul uf wounds will not be 
»ttaioed by «bfloiuto innttcntion, but that the form uuJ position ot 
the wuund may greally itupedo tlio escape of seorelion, aud ska that 
the i!«rlT, firm union of tlic Bkiii may shut off ocriaiu parls of tlie 
wound as efferlualljr ax if a >uturv bad been introdticcd, and tliuK 
tbo same icrcre diseases muy bo itiducod as by tlic old molltcMls of 
treatttivnt. In Operations wc may do miK'li to make wounds of such 
a shape that tbo secretions will ruii off ut once ; but in accidental 
wounds tili» is often difficult to do, and rcfpiires a certain oxpcri- 
eooe. to regard to tb« above-mentioned fonnatioo uf pockets, we 
ahould prevent It by daily breaking up tbo adhesion, or from »lie 
fitat lay draiuagvtubes in all tbc anglvs and hollows of tlio wound, 
through which »ny »eereiioti from the devixr parts nuiy readily es- 
cape. These drainagc-tubes, introduced by Vhatmignac, arc made 
of vulcaniied rubber of various caUbro, with boles along the auleo. 
Tfaf^ term "drainage" is tolten from agriculture; land may he 
drained by laying a system of porous tubes at a certiiin depth 
ihruugh tile soil; the water trickles into tbesu tubc;<, and flows 
through ibem to lar^e ditchos. The rcvults from carcftd trial of this 
motlind of open trestment for years fur surpassed all prcviouti ones. 
Fram the publications of Jitirtttchcr^ Vtzin, and Jiuroie, T hml my 
ilioa called to litis plan over tea years ap^o ; and as it fully 
with tbu rinws I had nrrivfid at from eliiiienl and cxpcri- 
nental observations and inwatigations on the {xiisonuus peculiarities 
L vf tb« first secretion from wounds, I hnve pursued it with purtieular 
[«•fe« and bnTO roaortcd to it in almost all deep wounds of the ex- 
tremities, whether incised or contiise<l. It was only after beinf? 
aasored by some of the most prominent Cicrman surgeons that bctt^-r 
molts wore obtained by Listt-r"» earefid antiseptio dressing that t 
wuiild t>y it, io lillle did I tbiiUc of tbo correctness of the theory. 

Tberu ia no doubt that it would be a great «dvuDtajje for Uie pa- 
tient and n ti-tiitnpS for aurgciy if wo could without danger induce 
ImaliDg by first iiiteulifm in nil tergu deep wounds. It is true, even 
in tbeop*^ tTeatment. of wounds, the surfaces inny so eomc in con- 
tact as t4t licid almost entirety by finit intention ; but this is rare, 
altIio<if[b partial adbeaions are frcijuent and do not require breaking 
B]i if tho patient remfcin free from fever and pain. FonneHy, by 
applrinir bAndages In pw-sg the sorfaces of the wound together, or 
brd^rp Rulurea, attempts were made to induce imractliato union; 
•H^h this Buceroded in sorao cues, it proved so dangerous in 
thöw where the aurfaees ot the wound were separated by blood or 
euidition, wbirh putrificd and could not cheapo, that conscientious 



103 



SWPLE INCISED WOÜSDS OP THE »OPT TARTS. 



surgeoita soon al»ndi>ned it, SobseqUAiitlv, wben attempts vrcro 
nude by luying Htrips of oiled ntg in the ati^lc of tbe irciund to 
give exit to the sccn-lioTi, it rareljr «jooceded. In my opinion kla- 
rer dvservcs great cmlil tor buvtii)( »batra tbat num«rou» drBinagct 
tubes, properly placed ia tbo wound and cut off even with tlio lor- 
£ace, will completely carry off all accretion, cvon li an accurately- 
fitting oompresiiivti (Irfisaing of bibulous material be uppticil nvor ihn 
unitod wound; if, by directly covoritig tho wound witb giitta-percba 
or oiled silk, wo prevent the drninage-tubeB from being »tuck up by 
dried secretion, sucb a dressing baa tlie advauUt^ of an op«a drv«a- 
lOfT, ^r allowio« fr<>o escape of stcwtion, as well a» tliat of a nooi- 
pressing rirossing, by wbieb union of largti wuuudcd Btirfac(<B ia so 
greatly faroreO. To prevent the escaping Bcerction from decoiQ- 
poking in tbe drcawng aod aSectiug tbc wound, tbe dressing slioulcl 
b^ frequently chsng«d at ßral. In tins care »bout dressings, as well 
as in cleanliness about operations, it aecms to mi?, lies the groat ad* 
vanta^ of Lister*» method. Rut LiMer started on tlic eonstnictioa 
of bis complicated dresi^ing from different ideas ; be tboufibt, just a« 
I have repeatedly issertüd, that tlif severe in Itamnia lions aboat 
wouihIs and the coustttutional implication:« are almost always due to 
decomposition in the wound. I think that dwoaipoeition of dying- 
tisaa« and exudation from tbe wotmd (for us a deeompositioa «f 
albuminous eubstanoes with funitaliuo of pyrogpiious and phlogogen 
nous matters) is a chemical prooesa that must, umk-r certain circoni* 
Stance«, alwuys oeour in these substance« without the ad<lilion of 
new ag«Dts ; while Liatcr agrees vrtlb I^tst^ur'» view that decompo- 
sition only occurs under iht; iufluen^-c of small vegrlablo organisms, 
just as ho claitns that fermentation ia only dcrolopod by yeast fun* 
gns. In regard to ihis question of living or dead ferments, I must 
refer you to organic cbemistry- In pbysiology you hare learned 
about Bulivari', pancrcntiu, and gastric fertiients, which, althouj^h 
produced by cell -activity, no longer act aa livinf; orgnuisnia, but in 
a purely ebemical way. In the same war, I think a suhBtatic» tmy 
he formed aa the last action of a dying tissue, that »ball have sumo 
of tbe peculiarities of a ferment, and at the same time have a pblogo- 
gmous action, and perbap b« very [xjisonous for tbe ctreubiting 
blood. It doe« not »cein to m« to liaTe been proved tbat tlio add)> 
tion of smidi organisms (rihriones or bacteria of Pofteur) i» »bao- 
lutely necessary to the fiinnation nf such substnnces. It U tme, 
they are generally found in sucb fluids ; but this may be expire«! 
by tbe fact tbat these small orgmiisms occur ererywhorc in air and 
trater, and develop particularly in dccompCKtng fluids. 

As wo shall often bare ocoasion to speak of ttie«e small organ* 



iJu. 



J 



ORGANIC FBRUKNT8 IS WOCNI». 



103 



isms, whoso iügnlfksiico is at present so mnch disßuued, I will bera 
iCi'C you m brief skutcli of tlioee foruu tliat ore meet frctiuontlf found 
in deoompming tissaes and tiuidti. Tiiej niny be minul« sph«-!«« 
^tnioroooccus, froro pucph^, small, ami & jhmucöc, tho gcnn), or tainutc 
rods (bacLuriii, (ram to iitUTTJpiov, the rod), wbicb oiujr ba ieolnted, 
ta puts, or ID cbuin» of from 4 to 20 links (streptococcus, from 6 
OTpemitf, ilie cbain, and 6 kokxo^) ; often the; are held in the shajio 
oF ft spbero or cylinder b;^ a glutinous substance which they throw 
out (ooeooglta, from kokkö^ and ^ ykla or yXaä, glue). 



*^.-.*v •- 









j5- 



.•^-// 

^'^n' 



/) 



/% 



*%.- 



i. fMni; <, Stnt-tonocH (Tanito> i A, Bt^olt: '. VQuiaM«: /, empubutarUiLaptBlbrtsvr 

Thi^Ro oI(<m«tnt8 vary grcAtJj in eiw, from a p«t<> splwrr, of «uch 
IzAineler Ituit it can smreely bo perceived with thn highest power of 
anicroscopA, to the- »izo of a pua-ocU ; tlioy arc sornetimea mova- 
►I«>, nt others <(uict. It is prctlr generally ajfrood thnt th*so minute 
fg^nitmB am rwgelaLIe in tboir naturp, and belonjf to the a1g%; 
ifc tikcir nrrurate botanical poeition and rvlalions \o each other arc 
till uinlter» of dispato ; their development is not yet explained, 
inrj «ntil Tery recently sonio believed that they were the result of 
tio twijuivoca nr abio^enesiHf thnt in, existed without influence 
ca any living orf^nnism. Prom my investij^tions, I think that all 
«hove forms belong to one plant, which, being compownl of coc- 
oi» and hcuitPiia, and bfing fmiiid chiefly in dt^eoinposing fluid*. T 
hav© calk'J Coccohacteria tepdai. Tliis plant secnu to me to do- 
^op as followa : first, its gontts are found in dry air, and may be 



lOi 



BIUPLE HitalSA WOrNDS OF TUB SOtT FAVOS. 



Tvcognizcd under the microscope aa Gne dust ; placed in wntcr, they 
HwoU uihI throw üiit mor« or less snuU pale apbercs, micrococcus («*, 
Vig. SI a). At'coriliag tn exUrnsl ctrctimiitjinces, tliusc assume the 
folfowing foiTDs : 1, AVIiil« incrcusing by Bi-f^cata.tioD, they throw 
oat a slimy cement {glia), by which tlicy bftn^ together in twila, like 
frog^jjawn (coccogH«, i>r gliacoccus, b, Fig. 21 a) ; on tlio surhoa • 
ofäuiüs tliis form often appran as coherent hright-lirownisb metn- 
bfsaes, ami it also grows iato the iatcratiocs of tiMucs, and ts found 
■s whitish-gfiay flakes in fluids ; thie form is always without UKition. 
Under ccnsin circumstnnccs the glia around thetio spherei and eyi- 
indera tbiokeu» to a mombranc, the coccus becomes Biuvalilc nnil es- 
capco through an opening in the capsule (awocoocu«, from AexS^y 
tube). 3. Tlie coccus divide« always in one direction, sod some of 
ihe divisions rttmain, like frog-»pawn, united br n rlrlicalc rnri^lopc 
of glin (•*, Fig. 31 a) ; thebe st rcptocixxi are sometimes in oiotiot), 
-wriggling slowly acrnss the ßdd of the micraacope, but usually Ihey 
are at rest; we may find them in fresh secretion from the wound or 
iu pus, und uftvn in ntkaltnc urine, uithout there licing ne«cs«arily 
any bad odor; the etreptococcus, along with (he isolated inicroooo- 
aOB and gliacoecUR, nrn the forms of eoecobaeteria which occur moat 
frequently iu dL-eumpodng secretion from wounds or in diphtheri» 
of wound», With absolute fe»t the streptococcus mny form lunjK 
upright filaments, but this is very rare iu living organisms, and is 
diJHoDlt to »ec under the microscope. 3. Ilio cocinis grows to 
rods, which inen-iii>c in length and then divide sciofls ; thus wo have 
baeterta I'bsins {/, Fig. 21 a), which iimy be moving or motionleas. 
In some fluids the division of the bacteria goes on very rapidly, the 
rods becoming eliurter, till tlicy arc Bnally square or roundvd ; aiuLj 
BO between ooceua and bacteria there arc numerous Imnsilion fo 
Bacleriu are not apt to enter tbc sccrrlion from wour»K p«i», tw 
decomposing blood ; on the other band, ihcy develop and remain tu 
alt fluids of (he cadaver and in watery exudations of almost all Its- 
Bues ; in the Inlter they are very movable. 

All of tbcie vegetations require plonty of water and oisanio 
substances, especially nitrogenous matter^ for their rapid propaga- 
tion ; tliey bear abstrartion of water up to a certain poini, Init if 
entirely dried out they die; and although they will subKcquently 
swell if placed in water, they have lost their power o( vegtrtating. 
They can bear temperatures as low ns the freezing point, and iioarty 
up to the boiling point ; but when it reaches tbe boiling point tbey 
tlie. Id fluids or moiat tissues completely excluded (ratn alino»- 
pheric air, they will vegctato till nil the air contained in the fluid 
hasbaeo used up; tlieu, no more air being absorbed by th« fluid, 



DROAXIC FEfiUES'TA IK VOVHI». 



106 



the coccobacteria die, as they cannot causo decomposition of wntcr 
or any or^Duwd eombination. 

Unddr tlit-iw condition» some of these coeoobACloria mny he 
LbiDim into ihc &tniU9j>hi;ru niid ho gvuemllj d is In but cd by the 
cvnporation of fluid», »o common in »»titrc. Stil!, when tb« sir be- 
• ooaiH very dn-, tbera Tegetatiuns might dry out, die, and beooine 
orgsnio but no loDger oi^nisablo dust ; but such an occurrence is 
provided igniast. As in many of the a\gK of stognaol wstor, hav* 
ing »iinilnr pcculiaritica and subject to beinj; dried out, »o ia some 
of the cl«ni<niu of coccobuctcria a Ikr^r quantity of peculiarly con- 
cenlratod pnitaplum imitca to form a K'liatvuin;^ vphf;r« with dnrb 
MMiUmre, vhiefa may be diatioguishcd from otlior oocc-us, but tianlly 
from tat globulus. These little spherea bav« the pecuUaritiea of 
fungus-germs and very resintatit seeds ; tliey may be entirely drird, 
cooled far bctow the; freezing and wormed above the boiling point, 
and k«pt bermi'tically oIomhI &>r along' time, without losing their 
germinal activity ; hence tbcy are called permanent germs {Vauer- 
tpoftn). According to my esperience, they form very certainly and 
not very rarely, under certJiin oirciimKtanees, in bacteria ; but they 
aUo occur ill coccoglia balls; I caunot state nrhetbor »omo spheres 
of streptococcus also hccomo permanent germs. These J}aunrsporon 
aro the driod germs from which we slnrtod for development ; thty 
require «{uict in or on some Huid or moist boily. 

I have here given you n brief review of the results to vhieh my 
inrootigations oa this point b«ve led. But 1 must call attention to 
the fact that botanists have not yet proved the correotneüB of my 
TiRwa, and that they are st variance with those of most others who 
liavc lavc*tigat«d thii subject, and wbo consider each of the forms 
aboTO described as separate plants, and aba make numerous specie» 
of each kind, especially According to I he diiwases induced bv each. 
Let me alw remind you that most pathologists term Uicsc »Igie fungi, 
and often eatl them all bacteria. 

It is to these sniall org-anisms that Putit^ir, ami after him Liif.t>r^ 
attributes de^roinposition, at least tliosti funns of it whose profltJCts 
ar» Uxal and general poison». If wc could prevent their entranoe 
into the wound or iU fwcrelion«, according to this view, tliore would 
be no det«mpo»ition of the Hceretions, evmi if w>ine of them did ro- 
maiD in the tvound. Willi tliis idea, Liator writen a number of rules 
lo be foiluweil in the operation and dressing of the wound, all aim- 
ing at th« dcstmction of the germs of coooobooteria which might 
reach tbo wound through tlie liniid» of the operator and assistants or 
the air. After tli«' oporaior and assistant», bcforf each operation or 
drsating, hare carefully washed with soap and water, they dip tlielr 



L 



ii;[UI>LB LVCISKD WOÜXDS OP TUE SOFT PABTS. 



bands in a 6ve p«r oont. solution oT carbolic ftoid; in the nne wij 
the parts about tlic seat of operation are to bo careCulljr washed and 
moLsteuod witli tlie aamo aolutioa of carbotio at-id ; and nil inatrn- 
tncntJij apongcs, and ÜKssings us«d lie in tfaia üulution, triiich i« sup- 
posed to kill all genns of onccobaderia. To i>revt>Qt tbme gems 
ffoin roacfaiag Uio wuund tliTQugli tbe air during tbc operation and • 
dressing, a two per cent, solution of carbolic acid id coostaotly 
sprayed ou the part with a special apparatus, bo that it Tslls on tba 
wound in th« fonn of a Tino rain. Wc have alreadjr described the 
cKwltoion Or " aotiseptio " dresaing, as it is termed, although tb« 
opi'» troatmoot of wounds and some other mcthuds aro jntiL as auti- 
acptic Tlicrc is no reason for goioj; any furtbcr into dclaila here, 
where wo are ehicB/ explaining principles. Liata't dreasiug, wbicb 
seems so complicated, in in pructice much simpler than would appoar 
from tlie dcaoription; for every st«p und rule the iiireiiLur had a 
definite rosso», and iberä ia nothing arbitrary or intentionally mys- 
terious. If wc inqaire into tho practical working of this trostmcut, 
we bear chielly praJst*, and many speak enthusiasticslly of tla woo* 
dorful cITcct». Altboiigfa my own experience with it is not very 
groat, I can rccomiii<-nd it as boiug generally very good ; it is eer- 
tuinly more popular thun the open treatment of wountlit; it is still a 
disputed point which of these methoibt nuswers beet in treatment of 
wounda of the extremities. I urgi-ntly rerommend you to {lerfvct 
younolrcs in tho principles and practical application of Liter's 
treatment, and you will have many furorablo reaulla. 

It is ditft-rviit if we socurntelv examine tho correetnefls of the 
theoretic«] views from which LiMer stari«, and in«iuif« whether by 
his mode of operating and dressing h» has attsined his object. In 
regnnl lo the Intter poinl, it ha« been often proved that in tlie secrp- 
tianof wound« treated according to ZiVrr'Ametho«!, and which healed 
rapidly without reaction, coccobacteria were found about as ofiea 
as in secretion from wouttds which wore merely dressed with attentioo 
to cleanline»«. This shoiTA : 1, (hnt the presence of these vegetations 
in itaelf proves nothing altoitt tlie pidogogenous or other poboaous 
qoalitics of tlie secretion ; 3, that Lüter'» dressing is no tniaraute« 
for the destnidion of bacteria. Against this second point it miglit 
1» nrge<l tint there is no proof that ihpse germ» reach the woand 
onti/ from without; it is possible that permanent germs enter tho 
blood through the respired air, and, though they may not develcrp 
under normal circumstances, do so in tho secretion of wounds. Ü 
this be possible, there ia no t*en»D In tbc theory of Liatfr*s method 
ss far as regards its stlacking organic germs by chemical means. 
Indeed, it is my opinion that those not very frequent cases wberv 



HEALIS'fl BY nim» IKTENTION. 107 

icteria Testations bavi^ been found in completely clowd, 

tpij-Kaled points oF üßammation, which oeTer comiuUDKatetl 

fvilb the air, cun oiilj- be cxplainwl Jn the waj above mcntioocd. 

^nB-n (ro«ii the faiTt iJiat TJiita^B [Iresning i» expeiisire if fiOIotrpd 

in ill it» detail», aiid that more or le«a severe poisoning U often 

'fau^M=*l bj the aiinoyinj; d^mnatitiji induc«d by the carbolic acid, this 

jneoctgni^Dccof tbvory aiMlpratiticobaidcd totbeemploymont of more 

uid more dilute «olutions of carbolic acid, and it» rrplacem^nt by 

odt^c* tntiscptic niid less irritatiDg: acids sud salt« (salicylic acid, 

71£e4wAy eulpUide of aodiutn, JIfinieh). Variotis change« havr 

tirv-n made in tbe mode of »pplyiii<; the dressing ( FbMmiann, 

'ti'ifbnt\ ; tbc Ipray ItAS tx-H-n L-iilIrcly omitted, and in its place 

sfUyr lb« opc-rntJon (he wound has been waslit-d with s mory coiiccn- 

txat«<l «Btiseptic solution, etc., etc. Thus Listeria drrssiitg bus 

been varioualy motlißed, and frotn each modific^tioci the same favor- 

sMe rwiilLs Imre 1m>cii obtained as from the original dressing. This 

oanGmia hk' in the opinion formed whuii tliis niotliod was Hrst de- 

■orjtscd, nod which I hare already stated, that tlw »crupulouii elesn- 

jiiOfra« aiiil l)ic cart;ful mnoval of secretion from' the wound i* the 

iß]|iortant part of it, and tliat it is ehioily popular among Hur- 

I ^euns who formerly paid less att«nlton to these point», and left tbt 

dwaaiingji tn the dirty hands of nurae» or to (rarelcsa «tudenta or 

^TiMao^ phvaicians, while now ihf dressings are nil appiird uornrding 

to oicliiiitc principles of cteanliiio««. Moreover, llie coDstanlly 

■pr^ading and more energetically prcaclied doctrine of local infection 

from wounds, of which we »hall treat bereaftor, has led to a reo- 

1p*ilioo of the ncccitsity of a rational treatment of wounds, and 

•la» cüntributed essontially to opening tho way for tho open troat* 

necaf of wounds — to l.lttcr*» method and nutiBcptic lotiou5. 



T^e« i» still another mode of adhesion of the edges of wounds, 
rhäcbonronslsin thfl direct union of twa adjacent granulating Bur- 
»«. Thia mode of healing, which you may eall liealing by the third 
t«l»Qn, Is unfortunately very rare. Tim reason of (his ia evident ! 
ia rcinslanlly secreted from the surface of the granulation*, and 
F«bVl« this goes on the furteces are only apparently in oonuot, for 
lb«' r Virtwcen them. Occasionally, it "s true, we mar.hy preiw- 

ing ^TTtuulatinn Burfaccs t<igclher, prevent the further forroa- 

^ra «f puB, and thcnlhclwo surface» may aohcr«; woaeeomplish this 
l»y dnwiog the ll.ipB of the wound firmly logntber with roo«1 adhesive 
pl*"*e/, or by the nppliralion of secondary piitures, for which it is well 
t" «mpkjy wire, Unfortunately, tUe attempt to hasten the cur© by 



108 



81MFI.K INCISED WOÜSDS OF THE SOFT PABT& 



these mean» so rareljr »UAceeda, that thoy nre only exccptiooally eni' 
ployed. The br«t results are oblajued from eet.'Oiidiir)' sutures whcDi 
six or Kveo dayi tftor the injury, tfacj ore oppUcd about four or five 
Unett froio the edge of tlie wouitd, beo&ui;o the tiseue is tliou more 
denao and firm, nnd th« sutures cut llirough It-sa quirk]}-. 

There la still nootlicr mode of hcsling, viz., healing of s superficial 
ivnund under a scab. This only oecun frequently in small vound«, 
chil »ecrele but littlp pus, for in thfse alooe does the jn» dry oo ihe 
wound to a firiuly-attoclicd ecuh ; iii profuse suppuntioo it is tnie the 
mpcrSdal layer of the pu« may dty by eviiporalion of the tntety 
portion, but, nrhile new pus Is coiittlantly being- e«creted under it, tt 
cannot fonn an adherent, Consistcut scnU VVLm audi b s^-^b Ua« 
formed, tlic granulation lis&ue doTclops to only a very small amoant ut>> 
der iL ; pcr^npR becauxe on account of the aligbt pressnie of the scab, the 
granulation tissue is 1e« mucous, so Uist the epidennia can more 
readily r*gcnemte nndor the »cab ; «u«Ii « «mall iround may be wholly 
dcatriied «rhvii llic n-ab falls. 



The granulation surface may assume a totally diflerent appeanmoe 
from thiit nlmvc described, cspt^ally in largo wound». Tlicre mn 
certain dUtate» of thi gtanüiaiion», vboM marked forms 1 shall 
briefly skolcli for \-ou, although the varieties are so numerous that you 
will only Iporu them from individual Observation. "We may dirfdc 
granulation surfaces as follows : 

1. Proliferating fungous granulations. The expression " fungous* 
means nothing more thnn "Apnn);;y;" hnnee by Aingous granulatimi» 
ire mean those that ri»« nbovc 1-liu 1cy<.M of liie skia, and lie over tfae 
edges of tlic wound, like fungus or spong«. They arc usually TCty 
soft ; the pus secreted is mucous, glairy, tpnadous ; It coolains Cffwer 
Mils than good pus, and most of the pus-cells, like gTiinulatioD-<iclIs,*rc 
filled irith numerous fst^Iobulos and mucous motcrisl, which 'n uisc 
mar« abundant than normal as Intercellular substoooe; and in lliese 
gnnulntions JiinctfleUch also discovered collectioas of Virrhene'» 
mucous tissue, fully developed. The derelopmeiit of ressdb ip«y be 
very prolific ; the fragile ti^stie often ble«fls on the slighted touch j 
occasionally the graniilations are of a rtry dark l>Iue. Ill other rasm 
the development of vessels is very scaaty, often to such ft degree thai 
the surGaco is liglit red, or in spots bs8 even a ycllowislt, gclalinous 
appenranoe, in very amcmic persons, often also in yoic»; children and 
very oW persons. The mowt frequent cause of dereli>pment of such 
prolifstating granulations b any locnl impediment to the healing of 
the woun<l, such as rigidity of the surrounding sk;n, M that the rnn 



DtSEASES or TUB GRANULATIOHS. 



100 



£«41 of tlie cicatrix is iHfficuR; a roretgn bod/ al llie bottom of a 

«u* gniDulatinf; wound (a fistula) ; this nbnomial prolifcmtioa ü 

J<« f!MrLiGuWL/ npl to occitr in large wountU, which cftD only miitract 

il^wl^'; it appears ns if the adivilj of llie tissuu vros occasionaltjr ex- 

l^nst«^ kod DO longer upabl« of coDliniäog the roquisita ooodeoM- 

t^ »Ad cdcatrizBttoo, so that it on\y produo's relaxed, spongy graiiii« 

Utiovxa. As \0Bg u there am granulations of the aboTc rhanu:tor, 

vitag above the edges of the skia, cicatrizution docs not usually pro* 

pt*A. The wound would prolwbly heal, but not &ir a very long timp. 

We liaTe plenty of remedies for basteniag the healing' under such cir- 

comfllAacE«; these ore especially cauatics, by which we partly dcatroy 

^ gnnulation surfaec, and thus cxdl« a stronger growth from the 

.Iff th. At first you uuty cauterize the granuUtin^ surfniHi daily, ec> 

pewlly along tlie cd^ea, with nitrate of sÜTer, whereupon a white 

^A^ will quickly form, which will beoome detached in twelve 10 

t«eatyfbar hoora, or even sooner; repeat this ciiuteriation as ro- 

(jmrcd, till tho fiTanuUUD;^ surlace is even. Another very jfood rem- 

rtij \i bfäukUag the wound n ith powdered red precipitiite of mercury 
(kjdnt. oxyd. rubrum), which also should bo ropcntod daily, to hn- 
pnre Ihs granulating sur&oe. Compression with adhesive pliisteni 
alwtdavcry well occasionally. If the giauulatious be execnliajfly 
ism sad large, we often may succood soonest by ontting some of 
An olT with the MUBOca ; the eonacqiK'nt hicroocrlinge is readily 
«nsted by applying chariMc. Wbcro the pmlifcmtion is lesa, as- 
tringent lotions, such ns decoction of nsk-bark, rin<')ions-bark, lead* 
ntet,ctc., insy answer to excite tlie aluggiuh cicatrization. 
!■ By crdltitic »jranuiation« we uie»ii tho»e diaraetcrin-d by great 
fain Ol the slightest provoontion ; they are usually very prolifcrant 
glUiiliUons, whtoh readily Iileed; it is a very rare condition. In 
omsin erethism of the p-anulations, thuy arc so sensitive that they 
flUM endur« the slightest touch or any drcsaing ; a less dcgreo of sen- 
■timienof tltegntnidatiansisnoteormre^ Onwhatitdepeads,isnot 
*tST ocrtiin ; gruotilation tissue itself has no nerves ; in most oaaeo 
^"■^iiig it causes no •cusBtiou, only the couductioa of the pressure to 
i^Mbjkceiit nerves causes scnssUon. In the above excessive sensibil* 
"Ti FnbaUy the ends of the nerves at the floor of the wound are degeif 
(Mpd ö a peculiar manocr; perhaps there arc miniature thickenings 
('tbclinost norr&«uils, like tiioM that wc shall hereafter sec on large 
"■^^^wnks. It would be a thankworthy task to make a careful ex- 
■■■"»OB of this question, W« oocasionslly observe similar oondi- 
h the eicalricps in large nerves, and aluUl B[H>ak of this hereafter. 
Fw 4ü ypr^ painful sensitiveness, which not only interferes willi 
but greatly worries the patient, you uwy first try soothing 
v 




i^i 



110 



»lUrLE LS'CIdED WODNDS OF THE SOFT tASlS. 



oiDtments, almond^iL, spermMeti-oiDtmfiiil', or simple cataplasms of 
boiled oatmeal or linseed-ineal, or warm-water compresses. The nai» 
cotic oompreaaes or cataptnama, niniie with the addition of belladoooa 
OT bjoacyuraufr^CBTva, are of Utile beuctiL If ihese aj^UcatioiDS do 
not answer, do itot itoiiiy <I(>slrojiiig Ute entire gnntilating' surface, or 
at bast tbc painful purt, witb cuuatio (nitrate of atlTer, caustic polaah, 
or tbe hot iron), with th« patient anaesthetized, or eJae exciaiti|f the 
entire surface wil k the knife. If tbe grcnt painfulness be due to bjs- 
teria, nnrruia, etc^ jrou nnll nnt altaia much hy anj local rei 
but aliould try to aaauage tlic funeral irritabiUljr by inlenial rem 
auch as Tiilerian, oaanfiiEtida, ir<rin, qiiinitic, warm batb«, Ptc 

3. In large vrounda, especially in fistula gruriulatiooB, a yellow riod 
«oiQctimca farms on part of the granulation sarEacc, «hidi may be 
teadily detached, and on careliil examination is found fo consiat of pot 
cells, very firmly attached together. Altliougfa I Iiave sometimea 
found coagulating filanieiits between the cells, they do not always 
owur, lieocc we must suppoee that the oell'body, the protoplasm itadi^ 
ifl tnnsfonncd into ribriiie,aa occurs in true croup, and eqieciaUy in tba 
fisrmalion of (Ibrinous ile^tusits on serous membninta. Here 
also a crc^u/) of the granydaticM, Tlie cconpoBs mentbrana 
even a few hours after ita Tenwml, and this is repealed for sevetnl 
days, till It either disappeais spontaneously, or (inallr ct.'aee« on on» 
teritation of tbc affected part Vcoy aimilar white spots are ooonnoa* 
ally found on larger granulation siBfaccs, which are probably t>ol 
caused by fibrinous dcporäta, but by loral obetmctioa of tbe blood* 
Vcasi-ls. Under peculiar, unfaTorablo conditinas, both states uiay re- 
sult in deslnxtion of the granulfttions, in a true diphthtHa of tbe 
wound, which we ahatl heraaft«!? tn-at of as fuuffittU ffonffmut. Vof 
tunately, however, it »rely goes on to Ibis dbeue, but the stat« of 
the wound improves again after a time, and tbe reoovtvy takes th« 
tutnalcoursa 

If diAeiise of Uic granulaUng sut^Ke be aeoompauicd by awcIHnf, 
f^tkX pun, and fever, we have a tnie acute inflommatioo of the wound; 
then tbe muL-ous grunulatiua substanoe aoinotimcs coagulates tfarough- 
out to a fibrinous masa ; the wound^urfsce loolm yeDow and groaay, 
I ebatl treat of the causes of these seooodary wflammatioaa under the 
bead of contused wounds. Usually tbe iroiipous inSanimation, whteh 
has aflocted part or tlic entire surfHCC of a wound, ends In sloogUog 
of the diseased grannlatioua, wbt-n-upon new gnmulationa spring fron 
tbp df-pibs. 

It cannot be dented that tbe perfectly local, superficial, and Inte^ 
Btitial deposit of fibrinc strongly supports tlie view that FZncAou 
has proposed for croopoui proeeMC« generally. It was formcrlir suf» 




DISEASES OF TOE ORAATLLTIOKS. 



Ill 



I 



» 



po«cd tliHt In all iiiflaminAtory croupous prowss, «ipeciiUIy io the 
ardinarjr form of acute infbniniatinn o£ tbo lungs aad f^eura, the 
IiIixmI vbs ovcr-rkb ta ßbriar; tliat tliemms a 6brlDOll8 cnutis in the 
Llood, 08 a result of which, the excOKSire tihrine e^cttping &om the 
cajHlUries, coagulates partJj' on, partly in, ttiu iiiäsniL-d suriace, and 
ao led to ilie fonnstion of thc«o pscudomcmbninous ilcpoüta. Vir- 
«A««eV on <he other bsnd, propos«! ihe idea, that, by the inflammatory 
process, ths tissue maj be placed in a condition to cause oosgulatiun 
of the fibrinous Milutioo mfiltraling it. I cannot here enter more por^ 
ticularly into the Tarioua grounds oa which Vir^ftow bases tjii> vicvr, 
but shall onhr call attention to the fact that in tlie ease In qtiosHun 
(of Ebrioous exudation on the granulating siirfiu.-^), at Icsst there can 
be no rnpidly coujinj; and cTanc»ccnt fibroos cni^ia of the blood; but 
evUvndy it is a local ]woc«s8 which may ri?adily bo rcmored by local 
reEBedies. According to the n-pcatcdly-mcntioncd observations of 
A. Sehmidl^ we may infer that in certain quAntilAtlve and (jualitalive 
{rritatioos of the tiggiie, mwe fihrogenou» tiiiaue than usiinl esenpcs 
from the capillaries. Vitrhow liad even previously caller) attention 
to the foot that, from repeated trritaLion, simple terotis exudation may 
become fibrinous or oroapoue. If you apply a »pnnifh-fty blister to 
the skin, a reueJe filled with serouK fluid forms — the superficial layer 
bctqg lifted &oin the reto niucosutn by the rapidly-forming serous exvf 
«latioti; if we rcmovo tbc vesicle and reapply the blister, m Duiny 
mm after a ft>w hours we shall Cod the snrfaee covered with a Gbrin» 
ms layer, which caotains innumcTabIc ncwly-formcd cells; indeed, is 
almo«t entirely roniposed of tbom. \Vc may attain tbc same result by 
applyin^f tbo pliister to skin already inflamed, or to a young cioalrut. 

Tbe treatment of croupous inflammation of the granulations is 
punjy loc&l ; wc should carefully seek for any causes of new iiritu- 
tioo, and try to r«novc tliem. Daily remor« the fibnnous rinds, and 
eaotetuBO the exposed surface with oitntt« of silver, or pnint it with 
llnoturo of iodtnr, and you will soon seo tbis abnormal state of t)ie 
graanlsltog sorCacc disappear, 

4. Bcwdc* tbo abore diseases of tlte gianuUtions, tliere is occa- 
SHMially a state of perfect relaxation ai]d oollapse, in which (liey pre- 
tctit an eren, fed, snwoth, shiny surfsice, from which the nodular, 
granular oppearanco has entirely disappeared, and, histeud of i>u», a 
thin watery scrum is aeorefced. This state almost always occurs in 
the (rraniilatioos at tbo cod of lifej as already mentioned, you always 
find it in tbe cndarer. 

It b still necmnary to add something about the cicatrices, con- 
t^rming certain subsequent changes in them, their proÜforatiön snd 
their shape tn ditTerenl tis&uea. 




tfT^ 



]];; 



SIMPLE LXCISSD WOUNDS OF TUB SOFT PARTe. 



Linear cicetrües of wounds, ttut liarc boultKl bv (int int«ti' 
rarely uiitjergo subsequent degeneration. Large, bruud cicfti 
especiuUy vihca they liu iinniediit«ly on tlie buoc, often open sgsia; 
tlic cpidemiis, vrbich is tender at fint, being torn off by tnotion or by 
tbo leuttt blow or fridion, and tliero is supcrficiul atiopliy, an exooriop 
tion of the cicatrix. Somctimca tbc young epidermis is ck-valwl like 
ft vceiclCf by exudation from the vceseb of tbc eiciitrix ; there moy 
also be some bsmorrhage, so ttist tbe vcsjdu will be filled wilb bloody 
senim. Then, after removing tlio resiclr, you bare an RSOoriBtiun, aa 
after liinple nibUug off of epidermis. Tliis opening of tbo cicatrix, 
if often repeated, may prove very annoying to tbe patient. Yoa pr» 
Tcnb ibis tnoAt readily by causing the )wtient to protect iJie young 
cicatrix f^^r a time wilb vraddiiig or a bandage. If the cxcoiifttioo 
ima lakeu place, apply only mild dreuings: oil, glycerine, nDo««|^^l 
etc., or cmplastrum oenutsa. In these ca«es, initatiog sulres «nlufB 
tbe wound, and conscqaoDlly should be avoided. 

If tlie granulating surface be once perfectly covered wilb epidcn- 
mis, as already stated, tbo rctrogressiro changes to solid oonnocüve 
tiaauc take place iu llic cicatrix, and it atrophica. But in raro cases 
the cicatrix grows independently, and develops to a Una ßouocctiv& 
tissue tumor. Tiii» h s'^en almost exclusively in small wounds tbat 
bare loog suppurated und been covered with stmngy grooulations, 
over which the opidonui» formed exceptionally. Vou know it is tbe 
custom to pierce the eur-lobes of little girls, so tltnt tbny may suha» 
quonlly wear car-ringa. Tliis little npcmtioa is done with a i^une 
needle by the moUior or the jeweller, and a small car-ring is at once 
introduced through tbe fresh puncture. As a rule, thin puncture sons 
heals — tbe ring pre^eiiling tlie closure of tbc ojicaint;. But in other 
oases there are active inflammauon and suppumtion ; indeed, If Ui« 
suppuration continui?, tlie ring- nia^- cut downward through the 1o1>e; 
granulations develop ut the openings of entrance and exit; finally, 
the trial is given up, and tbo ring remoTod} tbea the opening oflen 
heals quickly. In other cases the graniUntions eii^trize, tbn cicatrix 
continues to grow, and on both aides of tlie lobe of Uie ear small 
coonoctiTe-tiasue tumors, small fibrfwd», form. These look like n UuA 
shirt-button drawn through the hole of tbc ear, and tbcy grow inde- 
pendently like a tumor. If you exaniinc these tumors, on seetiim 
you iiud them of puru white tendinous appconnce, like the cicatrix 
it4clt MicroBcopieuIly tlio tissue is found to omisiät of conocctiT« 
tissue with Diuncrous cells; it is simply a proGTention, an hj*pcrtropliy 
tlio cicatrix. I have seen this twice in the ear; anotlicr case it 

Dtioocd by J^i^cnbach in his opemtir« surgery, t one« taw 
similar tuman on the back of tbe neck, where they lind fbrmed at tbe 




CAANG^ tu CICATRICi:& 



J13 



•peuioga matle fur a ttulon ; they wore about the eizu of a horeo* 
dicsUiut. Tlio^' sliould ha carefully removed with tho knife, aiid *ny 
tuW^uent granuIattODS kept in Buhjcclion bv nitrate of ailrer. 

I^Tlio tranalator has seen the alxnx tunii>rä on the lobe of the ear 
^rcral tiroes; in wM but tvo instAnccs thcj occurred in mulatto 
feauleä' in one cusc the tumor had roltimed after n previoita it» 

In the above description of tho foroiation of graaiilationi and eica- 
^ice», for tlio soke of KimpUcily wc have only referred to the process 
jtj» it is found in connective tissue, but must now speak of it as it 
flftytun in cioatrizatioD of other tissucsi. 

The deatrix in muscle is at first nlmoitt entirely connective tissue; 

rui. ifi. 









Ikon «rr b*f« Mnonhiä lor* tliiin diiuuiw. Mid icnolaau ti ■ coitct] itiapa. Müiik 
^«4Kadtain«toK 

in *-lje cwl» of the muscular fibres there is at first dostruelion, then »t 

a c>^ärtun boutidiry a oollucUon of nuclei ; tlicu there is rounding off 

of ^13« fibfes, sometiincft club-shaped, sometime« of more conical form, 

aaiA llic aliuups oC the muscular obres unite with thu connective ttssiie 

ot Cfcc cicatrix jtiat as they do ivith the tendons ; the muscle cicatrix 

beooDHB on inseriptio tCDdinca. I mywif bavo only observed them to 

»t>«aial8 of musclo that hud heided by first intention, and liiivc never 

th^rc scm any t ilin g tliat I could decide tvas n nen* fi^rtuutiuu of mits- 

eulxkr liasue. In suppurating ends of muscle, O. TFl^ has tvitncMcd a 

tti^lit fnnualion of netr muscle ■ this appears to otxiur ehiclly in fur- 

Bu&'fcioa of grvnuladoos oo muscle and in certain tumors. 

TTiier is of tlic opinion that, young muscular fibres lypiciUy fonn 



IH 



SIMPLE INCISED WOCJTDS OP THE SOFT PABTS. 



fnm the cells of old ones, but ooosiden it impoftubl« to prove tbnt iio 
rauM!uLu- ccIIe onginate from othor J^ouzig cells. As n. rtsult of bis 
exaniinutit^ of oM musculur cicalrioes, fac abo mainlains tlut the re- 
geucnilioii continues n long lim^ tad in most ossch is more oomplcl« 
than is gcnenlly i)upipo8«<L Mathu^y has afBnned the InetaIno^ 



no. I». 



'/Tjii 



M 



ftidiofdhtMmaMobribratnvnih'MwpaiBwtttvfft nU4t «bbt 4^7* •Rot Ibe talMTi 
■ »A old nMtenlu SbrM: dLUi«cuiitimcilla*iibaUUiwndttd ip «ad Mtlod UHlMMr: U* 
MM» ii»f Im thabaoilW ahojod; Ih« woi» wtik Ih^Mvoahama dmm oot to a polnl; a 
laM the pslDUd BOTnrt'«lm»ga MHulcDuiia luboexunAikMita otjovumatatiat affcM, 
lw* w w «-bleti IlKin U «tty dnlloin tniitr*ntr «tftewd M)i*ta»Mt «. 11m *bb« «rlik 
rouw. ftM fbOKto-edb : /, iwa jobiik tibbMiliLs mwrepkr OImwbh ; f , U> mu «tn* 
ou di* l«ciiUd. llagBatd4WdlaaMi«n;Bntra IRMp. 



pbofilB of waodcring celts to mu&cle-oelU ; liuti ooD.<iidcr lli'> ctnnafnr 
metAott enplojod hy Uim lu üuufficteut to prove iliis aMciiiuii. [Ciu- 
Dttbur or reraulion iiijecte^l into the blowl ia takün up hy white OCV* 
puscles, aiid majr aAcrwsrd be discovered on inflamed (issue.} 

O u m m i aiiur has shown that, after iojuiry, the nitsoakr filaments 
usually break donrn into Ditkes, and then dov }-ouiig muselfr-ceUs 
fonn, m^er tlie type of embr/oual dcrelojiment, from the cells con» 
taiuod in the old musde-filamonts ; the amouot of the now formation 
depends on the qualitj and duration of the irritation. 

If a nerv« be divided, its ends separate, froiu their elogticitjr, tbej 
swell sUglitly, and subsoqucntly unilo by devolopOKnt of a ncn' formo- 
tioQ of true ncrvc-tUauc, so that the nerve is »gain capable of cobdoo- 



CICATRICES LV MTTSCLES ANB NERVES. 



115 



Itfc9X^ -throu^ ibe cicabix, I» large tiup«rficiitt cicutriccs, new nerres 
(/f^-v^^Inp; wSen voubucc pxclced portions of skin flmlliavR brought 10- 
{ ^^ C.,Xs c^r mul uniltrJ part« IvinfT >t a dislano*, new ti>_TVL-8 ^rocr tlimu^ 
if/)«? «sicTitrix and perfect power of conduction comes a[tcr « liinc, oa 
|ifj^._y fce ofUm ohsorred in plastio openitionB. These f«ctii arc rerv 



Fio, M. 




ä 



.^^' 



■J/. 



renukrkklilp, Aiwl phvs*o1ogically arc still entirely inexpliouble. Juat 

think bow wcmderfut that tliese Derr^filaments, sensorjr and motor, 

should find e»clt oilier in tire new adliewoD, ant] that even, as we most 

■appose, the «tum|» of tb« primitive fibres eboulil unite us titc^ Imd 

been miitiM], Ro tluit rorrect conduction «nd tocalication might rcsuU 

>* Ui^ actualljr do I We oaiioot lierc go more exactly into this suV 

|eot« I will only mcatioa ibab tbc more minute procees, wbich bas 

D«!<rQ very rjirtfully followed by Schiff, IljeU, and otbäre, is gi-nonilly 

*» folkitr» : finst, in the stump of tliu ncnc there is a dcslruetion of 

'he n«nr«^heiith, possibly aUo of the axis cylinder to a certain extent ; 

U the saaie time in the neurilemma there is a colleetiou of cells, 

*nücilt proccoiia to the derelopmcnt of spindlc-aliapcd celU in the su1> 

*^otc« lying between Üw ends of the nerve, aud extending into tlie 




lift 



S[UPLE ISCISED W0CN1>3 OP THE POPT V.KKT9. 



VI 



V 



stump. From tbeso oelU, just && in the embryo during; iatra-utcrioe 

life, new nerve- Gbrillie derelop upward and down ward; llic lilamoDls, 
wliicli nn? at lir^t vrrv ]>nlc, Hultserjiiently acquire a sbeacb, aud llien 
VBDDOt be diätiiiguisb^d from oniiritirjr nervc-filaineut«. 

Tho most recoDt 
'^ **■ '••• •*■ inrestigatjoni as to 

tho stgniBoanoe ot 
wandering oella in 
new fonitatloa of tls> 
6ue, 18 well u llic 
special rttidi«« over 
the furmatiou of 
nerres in portions of 
tadpoles'* tails ccg«o* 
erat«d n.rtcr ItijiirTt 
have nvndc mo doubt 
the fortDcr view, tliat 
younff r^«nenit«d 
iierve-fdaments were 
composed of spintilo- 
cclls. It semts to nte 
muoh mcire probnbte 
tliiit the divided axis- 
uylindem grow out in- 
to ^(King- fierre-ßlamotit», and thai tlie plcrigritod xpiiidlo-odla, which 
iindoubttHlly exist in tho nenx-cullus in certain »la^», cillicr bolong 
to the conaoctivD tissue of the iicarilemniB or an dctAch«d portions 
of young nervc-lilaments oontaining nuolei. 

The UiAt invest igatioits of ITeuiimnn and Eiehhorat confirm prv- 
rious ones in n.'giird to Ww immediate; results of djvitüoii, but »how 
that the young nervi>-filnment»t gw>w diwwrtiy from the axiÄ-eylindop, 
as w^ fron» tin? eenlral as from tbo distal part, me«t togotbcr, sad 
Ucod, a« the oSnhoot« from a capillary wall sink into tlio wall of 
another vessel, and ro may form a communicating eanal botwcen two 
veuein {^Arnold), Tho pmoess in th« wounded nerre correspond« 
moat bcflulifnlly with that in wonndcd muscle. In llic muscular as 
in the ncrrous filament »crend young filaments Bprout froo. OIM 
primitive filament {a. Fig. 33 a ; compare Fig. 20). 

So it is shown that musrleü, vessels, nerve«, and cpilbdium are 
not regenerated from prolifemtinj; conuecttve-tissue celb or wan- 
dering eelU, but from throwing out oBichoats from their tusuc, or 
from cells derived frotn the protoplasm of their tissue. It is vury 
probablo thai counccUve-tissuc cclU alao, specially those atill oon- 



illrltlaa; jonnc 
frMB Um 
Martkniiw. 



V\t, V. Aqm ■ nhbit Aflrm itjt afttr 

tlHiMMHl tnUinaUly mniutt»! '*Iil> ilie 
riK. U. frnra ilift Ihc (en wcrili aArrdlililnD: 
dnalooBWDldf ]rü<ti«n«n>«'prll*h<iiintlioinladl«-t«Ut. Mu- 
UOmI Wa ütomslm, dUr Bjtlt. 



CTICATBICK3 Vi MDSCLBS AXD KEBVES. 



117 



toinbff protDpla«tn, ecoil out offshoote at tbt wounded part In whioh 
tuidei sab»quently form, nn is done in the norvos of tb« tadpolö's 
teil Thi« point should he inrestigatod ngain ; titl then w<i ni«y n;- 
gtrA wfcod^ring c*!b ■» the sourc« of the jouog regencnited tissue. 
Since ^cAwonn'j twicliing about tho dovelopmeut of lissite from 
oelb, we are so cotiviiin>d that every ni'w Lissue pmccAds from youajr 
««lis, that tho «nnouiitenicnt of independent growth of it purfert 
tikHW witbout (olerrentiofi of ceris finds little credit ; and the incream 



rut. a *. 




I capi 

■r 



of oeUs bj nOr^hoota, vilb suluoqiient dvv«loi>nicnt of nuclvi in theRO 
oflftbcols. Is B procvd«rfl Ihnt liistologists hnro long kopt in the 
bftckgifMiad, «ubatituting for it cell-division, nllhongh botanist« hav« 
••cfibct) a Terr prominent rAto to this modß of developnent iu 
plants. FrtKii tlx' laio^i ptihlialK^ obftun-aliiw« wc «w th»t the 
capiHarj walls, the Hxiy-Qjrlindcr of norvM, nod tho contents of niuit- 
eular filaments poMcss thi» capocity for outgrowth witlioat dii^et 
;i of now rt'Its. Jiokitiinnly ascribed to connective lis- 
. ily fiT iodeprudi-nt outgrowth. 
In thp hnfUati being thi» regeneration of tifrrvr*» only tskes pIsco 
witfain KertJiin limit«, whirli, it ia Irue, cannot bo very accurately de- 
fiovd. TIip ct>niploto t^gvncration of largo nerve-tninks, as of the 
Mtsltc or mt-dian arrrrt, dors not oc<:ur; nor doM it take plu«? after 
etciclon of large |v>rtiona of ncrre, ii the ends n-niain, »ay llirce or 
fot» Knot apart. Very accurate apposition of the cnda of the ncrre 
i» n*>ces*»ry, for np;<an>iitly th» t ransf orniation of Ihc ncwly-fumicd 
iuterinr<Iial«' <uih>>liiiiro to nerve-siibslance can only tako place by 
means of (lie nerre-siump, altliongh there are difTercnt opinions aboat 



118 



SIMPLE rSClSED WODJTDS OF THE SOFT PARTS. 



Üic modo of tili»! proceft« ; vre shkll ie« slmiUr oontliUons in Üie heal- 
ing of broken bones, wlit!?« bony union oaljr (bllows Kocornle coapta- 
tion of tlio frtgrneat». Kow, bow is it ia tbü respect with btain «od 
spina) tiasue ? Id tbe bumaa boln^ tlicre is no n-goncTmtioB here 
afWt injury, or after loss of »ubstancc Irom idiopathio itiflimnuition, or 
at Icaat not sufficient to restore the po\r«r of conduction. In aninuils, 
indeed, as JlrowtfSi^uard baa shown in pigoooa, after divi*liu^ tlm 
^nal marrow, there may be rcgt-iicratioii with dtsappearaocc of the 
pmalysis, which bus of course occum^l in all purta below tbe poiut of 
dirision. Unfort-unntelj-, this power of rcgenprauon of pfirres dccrcnse« 
in proportion to the bigfatT davvlopinciit of tbe vertebnte uniinnls, 
and it is least in man. As ie known, in jounj^ BalnmandcrB wbulc 
extremitiee (frovr ag^in whoo they have boon am]>iitatocL 'Wliat a 
pitjr this is not bo in man I However, a& rpgnrds the nerves. Nature 
occaftioniLlly seems lo make a fruitleaa attempt at rt^ncratinn ; for 
quit« otiCTi the ncrv«-eQ(Is in amputation-etumps, instead of simply 
cicAtriziiig, develop to diib-sliaped noduleii, which arc oocaMonalljr ei« 
occüvcly poiufui, mud require subsequent cxci»oit. Tboae nodules on 
tbe ncrre« consist of »n cotanglonioitt of iho primitive ncn'e-ftlnments, 
which deTclop from the atum)i of tim nerve a« if Uiey «rouUl grow to 
meet c^iposite ncn-c-cods. The. ricatrices Ui tbe conUnuilj of ocrrea 
also ate somctimH nodular from tbe formatkn of coQToluted primltirA 
fihiRitMits. Such »mail nerve-tumors (true neuromata) aro oooa«ion* 
ally excensivelj: painful, and muM be removed witb the knife. But 
there arc also traumatic neuromata, ivhicb uro not nt all painful, as 1 
haire seen in old amputation-etuinpa. In gunerel, these prolifemliona 
of nervMUcatrioea are to be compared with tbe previouslf-[n<>otioaod 
by|>erttoplij of connective -tissue oicatnocft, and witli proliferating 
bone, wbioh, although larely, is formod in great oxccw in tlie bcaltog 
of broken bones. 

The process of boaling vSUn injury of great vessels, especially of 
arterial trunkfl, has been carefully dctcrmiDcd by expcrinieot. If a 
large ortcrj be Ugated in an amputation or for disease in its ooulinu- 
ity, as tbe ligature ia drawn light, tl>e tunica intima is ruptured, and 
tbe lu>m-u riiuscularts and adventitia arc 80 constricted that tboirinDet 
snrfnix« folded up lie in exaet aj^positioiL Yuu may satisfy youtselves 
uf tbe Irt'qucut altliough not Detxataarily lutircTsal niptun: of the ii»> 
t«nutJ tunic, by Ugatiag a largo arterial trunk in the cadaver, for you 
not unfrequently experience a alight grating or crackling under tbe 
finger when tiglitcning tbo ligature; you may abo see it oa cutting 
open a ligatcd artery after detachment of tlto ligature. From tbo 
pciLnt of ligation to the next bcnnch leaving the artery, both at the oen- 
tisl and peripheral ends, the callbra of tbe vessel alls with coagulated 



i 
I 



FOKXJTIOK OF TTIR0KOC& 



11» 



Fian. 



[ h*» I m* »trrr- tgrwln* Una» In ui oM iimpi;bll<>a-Hninp of V'O »m. rmm BpreiMrailnn la 
ttft« AgmmoUU HsMiiH *t Bfliik. U)pl*dan4r/Vc«wii.''BiirsktJDDp(M4platM." M.L, 




Uao^ the so-caOud thromiue (from 6 Bpofißof, the bloocl-clot). The 
<«r«Ioping ligAtnre kills t\w cnclo9C<l tissue, which gradually broaka 
iam lato pus, aixl vrUen this process It completed iJie ligature Jails, 
«,na we tcchnicaJly cxprrss it, " the llgal^im lias cut through," " comrn 
ly." Whca tliis has token place, the «Ubre of the artery must be 
ally RDcl certninly dosed, or tliorc will nt oiice be another 
age. Un(i'?T unfavorable cirtniniBlances it miiy certainly happen, 
In null as well a« in ortories of medium or lar^ size, tliat tJie ligature 
call ihtwigli too soon, and then dnngerouK, »udden secondary hsemoi^ 
Atgt Mcura. We toay foreseo tJiia if tba wall of tha urt«ry vra» di»- 
9Wl; oAea calcified u-t«riM oanibot be lij^tod, as tho ligature doca 
<>ct oomproM tlwm or cuts through them iit once ; sometimes the ar* 
•«7 15 softened (fts, tor instoDcc, wh«n iwirt of ita courso ha» b«!ri 
f^f^h the wall of a largo abscess) eo that on ligation the ligature 
^"^ tluougli and must bo applied hrther ujx But unfortunately, in 
P^^Srtlr healthy subject«, as I fbimd iu tbc Inst ■war, hifrnorrhiigca 
*^ often occur from iho point of ligation of largo arteries, where 
'*'*^y -applied ligatores cut through before the organic olobure wns 
nm tjioQgh to romst the currcot of blcxid ; this greatly impairs the 
T»hie of such operations, which are often temporarily DoecEsarj le 
teTB Uie pBtienl'fi life. 




MO 



SIMPLE INCISED WOUNDS OF THE SOFT PAKTS. 



rio-M. 



Artorr Bfftti ht Uw 
raaliiHili)'. llmM* 
taw; «nor AortVi 



PaAsing now tp tbe coosidtnatioa of what has taken pluce in tlie 
end of tlie veosel from the coegulaUon of the b1ix>d till tlw finn dosurei 
cxporimcut» on animals and acctd«DtaJ obs«rrattonB 
on mun bavc given tlie roltowiiig: tlic blood-ulot at 
first Ij-ing loose in tlic vc-sscl gruduallj bocumcs more 
firmly attadiod to the wull of tbo Tcsscl, and «on- 
Ktautly grows banlt-r, but still n-tnains red fora lung 
time ; it docs not lose ila color for weeks or months, 
and then dues so first in the oeutre, eo that the rest 
of it still retains a slight jrellovLsh tinge. After the 
detachment of the ligature, the ihroinbits is so baid 
and su firmly attuchud tu tlio walla of ttio resftol 
that the calibre is «ntircly closed. The preparation 
(Fig, 24) shows you the thrombus formatioio in an 
artery after ligation in tlio continuity; tfaa loner 
thiombua reaches to tliO point of departure of the 
fitst branch, the up[ier one not so far ; the fonner is 
the nilo as laid down in moat books, the luttor is a 
not uDcomraoa exception. Plugging of the artery 
bf a blood-otot, which beoomes firm, is, howerer, only 
a provisional state, for tlie thrombus docs not remain so for all futufO 
time, but tiie eicstriciat Ussu« shrinkd and atrophic«; thia takes placo 
in tbo course of montlis and year«, at which tim« th« bloanre of the 
arlerjr at the point of diWsion has become solid by adfaesioa of the 
walls of tho Tcsscl. If you oxamino such an artery a few months after 
the ligation, you find nothing of the thrombus ; hut the artcry^ terroi- 
natcs in a conical point of otcatricial connective tiRsue. 

The above ohange«, whioh we may follow with tlie naked ejc^ 
chow that in the blood-olot there is n change whidi csaontialJj consists 
iu its iucreaiiing firmnes.« and coherenoe to the wall of the vessel ; «a 
shall now study with tlie microscope on what this transfbrmation of 
the blood-clot depends. If yon examine tho rccwit blood-clot, you 
find it to consist of red blood-oorpuscleo, a few colortcsa Uood-oeUs, 
and of fine filnraenta mid ooagidatcd fibrine, orrsnged in irregular net- 
wock. If you tukc a tbrvmbus two days after the ligutioo of a small 
or medium-«i&;(] »rtcry,it is firmerthim at first, and is bruktin up with 
dKGculty ; tlie red Mood-ccUs arc tittle changed, the white ones are 
greatly increased; they haro sometimes two and three nuclei as pre- 
viously, sometimes single luilc, oval nuclei with nucleoli; some of 
these cdls are alniost double tlie size of white blood^ells. Tho fi: 
filaments of the fibriue nie united to on almost homogeneous m. 
wtticb is diificult of division. If you again examine a thrombus si 
days old, the red blood^cells have almost disappeared, the fibrina 



4 
i 





FORUATION OK TUBOUBCS. 



121 



PM.1E. 



toore &nn awl liomc^^eiieouB, and even more difficult lo separate than 
preriouslj; m brge Dumber of epiodlu-aliiiptid cells with ovii] nuclei, 
■bowing diAtiuct diiisioas, appear. From the alK>vc, it appeon 
tliat evt-n quit« eaHj a number oT iii-ing oelU appear in tito blood- 
dot, wbo6fl furlber dcvülopmcnt will be seen from wtuit follows. 
Sioc« we obtain a more accurate uuderstandiug of tbe cb«iigi>8 in tlie 
tluombiu and iia relation to tlie arterial walls, by mnlcing tnuurano 
Kctious of tbe tlirontboaeJ artery, we sb»ll proceed to Ho this. 

Tbis prejMLralioii ttbowa a Iraosverse »ectioa of a rcccot throm- 
liua inaBiBallarU-rT;ivitltin,thc d<^licatc ino«aio fortnerl by the crowded 

red blood-forpiisclc*, amoDg tliem a 
few round while bloodHxUs {which 
bare been nmdercd visible by cat^ 
mine); next comes the tunica iutinia, 
lai<l together in regul-ir folds, in 
vhieh thfi blood-clot olings ; th«n the 
tunica niuiioularifi; tlicu the ttitiii:» 
adveiiLitia, with the nct^work of c-tiis- 
tio fibr«« ; to the right Mme adherent 
loosti cotmectiro tbgue. Tlio next 
preparation (I'^. 26) ü the transverse 
&cotiou of a human artci^} oloscd with 
a thrombus for six dnys ; we eee no 
red blood-ceUa ; the whit« oitea arv 
.greatly increased, mOStljr round ; but, 
in ibe tunii» adveotitta am! surrouuding coouoctivo tisrae, thoro bus 
already been some cell infiltration. If we now examtue a tenikyold 
tfaioi&bus from n large mascular artery of the tlugb of a man (Fig. 37, 
a), we fiod it already oontainiog numerous spindlc-oellfl, wliich are partly 
arranged in stii» {subsequeotl/ veuels) ; the intercellular substnnr« 
u £huiietitary\ here reoilered trsn^HUrent by acetic adiL Finally, thera 
is also fennation of blood-vessels in the organized thrombus, as you 
ses in the folloning preparations (Figs. S8 and 29). 

It hoa been ualiiblitshed, by ilie iinTStigationa of 0, Webern that 
tbe Tcsicls of the thmmhits communicate partly iriih the calibre of 
tbe thrombosed veasel, partly with its \»n% vasoniai. 

The process of healing in transvcrsely-dirided veins appears at 
the firrt planwi to be mitfh simpler thnn in the artorioa; even in the 
Urge reiuB of the extrL-miti^it, the divided eiiiU f»ll («'■gether, and ap- 
pear lo heal at oocc, as soon as tbo blood has been obstructed at tbe 
ii«tt tbItb above ; at these valve« dots form, and they arc often much 
larger than is desirable ; this fonnatioa of cluts extending toward the 
Iwart will liercafter occupy our «amoat attention. But I have of late 



?S*an«tM HMkai of • fK*b duumlnii. 




FORKATtOX OF THROHBtJS. 



133 



If jaa clrstr Doocluslong from Üiose pn^paniljoiis, preeontod in suoh 

Öngtnuntarj- way, it uppcora that m the dott(;d WcxmJ there is a c«l- 

tnSa' infiltrfttion, which here leads to development of connective tissue ; 

j_ tfbort, that ih« thrombus becomes orgnnized. The thrombus ts not 

yyc^nouiCQt tissue, but grsdiially disapjtoars agntn, or, at Icnat, is re- 

Atx*'^^ ^ * nunimiim, a fate whidi it shares with many new fomiatioos 

P-- it ting from innanmmtiofi. 



V». K 



i^J 






- * 



■--/K^ 




iuo>pl*UT-oqmalM()UitiNilN*laibobaBi>Dart«rtal1blalU)Ki«Uo«. 

••tak,|Hifln)r«iütnd wllhIhklaD««niMlbMrof Uu lulfana; A.the Uiii«ll>ar the lonlsa 
tnUäsift iMtoalcaMBMBltfiij tnTarMdVriiBDietwiianmnmlT« tlMaa«id«k*tl«ftl»- 



s. Tbrombni wUb t«» 
lie Un 



Peculiar reatom cause«! me lo investigate more accurately the or- 

Eunaatiou of the Üirombu». Tbc importance of this process is mtber 

cxtensire; % point on ffhii4i joit cannot at present judge well, but 

«ill IiereafW be in a position to estimate fully, when we oome to 

**^t of diK«ecfl of the tcwcU. 

from my iavesCigatioiis up to tbc present time, I do not think I 
«Uie ntnci tlic assertion (hat coiigulatcd fibrino muy, bj-tüd of cells, 
U trsjufonseil into connccüre-tiasuc intercellular »ubetancc, altliouifh 
I Annot decide whether this be due to true metamorphosis, or to a 
cnclual ' i I'l of uell protopbisin fnrdi.sapppnring Rbrinc. Some 

'■IT« all. . > n:fcr (he oii^u uf ibo ^U, \(liii;h appear iu oon- 




184 



SINPI-E IKCISEI» WOirSDS OF TUE POIT PARTS. 



etmnUy-inoreasiug ninnbers in (be tlimmbus, to the wall of the rpuel • 
tbc arteries, ns well as the TRins, «re coutcd wiLb it lining of vpiUie- 
lium, wliicti to some extent represent« tho intwrmöst lamella of the 
tunioft iutioia. 'iliMc (>j>itluflial colU and tlie auclei ut tlie sLrblvO 



rra.m 






ML.; 



'Xy 






i 



i 



LOHltnifiut iKllnnnf 111« IIikimI »1(1 of th* cmnil in*i7 «f • dn«, tft 1 4*f* »Rar I 
tttUimdVia )*lnjm»nl; a a, laalt* tutluM «oil ta*iU*;t^ twaoi MTantltlk " 
4t dltsHin*. 

Uiiiellie of llie iiitima hare been claimed a jf>rt<^ |iy some aiitbai!%Mi 
that tbcy could let new cells be fnniied from tliem, and gn>w into tlia 
Ihnmbns; in hi* last work, I'hitrKh also inclinr-a to tlrisTicir. I 
adcnowledge that I my^eir ft^rinerly stnnigljr oornbaiod the suppoiü* 
tion that tlm blood cuuld of itficif become orgTinizod to connecllvt* 
ti»8U0 with Tc»icU ; Sut f^m examinations of tmnevcnc BectJona of 
tlirombosed arteries, I am Battsficfd of iu correctness. Alter liaving 
abandoned the idea of proliferation of stable ti»!'.tif^<ri'n9 in influtnma- 
tioD, wc oan uo longer talk of a prolifcmtton of the intimn iu the old 
sense. Iliit nlien«; eoine, then, these rewly-fonned cells? I have m 
doubt tliat thcj- originate from the white blood-cclls, wliSdi Iiare been 



J 



FÜKMATION or TOßÜUBia 



12S 



■\i,* J 



-V 1^.^ 



■ ^ \"- 



^-^-. 



'^''^^ cdtnmivrMMCttgacf ahqaii Iknnral T«la, wttban on:atil»ud iiKiiUr IhninibM. 
»4«nanirHipni«kuii(l)Mtbbcb:a «. Tuila tnilau! bb. ai«llii: <f.uimUiU:di/, 
;r*w l » > l^ mIUw tlMMi n, imßa\mä Ihrambw «llh tibboIs; Ihe lanrtnj <rf IFia 
■wriM li AIO dlHlPCUr mtO* la Um ptrlpbvir dT Ui* Uirtxabiu. Ua],i>liltd 1«U ilUiiietst«. 

l^^^y ciwlos«d in tho llrombus, partly may have wandered into il, 

•Mording to llie observationK of T' Jltcklinghauten «nd JBubnoffi 

Aa Vvginls the red blood-cells, it eecms tliat tliejr gnitlu^ly unite with 

die OCagutabed fibrine, lose tbcir shapo, become intirccllular eubstanc«, 

nd loee their oolorin^ matter, which is separated as gnnule« or cr^K- 

öU (rf benialoidio. Utile ss we know Mhence blood-celts cotnc, and 

*^itlwr U107 g<>, Blill it is certain tlnit the \rhite ccIU eiitcr the blood 

II** iW Ivraphnlift ve*»cl*i, »ml tlmt (Jiej enter tlic kller from the 

Tf^tio glandii tir cviincctiTe tissui! cls«wh<rre ; tli«?y are c^s thai 

"ifÖBt« diitctlj from oooDcctire-tisauc cclJe, or from & protoplami 

••■logwu lo oounectjva tissue. Are those cells »till viaUc wht-n cii- 

'"^ In % blood-rlat ? After coining to rest here, can they transfonn 

""■•Jim to tieaiie f It is impo^blo to arEnn or deny thcso 

<Pnti(HH absolately : 8iD<« ^ubnoff hau shown that wandering oeUs 

""'ertiip throRibiia, sod may tliene eontimie their moveraeiit«, (hero 

• I« DtocadLj for suppoeing lliat the while blood-ccUa (whicli ore 

*iiUeiJ with wandering cells) ©ndosed in the thrombus, on coagula- 



136 



SIMPLE nrClSED WOUXDS or TBE SOFT PAKTa 



lion, no Innger move, aod cnnnot be tmnsfonncd into lissuc. BUh- 
erto ttcre Iiuv« been no iaTCHtigatioos as to vclictber wftndcrtn^ ccllf 
pnsa Itiroiiffb tlio wall» of arteries bb readil^r as tbtougli thus« of veiti^ 
us Ji'töttojPa invi-MigHtions only refer to venous thrombi. Scnnc nf 
iiir invcstigatJcias in thb direutJoti skon'otl me ibat niiiiut« cinnAbw 
frruniilcs ptt»HHl llirtxigli llio ciirolid of u liog into tlie tlirombus, buti 
I oou]d not aatisfjr mjrsvlf tliut tht^y were repliioeil by wandering ocDs. 
So at present tt i» uoccrtoin whence the ounicrous wnntlerin^ cells in 
an orgamsng srtcri&l itirumbus original«, and bow they ttitcr there. 
TtcAauaa^j in a very oarefidly-studied work that has lately appcaretl, 
cidla attention to Ibn fact that a great portion of hirgo throoilü ant 
destroyed by dinintcgration. Tbia is ray tnie, but be goes too £» 
when ho entirety denies tlie provisional Organization of the thrombai^ 
and Bupix>s(.-9 that the disintegTatton of the clot is imniediately ful- 
lowed by th« adhesion of the wall» of the vessel, to which I have 
called attention ms tlm definite termination of tfau wbolu process.* 

As 1 hare already stated, peculiarly favorable conditions are n> 
quisite for tho blood-clot to bcoome organized. It is an absolute Uw 
in the hnman organism, that non-raseular tissues, which are nourished 
by means of cells alone, have no great extent; the arltculiir cortilogM, 
the cornea, the tunica iittima of tlicse restels, tb« tiasu««, tt« all in thin 
]»yen ; in oÜier words, tbc ccltsof the human body cannot^ liko those of 
plants, carry nutrient fluid to any given distance, but arc limited in 
tiicir conductive power ; at coitün distances new btood-vosscls nttst 
appear, lo supply and carry off the nutrient fluid. Tlio blood-clot^ 
ooonnting of cells with ct)ngulated fibrino, is at first a non-vasoulv 
cellubr tissue, whicli can only muintnin its existence in tliin layen 
This appears from ob»orrations, which we shall hereafter ofVia hare 
occasion to mention ; namely, that large blood-dots are not organized 
at all, or only in their prripherol layera, while tliey dl-üntf prate in tlie 
oeatre. From this it appears that, in healing by the first inl«i>tioa, a 
«luoll amount of blood lying tictweeti the edges of the wound tloBS qo« 
liarm, white a larger aiaoiint inlerCeres with heating;, or preveoto r 
altogether. You will soon bo able to rcrify this observation )o t. 
cUnie. 

llie fomatioR and organixation of the llirombus bave engagwa 
tlie attention of surgeons and anatouista eioco llto ttnw of Johst 
Hunter and cren yet thry are not fiiUy understood. 'Wa must 
sider ttiem here on acooimt of their gfineral biatogeootic tat«re«t, i 
though of Into it is doubtful whether thrombi are pmctically oa t: 
portant for tbc results of ligation as was formerly supposed. %v 
Pitrta called attention to the £ict that ibe qiiiclc odbeslon aod uni 
of the Ussoo around the ligalc^l artery was as important as OT:g»ni^ 
tion of the tbrombtis. Surgeons have kept this point well In Tii 



CIBCULATIO:« ATTEB LIOaTIOX. 



rays striring, bjr most cnrefuU/ opuniting aod atteoding bo tiie 
incL, to attain boaliog by the first intention. But it va» the n^ 
ce» of acupressur« wbiolt tint Bbowed clearly that the «dliostcm of 
til« tümios by ooagulable exudation erca in Torfy-cigtit boui« is 
vaoKtgh to ic«^ s«ear«Iy tlto comprwacd or twisted artery, crcn 
wben H is tbe eEzo of U>o femoral. Although SocAer has Bhoi«-o thai, 
rven after oouprcsaure, thrombi occur in ertcriva, yet they are too 
aniAlI to cheek bleeding ta a largo artery vritbia foity-cight hour«. 
H«aoe<, eren ^rora this point of view, attempts to n?p)Bcothu ligMlurr; 
by other methods, which leave no thread« in the woutid but permit 
iu estira dosore by first intention, should be encouraged without 
denying in any way the eitrm<»idiiiary odrantagea of the ligature. 



Let I» now look at tb« fate of the circulaliou uAcr ligstiug a bi;go 

' Waj hi the rontiauily. Suppose that, for a tweinorrhagu in the log, 

Ua bmoral urtuiy has been ligated ; huw dues the blood auv reach 

UkI^? bow will the circulatiuo go on ? Just as on cloeuro of capil- 

biT districta, under incr<Mi»v] prt-MUro, (be blood prcHses llirougb the 

Mot permeable rcsscts, nitich are thereby dilated ; the aarao tiling 

^WDon oa clQSitfe of small or racdiuni-&izcd arteries. Under increased 

wfatare, tlis blood Quwa llirough tli^ branches ctose abüvc tbe 

lUircabus, and from tbe numerous arterial iiunstomoses, botli in iba 

rie.ai 
rts 31. 



MM arwrr of • mliMt. 






ise 



BIVPLK [N'CISED WOtTXIM OF TUE SOFT PARTS. 



rM.ki 



lon^ axis &ii<l various transverse axes nf the limb, reaches other arlcrieay I 
tlirouf^h whidi it saoo a^nin etrrainti into the periphontl cml of the li^Ht» 
«d vessel An arterial collateral drculatioa ü eetabUsbed to the side of 
the Ugated and thmmbosed portion of the BrteriaJ trunk. Witliout thli, 
Uie part of the body \yiag below iliis point would not receiTe «ttlB- 
duDt blood Bod would die ; it would dry ap or puft>cr>-. Foriuiiatelr, 
artürial miastoiDoees arc so free tliat, even aAer Uguliun uf a Lir^ 
artery, like the axillanr or fi-moral, such a msc 'a not apt to occur; ill 
dieeased arteries, however, which do uot distc&d sufficiently, tuortiB-l 
eatioa of the affected extremity may occur. The modes in nvhich I 
these new vascular cnnncctiotis form rary greatly. Vcara ago, 
made reiy proJbund researched on this point, aud frota liia uuoliroua^ 
experiments stnt^xi the foUowinj;, a» the types of collateral circola- 
tion: 

1, J}ir«i cnllatcnU circululiun is established ; i. c, there 
Btrongly-developed vessels, whieli puss from the central end of 
artery directly to the peripheral ewL 

lieM uititiiig vessels arc 
«bicfiy the dilated vasa Tssonun, 
and the vesaels of tlic thrombus ; 
it might happen that one of 
these uiütüig veaaeU should di- 
late so much as to acquire the 
«ppcaranc» of being simply the 
trunk rrgenenited. 

2, There ii an indirect eol- 
tateral eireulation; i. e., tbe 
conoeeting branclica of tlie neat 
lateral orteriea are greatly di- 
tated, as [n the following case, 
Fig. 93. 

Tlie most striking examples 
of both varieties uf coUatetml 
circulation have here bevn cho* 
KQ ; but when you examine tbo 
numerous Hkctchos of I^rtOy 
and youtselveA repeal these ex- 
pcrimentA, you will find that in 
most coses direct and indirect 
oolUteral circulation are com- 
I'incd, eo the Only \-aIue of tJie 
classification is to group the 
different forms in souis way. 

Ti 19 an excrilrni nnatocnt' 



\\ 



ß 



FCfDonl irl'rr it • lart* dw. ln}Mt<4 1 1 
■fur ll^liuK. Afto PrttiM. 



CIRCULATION AFTER LIGATION. 12» 

cal exercise, to represent for yourselTcs how, after ligation of the 
different arteries of one or both extremities, or of the trunk, the 
blood will reach the parts beyond the point of ligation ; in this you 
would be well aasisted hy the plates of arterial anastomosis in Srawie's 
text-book of anatomy. In the surgery of old Conrad 3fartin Jktn- 
ffenbeek, these conditions are carefully described in the chapter on 
aneurisms. The reversal of the blood-curreut, which not un&equently 
takes place in these collateral circulations, occurs with wonderful 
rapidity, when the anastomoses are &ee ; if, for instance, we ligste 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 &om a vein.' In all such cases, where the artery to b<* 
ligated has free anastomoses, if a piece is to be cut out of the artery, 
we should first ligate both central and peripheral ends, to be insured 
against luemorrlisge ; this is an important practical rule, which ie 
often neglected. 



CHAPTER U. 
SOJ^fE rECULIAItlTTES OF PtT^TCTUnED W0VN1>S,\ 




LECTURE X. 

VMdlMnmalnlni; in iht Hoilj-, ihslr F.xt radian.^ — PnnotinvdWeaiKliaf ibsMcrt 
AaattrytuuiUQija.— Puneiurwd WobdiI* of Uia Vciiti, VcMMcläoB. 

Most punctured wounds Arc simple wouihIa, nnd uaunlly b«aJ bj 
Grst iiiteiitioQ ; maay of tbem are nt the some tiino incifiod wouat 
when tlie pitiu'tiiriiig iiisb-umciil lia« a vertain breadtli; aome hi 
ihe ctianictcristii:6 of contiucd n-ouoda, wlicn tlie pttocitiriiif ina: 
rncDt WHS blimt ; in tbia case ibcie is ^^crall^ tnoro or less sup 
tioD. We make miuiy punctured wounds vrttli our suigicid ii 
tnenta, m with acapunctitre needltt — ßnr, long needles, tliai 
OOCoAionuUv cmploj to cumiue vrbclbcr und Low deep bdow a tumor 
or ulcer tJio boucis di^tro^-cd, etc ; nitba?u^e«»ursiu«JIlB(,whk-li we 
use for aircstin^ btcmoirba^ ; witb Ibo troaxr, a dagger witb % thre» 
Bided point, fumisbcd witb a cIo&cly-Gttlng canulo, na iutminent &i^ 
drawing off fluid frcm cnrities, H 

Dirk, »word, knife, and bn^'onet puuctures are often slmulbuicoiuljr^l 
iocia«d and contused wouuda. IT tbese punctured wouoda be tiot^ 
ftooompanicd by injury of large nrterici, veins, or boDCB, and do not 
enter any of tbe »vitic« of the body, tbey ofieii bcal rapidly aotLH 
without trratmcnt. fl 

The most frequent punctured wounds are tbose mnde witb nt^tBt^^ 
esptäaSXy in women, and how rarely a doctor is called for tlie-ni !■ 
Sucb an injui^ is only complicated by a needle, or a part of one, en* i 
tering the soft parts to deeply that it cannot readily be cxtmctedJ 
Tbb occasionally liappetis in dlQervnt purls of tho body, as Gtom •' 
person sitting or fiiUiu^ on a needle, or some eueb ooddcnt. If a 
needle baa entered deep under the »kin, tbo syiuptoios are usuoHjr i 



VKEDLE WOCNOa 



181 



» 



tt thnt tbe paticatg rareljr hare anj decided seiuatioo of it; in- 
th«v oft«» caiiuot Bay wfaotber tJie needle has really cutenxJ, 
imd nliere it is. And in ihe soft parts Oils body usually induoes no 
rxt^roal eyniptomfs but may 1» oftnted in Uie body for moolbs, yean, 
or «en a lifetime, without trouble, if it do not enter a nerve Tlic 
needle nrely feinaias stalionajy at the poiut u-bere it eiitcrv<l, bui 
wvndets about ; it is sbarc-d aloog to olbcr parLs of tbe body by con- 
trsctioD of tlio mu&clc«, and tbus may come to ligbt a long distance 
from tbe pcHDt of outmoce. Cases have been observed where b>'eter- 
ical iromrn, frnin tbe peculiar raitily of attracting ibo attention of 
{■fayaioiaos, bore )i)»«rted nuracrou* Deodk» in difTcrcut purta of thi? 
body; thcM» needle« appeared now bere^ now there. Eren -when 
oeodles baro been awaUuwt-d, ibi-y may wilfaout danger pass tbrougfa 
tbc walk of tbo stomacb nud intustinco, and coin« to tbo BurfiK« ut 
any part of tbe abdominal waU. M. eon I^ingenbedi found a pin in 
tbe oentre of a reucal calnilus ; on nx>re rareful in<{uiry, it waa found 
kbat, vbcii a child, llie patient had Bwaltonud a piu. T^c pin ntay 
bavo passed through t)ic ialcHinc into the bladder ; here triple phos- 
phates were dt'po&itcd around il in Uycnt, and this was poüaibly the 
ucigiii of tbe calculus. J^ittle liad a »iniilar experience. 

Wbeu {be needle has remained fora time in tbo eofl parts without 
exciting pcibi,or when ncedU.'S, passing tliroii^Ii the liody front within 
outward, nunc to the surface close uudur tlit- »kin, they usually cxdt« 

■ little suppuration; tbo piercing fcclinit becomes moro docidod ', we 
make an innskm at the painful eftot, let out a litllo thio pus, and in 
ibe pu»«arity find tbe needle, which may bo readily removed witli 
forcepa. It is didtoidt to ej:plain why this body, which Sot inooths 
ha> iDored about in the body, should at length excite suppuration 
when it orrires under the akin ; you nnist ben> satisfy yourselves with 

■ rin iph? knowlod^of the facts. The following iutorc-stiiij; vase niny 
reader tliO course of those injuries more clear to you: In Zurich a 
perleclly idiotie female deaf mute, tliirly yuiir« old, was broi^ht to 
the clinic with the diagnosis: typhus. No history of the case could 
be obtained from the patient or those about her, who were also lack- 
ing in intelUgciice. The patient, who often remained in bed for days, 
had oouplained for a short time of pain Itt tlie ileo-csecat region, and 
bad nodcntc (ever. Examination showed a swelling at this point, 
which increased the following days, and was very pninful on prCMure; 
the aldn rnddr-ned, fluctuation became cridcnt. It wns clearly not a 
fsan oC t)-phuft, but you Duty Iniagin« what diderent diaf^oscs there 
wcK^ aft to the seat of the suppuntion, for Ihero was undoubtedly an 
abaecM ; it might be inflamnuilion of the ovary, prrfDration of the 
rertnUbnn pnwess, an abseew in the abdominal walls, etc., etc. : still, 




132 



SOME PECCUARITIES OF PÜNlTCRED WOCST». 



tometbing could be said agaitut all tLes« hypothcscfl. After a few 
dnj'S the reddened skin boonme very thin, tlie ub«ccs8 pointod «bout 
ibe liPiglit of the antcnur K*iiM.>rioT spinous process of the ilium, a frw 
fingers' breatltlia «bcivc PiMipart's liguncnt, and X made an iacisioa 
tlirougb tb« iikin ; tlier« n-»« evacuated a gasaj, bronmish, unions pus« 
witli a strung fc^oil odur. A» I exiimineil tlie »bscess-cavity with mjr 
liiigt.T, I fuH a linrd, rod-like-, Jinn body in tlic depth uf the nbaoCMi« 
and projecting slightly into il. I began to extract it, and puUed ani 
puUed till I brought out a kniitiug^eedle almost a foot loa^, vrhicb 
was somewhat rusty and pointed down ton-ard the pchns. Tbc ob. 
scees-carity was clothed with flabby granulations. When I tried Ut 
examine the opening that tlie needle miist have left bebind, 1 eould 
no longer find it ; it had closed agnin, and was cnreri^d by the gmQ\f 
IntiotLS. I1>e nbsoen took a long time to beol ; it at last did «o 
witlioiit furtlier aoradeot, 80 timt in four weeks tlie luiticnit was di*. 
missed. As I allowed the unfortunate cretin the extracted needle, die 
laughed In bor Idiotie way ; that was all wo oould moke out of Ler; 
pnhaps this may bave indicated some slight reooUeodon of tlie needle. 
It is most probable that the {Miticnt bad inserted the oe^NlIf into the 
vagina or rectum — procedures iu which eveu women not idiotic find 
some incredible plc-osure, as you may tee in J>i^enl>aek*a openUro 
singeiy in the cbupter on oKtrsvtSon of furr-ign bodiiTE. It Is not im* 
poaaibio that in Uiis case tbo ncrdlc paEsrd by Ibo sjdo of the raginal 
]K<rtion of tJie uterus through the cieeum, for, from the gaa-oontaioing 
pus of the abscess, we may decide that there was at least a lempomry 
communication with Üic intestine. It is true tliu cannot be reiganlcd 
as absolutely certain, for pus in tbe vicinity of the intestines by the 
derelopmenl of stinking gases may putrefy, even wben no eomrouiü* 
cation with tbe interior of tbe intestines exists or lina existed. 

Tbe eztraotioa of recently-entered needle« may b« vt^ry difficult, 
especially as tbe patients arc not imfi-equcntly very undociJod in tbeir 
infurmntioii about the location of tbe body, and occasionally &otn 
aliHiiie will not ociiuowledg« bow tb« noodles (in tlio bladder, lot i»- 
staoce) obtuiiicd entraoee. Wo Kbuuld, witb llic left liond, üx tbe 
spot where we sball roost probably find the Coruign body, »refully 
citdcaToring to piMS tbe skia together in folds ; wo most at tbe same 
time bo (sreru) that the needle does not again change its poati 
while we nrc making tbe incLdon. Somclimea wc feel ibc Imily 
or less distinetly, ami can cause pain by pressing on il ; these atte 
must decide the point nf mir ineiMon. After dividing the skin, 
attempt to iwiae the needle wiUi a puir of good dissecting finroef» 
very tense bands of iascia nmy readily deceive us, eapcciitlly abowf 
tbe fingers, for witb foroep« our sens« of feeling it always unonvtnin. 



i 



KXTRAOnUX OF rOKEIOX BODIES. 



133 



I 



• 



If wc cannot find tlic needle, we may move the parts some ; tlit* 
ncodle U Ihen somctimee moTed into a positioa wliero it maj* bu 
BCiwd »Ore readily. Tbc cztniotiou of forvig» bodies require« a oer* 
tain auiouDt of prnctioc nod manual dcxtcri!./, which ire acquire only 
w]th time and pructice ; here natural ktiock is uf gre;iL Bcrvioe. 

Puocturcd n'Ouods, made with instnuncnts iioL rcry sharp, are 
ooawtao&njr tntemi|)ted in their process of hwdiug. ExternaUy they 
heal hy first intcntioQ, but after a few days there are suppuration and 
iAflauunativ» to the deeper i>iirl3 ; the wound either opcns^ and the 
whole tract of the wound suppurnles, or the pua breaks through at 
some other point, Tliia ocvura pariicuUrly in cases where a foreign 
body, 08 the point of a knife, remains bchiud, or wheru the wound 
waa made with a blunt instrument. In examining the wtiiind, you 
ahotdd alwmya bear in mind the posribility of a fonign bwly remam* 
iog bdiind, and, if poedble, see the instrument witlj nhicb the injury 
wmt done, and find exactly in what direetion the tustraraent passed, so 
tltat you tnny kiiuw about what part« arc tnjureiL Xlowever, even iu 
un l h vocable coses tlieic arc occasionally TCry liltle iiiflumniatiun aad 
euppur«tiofL A short timo since a man come to tbc clinic who, a few 
days pf«vii.iufilir, bad fallen a moderate height from a tree, lighting on 
bis left arm, while en^gcd dipping tbo small branches. On the dor- 
sal «ur^Kc, a few iDcheti below the elbow, tbe arm was swollen; on 
the rolar surfac«, just above Uic wrist, there woe « slight eicorintion; 
ibm nna could bu extended and Sexed without pain ; only pronation 
and nupiuiiütin were impaired and painfid. Hicre was no Eohition of 
eootinuity o( the bones of the forearm ; the bones were eortuinly not 
brokeo through. At tlie swollen spot on the dorsal nda, an inch 
bdow the elbow, immediately under Ü*e skin, we could, howerer, feel 
a firm body, wliioh eould be presMd back somewhat, but it at onoe 
n>tnmed to its old {lOKiiio«. It felt jist as if a piece uf Wnc had 
been broken off lengthwise, and lay close midcT tho skin, lucomprc- 
heosiblo as it must seem for such a detaehuicnt of bone to occur by 
g on tbo arm, without fmoture of tbe mdius or ulna, I 
hod the palieot anirstlictizcd, and agniii made tUc at* 
tempt to press into position tbe 6u«pectcd fragment ; but it did not 
As it lay so oloee under the skin that it would necessarily 
perforated ero long, I made a snutU incision through the skm to 
ettract it. To our grent natonliitimpnt, I drew out, not a fragment 
of borne, bat n Binidl bniich, fivo iiiclttfs long, whioh was quite firmly 
held by the two bones of the furcarm. It wns incomprehensible how 
oouli^ have ei^tcrcd the forearm • but^ on more careful 
ion at the nhore-men Honed exvorinted spot on the volar 
flir&cr, we (bund a linear, sltt-like wound, which had already rioaed. 




^^ of bone, b« 
■ beldbythi 




134 



SOME PECDLIABITIKS OP PUNCTURED WOÜSDS. 



llirougb w-hiob the body bad apparently passed so quickly that tlie 
puticiit bud nut uottced its entranoe. A^r its extrudion the very 
uodcnto fiwcUiag cntirclj Bubsidcd; tbe email wound disdtarg^ 
but liltlti puH, and vas PiiUrcIy closed in cigbt daje. 

These fsTorabIc amditions of punctured wounds bare git-en rise 
to tbe ao-cuUcd aubcutantoua operatiotis, wlüdi were introduced into 
RUrgery more particularly by Stromejfer aod J^i^enbaeA, and oonsUl 
in juasain^ a pointed, naiTon- knife under tbe »kin, and dividing- ten 
dooB, muadca, or nerr««, for various puipMoa of tnmtmcnt, whlioat 
muking any v-ound in the skin otbcr thnn th« small punctured woiuid 
tbrmigb wbich lb« tcoutonK! Is iiitroduoed. Under those ctrciun» 
stances the wound alnko&t idn-ays quickly doRcs by lirst inieation, 
wliile in open wounds of tendous ibere is almost always suppuration, 
oft«n eitcusive death of tbe tendon. Of this we «ball speak furtlier 
tn the cbaplcr on dcfumiili(.''a (Chapter XVIII.), 

If the puncture bu$ entered one of the entities of the body, and 
caused injury then?, ibc prugnuels wilt always be doubtful; there is 
more or lesa danger, aocurdiug to the physiolo^cnl importance aad 
ruUicmbilily (the greater or less Bu&coptibility to daugemua inBain* 
mation) of the organ implicated. Sucii a punctured wound is not so 
dangerous as a guiiitbot wound. Wc shall not nt present pursue this 
subject further, but must oow say something about punctured wounds 
of the ncn'os und arti-Tics of the extrvmilies. 

Punctured Hounds of nerves nalurally induce, according to their 
extent, paralysis of variable amount ; otherwise they have lite same 
effect as iodscd wounds of the nerrcs. R^feoemtion ooours the 
more readily wlicn the whole bmadtb of tbe nerve bns not been punc- 
tured. I'lie nise is diflereat when a forei^i hoAy, as the point of ■ 
ooedle or a bit of glnss, is loft in tho nerve-tnmk ; ibry nmy beul in 
bere as in other Itssues. The cical ri x in llie uvrve which coiilains thitf 
body may remain excessively painful iit every touch ; there may alsc» 
bo neuralgia or norvoDS pains extending cxccntrically. Moreover» 
the severest nervous diseases, acute or chronic, may be iudwred by 
these foreign lx>die». £jnlfpfi/orm ajitum», wilb sn owra. ■ pain 
the cicatrix preceding tbe spasm, have been observed nAor sucb in— 
juries ; some surgeons also assert that trattmatic Manui may also b^ 
induced by this uerrou» irritation. Tliis aj^ars to roc vcrj- doubtful, 
but of this hercaßcr. Tbc first of these diseases, tbe so-iullcd reflex. 
epik'psy, may usually bo cured by tbe extractlou of the fofG^ body. 

Punctured wounds of arterial trunks or their large brancbrs may 
induce various resi^itts. A ^-ery small punplurc usually clo9c8 by the 
clustieity and contraetility of the onats; indce<l, there is not alwaya 
a hemorrhage, *ny more tlisa there is always escape of tiwx^ from 



PUNCTIJHED WOUNM OF AHTEItlEa 



1S5 



puncture of lite uitL-stinc. Ji llie woimfl be slil-slinpcil, tbe 
Dg taa.y also bo insignifit^iit if tlic opening ^p<>R but liltlc; 
t III oilier coxes screrc srt(.*riii1 lm>inoril]agc! is tlir iruinediato n?:^u1t. 
n>rapre68i<m be at one« made, bdiJ a baoda^ oceunitoly applied, 
shall usually succeed not oa\y in arresting Uie hinnorrhaj^e, but 
o in dosiag the puncture in the artery, just aa we nhoiild one iti tlie 
ift parta. If tlic bleeding be not arrested, aa aJreudj- slated, we 
lonkl at once ligate the arterv, after enlarging tbo wound up and 
iwnward, or at a Iiigber [KÜiit in tbe continuity. 
llie olusure of tlie arterial woiiiid tiikcjt placu ns follon's : A blood- 
■i Jomu in the more or les« g^pitig wound of the art^rinl wall ; tbis 
t projects sltgbtl^ into tli« calibru of tbe vi^ssel ; but uxtcmsUy it 
usulljr floracwbat larger, and looks like a maüliEbom. As described 
intm-rasonlar tbrombus, tbis clot is transfonncd to connective 
He ; and tlius there is permanent organic closure, without cbongQ 
the calibre of tli» artery. This 
ocmal oonrse may bo corapUoated , "'*■ ** 

y layers of now fibrino from llic 
Iroulating blood, depositing on 
pari uf the plug projecting 
to the calibre of the vessel, and 
lu» ebi^ing it by a clot, fonning a 
itiipK-tc anurial thrombosis; but 

It» is rare. Should it happen, we would bare the same result aa 
ftcr a throtnbous following ligation— development of ooliatenil oir< 
uiauiin, and evootual obliteration of tlie vessel by orgnnizatioD of 
thn»nbus. 

Punctured wounds of the arteries do not always take so favorable 
ooursow In maiiy cases, soon after the injury, we notice a tumor at 
•eat of the young cutaneous ckntrix, which gradually enlarges 
perceptibly pulsates tsocfaronicolly with the systole of the heart 
td with the arterial pu}se. If we place a stethoscope over the 
■, we may bear a distinct buzzing and fnctloo sound. If we 
ipcesa the chii-f artery of tbe extremity nbove the tumor, llic pul- 
tion ftnd murmur cense and tbe tataor diminisbea somewbaC We 
ill such a tumor an aneurism (from ävevpvvav, to dilate), and this 
LTiicular fortn, arising from wound of an artery, we call aneuritma 
rium or trOumattoiM, in oontmdislinotion to tbe oneurisma 

'ft, arising apoutaneously Iicm olber diseuses of the arteiy. 
"Wboaee oomes this tumor, and what is it ? Its origin is as fot- 
Tlio external wound is olo«cd by pressure, the blow! can no 
Ufger fiow out of it ; but it forms a way througli the 0]>eiitiig, wliieh 
not ret firmly closed by the clot, into tl]0 soft parta, and wtiids 



Atttrr «Mmded no tbo •Id*. wiiTi cbff. (bar 
ih;« >ft*T Ilia li^nry ; aflcr Arid. 



U8 



SOME PEfTLlARITIE« OP PTNCTCltED WODNDS. 



JJ- 



>.N 



obuut tttnong tliciu us long us tlie pressure of Die blood t9 stronger Utfta 
Üie resisuuou of t)io lisdues ; • citTitjF filled with blood is fonued in 
immt>diate oommuDKHUton with the calibro of the artvr^', part of the 
blood soon coagulates, and th«ni is sligbt inBaianution uf the tissue 

about it; « plastic infiltn^ 
f^* *■ tratmn, which leads lo coo- 

nectifc tissue ocvr forma- 
tion, nod this thidccaed 
tiftsua forms a sac, Into 
1^ ^' , :'\ and. from whose cavity tho 

^ blood flow«, whilo tlio pe- 

ripherj- of the cariljr ts 
fill<:d vith layers of clotted 
blood. The buxäng and 
friction tlmt we pcreeira 
in the tumor uriso partly 
from the blood Oowiitg out 
through the nturow open- 
ing in the artery, partly 
by its friction agitinat the 
cofl^um, and liutly by 
the regurgitation of tlie 
blood into tho art^^ry. 

Such a traumaUo so- 
euriRin may a]»o oocur in 
»iKitlicr, mure secoodary 
V ,;,- ; tliu arterial wound 
:i( lin-t heals, oiul subee- 
qucntly, after removal of 
tho pieMuro bandage, tbe 
j'oung racatrix gires way. 



\J 



■.y^'. 



luRitnna traanullcaTii of cbs htwhU ifMr: ■A^r and tlien for tlie Srst time 
pyvn^"8u^.o,p^u.^- w.iv::K..«i the blood escapes. 

Treiimatie anouriama are not always Gauit«d hv ptmotured «rounds 
of arteries, but nipturc of tlteir coat» by grwit Icifioii and contuUoas, 
wiÜiout any cxtcmjil wound, may n.'sult in thvir duvclopnkcnt. Thus, 
io his surgical lootun^s, A, Coopfr tells of a genttemnn wlio leapoi] a 
ditdi while out Bhooting, und at tlio time felt & pain in the lioUuw of 
his knoc, which prevents his walkin;:;-. An aneurism of the popliteal 
artesy soon developed in the bend of the knee, that fintilly had to be 
operated on. Tlie artery was partly nipturod by the leap. Bujiture 
of the tunica intinia und mu&cul&ris is sufficient to permit tlio forma* 
(ion of an aacuriem. Should the tunica adventitia remain uninjured. 



AN£m»SM FROM PÜNCTÜBKD WOCNDS. 



1ST 



the blood nuty detacb it from tbc tunica media ; this fnnms ■ i-nrioty 
uf aucuriam vailed antwiuna dUaecana (di&secliag nneuriam), Cu&us 
<if punctured wounda witb subsoqti«>at aneurisimi occur pnrticulitrly iii 
iiuUtarj practice, but not unfrcquenOjr niso in civil pnicticc. I »uw a 
btijr viLb on oocuriBtn, ns lor«^ us m hcni's-cggy of tlio femora] artery, 
about the middle or th« Ihigli, that had h««D caused by puncture witb 
B pen-knife, on which \he boy te\l. A short time sine« I nperated on 
an aneurism of the ndial artery, t)i»t lind developed in a shociiiakcr 
after an a«»dcntal puncture witli au itvrl. 

An aneuriam ia a Itiinor eommunicatinff direclli/ or indirtct!>f 
uUh the calibre of an artery, niis is tJio common definition. The 
commuoicatioa i» immediate iu the case juat described of » ümple 
tmumntie oocitrtitm. Still, the aontoniical conditions of this tumor 
may be more complicated. 

For instance, io a ToocsccUoa at the bcsul of the elbow, that is, 
frocn intentionally puncturing a veio for the purposo of abstncting 
Uood, beflidea the rein, the braehial artery may be wounded ; this is 
one of the most fre<|ucnt causes of traumatio aneurism, or ak least wna 
»0 foraierly, when bleeding was more common. In such q ea.*«, beside« 
the dark, todous b!ood, wc may readily perceive the bright, arLerinl 
blood ; the whole arm is at once hound up and tho artery oompressctt, 
and In aone cases the openin^^s in both vessels heal at once without 
further eonscqucnceit. Uut ocxMsioimlly it happens that thüt accident 
I b followed by an anciiriNn ; this may hare the simple form above dc- 
Embcd ; but the opcnioj^ in the two vessels may BO pTOvr together that 
part of tiic arterial blood will flow directly into the vein as into an 
•iterial brsnoh, and must then meet the slrenni of venous blood. This 



rM.» 




tMl Ml 




•, BncliUI «rtrrv: *Bri tMt. Fmrirjii. "Snr^ul CopptrpltlM." 

tw.lii.. tbc «a. 



138 



30MK I'ECÜUARITIBS OF PCSCIÜBED WOO'Da 



causes obstruction of tlie venous cunent &Ddcotiae<iueQt saccaUtionfl, 
(U]atatiuns of (ha cnlibre of the rc-iii, «bicb vre geaerally tf-rm vmv 
(«j ,* in this pertleular caue tlie viirix is called varu: amwrimtatlcxu, 
because it comniutüofttts with na t^^ry lilie »o uucurUrn. 

Anoth'jr «afto mny Biis« : sn nneurism tonn» between the artery and 
vein, both of wbidi oomniuuioitc witb tlte ancurismal saa 



Ft«. t7. 



./J 



Titma Tiri(o*nqi. o, BncliitI «Ttf ry; \ nMlbv rata. Th' oMmtlmMl Me I* cdI opt» > 
■iltritan^. J>(irt4i."Sais{iiil0app«rplu«NL" lU. UL, nc ad. 



We eiill tliis anatrUnui Earicvsum. There may also b« 
Tariutiirs in tlie relatioa of Uie aaeiirisniat sac, vein, and artery, to ' 
otlier, which, howcrer, arc only important M b^Dg curious, au<l cbang« 
oeither tbe !>rni[>toais nortTcatmeiit,an<IfoTtunat4>lj' luiveanparticvlnr 
names. In »U these cases ivhcre arterijil blood flow!« >Iin.-ctljr or tndi* 
rectly through an ancurismiU sac into the vdna, Uicrc is di&toutJou of 
tb« veins and a thrill in them, which may be both fült and heard, and 
may even be occaaionallr perceived in tlie arteries; it probabljr reaalll 
from tlie meeting of the currents. However, tlita thrill in tlio voiMflfl 
ia not charactcnAtio of the above sUte, for it may sometimM be iu- 
duced simply bjr itreseuro on the veins, and occurs in some diaeaeos of 
die heart. Wo also oocasinnnlly see a irruk pulsation in veins dLs* 
tended by the above causes, ivbioh would even earlier gire a correct 
diaf^nosts. 

Quite recently I aaiv a number of aneurisma resulting iium gun- 
shot-wounds; in three ca»*» aiTeriing tbe ibmoraland cstcmal iliac 
arteries, the above-mentioned thrill was very prominent, rendering it 
pretty certain titat tlicre was a communication between th« nftery 
and vein, as was proved by autopsy in one cusc ; but there were no 
Varices in any of these aiscs ; hence tbcir development i« not a ocoea- 



J 



u 



VENBSBCTIOX. 



139 



k 



nstUt of «otnmunicatio« between arteries and reins, or else tbcv 
in some« coses not dere]op for soma years. 
Aneurum» of tbe arteries, in whatever form they como, if they 
only roaoined mull, irould cause no great iiiconTeuicucc. But in 
most cases tho aDeurUmal lacg grow larger and larger ; ftioctional dis- 
torbancca oocnria the nK;ctcd extremity^ nud finally the ancuriüm 
nay niptore, and a proftuo lucmorrhago terminate life In most casoa 
the treatmeDt must eoosist in ligating tho anourismal artery; but of 
ihifi hereafb.T. I hara considen.'d it pructical lo explain to you bore 
tbe devdopincnt of tmumutic aueurisuia, aa in practice they aro mostly 
doe to punctured wounds; while in other text-books you will find them 
systematicallr treated of among diseiisf?s uf the arteries. We shall 
speak, in a separate chapter, of sponlancous ancuri.snis and tltcir trcaV 
meni. 

Punrtur^ taonnJa <ifvtini heni jufii like tliose of artcrica, so tbnt 
I need ndJ tiotliiiig here to what was said above ; wu Dc-ed oiily re- 
niuk here that extensive coagulutioi» fona more readily in vciua than 
in arlerii.>B; traumatie venous tArombotia alter veneseetioo, for he 
alanoe, is tu more frequent ihau traumatic arterüü thtombosia after 
punctured wounds of artcriee, and, what is far vrnme, tho fonner variety 
cf tliRMnbosis hns much more serious results than the latter; on this 
pobt yon will {wibip» hereafter hear more tlian will be agreeable to 
wo. 

■Wo hare frefjnently mentifin«! pen«aection, whtcfa is a very fnyjuent 
msU lurgkal opentioo. We shall hRre briefly review ita peifonnauce, 
tltboDgh you comprehend sudi tilings quicker and better by once see- 
lug ikcm than I could represent them to you. Should [ attempt to tell 
wiu uoder w'hat cireumstan««« \-euesectMjrt should be performed, I 
ibouU have to t-nUir deeply mto the whole subjiret of medicine ; quite 
a la/ge book might be written on tlie imltcalious and oontraindleations, 
Ibe a/i in iiM i bJh ty , tho l>enefitsand injurioitor \*enefH>ction ; tu-'nce I pre- 
&T to aay Bothtng on Uieae points as on so many oUiers which you will 
P'A up in a few minutes at your daily viitita to the cliuica, and for 
"Akcs Uioorctknl cxposttioo without special caMS we should require 
In regaid ui the history, we will only meatioo that, while for- 
'fy~ TiuicaecLion waa pnrfonnnd on any of iImi Rulwutaneous velua, 
ä ^. is only done in the v^ins of the bend of tbe elbow. If you 
"C^«) bleed a patient, you 6rst apply a pre-SHure-bandagc to the arm, 
*~m^ie obstnietinn of ilie pcriplit-ntl veins ; for tliiä purpose we cm- 
=-». jifup.yly-iippliecj hnndkerelticf or the old-fashioocd scarlet bloed- 
^~3Um, a finn bandage two or itiroo fii^jcr-breadtlis wide with a 
•^'-^ ; when lliis is Srmly applied tho veins of tho forearm swell up 
^ «0 \-ena cephalic« aoi basilka with tltclr corrc&püuding median 




L40 



SOMK PECrUARITlES OK PtTSCTl-'RED WOlWDi 



Feins appear in the beiul or tlic elbow. Vou cIkxm«, for opet^t^, tin 
ITIQ which is most prominent. Tlie arm of the [mtieiit is tiexcd st nn 
obtuse «ogle ; with the Icti thumb jou fix the mn, Hitb the lancet or ■ 
very pointed Htnii^lit smlfx*! in the right Hand you punoture tli« rein 
ant) 8lit it up Imigitudiiiallir tiro or three lin<>fl. The blood eccape« iu a 
alrentn; you iillow sufliciunt to Bow, cover titc puncture with jout 
thumb, remove the hnndngi' from the nrm above, und th« bleeding will 
cease «poDtane<nt«1j j tlte wounil should bo (.-orcnxl with a omkll eon»- 
jKCss anil a bondage; tlm arm should be kept quiet Üiree or four d&js^ 
then thv wound wilt bo healed. Easy aa Xiaa operation i* tu mosl 
eases, it still requires practice; Puncture with tiie lancet or scalpel is 
to bo prcfcrred to the aprin^^lancct; the luttorwus formerly Tcty pop- 
ular, but is DOW very jiutly going out o( fashion ; the spring-l&ncet ta a 
Bo-cHlled Dc«iii, which is drireu into the vtnn with a i^mng; we allow 
the instrument to operate, instead of doing it ourselves more certainly 
witli the band. 

Varioua ohitadca may interfere with vene«eetion. In very fat pet^ 
sung it is often dÜBcult to see or feel the reins through the aldn; then 
bcudr» compression wo employ sDotbcr UHSons, that ts holding the 
forearm in warm water, which incncuacs the afflut of blood to this put 
of tlie body. Moreover, after opening tlio vein tlic fat may impede the 
escnpc of the blood by fat-lobules lying in the opening; these alrauld 
be quickly snipi>ed off 4uta the scissors. Oomaiooiilly thü flow of 
blood is mocliiuitcnily obstructed by tho arm being rotated or beoi at 
a different angle after the puncture bus been made, so that the opetk' 
uig in tbc vein no longer corresponds to that in tho skin ; this b to be 
met by chiin^ng the position of the arm. There are other causvs for 
tlie blood not flowing properly; sueh as the puncture bcäng too small, 
a ftequoni fault witli beginners; the oompreesicn is too weak, ihis may 
be Ropcoved by tightening ilio bandage ; or, on the eontiary, the ODIB- 
prctnon 18 too great, wo that Uie nrlory is also oomprcssed, and liltk 
or no blood flows {mm tJic aivi, this may bo obvLitcd by kxisening the 
venesection bandage. Aids for increasing the äowof bloodare: dip* 
ping the hand in wann water, and having the patient rhytluntoally 
0[]cn and clone the hand, so tliat the blood may be forced out by the 
inuftcular contractions. We shall apeak further «idiis point, as op 
portunity offers, In tbc clinic. 



CHAPTER m. 

^ONTUSIOKS OF THE SOFT PAJiTS WITHOUT 
W0U2fJ>S. 



LECTURE XI. 



Cmamaa *r OonUilou.— Narr«iu Coiuu«I«ii.— 8abeaUiiaoii*Bi>pliu««f V«m«1«.— lUp- 
tUM of JLrtBW«*.— 8l^gül^tie^l>■ — Eoefcy m at «■.— Bc«b»o ry tlon. — TwaÜBAtlo« is 
I^ifcfOBi Tninon, In C^ita, in Smpf nnitioa, aod Patnlhcüoa,— TrMitmaot, 

Or tbe MiJoD of ■ lilunt object on Uie sofl parts, tbc eldo will 
VOcnclimes bo iDJnrcd, sometimes it will not;^enoe we diatln^Lili ooii' 
(«131005 with or without wouiida. Wc aball VH consider tbe Uitter. 

Tlies« ooalusions nre pvilj oauKd by tlie laUing or «triking-of hcnrr 

object on tho body, partly by the body (kllinf; or strüdog against » 

Hard, iu-m objecL Tlie inunedlnt« result of eticli a contusIoD U ii 

cz-usblng^ of the soft pnrtd, whioli xa*y he of Kay gnulc; often wo per. 

(M^re acatceljr any chunge, in other cases llie parts wo ground to n 

palp. 

WbetliQr thc^n suffers solution of coottnuity by this spplicatioo of 
(oroA depeoda oo various circnmetancos, «spccinllji' on the fomi of tliecon- 
tyäng hoAj and the foree of tbe blow, also on the nature of the parts iin- 
^ the ^iD ; fur inslaoce, the «ime force would cause CODtuuon without 
X «ouod in a muscular thi|i;b, that applied to the epinc nf tho tibia nould 
fgt^e a «ound, for in tbe lultor cast,' thi- sharp od^ of bono would cut 
^ akm Erom wUhin outward. The chuftictty and thiclcn^ of the 
^tlMMDUtintooousidontioQ; these not only vary in diCcrcntpei- 
MDi) bat may differ io different parts of tho body of the Mme indj- 
vaaL 
£| ootitusioa without wouiul we caunot immcdiiitclj rccoj^nizc tho 
"Mnt c£ dcstnietioa, but only in<Hrcctly from the state of tlio nerves 
""Issacls, and also Aom the sub«oqiient course. 
^ o<<iatitaioo the Gnit s ym p t o m in the ntrvet Is pain, just as it is 



142 CONTUSIONS OF TttB SOFT PARTS WITBODT WOCSOa 

m wounds, but pain of i duller, more undefined disracter, Rlthoagb 
it may be very acrcic. lu maay oucs, especially wbea be bu struck 
ftgainfit ft h&M body, tbc patient bus ft p«cullttr vibntting, tfaremt«iiing 
feeling in the injured part; this fcieling, vrbicb ozteiKU »oidc distaaoe 
bejond tlto scat of injury, la caused by tbo eonctunon of tbc dcttc» 
For instaooe, ifwc strike tbe hand or finger qtutc hard, only asmftll part 
is actually contnsed, but not unfirequently there is cxHtoussioD of the 
norvcaof the whole band, with great trembling, dull pain, on account of 
n-bicbthcfingcTS cannot be moved, and therein almost cx>mplete loss cf 
feeling for tliemomcnU TlitsoondiUoopaMesoffquicldy, unuallyiaafe« 
seconds, nnd then a burning pain is felt iu the eoniuscd part. TIm 
only explanation wo have of Uiis l^Riporary Rymptom ia that th« 
nerve-substance of the axis cylinder Buflbrs mulcoular displaoonwot 
from the blow, which spoDtoncously pii:^scs oS nguio. These syroptonu 
of con<»u8ioo (the comtnotion) do not by any means aocompany all 
eootunoDS ; titey fail cfipedolly in cases where a heavy body comei 
against a limbnt rest, but they are not unfreqnenüy of great signifi- 
caooe in contusions of tbe hvad; here «<fmmotio cerebri is not uufre- 
quently united with eontiisio c«robri, or tbo former appeani alone, for 
instance. In afnll on tliufcctor buttocks, whence the coacusüoQ is projy 
Bgatcd to the bmia and may induce very scrcro accidcola or crcv 
death, without any preeeptible anatomioal changes. Conensaioo ti «a- 
•entially a cliange in the ncrrooa aystetn, hence we apeak düsfly of 
oerebnil or spinal ooncttHsioo. But the peripheral nerves also may be 
concussed with the above symptoms ; but siiire in sueh ease« the nor« 
localised contmion Is especially prominent, Ibis iiervoua state is pM> 
haps too much neglected. Severe concusaion of the iliorax rosy iih- 
duoc the most dangerous symptoms simply fmm ooncusston of Iho 
cardiac and puhnoaaiy nerres, whereby the oireulatioo and respiratioo 
arc disturbed, althoiipb for ibc moat part only temporarily. Nor CWD 
a reflex action of the concussed Dcrre, especially of tlie ayinpathetfa 
on the braia, be entirvly denied. Doubtless some of you, when wreatlbg 
or boxing, have received a blow in the abdomen ; what terrible pain I 
a feeling of fiiintnessalinostOTeKomes you fern time; hero we luve an 
action on the brain ami on tlie benit; one holds his bn^atli nnd gathers 
hb strength, to prevent sinking to the enrtli. Coneuasiuin of the oloar 
nerve often occurs, when wc strike tbc elbow baid ; mostof you proba- 
biy kiKiw ihv tieii\'y, dull pain, extending even to the titüe finger. 
ComprCKtion of scni^itivu nerves is aaid to cause cootttiriion of the 
Wiebral reaaols, as is shown by recent oxperimunls nn mhliits; pOBst- 
ttly this explains the faintness from severe pain. 

AJl these arc symptoms of cooeusBion in the peripbenl nervca. 
Kow, as we do not know what specially talcc« plnoe in dio oerres, 1 



COlfTÜSIONS OF SEIIVES ASH VESSELS. 



I4S 



I luive liny cObct, Kod^if to, what, oo 
sion, Bitil of til« contuiscd wound; 
we cKoooi Iiete ttuäy tbc nerre» any furtber. Som« tmim- 
Jo obaonwtiaiia team to prove tbot tliis oancusBion of pcriph- 
nerves may induco motor and Mosoey panlyilB, u w<.'ll as atrophy 
of tbs luuRcles of a limb ; but the conoectitm between cause sod nffect 
ia odea difScnlt to prove 

Contusion» of th« ocrvcs nrn distinguished from eonciuwions by 
tiic fiiot that in them cortatn part« of tlic ncnro-tninks, or their wbole 
t-hickncas, la destroyed, to t]ic most varied extent and degree, by the 
fbroe applied, so that wc find them more or le«a pulpy. Under tbuc 
cnrciunstance«, tliero must bo a panilysi« oorrMpooding to tlie injury, 
Ciom «riiich «e determine tbo oerre «.HSected, and the exlcut of tlie 
«ffect. On the whole, fiucb contueioiu of nerves without wounds are 
rare, for the chief Derve-trunks Ho d<!«p between the muscles, and so 
are Ir» apt to be Injured directly. 

It most a priori bo acknowle^^ that coocuaaion may affect 
other organs and tissues than nerrea, and induce temporary or per- 
raaaent disUirhancei, not only of tbe functional but of the nutritive 
fKDCcases. Such dtsturbano» may alao have an important iuBuenco 
«M tbo ooivso of repafr after the injury, and are mentioned by some 
mnrgjBOoa as the cliiuf causes of infiammations that are oocafiionally 
«eijr violent and develop ea^ily-dccompouog exudations and infiltra* 
ftioäl. I am far from denying the inOuenoe of an eoergetio oooous- 
sioa oa a bono witoao nitKiiilla and Teeaels are thereby torn, without 
sta beiof fractured ; under aonie olrcumstanoee tbe result« of such an 
Äu3uiy miglii be more exteusive and tcdioua than Iboec of a fiactoiv 
^DBi too great bending; but we sliouIJ not aitcribc Urn frequent 
jawiiiitj of tbe course of contused wounds entirely to this cause. 

ConttiiiOnt of the rcascls must be much more apparent, since the 
I of tbe smaller veesela, eepeoially of the subcutaneous veins, are 
leitnoycd by tbe ooortusing' force, and blood escapes from ilieni. 
^^tiicutweotu hcpm<rrrha'ji is the almost constant oonsfqueiioe 
' a contudoiL It would he much more considerable if in tliia variety 
' io^ui^ tbe wound of th« vessel had »harp edges, and gaped ; but 
usually the case. Contused Trouads of the vessel are 
ren, ra^^d, and these irrcgulariti«« form obstacle« to tlic 
spe of th« blood ; the frictioti is so great Ibat tbe pressure of tlie 
Uood is unable to ore(«omc it ; fibrinous dot« form on these incqual- 
■lica, ereo extending iulo tbc calibre of tbe vessel, causing meGhanical 
domre c4 tbe vessel, or thrombus. Contusion of the wall of a ves- 
kI, -with alteration of its atrucrturc, may alone cause coagiilaUon of 
tkieläood; for Srüebe has proved that a living, healthy tntima of tbe 



144 OONTCSIÖNS OF TOB SOFT PART« WITHOUT WOtTNDR 

T<<«nc1 is Tcrj itnportont fbr tlio fiuidity of the bkxMl within the Teasel 
We sball tig&ia rotttni to Uiis subject, iittder contused wounds, TliO 
oountcr-pieSBUre of tli« soft part« prerent« an exoessive cccape of 
l)lood, for tbe muaclca and fikiii exercise a »atunl counpresBion ; lieooe, 
these nibcutaiieoua htemorrb«]^s, even when from a large vcMel of 
the extrem ili«>«, arc ver/ seldom iostantly dangerous to lif<v Of 
course, !t is different iii hAemorrbagcs into the cavities of tho body ; 
here there is üttlo beüdos movablo part«, that can oQcr no suffident 
o])poeJtioii to the escape of tlio blcxicl; becce, tbese bstnorrbages are 
not inlicquentlj iatah This may he in two ways: partly (rota Übe 
«mount of blood escaping — into the llioniz or abdomen, fur instaDcc — 
partly from the preuure o£ tlie blood on tbe purt» In th« e-avity — on 
the brain, for iosianoe— wliidi ura uot only porUy destroyed by tlie 
blood flowing trom lorgn Tcsscla, but ore compros^cd in rarious dlxeo- 
tions, and their ftmctjons thus impaired. Ilt-ntv, bjeinurrhages in tbt 
brütt caus« rapidly-occurring paralyses, and often, also, dtstorhaoce 
of thti oeusoriuin. In the bnuu vre call tbis escape of btood| aa well 
tm the symptoms induced by it, apoplexy (from ä^o and irXfjeou^ to 
knook down). 

If a largo artery of an cxlrcmity bo contused, tbo conditioog are the 
saaic as in B Btitche«] or ooniproascd puucturcd woand. A bnumatio 
aaeurism, a pulsatlag tiuuor, fonQB,as deMlibod io tho last leotiu«, 
But this is tare as oomparod with the numerous oootusioos occurring 
daily, and is so, doubtless, becauae tlic larger arteries Ue qiute deep, 
aud tlic arterial ooal« are finn aud clastic, so that tk«y tear for Itaa 
readily thu» tlic veins, altliougli a short Unie since, in the clinic, we 
saw a subcutaneous niptura of tho outuriur tibial artery. A strong, 
musoular roan had a Jrocturc of tho leg ; tho skin wasoiniajurcd ; the 
tibia was Üractured about tbe middle, the fibola rattier higher. The 
oooflidersble tumor that at once formed at the seatof fj-acturo pulsated 
visibly and perceptibly to ibo touch ou tbe anterior surboe of tbe leg^ 
Thcr« was very evident buuing sound in it, whieb I was able to de 
moiutr&te to the class. The foot was dre8»«<l witb splints and band 
ages ; wo avoided tbe application of nu imiitovable dressing, so that 
wo tnigbt waleh tl>e furtJier course of the traumntie Aneurism that had 
evidently formed bere. Wo renewed the dressing every three or four 
days, and could sco the tiunor gmduully becomiug smnUcr and pulsat- 
ing less etroogly, till it finally disappcarod,a fortnight after the injury. 
The aneurism bad been cured by the oompreesion from tlm baudnge. 
Nor was tlie reoorery of the fracture intcmiplcd; eight weeks afUjr 
the injury, the patient had full usu of bis UmK 

Tbe most frequent subcutnaeous btemonfaagei in contuüon« : 
from rapture of tbe subcutuiicous veins. These efTusions of blood 



COSTDSIOSS OF BLOOD-FBsSELS. 



1» 



* 



can» risible svmptoma wbich varr, parti/ from iho qiuntJt/ of Uie 
effused blood, partly* from tbo dtetributioQ of tlie blood in Üw tiasne. 

The zoore vascular s part, and the more severely crnntuscd, tbo 
gmter tie cxtiaTasatioo. The cxtravasatcd blood, if it escapes irom 
tbc TMftcU slowly, forma a possage-wajr between ihe ooDDCctivv-tituae 
buadles, espeeiiilly those of tlu; siiI>cu(Aneou8 conneeUr« tüsue ud 
fmtBoW ; tUs must mii^«e iDfiltration of Uie lisuie wilb blood and coi> 
•o(|uecit BwcDin^. Tiiesc dilTusc and BubcutoQcous bjemorrhagm wn 
tarn tuggillatioiu or auffufiotu. Ttie tnorc relaxed iiod /icldiiig,and 
tba easier to press apart thu tissue 'u, the more extensive will be the 
lafiUration of Ucxx!, if it ilon-s gradually but coutiaually from Uie 
veueU fur a timo. Hcoce, as a rule, we fiod the effiisiona of blood in 
(ho eyelids aad Borotuin quite extensive, because the subcutaneous 
oouacctiro tissue Lhero is so loose. The thinner the skin, the more 
readily and fjuickly we shall recognize the suggillation ; the blood has 
n blu« oolor tlirough the Kkin, or preK»es into it and gives it a steel- 
blue oohir. Under the conjuncüva buibi, on the contrary, the blood 
appean quite ted, as this membrane is so thin and transparoQt, 
Blood extravasations in the cutis itsolf appear aa red spots (purpura) 
or itrtae (ribices) ; but in this form they arc Tcry rart^ly due to oonlu- 
«»on, tliey are caused by spontaneous mpture of the vessels ; whether 
becauao tlie walla of tlie vessels are particulaily thin in som« porsons, 
oa in thoee already mcntJoocd as bdng of hicmoirhagio diathesis, or 
bocaase thoy are especially brittle and tender from some unknown 
onnditioa of the Unod, as in eoorbutis, sooio furma of typhus, morbus 
maculosut WerQiorii, etc. Contusion of the cutis may usually be reo 
osniaed by a venr* dark-blue color, pawing into brown ; also by stria- 
tioa of tlie cjiidtimis with so-called cAo/M, or, as they arc teolmicolly 
ttnned, ezeoriationt. Haying of the skia 

If tnttcb bloTKl escape suddenly from thu rcsscls and be cBuEcd in 
the loote cellular tissue» a more or less bounded cavity is fonnod. 
This forat of «"ffuMon of blood is called ecchymMts, ecchymomOj htB- 
matoma, or bk>od-tumor. Whether iho skin be discolored at the 
•ame time, deponds on how deep the blood liee under it In deep 
HhHaOOS of blood, diffuse as well as drcumscribed, wc often Gnd no 
diMolocntinn of the skin, especially souii after the injury ; we only 
perwfTc a lunior wlioso rapid dcTclopmcot immediately after an injury 
»t oooe shows its nature; this lunior feel« soft and tense, llic rir- 
tRnaaertbed effusion of blood ofTcrs the very diaractcnslic fcellii(r of 
Jtutiuation. Vuu nmy most readily obtain a clear idea of this feeling 
hy suing a bladder with water and then feeling its walla. In sui^cal 
psmctioe the rMOgnltioo of fluctuation is very important, for there arc 
b < i^ Hff !* Vf case* where it is important to deleimiue whether wc 



HB COMTCSIONS OF TOE SOFT PARIS VnTBOn* Wor^Dä 

b»re to den) with & lunuM- of firm ooiu»t«noe^ or «itli ose ocntainbj 
fluid. Vou will bo flltown in the clinic bow it is bout to nukt Üät 
cxmnunation in lUiTcrcaL cftsc«. 

Eotne of th««c effusions of Mood Imt« roMired pariii-nUr una 
■ccording to the localities wbt-re tbejr oooar. Thus those caming oi 
the houl» of tlic nenijr-baro, between th« various or>T«ring6 of tlw 
skull Olid ill it, aro called eephtMeBmatoma (from xe^Xj, bead, ami 
df/iaräu, tn mil with blood), cephnlia taiDors of the oowlj^bora. IV 
extniTiuuktiLwia in the labia nisjoni, fmm contuiüoiu or the apnataiKiODi 
rupture of diBtcoded veins, hare received the neat naioc of ^MioAest» 
toma or fpisiorrhagia (from tr-ttmov, the oxtenial gmitals). Bfr 
aionB of Mood in the pleura and pericardium have also ^ledat tlajp 
nations: h(9m<a«thorax^ hasmatcperitardium, el«. On th« trfaak 
we attach little importance to these eupbonio Latin «od Gredctua»; 
but you should know them, bo as to undentand tbem when naUof 
medical books, and not suclc for aiij tliiiif^ mnterioua behind iktu; 
also that jou may use them so as to express joursolf ({uicker, tail bt 
rtsiulil}- understood. 

Hie Biibsei|uent coiinm and sjinptoms arc very cbaTactctülic U 
these sabcutaneous effusions of blood. I^ooking first at the (KAs* 
efiusions of blood, imtoedistel}' after the injuiir, we are ran>ljriUetD 
deeide bow extensive the bleeding has been or still is. If yoHCl- 
unine the oontueed part the scoood or third diir after the injunr, J9i 
notice that the diseoloratiou is more extensive than on the fint ^; 
this appears to increase subtcqucntly ; thai is, it becomes motr pH- 
ecptible. Hie extent is sometimes astooislungt Wooooo hadtot))! 
clinic a man with fractured scapula ; at first there was only slight ^ 
oolomtion of the skin, allhongh there was a largo fluctuating taaet- 
On the eighth day, the whole back from the nedt to the gluteal nn^ 
des was of a dark steel-blue, and presented n peculiar, almoat comical 
appearance, tbo akin looking as if painted. Soch widelj-spreadlug 
cxtravasatioQii am particularij apt to occur in cuac« of fractured bontft 
especially of the arm or leg. But fortnnatelr this partly dark-Une, 
partly bluiah-rcd oolor, along with which the skin is not sensitive aoi) 
Bcnroely ftwoUen» does not remain so, but furiber changes talc« place; 
first there is further change nf color, tlie blue and red past into 
brown, then to green, and finally to a briglit lemon yellow. Tlita 
liar play of colon« baa given rise to the ciprcssion of " booting 
black and blue," or "giving one a binck eye.'* The last cdor^ 
yellow, usually rvmains a long lime, often tar months ] it finally di>> 
appears, and do >-isible trace of the extravasation icnwino. 

If we ask ourselves whence come theae rarions colorings of the 
skin, and if we have the opportunity of examining blood oxtravasa- 




OONTUSIOWS OF BLOOD-VESSKIÄ 



147 



VBiioua stages, wc fiod that it is tbe coloring matler of tJie 
lood which graduiill^ passes tlirougli the metunotphosea and ohulca 
lef color. When the bluod has escaped fixiin the vessel» and entercci 
the connectire tiuup, Üie fibrine coaguUte». The ecniin enter» the 
Ctmncctivo tusuc, and tbeoc« passes buck uito the rosscls ; it is re- 
slMOrhetL Tito coloring tnatUir of the b!oo<l h^Aves the bloo^-c-Orpus- 
cles and tii a slate of »olutioD is distributed through the tissueL The 
fibrioo and blood-oorpusclea, fur the most part, diaiatcgnito to fine 

I Bioleeul««, and in this »Inte nro n>al)fturbcd by tbo vcssoln ; as in the 
thrfitnbus a few while blood-cclU may altsia a higher developmeut The 
coloring ntattrr of the blood which saturates llic tissues passes through 

' rarioaa, not thoroughly understood ni«t«morphoB«s vith change of 
color, tut it ia Gnallv transfonaed into a permanent cokiring matter, 
which u no longer eolablc in the fluids of tliu body — hamatoidin. 
As in tbo thrombus, this is partly granular, partly crystalline; in a 

»pure state It is oniiige-ookired, and 
no. ML if scanty gives the tissue a yellow^ 

iflh color, if plentiful a deep onmge 
• ' A "Ü' ^- •**'*«>''• J' A ^"®" 
ifi V *^'»^!/r'7» V lUaltorytion of the extraTasa* 

^- " *•■'?-•■ * ■'^'*:Jr«/«»*- tion alniunt nlways lakvs phtcc in 

diffuse eug^llations, us the blood 
is very widely distributed through 
the tissues, and the tcbscIs that 
bare lo aocompiisb the rcabsorp- 
tion have not been affected by the 
contusion ; it is the most desirable 
and under farorublc eircuinstaiicca 
the most frequent result after sub- 

Ktaneous tod inteimuscular cffusiuns of blood. 
The cafie is diffcreoi in drcumncribed cSusions, in eec/iymow«. 
sre the £rst qucation is as to the extent of the effusion, then about 
s state of tho vvsxi'b surrounding it ; tito more developed the latter, 
the leos they have been injured by Ute cxsntusioii, llic more hope there 
is of early reabeorption ; but it« oocurreiioe is aivrnys Icis oonstaot in 
Urge eiTusions of this variety. There am various (actors wliicli intei^ 
fere with it ; in tl»; linst place, there ia ihickeiiiug of the connective 
tidme arcFund the uGTudion of blood, as around a foreign body (aa in 
traumatio aneurism alKO), by which the blood is entirely encapsulated ; 
}he fibrine of the effusion is deposited in layers on the inner surface 
_«f this sac, the fiuid blood rcm;üns in the middle. Hius the vessels 
kbont the blnod-tuiuor can take up very httle Quid, as they are 6i>pa- 
Frnted from tho fluid part of the blood by layers of fibrine, whieli are 




OWrtw nd lj;iMfci iMnuMte oMhr 




148 C0NTÜS10K8 OV TBE SOFT FARTS WITHODT WOUXDS. 



often quite thick. Hero wc have tbe aamc oonditloos as in Urfre 
fibiiaous exudations in tbc pleura ; there also the fibrotia d(>posit« oo 
. tKg w«Us greatly iiitorrcre witb rcabsorption. Tbis oaa only take 
place perfectly when tlie fibrine disintegrates to moleonlea, beoomca 
fluid, and tlius nb»orbablc ; or wliea it is orj^aniited 1o ooooeotiTe tis- 
sue, 1111(1 Nii[)piie(l vritli blccxl nnd lymph vessels. This is ncpt sorei^ rare 
in pleuritic deposits. Dut there i» sifto snotlicr fat« for such extrnva- 
satioQS. llic fluid portion of tlio blwxl may be completely reabsorbed, 
%nd ft firm tumorcoinposMi of conc'entrie,oDion-Iike layers may remain. 
nUaicndtsoccanonallyfroai cxtrarssatioQs in the labia tnajora; aso- 
tu^ksdjürpw tumor is thus formed ; in the ravity of the uterus, also, 
Ruoh fibrous tumors oceauonolly develop. Some hiematomata may b^] 
partly organized to connective tixsue, and gradually take up Ume-ealt 
«Dd entirely calcify ; a rare tcrminailou, but ono that oocuis in effa 
siona ot blood in Urge goitre«. Another mode is the transformaijoal 
of tlie blood*tumor to a cj/it/ this is S4WD in the brain, uud in Sufl, 
tumors. Besides other modes of ori^n, somo cysts in gtutrca tnay owe 
their origin to such effusions. By u cyst or encysted tumor we 
juicfl or bags conlainingf more or less fluid. Hie oontenta of 
oysls, resulting &<ora estravasatii»! of blood, are darker or lighter so 
coidinj^ to thvir age ; indeed, the blood-red may totally disappear 
lixjm thetii, aud the eoiitetils becoino quite clear or only slij^hüj 
cloudt^d by fat molecules. In Inr^ circumscribed extravasatioDS ^ 
will fmd numerous awl bcauU fully- funiiecl hemntoidio crystals morS^ 
rarely than in small dilfniic ones, for in the former fatty diaintegratioii 
of the elements of tlie blood pn^nlomiiinti'tf, heuce excretion of diolt 
tcrine cijsbiU is more common in them. The capsulu cocluiing tLes43 
old effusions arises portly from organiaitioQ of tho pcripboral parts 
of the blood-clot, partly &om the circumjacent tissueu 

J^ippuration of circuinscrib«:! extrarasalious ia fiv more fret^uent 
than the tiro la5t described mctamocpbosci, but la Dot ao conunon 
reabsorptioii. The iuflammalion In tlio vieinlty, and the plastic 
cess in the peripheral part (^ tltc cztrux-asntion, fcom whioh. In the 
two preceding case«, the thickened cooncotivo tissue was deroloj 
which encapsulated the blood, assume a more acute charaeter in 
case ire are about to speak of; a boundary layer is formed liorc also, 
hut uot slowly and gradually as in the preoediog caacs, but by rapid 
ocll-formation ; plastic infiltration of the tissue doea not lead to devel- 
OfMneut of connective tissue, but to suppurallon ; tlie inflamnutic 
after a time attacks tbe cutis, nnd it suppurates from irithin outirard| 
and b finally perforated, and tho pus mixed with hlood is evacuated ; 
1^ walls of tho cavity come together, ciostrÜBe und grow togi-tlier, 
and healing tlius takes place. "Wo shall speak more cxactlr of tliis 



W)STU3I0XS OP BI-fWD-VB^BlA 



149 




tDode of holing wlien trcutiiij; of ubsccas ; wc coll any pua-tumor, 
1. e., cirouinscrEb«d cullouttoo of pus under tlia skin at »ay depth, an 
abaen» i hence we tenn the above process Üw ooaTeraton of xa ex- 
ttioQ of Mood into an abeccse. This process may be very pro- 
letcd, it may last three or four weeks, bat, if not dangerous from it« 
itioQ, it generally runs a favcraUe counic. We recognize iJie ku|> 
puralioQ of aa cxtrarasation of tloud Ly the iDureasiog infiummatory 
tvdoOM of the skin, the grovrth of the tumor, incrcftsiopT |^i'>> occasion- 
ally srcompanied by fever, and finaJly by tliiuiiin^ of the &kJo at soino 
' point, where it is finally perforated. 

Lastly, ih<^r« muy bu mpid docompositioo of the extravasation; 

iDTtunatc^Iy, this is rare. Then the tumor grows hot, tense, and very 

pamfal, the fcrorusnally becomes oonwderabic, chilb and other lewre 

getienl symptoms may occur. Ulis tenniiiatioa is the worst, and tho 

, o af ODC tliat reqiures speedy relief. 

^B ^VltdJier there shall be rcubsorption, suppumtion, or putrcfuction 

^Ktf 4a extntTasstlon, depends not only on the amount of the cSuscd 

^Hriood, but vpry much ou the grade of ihe contusioa that the tiasoea 

liare sofibrcd ; aa Long as these may retuni to their oormal state, re- 

. wilt be probable; if the tissues be broken down and paj^s 

Ikto disntegration or docomposilion, they will induce suppuration Qt 

ntion oi the blood ; briefly, the cfTused blood will bare the 

fate as the contused tiasuc. 

While the skin is uninjured we cannot judge accurately how much 

I mufcle«, tendons, and fascin?, are injured ; occaiionally the size of 

extimvaaation may giro some uid on this point, but it is a very 

measm^ ; it is better to tost tlic amount of functiouul ao- 

'of tho affvctud muecles, but even the results thus given must bo 

ly accepted ; the amount of force that haa acted on the part 

to an appioxioMte estimation of the existing subcutaneous 

3Q. In contusion of muHcles, ns in wounds, healing takM 

I tiie crushed muscuLu* element« undergoing malecuLu disiii- 

t and beiu;^ absorbed, or by being tUmiuatcd with the pus on 

»tion of the extravasation, but then there i» new formation both 

vt coDDoctive tissue and muscle. 

TTic taj;^:&t extravasations, cither diffuse or oinmrnscribed, ore 
«mally Accompanied by injuries of the bones ; but it witt bo bettor to 
ooiuddef the injury of fhe bone in a separate section. 

If a portion of tlie body be so cnwiied as to be entirely or raostly 
BHSpabk of living, it becomes cold, bluish red, brownish rod, Ibeu 
fahulf; it begins to pulrefy; the producta of putreiacUon enter the 
nd^borittg tissues ami tbu blood; the local inflammations, as wcUas 
Ihe fcvi-r, ii»«iimv peculiar forms. Ail this is the same in contusions 
' wilbuut wounds, we shall apeak f^f It later. 






160 COSTOSIOSS OP TIIB BOIT PARTS WITnOIIT WOUNM. 



Tbe treatment of contiudoDS without wound lias fur it« object tlic 
oondtKrüon of tbo process to tlio most EtvonUe t«namatioa posfiibW, 
thnt is, to rcabsorption of tlie extravasatioa - wbea this take« plaa% 
t1>e injuries to tbe other »oft parts also pro^frcss fsTorabl j, a» tbe wbole 
proccaH rcmsios subcutaueoio. We bcre refer »olcly to ibo«e cbms 
whora the contusion of the soft ports and tlio extravasation ue 1h« 
only object« of treatmeut; wbure the boiie is broken it sbouli] be 
treated first of all, the cxtrarusatioa of itself vould scorodj be na ob- 
ject for spcoiut trcatmiL-nL If called to a contusion that has just o» 
curred, the indication mnj be to arrest any still coniinumg bamol^ 
ihag« ; this 16 best done by oomprcssion, whicb, wborc cooTenicnif ia to 
be Diade by ercnly-appJicd bandages. In North Gcnnanj, when a 
oliild falls on its head, or linocks its forehead, tbe mother or nurso at 
one« presses tbe htiudle of a epoun on the injured epot lo prereot tbe 
formation of a blood-brwsc. This is a very suitable popular remedy; 
by the iofilautaneous comprcsrioa tbe furtlieT escape of h'i'Mx\ \» bin- 
deied, as is also its ooUoetion at one poiot» bccaua« it is compelled by 
the prMUr« to distribute itself in the surrounding tusue ; an eociby' 
mosts just forming may tlius be traosTonaed into a Buggillalioii| ao that 
tbe blood may more readily be abttorbed. You may occaaloBally si- 
tuia the same object by a well-applied bandage. 

But we rarely sec the injury so early, and io the gre&t majority 
of cases there is also an injury of a bono or joiat, and the treatment 
of the blood-extravusation is a Boooodary object« 

The use of cold, in the sbope of bladdci« or rubber bags filled with 
ioe, or of cold lotions, to whioh it is an old custom to add Tinegnr or 
lead-water. Is resorted to as a remedy in rvocnt ooutosiona; ii is 
said to prevent csoessiTo inflammation. Hut you must not rely too 
much on these remedies; tlie means that most aids the reabsorptiuo 
<rf blood extrarasations is re^lar comptiessioa and rest of the p«rt. 
HcQcc it ia best to envelop the extremities in moist hfn'1"g*'*i <uk1 
OTor them apply wet dotbs, which are to he n^iiewed every throo or 
four hours. Olhcr remedies, which usually aet wull in iuflanimatJom 
of tbe sldn, such u mercurial ointment, are of little use hcrcL But I 
most sot forget aruica ; this remedy is so hnoored by some Camiliw 
and pbysioians that they tvuuld consider it unpordonable to neglect 
proscribing lotions of infusion of arnica, or of water with tbe additiou 
of tincture of omii'a. Faith is mighty; one boiicv'es in antics, aiv 
other in lead-water, a tliird in vinegur, as the potent external reab' 
soibcuL In all coses tbe eJFeut b doubtless nmply due to tbo tnoist- 
nre and the Variation of temperature of the skin cause<^ by tbe eoo»* 
press, whereby the capillaries are kept actire, now broitgbt to oootiai» 
lioo, now to dilatatioa, and thna placed in a better state far laabacmK 
tioo because thev aze active. 



t 



4 
4 



TftEATlIKNT OP B[/M)D-EXTRÄrASATIONa 



ISl 



DtSose blood-oxUftvumtioits of tbe skio wiUi moderate oontusioa 
nf tho soft paitK axe luually absorbed vitliout much tfcatraoat. If a 
circumscribed cxtraTasatioa does not change considerably ni tliu ooune 
of a fbrtoight, there is Derertheless no indication fvx- further iotorfcr- 
; enoa We then paint the «welling- onoe or twios daily with dilute 
tinotttre of iodine, compress it vrith a suitable baudagr, aud oot un&o- 
qaentl^ see the swcUing gradually subaido after seveml weeks. 
Should it become bot, and the skin ovor it grow red and painfiü, wo 
must expoct suppuratioQ ; theo even the continued apj^icntion of cold 
will nrelj dtange tbe ooune, though it may alleviate it. Then, iu 
order to baitco tbe t«nninntion of tbe nuppuration, which eaonot be 
avoided, we may apply wann fomeutatiuiis, either siniply of folded 
tnusltn wet witli wnrm water or cataplasms ; now you quietly await 
the forthcr coureo ; if the general health bo not impaired, but the pa- 
tient feels pretty well, you calraly anait perforation ; it will perhaps 
be weeks before tbe skin gradually Ix^roroea thinner at souhi point 
ud finally opens, the pus is evacuated, the walla of the Urge cavity 
tau together, and in a short time the parts are all healed. At the 
coaunenoemeiit of llii» lecture 1 mentioned a ciac where, with a frac- 
tured aeapula, there was an enormous partly diffuse, partly cinnim- 
scribed extravasation ; here there was a strongly-Quctuating tumor, 
which was not reabsorbed, while the diffuse eflii&ion was rapidly rt> 
moved ; tJio BujipuintioD did nut end in perforatiou till the fifth wevk, 
then one and a, half to two quarts of pus were evacuated; a week 
later tliia eoorroouB cavity wea healud, and the patient left the huapi* 
l«t well. "Why we do ant hero intcrfrro carlti^r and aid Nature by an 
tMssioa, w« shall cooftider mote closely when we treat of absoesses. 

Should the tension of the swelling rapidly increase, however, dur- 
ing the suppuratioo of the exlravasaiiou, and liigli fever wiüi chills 
occur, wo may suppoM that the blood and pus are dceompo^ng, that 
then is putru&ctiou of the enclosed fluid. Fortunately, this is rare, 
and occun almost exclusively where tlicrrc is groat crushing of the 
muscles or splintering of the bone. With such svmploms of course 
ibe putrid Quid should be quickly evacust4^d ; then you diould make 
■ iarfft incision tliroiigh llie sldn, unless this be roTbiddcn by tbu auu- 
tonut-al positiciD of the porta ; iu which ca&o several entail incisions 
should bo made at points wlierc tbe fluid may escape fireely and easily. 
Tliese iudfiions greatly alter the aspect of tbe cose ; you have changed 
tbe mibcutaneoua contusion to an open contused wound. Now othoc 
OOdditJons come into play, wbiüh wo shall treat of in the next lectiucL 
We must still mention tJiat, if extensive putrefaction of the »oft parta 
fallaws Buch contttsiona, amputation is indicated, although this uufortu- 
o»le CBAO rarely happens without coincident frocttue of the bonea. 




CHAPTER IV. 

CONTUSED Ayj) LACERATED WOUXDS OF TUB 
SO^T r^LRTS. 



LECTURE XII. 



UoJeof UccximoM of tbeao Woiuul«; tliMr AppcanuK«.— STiglitBKnMrrliAfQinCvii- 
twwd Wotind». — Evljr Svoondwy UwmarTiuig^«. — Gftngnao vf Ika E<Ic«« «f Ih« 
^T«ut>d.— led wncM' tint elbc4 tba Slow« «r mor« Bapid 1>«tKihipaDt of tbo Su4 
Tliage.— tnilicaüoDi for PrimBy Ampuutioo.— Local Complieuioiu in CcntoMd 
Wounds; Ikoumpotatlon, Putra&atMn, Svptio *"*■■—""'"-■• — Coutusioa of Ar- 



Tub causüa of coittus^d wotrnds, of vhicli ve iiavc to treat to-day, 
are tho samo as those of eünplo oontusioos, only is the first cases the 
force U uHuilIy grealor thfiD in the latter, or tbe body by wliich tliey 
are todoced is of such a form as to divide tbe skin and soft parU 
easily, or else parts of Ute body bave been injured wlicre tlie 6kiu i» 
partioidarly this, or lies orer pnrtB umuually firm. 

The kick of a hone, blow from a slick, btte of an aniuxü or a man, 
bcii^ run over, 'n-oundiiij; with bluut kuivc», saws, eta, arc freqncnfe 
causes of contused wounds. Nothing, howcTCr, causes mot« contused 
wounds than mpidly-moviag whecU and rollers of machinery, cutling- 
machines, circalar^nws, apinnin^jenniM, and the various machine« 
with cog-wheels and hooks. AU of tbcM lostruments;, tLc product 
of adv'Bncing industry, do intich injury among tho cppeialivci;. Kien 
and women, adulta and children, with crushed Sngcra, maabed banda, 
laggod, loccmtcd wounds of the forearm and arm, ore now amODg t&e 
couataut patiruls in the Eurgiosl wards of hospitals in erery lai^ 
dty. Innumerable persoas are thus maimed of fingers, lisnda, or 
amis, and many of these patient« die as a result of their injuries. If 
to these you add (what recently is becoming rarer, it is true) railroad 
Injuriee, those caused by blasting, building tumieU, etc, you may 



AFPEARANCC OF 00>TITSED WOÜKDS. 



153 



in^pito, not only bow inucb sweaty bat how much blood, clings to tlis 
' «rid«D(Ka o/ modem cultuic. At the same time it is not to be 
deni«<l that the chief cause of these accidenU ia the cnretessnrmt, 
often tke foolliardiDesA, of the warkmso. Fniniliarit; with tbe dau* 
g«nnts object renders penon^ at la»t carctes» nnd r&ali ; some pay for 
this wlüi tlieir lives. 

Ounabot wouuJ« also essentially belong to contused wouuds; but, 
as tbcy hnve some pcinjlJaritica of their own, wc slmll treat of them 
in a special diapter. Laoorat«! wounds, and tearing out of pieces 
imm the limbs, we sball consider at the end of this chapter. 

Fmciures of buoes of tbe most varied and dangeroua varieties ao- 
company contused wounds irom all the above causes; but for the 
present we sbaO leave tLcsc out of oonsideniUon, and treat only of llio 
«oft part«. 

Ia most cases, tbe appeanioce of a wound indicatca wbotherit w»s 
dtw to iociaion or contusion. You already linow tbe charaeter of in- 
cised wounds, and I have alluded U> some cases wliere a oontusod 
woond had tbe appcvaDoe of an iitdaed one, aud tliu reverse Cor> 
(ltd wounds, like incised, may b« accompanied by loss of subalanoc, 
or there may be nmply solution of continuity. Tbe borders of tbea« 
«ouikIs are generally uneven, especially tho edges of tbo skin ; tbe 
BmselM oooasioiially look sa if chopped; tagt of tho soft purt«, of 
ranous rises, not uafrequcntly \ugQ flaps, bang' ia tbe wound, and 
may have a blaisb-rcd color, from the blood stagnated or cfTusod in 
ti^em. Tendons are torn or pulled out, fusciis are torn, the akin, for 
sone distance around the wound, is not unfrequcntly detached froin 
lbs fiuda, especially if the contusing force was combined witli a tear> 
log Hid twisting. The grade of this destruction of tbe eoFt ports of 
emrse varies greatly, and its extent csnnot always be accurately do 
totaloed, as we cannot atwa^'s see bow fur the contusion and tearing 
SxtCDd beyond tfac wound; from the subecqucat counc of Ibc wr>und 
we often satisfy ourselves that tbe contusion extended much further 
iban tbe size of tbe wound indicated ; that separation of muscles, di- 
nstons of bscif, and eiTuaions of blood, estciidcd uuder tho skiu, 
which may hare been but little torn. It is unfortunate that tlic skin> 
wound gives no means of jttdging of tlie extent and depth of tba con- 
tusion, f'jf it renden it very difiicult to correctly estimate such an in- 
Jury at 1)10 first esAinitutti<->n ; while the ftppearanoe of the wound 
gires tb« laity no idt.-a of danger, the expcricooed surgeon soon sees 
1^ gniity of the ose. 

SioM tbe injury, especially when due to machinery, is very rapidly 
ikne^ the pain is not great; and immediately after the injury the pain 
(ram contused wounds ts often very slight; the more so, the greater 




■•• •"• ■"- 



164 C0XTIT3ED AWD LACERITED WOOXDS OF TBE SOFT PART9L 



por of^ 
itoaadfl 



: 



the injui; aixt crusliln^ of the parts; Tbis U readiljr cxplsincd by 
(be nerves in the wound bciof; Cnlirclj msflbed and destroyed, cooeo- 
qucotly incapable of conducting; moreover, what I told you ia the 
last lecture about local concussion of tuervcti, the «o-callcd stupor of 
tl»e injured pari, oomes into pUy. 

At first »igbt it deems mth^r ivmnrkablc that thpse COD! 
irouuds bleed little, if nny, ereu if liirge veiui or art^^ries he cnubi 
or torn. There uro well-obscrrcKl coses to ebov that, after complete 
cntsbing of the femoral or axillary arteij, there wiia absolutely no 
pliniaiy haemorrhage ItiAtnte^thisisrare; innuuiycoBGavbeTe then 
is ocmpleto solution of continuity of a large artery by a contusion, 
although tliorc is no spirting- slrcsjn, there is oonstant trickling of 
blood; this, oomiug fium the femoral artery, trould speedily cause 
dentil. I bare already told you how this arrest of ha^morrhaj^ takes 
place in small axt^nes, but will nuike it dearer to you by na illustnp 
tion. A TUlrood liniid was nin over by a looomotivo^ so that the 
nrlwd passed oror his left thigh just below the hipjoint. Hie anfot> 
tanate was at oneo brought on a litter to tho hospital ; meantime be 
hod lost much blood, and came in very pale and anaemic, bat perfiactly 
consdoos. After complete removal of the torn clothing, we found a 
borrihle mangling of tiie skin and musdee. The bone was ouahed to 
atoQiS, the muscles wer« partly mashed to pulp, partly hung in toga 
from the wound, the fitun was torn np as &r as the hipjoint At no 
point of this horrible wound did an artery spirt, but ttxxn the depth om^ 
sidenbic blood constantly trickled out, and thegcneml s tale of the p»* 
tient dearly showed that he had nlreaily lost mudi blood. It was eviden t i 
that the only thing to be done hare was to amputate at the hipjoin^^H 
but in the condition the patient then was, iLis was not to bo thoogb^^ 
of; the new loss of blood from this sercro operation would undoubt- 
edly have been at oooe bttut. Henoe it was, first of all, necessary to 
aireot the bGQm<HThage, wliicb evidently camo &nm a rupture of the 
fcnwral artery. I first tried to find the femoral in the wound, while it 
was ooniprcssod above ; but all the musdea were to displaced, all the 
anafoniica] rdaUon:) were so dianged, that thb was not quickly done, 
henee I proceeded to ligule the artery below Poupart'a ligament. 
After this va» done, nwet of the bleeding ecascd, bat not entirely, oa 
account of the five arterial anastomosis ; and as no regular dresting 
could be applied, oa account of the existing mangling, I surrounded 
tJic limh finnly with a toumiqiict, close bdow where I proposed 
to cxatticulatc. Now tlie blee<hag stepped; we gave various 
remedies to revivify tho patient; wit»e, warm dtinka, etc, were ad- 
ministered, 9o that, toward evening, he had so far rooovwed that bis 
temperatiinj was again normal, and the radial pulse was again good. 




D.EUaRRIUOe FROU CONTUSED WOUXDa 



156 




should hare preferred postponing the operation fill tho loDoning 

ty^ U^ ta »pile of ligaiuro and toiuuiquct, with Üic etrcn^hcaio^ of 

the hnul'« beat, there liiid not been some bleeding fiom tho wound, bo 

U)«t t feared tlie paUt-ut luiglit bleed to death during the nigliC 

Huocc^ witb tbc nbit: holp of my assifitants, I oxarttculated tlio Mgh 

u npadlj as poaeible. During ifaa oporation the ftb6<dtitA lo« of 

blood was not great, but it vtm too much for the idraadf-debUltatad 

pKiitnt. At firat all seemed to go well ; the spirting vosscb were all 

Ugated, the wound eleaoscd, aikI the patient pluccd in bed ; won be 

Guffured from rvstlcssuoss aud dj'Spnu-a, wbioli iiicreaaed, finally con- 

Tuloions oecurrL-d, imd tho patient oxjnrcd two houn after tbc opera- 

tioii. Examination of the femoral artery of the crushed extremity 

showed the following : la the upper third of the thigh Oiere was a 

sod torn part, cotnprising atiout i>iie-Oiiid tlie calibre of tho 

Hio lags of tho tunica iutimn, ua well as the other coato of 

lel, and the connective tissue of the slieath, had rolled up into the 

' Calibra of the artery, and the blood could only escape slowly ; the 

sunounding tissue was completely (saturated with blood. In this case« 

BO elot bad formed in the artery, as the eaeape of blood was still too 

free to permit this ; but, if you imagine that tlte oontusion had affeoted 

the eoUre circumfcreooo of the arter>-, you may understand bow the 

tags of the coats of the rcsMl pceseiog into its calibre from bU side« 

n^t have rendered the escope of tho blood more difficult, or eren 

impoasibic ; then a thrombus would have formed, and stopped the 

ftufil, aad gmdually huro become orgnntsod, so aa to cause {lennoncnt 

clonoe, jtist as after ligation. If no luemonlMge had followed llie partial 

«nalung of the artery in this case, If, fur iustsniie, the crushing bad 

^nttrred wilhoiit an external wound, possibly a clot would simply hare 

ßamtd at Üie part roughened by the contusion, a thrombus forming 

^hm tile wnll ; io this case there might have Ireen crusliing of the 

^tftcty wiiJi |Nt»erration of its calibre, a result that is is»id to have 

Cjcon obserred. 

If jroii apply the aboi'V^escribed couditipn of » large crusJicd oi^ 
tjBry to smaller artcrk», you will imderstand how thcro may here more 
f-ea^V be complete spontaneous plugging of tho calibre of thcveucla 
pttTily by in-rolUog of the Dngile, torn tunica intima, partly by oon' 
tr^jctioo uf the fume« tnuscularis and by tlte tags of the adrcntitia, 
axid tlat conscqucoÜy bIcoJiug may fail almost entirely in such cou- 

ridtronoda. 
Ofaservatiou of this led a Frendi surgeon, Chaataii^nac, to invent 
iutnnoent for onuhiDg off portions of the body ; he terms this 

ppenäon ioroMnunf, the inttrument be calls an icraaeur. It con* 
)i>b of a strong mctallio ligature, composed of small links, which 





. 



c;css£oi^1 



OONTCSED AND LACERATED W0DND8 OF THE SOTT PART& 

is to be applied around the port to be remored, and tben drnum 
\y into ft strong metal frame by mcanB of a ntch arrangcmen 
When tlic iatttrumcDt is pcoperlv used it causes abeoluüily no hannor- 
rbagc LitUc favor as the instrument at £n>t found among eurgcoD\ 
froQi thoir dialiko to contused wouoda ia operative surgery, tbere is 
tio doubt of its advaatages in suitable cafieü. Wounds caused bjr 
ierasement usuaDy he&l iritfa very little local or general reaction ; cu> 
iD<:ident iaflamnmtions occur leas frequently with this dose of vouoda 
tbsD witU pure inciücd wounds. KeverthdeM icratement will alwa 
be limited to a small number of opcrattuus. 

llicro is SDotbcr factor for limitiug tlic bmnorrliagcs in cxtenai 
eontofiions, that is, the weakening of tUe heart's aotioo caused by 
injury, probably due to redex action. Persons bndly injored, 
eufferiog Jiom lose of blood and injury of liie nerT^-centres, are usuall; 
for ft timo in a state of oumbccs« or stupor ; tb« word most common^j 
used to express this state of depreraioti ia " shock." The fii^t bvat^ 
the injury and all thoughts about it, which follow in rapid succi 
unite in producing great peyckical depression, which has a paialyzi 
effect on the heart's action. Stilly eren in persona not greatiy 
fccted pflycliically by the injury, as old tmldicn who Iiaro oflea 
wounded, or very [dilegmstic persons, n severe injury is not entirel; 
without this effect, so that we must suppose that there are purul; 
physical cause« for shock. Conttisloos of the abdomco have an 
mora deprceeing effect on the nervc-ocntrcs than do iboec of the ex- 
liemitics, as I have already told yoa In tliis connection ihc so-csll< 
beatingK^xpcrimcnt (KlopfrcTsucb) of Gok is very interesting: if wi 
lepeetedly strike a frog sliarply on the belly witli tbe handle of a 
•onlpcl, be becomes as it were pamlytic ; as a result of paresis of tlieir 
walls, tlie abdominal vessels distend greatly and take up almost «H the 
blood, so that all the other vessels and even the bcari become blood* 
less, and tho latter only contract« feebly. 

Wben the patient has recovered from this state of psycbical and 
physical depressiaa, the heart b^ns to act with ita fomMsr or even 
greater eoorgy, then hemorrhages may occur from roatel« that bad not 
previously bled. Tliis variety of secondary bsmonboge occurs 
operations, when the effect of tlio amcsthctio haspusscdofil 
tlie patient should bo carefully watched at this time, to guard 
such Becoudary h»niorThagP8, capi-cially if, from the locality of the ia-" 
jury, there be reason to nuspcct that a large artery has been injured. 

Now we must again cxaniine somewhat more attentively the local 
changes in the wound. 

Altliough doubtless the processes tlist take place In the contused 
wound, the changes on its surface and final healing, must he essentially 
tbc same as in incised wounds, still in ttic nppesraoccs in the two eases 






^liadnot ^ 
HmoH 

f the itt-^H 



nsALiya op oostpsed uoukiis. 



un 



M bo « 



mn wMisidcnhle clÜfcr^nriM. One very important dmmstiinoo 
is, that in contusei] irounds tlio nutrition of Üw Hge.s nf Ute skin uid 
lofE parU i& more or less extensively destroyed or impaiKd, or, to ex- 
press this more •Dstoinic«Llly, the eircalation fen<I nerve influcoc« in llic 
botdeis of ooatused wounds are more or les« lost Tliis st one« pr»> 
nt* the possibility of healing by first intention, «s this rrqiiirr» ixw- 
TttaUt}' in the Bur&ccs of the woiiniL Hence contused vtouikIs 
slway« hxttd with siippuiation. 

"Diis abaerratioR onuses t» to iitlnxhice suiureftortnrflrmunifti by 
plutcn rnrnrclyj you may coiiüdcr this u n funeral rule. Tfacn^ 
on* (•xcc])4ioiiK to this nil(>, which yoti will only loam exactly iu the 
dmic« and of which I shall only incidentally rcmark, thatoccasionally 
we £utcQ large, looae Hups of skin in their original position, not ho- 
otuie we expect them to noite by first intenlioa, but that they may 
Dot from the fintt retrsct too much and atrophy to too great an ex- 
lent. 

Granulation and fnippuration on.' «■«i^nliallr th« nnmr- lui in wound« 
Tith loss of snbaUuiLH-, except llial lln-y nru slower, imd we might say 
unocrtaiu at mutty pLaecs. In iariaod wounds with loss of sub- 
lOe also a thin superficial layer of tissue is oocasiooally lost, if it 
Dot veiy well nourished j but this is inst^iürnnt as compared with 
extensito losa of liiuoe-ehrtHls ihnt ot.'ciirs iu contused irounds. 
days, oflcu fur weeks, tigs of dead (nccrös«d) skin, fascia, and 
tendons, lutng Iu thu edges of the wounds, while otfa«r parts are 
iuxuriautlr granulating. 

Tbia process of dctacfamcDt of tlie dead from the liriug^ tissue 
lakes ptncc as follows : A cell tnGUration nnd formation of vends, lead- 
ing to dirvelopinont of graimlations, »tart frotn the borders of the 
nrw tissue i granulalioaa form on the border of the hcullhy tiasuc, and 
tfaetrsur&re tireaks down into pus, Witb tlitg change tu the lluid state 
at it were the solultoa and melting of the tissue, of course tlie cuhe- 
rion of the parts mu&fc cease, and the dead slirods, wbich previously 
«ere in continuity with the liring ti-i^uc by their tilamentary oonnce- 
lien, must itow fidl. 

Hence part of ibc surface of contused wounds alrooat always be- 

nttroted (£rom vexpo^, dcnd), gattyrcnoua (from t/ y&yyf>atva 

\ 1 ooiiBtunc), which are both expressions for jiaris in 

iirh dnruUtion and Innerrvtion linvo ceased, or which are entirely 

od. Tliu part wltcrc the detachment takes place is technically 

illcd tlie Une t^f deniareati4>n of the gangrene. These technical 

which refer to every vuricty of gangrene, no matter hnw it 

ymi must only notice provisionally here. 1 will try to render 

pMnem of detachment of neeroaed tissoe by suppuration more 

itlnet by menns of a dingmm. 

13 




159 OOSmSED ASD UCKRATED WOCSDS OF TIIE SOFT FsKTS. 



In the portion of connoctire Lhtsue represented, mtppose.c, the 
bonier of tbe wound, be m> dcstr<»yed b^ the injury thitt ite drcalation 
is arrralod aikt it is no limgtT iiouritibix) ; tht blood is roagttUt«<l tu 
tl>c vceacls as Jar ■» the shading cstcuds in the diagniin. Now ceU- 
infiltration and ioflomtnator^- new funnalioa bef;inat tbeout«rcd^Ql 
III« living tissue, atthe border between a and Au-homtlio vn!wi>U Ij^rrai* 
Tiattt in loops; tlw«e rascular loops dilate, grow, and ninltiplj ; in ibi? 
tl»uo the infdtriLtiDn iJi ooii»tAntIy iiicrt.tuicd bj wandering cells, u if 
the edge of the wound wore htrrc ; granulatioa tissue Is formed ; this 
turns to pus, on the surJaoe, that is, dose to the dead tisrap, and 
then of roum tbe oecroMd port fnlle, becausn it« cohesion wiüi the 
livinj; tissue has ceased. Hence det&chmcnt of the necrosed ahredi oJ 
(iuue remits &ofn inflanunntioa with mppuratinn ; when tbe doad par» 
tion of tissue lias fiillen, the subjoocnt, !<iippiinilin£ layer of gianuln- 
tions comes to light, lumng been niready developed before tbe 
detarhmfnt of (he nrcrosed |mrt. What you here see in conMcltr* 
tüsueift (nie of the otlicr tbsucs, bone not cicepted. 



/" 4 



''/■■■ mk''^- -.Mf-.-'i- 



»< 



.F 



■-' I 



^^ 



Jhrrtm or itM praon ' r 



HEAtLSO OF tXiKTCäBD WOtTNDS. 



U9 



vna 
Kiel» 



In many cas(>.<i, on tlie fr«sli borders of the wound we may see 
abuul how much will die, but hjr iio nMmns in ntl oases, and vre cui 
never decide from Üie first u to the 1x»rdcrin{f line of tlie dead tisstK^ 
ComplHcIy crusbcd skiD usuoU/ bos a d&rlr-Muc riolct appßarance 
•nd feeU eold; in other eases ve at fret Eec no chan^ in it, but in a 
fexv dajB it is white, without senüation, later it becomeBgrav,or,when 
quite drjr, grajish or broTrniab black, llieee rarioiia colors dc-pcnd 
chicdy oa the amount of coafpibitpd blnod rAmainin^ in (be vessels or 
infiltrated in the tissue itiK'lf by lb« j^rtial niplure of the vfBsoU 
Tlic benlthy akin is bonlerrd by a rosc-tcd line which loses itself in a 
diffuse redness ; this is due to iwllatoral dilatation of the capillaries, 
and is portly also a symptom of fluxion, of which we liavo btifore 
»pokei) ; it is tlio reaclion rcilaess about the wonsd, which wo have 
alnKidy described ; for the Uring woand-aurface only begins vhere 
blood still flow» throuj^h the capillaries. 

la miuclea, bad», and t4Midon.s, wc can decide far lena frequently, 
. often not at all, from the appcuraucc at first, bow far tbcy will bo 
etadied. 

Tlie time required for the dead tissue to be separated and detached 

fron tlie Uriog rariea greatly with (Jie different tiasuea. This de- 

p cade fawt on the vucolarity of the tisAuos ; tho riclior a tissue in 

^BkpUbmcs, the softer it is, the more Tcadily cells spread in it, and the 

^jBohcr it is by nature in cells capnhlo of development, no much the 

fnora rtpidly will the formatirm of granulations and the detachment 

of the necTOCed parts eome about. All tbeso ciivum.stnnce8 combine 

best in the subcutancoits cellular tismte and in the miiacles, Icrast so in 

trodoos tad taaOK ; the cutis stand» in tho middle in this respect. 

The clrcamsta.nce8 are Ibo most uo&mmble for the bone«; coose- 

qnently the sopamlion of the dead froni the living- takca place must 

(Jowly. Of tbia mora kereaftor. Rinli suppJy of nerves seems lo 

Kare little ^eft in this prooeast. 

But there ura many other iiifluenoes thaL hinder the detachment 

^Hbf the dead parts, or, what ia the mime thing', that retard tho furmn- 

pfton of gra&ul&t^ns and pus ; sudi ns continued oolion of cold on the 

wound, as might be effected by applications of bladders of ice. The 

cold keeps the Tr8»?la contracted. The ccU-moremcnte, the oscnpc of 

I c ells from the vessels, go on very slowly under the inlluciico of low 

^■tomperBtura Treatment by continued warmth, as by the application 

^^f cataplasms, has the oppoütc effect ; by tliis means wo increase the 

liimoQ to tho capillaries and cause tbem to dilate, as you may readily 

He Crom the redoes« you induce on tlu) healthy akin by applicotioo of a 

hot cataplaira ; it is known that the bi^ temperature ebo faaetcnt 

Ibo o^-^ctivity. 




IdO OOXTDSED ASI) LACERATED WOFSüS OF THE SOFT PARXa 

It is nntirel; impossible to tell boforelinnd the lufluonoe of the 
^nural atstt; of the patient on tliis local process. It U true we m^ 
saj )□ i^'uvral t«nns llut it is cacr^tio la the etmng', stout, ftod 
yaang, more niod».T«tw au'I slug^h in wuak person« ; but on this 
point we are often dvcciircd. 

From what IiaA aJrcA<l)r beeu said j'ou may suppose that conloscd 
-wound« n«Rd much longer to lieal than tnon» simpl«^ incised on»«. It 
wtl] n\»> be (M'idmil that th«re majrlH* circn install era under whiclj 
aniputalion of the limb will b« necessary, all the soft parts boin^ ea- 
tireiy inaslicd and torn. There are cas«8 wber« tb« soft part« at« so 
ton] from the bone that this atoue remains ; so that on the onr> band 
ciuitriiatiun oannot occur, ami on the other, if Ihc estremily dki he-Jil in 
months or years, it would bo perfectly usclos», and het»c« it would bt 
butter to rvniovß it at onco. Still, even the simple oompluto'dutAdi- 
moot of the skin from Iho greater part of an extremity may some- 
times, tbcm^h rarely, render amputation neeessary, n« in the c«tie of 
a girl who lost the skin from tha wrist to tbo ends of her fingers be- 
tween the rollers of a spinning mnchinc. 

Fortuoatcly audi caaKS arc Aot frequent ; in similar injarirs of »in- 
gl« fiiigvrs w« mostly Icavo the detachment Ui nature, Kothnt no more 
is lost than is absolutely iucapable of living ; for we sliould always 
remember in maiming of the hand that erery line, more or less, is uf 
importance, that especially single fingers, and partiealarly tlie thumb, 
dlioiild be preserved wbcnoTer possible, fiw »ucli fingers, i f only sliprlii 
oapablo of pcrfonniog their fuiiütions, are more utiefui than the he 
nado artifioial band ; for the foot and lower extremity tliere 
other eonsiderHtions, uf wliieli we shall boreaftsr speak when we 
com« to complicated fmcturea of bonrs. 

Would that this msiiniug and »low healing, bad as tboy arc, were 
the only prp(« w« bad with otir patients bavinf:; oontusod wuunilsl 
Unfortunately there is a whole series of local itnd general enmplica- 
tkuia which directly or indirectly endanger life. Wc ehal) first 
speak of tbe ehief locul cumplicalions ; for the more general, t| 
"aooidental diseases in wounds," we reserre a future chapter. 

<IVinsiderab1e danger may ariM from the deeomposinj; tiasne on~ 
the wound infecting tbe healthy parts. Putrid mntler« act as fer- 
ments on otber oiganio combinations, especially on fluMla txmtaining 
them ; ibcy induce progressive decomposition. Wc might wonder that 
such extensive decomposition of the pmt which is injured, if not killc'd, 
should not Dooor more fr»]uently than it actually doe«. But in most 
eases ecll-aclion oeenrs so quickly on the liordor of the liring tiasue 
tliat a sort of living wall is fonnej ; this new formation does not read- 
ily permit (bo paMageof putrid matter, and the granulation eurfaco, 



UEAUNO OF COKTTSED WOUNDS. ]fll 

if otic» fcirmcd, is pirliinilarly rewttftiit Lo sucli mllucnre». In manjr 
[lUcca it U ft populur rcincdy to cover uIo«n( with oow-dung arij otlit-r 
dirty things; this uevcr cause« oxtoasive putrefaMioiii) un ^raiiiilHtinf^ 
» ouDcl». But if you Hp]>Ij' Bucli substances to fresh wnundsi, and bint] 
ibea finnljr ou «o tbol the tisau« may be aiccIianicitUy impregiintrd 
uiih putrid Dutter, tlu>y will usually become gmigreiKius to ii ccruiin 
tk-|ith, and then ah eiiiTgi'tic t'l^H-foniiatioD oppoM-s the pulrL-fatHlun, 
The rtksou wtiy ilecoin posing timttcni act «o injuriously on trtA 
wuciikU, uul so sliglilly on granulating on«a, I consider lo be, lliat 
they ftt« diiflfly ab«orbml by the lymphatic veHsic^Iii. If you inject a 
drachm of putrid iluid mto the suWulnncout* ci-ttuliir tiM<uc< of a dog, 
iLte rrauJl wtU bo inflamination, fever, and »optii'o^iita. If you tn&b« 
a lafgp gnuialnting surface on a dog, and dress it daily with oharpio 
suakcuMu putrid (liiiil, it will have no decided efTccl. Certain dia- 
aolnd putrid mutters may patu« tlituugli the walls of llic veins and 
capillarie«; but Bur^ral experitncu toitolu^ that lympbaagitjfi ao- 
ootnpauies poisoned wounds murb oftenur than pMebitis docs. 

Tbc mem the tJsKuc is suluntcd with Buid, the more it la disposed 

tlo ilecoQtposiüon. HontN', the oases whcro j^rcat o^dcmaloiis Bwell- 
big occuni after oontusions are the most dangerous lu tliis respect; 
but tkis csdema oomos on rery readily aa the venoiu ciiculation is 
' il, from tsi'-rini»-« niptnre and crushing of the vessel«, which 
! I neu extend fur beyond Ihe border« of the wound, 

, Imagine a forearm cnu^t imdcr a stono wcighiop scrcnJ hun- 
tlred-vrcäefat ; tbere will probably be only a small ekin-wouod, but 
eitCBsiTV tinisbin)^ of tbo uusoles, tendons, and fusd» of the fnreann, 
and myttiwy and nipturo of moat of the iiX'InH ; great oodcnuitous 

rairelUtig yeHl speedily ntult« na the blood frota the artcric« is driven 
■will» greater energy into the capillari<>s, and cannot escape by ita ciw- 
IOfBai7 passage throug)) the reins, and hener, under the increased 
prewuf«, the scnim esoapes through tlie capillary walls iuto the tissue 
in gmt«r amount. What a tumult in the circuhiUon and in tlie 
«hole nutritiun ! It mmt soon ap[)eMr where the blood can still cir- 
culule, and where uuL In the wound, nt [irrd, under the influence of 
lb« air, decomposition of the part« inoapoblc of living begins; tlii« 
adt«aoes to tbo etagimting fluids, and, in unfurtutiatt* eases, it coi>> 
tliatly progressca ; the whole CTxtreiDtty swcHs terribly as for as tlie 
ilionlilcr; tlic skin becomes bright red, ten-sc, painful, «>Tcred with 
tndclu!«, fr\iTn tbo eacape of serum from the cutaneous capillaries 
under the opidcrniis. Those symptoms usually appear with alarming 
rqiidity the third day after the injury. As a result of this disturb- 
vm o( oirculation, the wholu ex1n:uiUy uiny become gangrenous; 
b otber oaaes, onlir the (kscüc, tendons, and some shreds of skin die. 




162 CONTUSED AN» LACERATED WDD.VDS OP THE SOFT PARTH. 



There is ceU-ioliltraüoD of all tlie oouaeoUve tissue of the extnmitj 
(of tlto Eiibcutaneaiift ocUular tbsur, Üie perirayBiuni, iK^urücmnu, 
Bbeuths of the tosmIb, periugtoum, et«.), which leads to suppumtioiL 
Toward the dxth or eighth dajr the wbole extremity- may be eutirdjr 
oaturated vriUi pus and putrid fluid. Tlieorcticidly, wc might imagine 
MCh <«set curable ; that is, we might imagine that, by making suit> 
•bl(v opeiiiogs iii tlw skin, the pu» and dvnd titisue might be evacu- 
ated. But this rarely occuri in proctiou. If the caac Iibk undt:rgDoe 
the above distention, gcocrally only quick amputation can save tb« 
patieot, and enm this is not always succt-Hiful. 'We may tern Urn 
variety of inliltration sanio-seroits. There is a orllular-tU.'niM; infUu» 
ituktion, caused by local septic infection; a wplic phli^mo»:, who« 
producM again have great tendency to deoompooition, but wliicli 
finally leads to exten«ire siippunktioii ami necrosis of tiiMuo if tlie 
puiicot live» through the blood-iufcotiuu which always acoompaoies ib 
Tlie earliur such prücüsstis limit tlicmBvlveft, the better the progDOsis; 
vriUi the nd^'Hocc of the lucuj symptoms tbc danger of death of the 
patient increases. 

With the detadimoDt of dead portions ol tissue, wc cnust again 
return to tlie arteries. An artery may be ooDtused, so as not to b« 
fully divided, nud the bluod continues to flowtbrough it sUhough part 
of itjt wall is incapable of living, .ind becomes detached on the MXtK 
to the ninth day, or even later. As soon as this occurs, there will hu 
a hanoorrhage in proportion to the size uf tbu artery. These late 
accoadary htemocrliagcs, which usually cumo on suddenly, are exoeed- 
ingly dnngcrooB, as they attack the patient unexpectedly, sometiraes 
while sleeping, and frc^iucDtly remain unnoticed until much Mood has 
escaped. Besidea the above manner, liito arterial Bccondaiy hfftaor- 
rhoge may also result inm mpptu^lion of the throoibit«, or of tli« 
wall of the arte-ry. I observed a case of ibis kind Into in the third 
week after a severe opcniiioa in the iumicdiutc vtcänity of the femoral 
artery, in wliich, however, tbc artery wns not wounded. Tlie bleeding 
began at night ; as tlie wound looked pejfectly well, and the patient 
had fur sotnc lime slept llio whole night, and for sotue days had 
boon promised permission to get up tlie next day, there was no uurso 
in his private room. He woke iu the niiddle of the nigbt (the 
Iwnnty-srcond day sfler tlie opetatiuii), found himM.'lf swiuiming lu 
blood, and rung at once fur the uunte. She iustandy called the aseisi- 
nnt physician of the ward, who found the putient unconsdous. He at 
once eom[>re35od the artery io the wound, anil, while I was being 
called, cvciy thing was done to restore the patient. I found bim 
luilR'less, unconsdous, but hreatliing, and the heart still beating, 



S£CU>iDABY It^MOHiinAtiE. 



16.3 



Wliile I made n-ad^ to ligatn tlie feiiKira] artery, ihe patient died 
be biul bled to doatb. A vety sad ca«o 1 A man otbcrtrJ»] bcoItbjTf 
stiong, ill tlw bloom of life, noar rocovecy, must end his life in this 
mlaenble \ny I Baretjr ba« a csao so depressed me. Still tb«re was 
no blame aa|trhrrr, ns it lisppencd all the circumslancses had been 
vety fitroniblc. Tbo nutso n-aa nwakc in the n<>xt room, the physician 
waa oolydown one flight of «toirs in the same house, iumI was with the 
(Mticnt in three or four minutes ; but ttte bleeding intiai have exiatcd 
tiefore be «oko. Ke was probably awakoited by the locliiiff of wet- 
lies» in the bed. Oii autopsy, a small spot of Uie femoral artery was 
Ibund supinirulcd ami perforated. Fortiiniitely, it. la oot always u 
femoral that bWd5, nor does tli« bleeding always con>o 6o prccipi- 
latcly. Of at tiiglil ; lieuce, we bIiouM not become dlssati&ticd witb ouf 
art fiota such a rare cost. Usually audi arterial hicmon-boKcs from 
■uppurstiDg wounds arc at £rst insiguiGcant, and soon cease under 
ft^-pcJcs or miiijirassioD ; but after a few days the bk-ediiig coini*s oa 
taorc actively, and is more difficult to arrest ; finally, tbe luciQorrbagcs 
near more and more quickly, and the patient constantly becomes 
«one. In all severe arterial lupmorrlin^ instantaneous comptessiou 
is the first n^medy. Every nurse bIiouIiI iin<lerst.tnd compresäinjf the 
uterial trunks of U>c extremities; but they soon lose their prcceuoe 
of miodf as in the abore case, and, iu their first tenor, run tbenisdves 
for tbo surgvoo, instead of compressing the rcsscl and sending some 
one dac. Compression I9 only a palliative rcnieily. The bleeding 
may oekse after it ; but, if it be coiusiderable, and you are sure of its 
origin, I strongly advise you at once to lEgate tlie artery at the point 
of election, for this is the only certain remedy. You ftlioultl do this 
lie sooner if the patient be alrondy exhausted ; r<-incnih<T that a »co 
ond or third sueb bleeding will surely cause death. Hence, iu the 
apermlivc course, you should particularly practise ligatbig the arteries, 
(6 that you may find tliem so certainly that you could operate when 
half asleep. In these pflrticulsr cases much time is unnecessarily lost 
ia opplyitig slyplio», which usimlly act only palliatively, or not at hII. 
[^^tioQ of arteries is only a trifle for one vrbo knows anatomy thor- 
oughly, anil has employed hia time well in the operative eounc«. 
Anatomy, gentlemen I Anatomy, and a^^n anatomy ! A human 
ife often hangs oo tbo certainty of your kuowlodg« in this branch. 

M'hilc treatirw of secondary haniiorrliage», we sliall £j>onk of 
partnc/tj/maiota hamorrhagea. The Uood rises from the grunula- 
tkna aa from a sponge ; we nowhere see a bleeding, spirting vessel. 
The whole curinee bleeds, especially at every cliange of the dressing. 
TUs nay be due to various causes : great frialntity or destructibility of 
the granulations, that i», titcir deJective Organization, may bo the faulty 



104 CONTUSED IND LACCItATED WOC.NDS UF TUB »OPT FlBTa ' 



■ntl tills niHlnrgTinlattionof lite granulations again mu^' depend on crjit- 
stitutioaal diai'-ttiM'v (hronioTrliiigic fliathc«», si-'OrbuUs, acptio or pj-umii: 
inref^LJon). Still, loi'al enures iitMnit lite wound ore iRiaginnhli*, a«, tf 
oxtt^'ti.-üvc (Xingi list ion gradiiallv funned in the surroundiiig vein», llip 
ciixnilutiun in the vessels of tlic ;;rAiiuIätiunfl would be so affected ; 
tttc [irL-f^urc of Hood would so iiioroasL* thiil nut oiiljr the suntm miglit 
escape from xhvtn, hat they nould niplure. It is true I Have bilberto 
bad no opportunity of conGnning ibis by autc^M', Itot I have seca vtaj 
fen* of these parenchymatous hfernorrliagea. Tli« Inllor explanation 
sounds verv plaiittihle ; »o fur hk I know, it (vif^nsleit witli Strotneyer. 
He calLt «icli bivmun-lin^a " Itieino^tnl ic." According to the cmuaei, 
it may be more or less difKcuU to atroftt »uoti litpmorrliagM ; in tnoM 
I'O&ses ice, coutprussion, ami bt^-plics, will be propi.>r, or, in etren 
' macs, ligation of the nrtcrial trunk, al'.Iiou^li this occasiunalljr faDa. 
This form of bsmorrliug« occurs chiefly in very dcfcilitatcfl peraooa, 
«bo hnre bc«n oxhaiistnd br suppuration and fever, and benoe baa a 
bsd Mgnilicanc« fur the general state of tbo patient. 




LECTURE XIII. 

fngitMlv« Soppnratiofi itaitlnn tnm Contiurd Wound*.— Se ton Jarj Inl 
of the Woond: Ui«ir Cuur*; LdmI Inraiiiui).— Fcbrilo Rtnction In 
'Wound*: Ssoondarj Feror; Suppiinuir« Fv*4ir; CliÜl ; their Cao>ei.>-l 
uf Coalused Wounib: Irnmenion, l«i>btu]dun, ImitÜtm; CriÜci«« of I 
UriliudB.— Ineiaioui.— Co<utiierH>ii«nin|[».— Uraibflit«^— Cat«|i)awu.~'J|>CB Tnau! 
tnttit n( Wuunila ; Lidtr-'t VmuiRg. — I't^'phjIftiU «foliul ^^vtmStaj InflatiiiB»- ' 
tlonii.— liitcninl Tmtnii'Iil t<t tbaie tevi-nljr WooDilucI: Quinlna ; Opium. — 
Liienfalcd Wuuiiil«: Suliculuni'OiM Kupiura of Uni«]*« and T«Ii4oh; Tonnc^out 
nf Uutclu tutd TcQiIoBa: Tuarlngoat of PLtooaof a Uinb. 

I'wR gmuulatiiig aurEnce titat dovctops on a contused wound 
ßt>nenilly vory irn^-!i:iil;ir, and o{Kt-i\ Itits Diimeroiis angle« and poolcets 
tlicrv b suppiirntion not only of ibe surface of tlie wound, but of 
surrouniliiig coiitu»cd partd under lite uninjured skin; bcnco 
nciglih»rinj^ skin ofl<>n np|M*nni undormincd by pus. The inQaim 
tioii and suppuration often uiicx])octedly vxtond between tbe niuscl 
along the bones, and in tbo slieatbs of the tendoiuf, because Ibeae 
pfkrte were also aEfected by the injury, Tbc prooes» of inflnmnutioa, 
extdtefl, ereeps along, especially in the sbeuttis of tlic toodoiu 
and in the ceUular ti.s3ue; new collections of pus fafTn,5opcr6oi»Ily 
or in thi2 dcptlis; tbe injured part rcmaios swollen and redcaiatous (> 
on tlie surfncG the granulations arc smeary, yellow, awidlen, and 
, «pongy. Wlicn wc press in Ibc vicinity of tlic wound, the pus lloivs 







INTUWIMATION OP COHTTPKD WOUSRa 



105 



^<jtflj frocn BmallRr or Ui^r opcotngs^ which hare formH tponta- 
iNwittlj, and lliis i>i» wfatcli 1im remxiuird for a time in tbe de^ith Is 
uot in frequent} J* Üiin uiid bud smvlliu'^. Should tlic pmcrss coD' 
linne loti)^, tbc ptiticnt beootnes more miBcraWo nnd v.'^ak\ h« has 
bigh anil continued tever. A wound, wliidi porhap« at finst nppcurod 
inai|^iicanl, perhsp<i aboiti tlic hnni), hiui cxli>nd<xl horribly, and ii»- 
duoed 8«rere geocral düturljunc«. Tbe shoutlis of the t^^ndons a)K>ut 
the handii and f«^t arc pnrticuUrly fuvoraWo W tho extension of deop 
«nppuration!), wbicli rcudilj attock tbe jointH, while, on the olher 
Jttad, articular ioQnnunationa of the cxtrcmttics readily attiick ihc 
mkmtbs of tlio toudons. TIics« states may t"ko n very daiigeroiw turn, 
mai jou shouIJ be roimtiuilly on your girard. From the cooatanb pu- 
x^i'at infection, a« well ns from the daily loss of pus, ovcti tbo atrong- 
^«t nun may emaciate in a few week«, and die with symptoms nf 
/«fbrile inaraHnits, 

Wo nonr know two forms of inQuniination whieh may attadc oon* 
«*iS*^ woutul«: 1. Kapid, ppogrtawive, «cplie inltammntion, wliieh 
^yfi^iriu» utioal the wound during ihe Gnt thn?c or four days (lurcly In 
I^PgflP tliHu twenly-foiir hours, and just as rarely al^er the fourth day), 
mn^^ «hich is <»UBe<l by local infectioti from parts that decompose in 
th^^ wound. 2. Pmgn^wve punilent inflaminulion, whidi is pnrticu» 
Invlj apt to occur in wounds of llie hnnds or feet during the cicnuatnf; 
of ^lo wound from nocroscl Ebrods of tissue, without the pus becom- 
in^p ichorous, altbough butyric acid often formed in it. 

Sat, even wbrii tbe wound has entirely cleaned off and gmnu* 
laf^sd, «rfaen the iiiOaiumatiou is bounded, and the wound be^ua to 
klrize, new influnitmition, with severe rc-'idtJ', m/ty begin. The«e 
ndiiry pro(jrcs»ii'e inflaminntiuna of Btippiiraring wounds, oeeiir- 
nx^lS CTCn scrcnU weeks aAer tbc injury, and sometimes coming as 
»*<i«?tpect«dly Ü» liglitning from a clear sky, are of great importance, 
and 8f¥ somelimcs vcrj- dungvrous. They are alnioivt alwny« of »up. 
r'^^ralivc! nature, and may Ix; fatal from intense, phlo^^istie, coiistitti* 
tiotial infection, just as oflcn as the primaty progrc^vc HU])pu(nUoni(. 
lo mjmo csaira, nlKO, tticy prove dAnf^ttroi» from thptr locution, »s in 
*v«>undB of tbe head. Tbeao cafiea arc so striking and tra^cal that 
^e mwgt give them ei>«dal eojjsidcration. Suppose you have brought 
of serere DmeblDg of the leg, with fmetum, sueoßssfutljr 
ith thr Uni dangers. Tlic pntient has no fever; the wound 
tfiulates Itenulifully, and lias ci-cu bt^-gun to cicatrize. Suddenly, in 
fauHh week, the wound he/^^ns to swell; tlie gmmihitions ai« 
i|iotu or s|x>nga-, tJtc pus Ihtn; the wbolo limb swellii. Tbe pa- 
it sgain has high fercr, perhaps rcpcalctl chills. Tbe symptoms 
n»y Jkass off, ami every thing go on in the old track ; but it often 




leo COXTUriED ASH LAOEIUT&D WOUNDS OF TflB SOFT PAKTS. 




Ulms out 1m(11}-. Ill u few day» the stroDji^t nioii mnj' bocumo 
corpse, ^mc time sitico »wii n cue occurred ia Zftridi, tn a Miow' 
fctudinit willi a woarul of llie lieiul; it nay surro jrtiu m a wuniug 
rxamplu. Thu young man roccivt-«] a bluu* orcT the lefi rcrtm; iha, 
lK>no wa« injured very supi^rficinlly ; the vroun«! liealed qaldclj* by' 
finil iiitcntiuQ ; only a tinall spot coulinued to stippimtc. As Üto 
p«ticnt fclt quite well, )ie paid im ailctilioii to (lie litÜo wound, aad 
went about ns if perfectly well. Suddenly, in tlie foortU week, afi«r ' 
n walk, he bad Berero headHche and fever. The fi^illowing day tlipr« 
VMS about a teospooofu) of pus coltei.it«d under the uintrix, irluch 
wa« eracuatcd byau iucisioa. TbUdid not bare the desired bcocficial 
elToct on lli<^ ßOTit>niI condition ; thu tevrr n-iimitiod (ho same. lo tlie 
eveoinp delirium began, then sopor. The fourth day tlie prerioody 
vigorous tnao wad dcud. It wiu oitsy to diagnose tliat tliere bad beei 
euppuralivetncaingitis. This n*8aprav»l on autopsy. Although at tbe^^^^ 
s|iü(, us big as a pe», where slight suppuration had beoa so 
kept up, tbc bouc u-as but »lightly diacolured by purulent iofiltratic 
still the suppuration on, in, »nd under the dura mater was greatest a 
tiic piu't exactly corresponding lo tliis pobt ; »o that tlic new inflam^^?^ 
nioUon undoubtrdly started fmtu the wuuud. A short tltoe ainc 
facfc io VicimiL, in private praoti<x', I eaw a perfectly similar ease, i 
fatal, in a man «bo aetwral week« prcnously bad received an wfii*"^ j 
entJy inaignificant wound, from a piece of a soda-wntcr bottle th^E^t 
burst, at the upper p«rt of the forehead, along the mai^io of t^^c 
hairy sealp, 

Tlic influnimaLioos oomrring under such drciimstanerfl, aa alir»m^^ 
rvtiwrkcd, arc usually of a diffusely purulent charsetcr, but oti&^sy 
fomis twx'ompany it, or oorur ejiontaneoufily, su<7b as diphth^lio S c«. 
ftammalinn of thcgronulntions (traumaiie diphtheria, ho*pit<ü ffCMx 
grene), iulhuiiiuutiou of the lymphalio trunks (fymphanffttu), «iid 
specific form of capillary lymphanf^tis of the sldn, erysiptiat or cry— I 
»{[•ekious indaminaliou ; and, IasiIv, inl]aininH(ioD of llie vdns {fi/*i 
f/iiia). Hut infrequently all of these prooesftcs may bo Men nuaubclj 
together. Wo abatl hereafter study tbe«e dlBease« mom accutBlel3r, j 
under accidental trsumaUo diseases. Bttt hero we must oonsider tta«] 
eottdM of these secondary inflammntions, before passlng to thr tr<-ia c* 
mcnt of MWtusMl vounds; and, in so doing, wc must antiinpitt^J 
BomeirliaL All of these forms of inäannmttion, and their 

, BctioQoa the or^piniaai, are so in(crtwincd, that it ia impoeaiUe 

iapeak of one without mentioblng the other. 

As muses of secondary inflammntions in and nmund suppumtin) 
miuods tlut liavc begtui to heal, we mnr »Mrnlion the fulloning : 
Uxccstire (low of blood to the wound, such lu mar be induced bv 



INFLAHMAriON OP CONTÜSSD WOUNDS. 



16» 




tnurfa notion of the p«rt, or by prest bodUy exertion, m well u by 
cxciting^ drinks, ineDtal agitation, id sbnrt, bj aoy great escitetacnt ; 
in WDuada of tlie Wad, bucIi congostions «re particularly ilange-rous, 
C'oQgesüoQ, Bfl caused hy too tig-lit baodsg^a, inoj prove iujurious in Ibo 
tamo-way. 2. Local orgeii«ral catching cold; about catching cold aa 
a cattse of infl&nimatlo» we know little uioro tban the simple &ct tliut, 
ondcn- certain circumstaacos, n-hirii cannot be acciiratcljr defined, a 
aoddon ehaogu of Imniwratiira induiv^irifUiinnintiuns, csjicciullj in a 
htmt minoris ntUtentieB of an individual ; in a nounded person the 
wouDd ta always (o lie considered a« s lotm minori« raiatcntice. The 
danger of catching cold aft<^r injury was cortainir ovcrH^Btioiatcd 
fenn erl y ; I luin:)Iy kiutw of any certain oxampleit. 3. Mechanical 
'ion of tfte Kt/und. TTii» is Tciy importunL The pu» from tl>c 
U ser-er reabsorbed by the uninjured ^nnuUlioii« ; but, if ihoy 
>yed by nMchanical manipulations, us by improper dresaings, 
much probing, etc, which cause the wound to Heed frequently, new 
inSamiaations may bo induced. Any foreign bodies in the wound 
might prove serious in this way, such as pieces uE glaju, lead, or iron, 
or sharp splinters of bone ; for tho first changes which take fiux in 
the wound, the ricinlty of such foreign bodies is less ioiportaat, but, 
vfaeo, &tim muscular movements, aad the motion communicated to ttie 
tiasue from the arteries, the »harp angles of a foreign body keep up 
oooatant frictkn in a part, severe iuUuiumutiou ocom ufler a time. 
1, C^Mi^Ual /smumU / bcrc I mention firat soft fofcigc bodies, sucb 
as pieces of clothing, jmjK-r wads, which liave entered the tissue 
tkroagb guiutliot wntinds ; tbetsc substances become impregnated with 
tbft 8««retions firom tlic wound, tlten tfao o^anic material (paper, wool) 
dooomposcs, and acts as a caustic and ferment in the wound. I am i»* 
to believe tlut oecroaedsplinteraof bone also act rather as clieoif 
tJiao as meebatücal irritants; intlie Haversian canals, or medullary 
mrity, Ihcy always cuataiu some organic deconipUuing i^ub«lancc ; all 
tuch pieces of bone have a putrid smell when extracted; if the sur- 
minding granulationa were portly destroyed by tlio sharp angles of 
■ach a fragment of b4>nc, ttio putrid matter paasca fiom it into the 
open lyrapluitic vessel», or possibly even into the bli,Kjii-vcs.'*cIs, and 
isdoiTCs, not only local, but, at the nainc litne, conatituliuiiul iafeo- 
KociDsod tags of tendon and fasciA at the bottom of suppu- 
wounds may induce tlie same results, althougli this rarely ba]v 
peas. In hosfutala, especially, t-hcrc are some rare cases whcix: wc can 
6od Dono of the above oanses; such occurrences naturally induce pc- 
alarm, and attempts have been made to exphUn tlieni by certain 
ijurlous ioAueaccs of tlio lio»pitAl atmospliere, especially wich as is 
led with the srootl of pus, 3Iany eiroumstaooca speak sgftinst the 







168 COSTTSEl) ASD I.ACKBATK» W«CXDS OF THE SOFT PARTR 

view titat the tujuriuus «ululaDccs nre gaseous; hy good TeatlUlioB 
tlie air of Ü10 lioepital may be kept pure, tiut tliic U no prutocUon 
■{[(ünst the «fiection in question ; louroovor, w omiiot oxcile inflam- 
m&üoos bv any of tue gases ilcreloping' from pus or putrefying »ul> 
otances, unlpss, perhaps, by sulphuretted hydrDpni,-whcn dissolved in 
wnter and injected into the suluutanoous ccUular tissue. Putrid 6uiils 
And pus from other patients would not intentJooaUy be brougfat in 
contact n-ith wotxida ; vre huvu pri>riously shown that tho vioinity of 
the vouod may, under somo ciroumstnnw«, be infected by pua from 
tbo wound, and excited lo new inflanunatlon. Henoe there U little 
left but the nupposition that the injuriously-acting subittanoes are of a 
molocular, dufft-likti nature; they may float about in tlie air of (lie 
hospital, l>ut they may »Uo adbpre lo the tMndiij|rRs, diarpie, oo«n- 
presscs, etc., with which wo dreas tlie wouiicU, or to the instniinciila, 
forecp«, probes, sponges, etc., «rilh which we touch tho wound. May 
tbi*y not be fungi, or other or^nio germs, wboce nature •^re do imt al 
present know, like those we know to excite fermeotattoo P Tia» is 
possible, for in every oubio foot the air holds quantities of suHi genna^ 
jitid in tlie hospitnl euch organic gcnnit of animal or r^etaUe nature 
might duwlop i» the seorctious from wounds. In Ute sputum or 
excrement, ond Lhc more bo in proportion ns the readily-deeampoai^p 
acorcuoofl &nd excretions arc coUcetod io hospltald, or in badlj^ 
tiuilL wateiT^'Inscta and soweis. On this |)oint wo can auly ha» 
conjectures, wfaitu wo may make expcn'mcuta nith dry putrid snlh 
IOCS and dry pus, by powdering thom, and then introducing tb«« 
Into the hoaltliy tisaue of animals. Such experirDents hare been made 
by 0. Wkber and myself, and they have shown that bull ' nail 

vegetable putrid, dry äuUitunce^ ns well as dry put', ii. < ' :itm^ 
mation; if we pulverize tlicso sul>»1ancc«, 6tir them np (|uii-)cly witJi 
water, then inject them inio tho subcutaneous otjlular tiasue of aal* 
mals, they will excite progressive iatlanunation, just, as fiulrid fiuid» 
and fresh pus do. Now, it muat at once bo ackii< that in a 

bo^itsl such injurious dust'likc bodies may reudily i.-:.. .^ Urcfwoga 
and bedclothes ; possibly, also, to instruments. In sburt, it is poesilile 
that the direct injiuious influence of boe^ntal air on a wound may bo 
due to fin« dust-Uke particles of putrid or purulent matter uomiaf in 
contact with it from the dresüngs or instrument«. Them ean be ma 
doubt tliat »uch injurious materials may enter the body tu other wayt 
besides through wounds, as through tho longs ; indeed, wc expUin tlio 
ocourrence of all so-eallod infectious diseases by the entranee in tho or« 
gnnism of substances which have a »ort of femiroting Influence on the 
blood ; but, whether the morbid material* which excite the infectious 
düeafes chiefly occurring in the wounded b« dilTennit from thoM aivlnf 



IKFlAlUIATlON OP 00XTÜ9BP WOUXDS. 



180 




the wooihI ilscir, may be a disputed point, so f«r as wc ftt prenot 
Wa slull rrluni In Uiis poiut-wlit^n speaking of accideolal 
Inummtio dioeaaes. Von will auspcct me of oüntradictiiig laj-SL-lf bcre, 
b«QMwe in jertcidny's lecture I said that no molecular body coiild en- 
ter tlie tiaeues through &□ uniajurod granulaüon-fiurlacp. I miiKt still 
claim this AS iisunl ; a strong, uninjum] gnnulation-Mirrncc is a de- 
nied pn.^tection against infection Uiroug-h the u-ouud, Ilut, when the 
[^ting material itself is very irritating, so that it deAtrojs the 
Ktiag surfuce h\ causing dooonlpc^it^oIl, a pn&sagc-ivay is opened 
tbe poiaoQ to enter ibc tissues. Still more, tliera arc certaia »uli- 
Btanoes which are corriod into the granulatiun-tissue, and perhaps 
trca ftirtbcr, bj the pufrcells. U jou Kprinlde a granulating surfare 
va a dog with Gncly-powdered oarmine, some cella take up tlic small 
ioe gianul«^ and wander with it into th« granulation-ituhstane? ; 
time you flml cells with carmine in the gninu1ution-l Usue. I 
jcr this ao abnonnal retrograde morcmcnt of the pusoelb, which 
le generally belicTC to pn^ from tbe granulittion-tusue to the surface 
the wound; it is true, no on« has seen this. Nevertheless, from tbe 
ite cxperitnent, it ia evident tliut even molecular substancea maj/ 
. frocu without into tl>e tissue of the edges of the wound, and, ii' 
i lubalaDOC« be very dooompoNable or cautf^rant, Ibejr vrill «sdta 
trtive inSanunatioo. But a.U of thu millions of molecular organiama 
the atinoapborc ara not tjikea up by tbe wound, nor do tbey r&ch 
]iie« inflammation. My beU(>f is that all miLTococei do not m-ces- 
'Aj have a pti1o«;oge4ioiui action, but only those wbicb aie formed 
certain producta of inflommulion, such as decomposing pas or 
Ot tbo borly, putrid urine, etc., aitd wbi<^ have there ab* 
the fernieot. This is the moat fiequenl cause of micnocoo- 
sas in hospit«!; hcn<^e its rlov^lopment there is to bo conit>ated witli 
energy. I do not beliere that these substanoes, wheLhor 
or living molecule«, sr« always tlio sonn?, but 1 think they 
fery numerous, as are tbe causea of inllnmmution generally ; 
ay all baro certain chcroicsl pcculiiLiities in common, as we 
; anppoae from their simitar action, allliough we know nothing 
irt Ibem. except this action; they also differ somewhat in their 
iimIo of uction ou IIiih or tlmt tissue ; the absurbubility of such sub- 
[•** may vary with tlie part of the body, and possibly, also, witb 
indh'ifiital ( but the large number of these injurious suhstanom 
,in fart,smnll as conipnred with tlie innumerable variety of orgsnio 
tuWlanres getierally, 

J^rbrilr. rt'irliim iji uüutitly greater f«jm contiiwtl than frnm inoieod 
accurding to our view, this ia because, fi-om the docomposi- 
»hieb is much mor« exieasive in crushed than in im^ed puts, 





170 OOKtTSED AND LAORRATED WOrSI« OF THE SOFT PAJtTtiL 



fitf moro putrid matter entere tlie blood. If in taiy esse tlie putrid 
matter i» p&rticulurly iutcnsp, or very inucli of it i» takoD np («»• 
pecioUy ia diffuse s«pt>c inflAmmationi), the fever RSsumcs tbo chanc- 
ier of so-callMl ptUrid /ever; ttis fttuto thus induced is called Mpti' 
cania; we fitiall hereafter stiitlv it more closely. If llie nippunÜn 
inlliuumatiuii exteoda from the wound, there h a oorrcspoDdinf; eoo- 
linuod inflftDimatory or Biippi)r»ti%-e fever; tliU hng the ebarscter 
remittent fever with Ter/ Bteep curves and oocasiooal eiaeerbatfc 
mostly due to progrca of tbo iaflammation, or to circumstoocea that 
furor the icabaorption of pna. If ve call tbo fercr, that often, but 
not uln-ays, aecompanies traumatic inflammation, aimple traumatic 
ftetr^ we may term tlie fever that oocurs later " teeondary /isver^^ or 
** »upjMtrativf /ever.'" This nuj immediately looceed the traumaüc 
fcTcr, if tbo traumatic inthimmation progreasaa i^ularly ; but the 
traumatic fercr may bare ccaacd entirely, and the wouimI lie already 
healing, and wheo new secondary infiammations, of which wo harti 
fully treated, attack the wound, tliey are aooontpanied by new suppu- 
rative fever; io abort, inflammutiuu and fever go parallel. OecasioD- 
ally, indeed, the fever appeara to precoda the »cooadary inBammatiou,. 
but thia is probably because the fiivt chsngea ia the wotuid, which 
may be only fdight, liave eaciqted our observation. .\t aD eveats, oa 
every aoocssion of fever thai we detect, we should nt onco seek for th? 
new point of inflammatioa, which may he the cause, 1 am far froam. 
asserting that it is necessary to measure the temperature in nil raaiT 
of wounds ; undoubtedly any eiperienoed surgeon, acvustotncd Ic* 
exainiae patients, would kuow the eon^lioQ of his pnlicnt without 
measuring the tcrapernturc, just »s an experieneed pnotitkner may- 
diagnose pnoumunia without auscultation and percussioa ; but no one 
who understands tlic significance of bodily temperature doubta that 
its mcasorement may sometimes be a very imporlant aid to diiifnosis 
and prognosia. It is with it as with every otheT aid Co observatiotl ; 
it Is Doi didBeult to detect a dull percussion-sound in the tlrorax wIk 
K should not exist ; but Die art and science of dcterminiog the sii 
nifioaooe of tliia dull percussioii-sound iu any given cose must 
learned ; so, too, with mcasurcDicut of temperature ; for iiutauoe, 
must learn whether a low temperature in any given cahs be of 
or bad omen. I Khali enter into more detsU on t)ii$ Mibject in thJ 
oUnio, 

Expcricaco teaclivs that secondary fcvor is often more iutenj 
than primary traiimattc fever. While it la looet rare fur tbe lat(«r J 
iK-igia with a chill (a slight cbilÜDcsB after great loss of blood 
Bcrero concufisioa ia not usually aooompanied by high icmpernlL 
it ia not at all BO for a secoudarv fever to commence with severe "< 




INFLAMM-lTtOS OF OONTtTSED WOCKDä 



ITI 



We shall ut oiice study this peculiar plienomenon more ttlteiitJrely. 
FornK-rly Uic chill wns alvraj^i n>gBrded fiB etaentially dependent od 
Uood-poiMjtiing; if vre now regsnl fi>ver generally «a duo to intoxi- 
cation, wc must scvk some apc'iul uiuse for tho chill. Observation 
abows tUat the cliUl, n-^iich is nlwnys fotlotrcd by fovcr and Ewcatiog, 
■g altrayd acoonipaiiied by rapid elevation of Lemperatura If we tber> 
taometrically examine the temperature of the blood of a patient with 
dull, we Gud it high and rapidly increasing, ubUe the skin feels oool; 
the blood ia driren from Ibo ciititioona vessels to tlie iutcroal oi^qansL 
As already remarked, Traule conntdcra tliiii m the c»iiBe of the ab* 
normal febrile elevation of tciupcratunv Wo shall not diacuss this at 
present ; at ull events, there is bo great a differenoe between the nir 
and the bodily temperature that tl>e patient feel» chilled. If we ui>- 
«Ter a paticut with fcrcr, who lies wrupped up in bt-d and does not 
feel chilly, b« at once boglas to shiver, Mao ha$ a sort of oonsoioua 
ieeling for the state of equilibrium in which his bodilv tcoiperaturn 
lUodfl to the sinTOUoding air; if the latter be rapidly warmt'd, he aC 
Mce feeb wanner, if it be rapidly cooled, he at once feels cool, ohilty. 
Thia trivial fatrt leads us lo another obsen-ation. litis sensitiveoess 
/br wanntb and cold, tliis conscious feeling of change of temperature, 
mrics with the indiridttal ; it may also be increusod or bluutcd by the 
niode of life ; some persons aro always warm, others ever too cold, 
v-liile for other« the temperature of the air is oompumUrely a matter 
ff£ iudUTerenoc. The nervous system has much to do with this. Ac- 
g^ -umto Studie» of Traube and JoeAmann hsre in fact shown that the 
jg^ff!rto\a excitability of an iuditidual has a groat elToct as to whether. 
Id a rapid elcvn tioa of temperature of the blood, the change will be much 
n0tf«eivcd or not ; hence that in torpid persons, in comatose condi- 
^ons, chills do not so readily occur with fi-ver, its tliey do in irritable 
pexvBS already delnlJtatcd by long iltiieAs. I can only cuufirm this 
(rom my own observation. Although I have a Kcncral idea that, 
«rliae there is sufficient irrilubility, rapid olevstioa of tomperaturo 

I «od diill chiefly occur when a quantity of p^Togcnoua material entera 
jSie blood at once, stUI I oonnot deny that the quaUty of the material 
h» alio ireportaat. We know nothing of this quality chemicftlly, but 
I %re nay conclude that it has varieties, because both the fev(.ii««ymp- 
UiBB and their duration oficii vary frrestly, and that this dovs nut 
wlelj depend on the pcculiaritiM of the patient. According to my 
obaaraaoos, in man reabsorpti<Hi of pus and recent products of in- 
Binunatiun is more apt to indue« chills tlian is absorption of putrid 
caller, «hich is pcrliniK» more poisonous and dangerous. I do not 
«■mil to wcaiy you with too many of these congidernlions, and so 
^tfj return to tlic subject in the section on general accidental trau- 



172 CÖNTDSED AKD LACEIUTBD WOÜSDS OF TUB SOFT PARTS. 

tnatic and ir-ltanunator)- disRams, nliicb yvu majr regard as a cunltni» 
atiott of this study of fever. I will only remarlc h«rc tlutt bolli titt 
HpUc and pumlofit primary nnd secoiiduty influtUDations, n-itli their 
■oooinp« Dying Tcvur, muy n\s<t^ (Hjciir from inoUcd wounds, cspccially 
■fier eirtcosir« operations (as ampiitatioru aod rosectioae]. We bare 
cnnsiderc«! this ciHidition uluog' wJlli i;utitusi*d wounds, because il 
complicates them much moro frrqiitrntly tliitn it does onlinitry iuclaed 
wounds. 



Now we pass to tlie treatment of coatused wounds. 

la many cues contused wounda rcquiro no more treiitment than 
incised wounda ; tlio condittODS for bc«ling exist in bolli. Honoe, 
a oootuscd wound it ii only neceftsary to anticipate auy acwideat«, or 
nt utl events to master tbeia so thai tlicy may not become dangctouaL 
In both rc»p«<i» wo may do something. Formerly it was always sup- 
posed tliat t)tr> air with it« oxygen and its fenucats particularly brored 
the dccompoflitioa of dead, or;ganic bodies, hence of coiituHed part«; 
to preveitt this, the wound was excluded from the air, and, to prevent 
warmth acting ns nn nid to decomposition, the wounded part was kept 
cooL We uttuiii butli ubjcols by i>Iacing the injured part in a Teasel 
o( cold water, whose temperature i» always kept cool by ice Has 
treatment is oallod ** immt-rsion " or " eontinued cold-water bath.'* 1 
fint saw tilts used with e^iocllcnt effect by my earliest teacher iii 
surccry, I'ruf. Jlaum^ in Gottingcn. This mode of Ircutnicnl is only 
KoUy pnicticn] in tlie extremities; in tlie Icff as high as the l:ace,aa(l 
in the arm to a littla ubor« tli« elbow. We pkco suitubly-consLructed 
arm and foot veowU filled witb cold water in the patient's bod, and 
Lave the woutided extremity kept in it day and niglit. The patient's 
position should be such tlial he lies cosily, and that the extremities 
may oeirer press loo hai-d on the edge of ll>e vesBel. Tliis is all very 
suople ; you will often see this apporatus in my clinic. Jn tbc most 
cominoa injuries of the ham), a liosin with cold water is suffieient Id 
private proetiee. In purls which enniiot be kept hi water in this un^ 
plo way, we tr)- to exclude tbc air by applying tnoist Uncm coniprosse^ 
which readily adapt Iliemst^lves lo tlto injured part ; m'-er these we 
spply a rubber bag (or a bladder) filial «nth ice, which is to be re- 
phieod HS it melts. It is stiU more eOicncious to wrap up a limb irdl 
and putck it in a vesstd with i<y>. A third method of appl_<i*in^ txiM 
water t» the KO-cidted intijation. Tor this we require sjitK-jid appan* 
tusuB. The injun-d cxtmmity is laid in a tin trough, auppUod with sa 
«•capc-tubo. Above tlic extremity wc plaee an oppewtus firooi whkh 
a contiiiued stream of cold water dro[M from a mnlvmta height t» 
the wound. I.Astly, we may ümply cover the wound from time tc 
tun« with compresses dipped in ice-water. 



I 



< 




TREATUBNT OF OOKTÜSED WoFXDS. 



173 



bare seeo all tbeee modes of treatment in practice. Here is taj 
union of then ; none of them aet ivTfniiiljr as propbylnolics. Id 
ntused wounds of the hnnda «nd tect liie wnter-batti is best; (br^ 
idcT thitt ImtmeDt, extensive suppumlion ix mrest. To atlma the 
aotne bvonble rcsulu by the i(N>tTeiitnioiit, we must covür not ooljr 
i vound but tbe parts arauiiO with th» ioe-bladders ; pack the poru 
ice. 

In applying cold-comprewe«, we shull only rc&Ily obtain the effect 
of cold if we change the coinprrssr« every fire minutes, for they 
wann very iiuickly, and tbe UAual treatment with culd-cornprevscs 
MttiaQy amounts to nothing mora than keeping tlic parts neust} 
baioa,lbis is, strictly speaking, iio peculiar mode of treatment; ne\-ei^ 
thdeflB, as I have already remarked, must smnll conttiscd wounds beol 
under it gprtntaneousiy, without our placing them under unnatuntl 
cooditions by tbe use of onld. Irrigation is not a bad plan of treat* 
ment, but It la trmiblesome, and it h oft«n didicult to avoid wetting 
the bwl ; the coodition of tlie wound aubsc(|uenily does not differ 
from that in the more eimpi« trenitnent by hnnw^rston or iec, so that I 
have not felt obliged to resort to irrigatiou. In Frunce, ibia uM^thod 
is pr»ctiBod and highly eetccoicd by some surgeons. 

Apart from the prcvenlion of accidents, fur ^Thich all remedies are 

as us«le«a here ils venesection is in poeunionia, we hare still in the 

abore modea uf trcotmcnt important means fur combuting the usual 

local ««cidenta. I har« atill a few spe<cial remarks io make about the 

WBt«r4«lh. As we here leave out of consideration injuries of the 

booet and joint«, 1 know of no contmlmlicatioD to it in conlufwd 

ttoiiiKU of the band, fvrearm, foot, and leg. In most cases of these 

injarios tlie bleeding is so flight, nad cesses so soon spontaneously, 

that tbe patient can pUce the cxtremily under water tcij soon if not 

'mBediately after the injury, without the ooourrencc of faictnortliago ; 

bat the blood clinging to the part should first be wasJied off, the water 

ludtbe perfucily pure and tnmsparent, and, if it becomes clouded by 

the loartion uf tbe wound, it shuuld be kept dcur by frequent re- 

tcvtb. Even when the wound is two or three dnys old, the water» 

latlimBy still be employed with admutago ; later, it ts of Itttlc use; 

I! die {»tii-nla lie eomfortably in bed with the tub^ they arc more 

I'MilcnVyl and free from pain under this treatment than under any 

«kr' TI»o tenipemture of the water may rary greatly witliout much 

cbu^ the con^liliuii of tlie tvouivl ; oidy ice temperature, and tJie 

U(k (npcratuK; obtained by tntaploams, cause a somewhat <Liffercnt 

«jyauince ; but from W to 90' or 100" F. it does not vary muoh in 

'*^ Pcrbapa suppuration comes on a tittk sooner at the htgber 

|*^P<Vfltiuv, littt the <USerence is not great. Ilence, we may adapt 

IS 



J74 CONTUSED JSD LACEKXTED WOUNDS UV TBB SOFT PABIS. 



the tempcratere of tlic water to the fcclio^ of the pxticat. At first 
tbe patients gcuerally prefer a lower t«mpcr«taro (54° -68"' F,), ]Ati?r 
m ntlier higher one (8S°-9&° F.) ; but there are also patlcnl« whc^ 
even durtn^ the first dftj*, complain of chills if the tcropcraturc of tite 
n-ater falhi below 08° F. Hence we eeo tliat it ü rather indüForraft 
whL'ther u-« employ warm or eoid water bathii. In sotne persons, on 
the tliiril or fuititli day, there arises a »täte which renders LininenBon 
unbearable^ that is, eu-clUng of the cpitlcnnis of the hiuda or feet, 
BDd tbe ii4X!ompanying tcuse, burning ftoosatione, which somcnliat t^ 
seml^ the action of n blister. The ihidcer iho epiileimis, the inore 
dieagrccahlc this accident. It maybe avoided bynilfbiu; llic injured 
extremity with oil, before placing it iu the water, and udding a hand- 
ful of anlt to the water; thU does no hann to the wouod. An im* 
ponant question is, How lon^ shall contiimei! imnicrsinn be employed? 
Rulea tor this can only be gi^cn after considerable experience. I have 
found from eight to twelve days enough. After thix we may teare 
the limb out of the water nt night, envclopiug it in a lufiLsi oloth cor* 
cretl willt oiled silk ; a few dttya later we may employ this dressfatg 
during llie duy alao, and use ttic water-lnilh oiily niüming and pnn>> 
io^, or inuniiu^ alooc, leaTing tlic limb iti it half an hour or an hour 
to bathe and clean« It, Finally, we leare off tlie ovaler entirely, and 
treat the gmnulntinff, t^catrizing wound att-i^r the eljiiple rtde« already 
giveo, Tlic changes ia wuuiida under this tn-almcnt are aotncwbat 
diQereul from those pieriously dcsvtibcd. In the first Jilace, all goem 
on much slower; somutimes, especially in the treatment with tbe 
Cold-water hu.lh, the contusetl wound IcMtks as fresh for four or fire 
days as when first rcccirod. The same thing is noticed ftv eonoe time 
umlor the treatment with bladders of ioc. This is not so '^Mf'Tiiahify 
as it at first bccou, for, as is well known, decomposIUoa of orgaoia 
sxil-stiinccs goes on more »lowly io water than in the air. Sohso- 
([uenlly tbe pua usually remains on the wound a« ft flo'Vident, half- 
ooagulRted layer, and must be washed or syringed off to obtain a view 
of the subjaoenl grai)u]ation:(, which arc infiltrated with irater, and 
often quite pAh\ Tliis obserralion is rerjr importarkl, aud protects U9 
from illusiuiM in regard to the efiicacy of the water-hnlh in deep sup- 
purations; wc mi^it siippoae that the pus flowed from tlie wouni 
directly into the water and was there diffused, so that it would riiopl 
l>e necessary to plaee the 8up]>uraltng pari iu water to have it alws; 
clean. TM tMter-bat/t doe» Jtot facer the eaeape of pus ,■ it 
prevents iK Pus on the granulations, or in cavities, coagulates 
onoeon contnet with water, and tisoally remains on the wound; 
big or sjrtinging- is necessary for its remoraL Swelling of tlie 
Intions entirely prcrcats the escape of pus from deep purl«. 



1 



TRSATUTST OF COXTUgKO WOI 



Bcc, wlicrc tlicrc is suppuration from a cavilj-, thiit the waler-hntli • 
of Qo U£C, but. is even ixijurioua, nuil thai an cjttreiiiity »Ituulil at 
inoe be reioovod from tJie wiit<*r tts soon «« deep progressiTC inflfti»- 
ifitions extimd out from Xhv woui»]. By litis we do not mean to ex- 
iudc a balMiDur'it butb of the pait. Should tlicrc be no progressire 
.flammnttons, tltcro would be no particular liarm from leaving Uie 
vouud iu ibe water toe two, three, or four week.<t, onljr lli« hculing 
would be tnucb retarded. In the water tl>e parts rcmiiia grcaÜ;^ 
iwolicn; the gmnulntioiu nro full of ^ater (.irtificiaUj tcdcniatou»), 
^—p«]«^ Slid dcatrizittion and oontniotion of the tround n-ill not occur. 
^^U^rou tbeii remove tlio extremity from the n-atur, the wound sood 
^HoDtract« ; in n few days the graoulatioos lo<^ atrongor, and lUe ]>ua 
^^peltcr ; heuling progresses. 

^H Now I miist say something about the continued treatment by Ice. 
^^Buppoac you cover tlio contused wouud from the Eist with a bladder 
of ice ? Here, also, you will find that tho cruslicd parts aro rory 
bluuly detfl<:hfd, and that no smcU artsea from the n'ound, uiiliva largs 
lOsaAcA of tisüuc become gangronouB ; to prevent tho hitter, if possi- 
Mc, I »pply charpie, or a Ihin oompress wet wiih chlorine-water, next 
to the wound, and hare it fi-efpiently renewed. If we now continue 
the trcalmo&t four to »ix weekts all the ucccssary changes in the 
wound will go on very slowly atKt slug^shly ; the cicutrizntioQ and 
enotraction of tlie wound »re also very slow uiidur tho iufluence of 
the ioc, and liettoc this method is cntin-Iy out of plnco if we desire to 
hactoo tlio process of healing. Moat eur^ous believe that we may 
prermt screre inflammations by applying bladders uf ice to the re* 
oeni wounds ; hence you will find ice applied at once to most cases 
of coutuscd wounds. Occasionally this proves rcry grateful to the 
pstientf by relieving; his pain, but it does not «eeni to me a propby- 
Uctic aotiphloigistic ; for ccntiuiea, men have sought such a prophy* 
lactic, just as they have for one for iaflammations of internal organs. 
By the application of ice to recent wounds, we ean neither prevent 
walo serous infiltration, nor «uppunitive infbrnmation!), at least, this 
itny opinion. As already stilted, many believe in the prophylactio 
Kboo of ice, and arc convinced that by this moans only Uiey can iuire 
fesoos badly injured. I havä becx)tno Biili»lied that tlie iliingerous 
cospSatioiia to wounds often occur iu spite of the ice, and are not 
gilMQpieotly wanting wheti ice is not used, when from tho nature of 
Aanimd tSiey might be expected. From what has been said, yon 
lifbt almost suppose that I consider ioe an incfGcient remedy thut 
■If be dispciued with, still, you will see it much employed in my 
due ; ta my opjiuon, oold i» one of the best anti|>ldogi9Ue8, especially 
ItiBlIaoimBtiot] of an external part where it can act directly. BencCi 



178 COKTDSID AND LACBBATED WOrSI» OP TOB WIT PAKTS. 

loe t« prop«- vrbcrD tliPTc is inflamoiAtioD, etped^y U aooompunod 
hy ^;reat Stiiion, uitli n trmlancj to SBppumtkm of tbc irMmd. If 

inflamTnAtion of tho c«11<iUr tütue, t)ic sttuntl» of tentloim or mwdei^ 
or of a ndghborJDg joint begin, you (liould apply ico to ibn iufluDcd 
part, iiud thus avoid the cxocastvc liypcnemb, and 9o ilie Uicrcmse ot 
the inflnmiration. Von think I am hczc contnidictiiifr luysolf, vliCtt 1 
Mjr ttiat ioe ie of no it«i> in pru'vuiiUiig the dovdopineiit uf inSamnuf 
tion about a wouiul, but it ia of use in IcsBcmog tbc commcDrinfc tnflain* 
mstion mid prcrcQUog its ft]>re«d. But let me «xpUin tbt» by an ex* 
ample, and you will readily bc« t\w diffi?r(T)ce. %V'h(!n any one stiffers 
frntn licadnrlic, lie ri?rtniniy wotild rot ihiiik of being blod for every 
attack, to prevent inSatiiinatioQ of the hzn'm ; btit, if the Utter be 
WAlly developing, Tcncspction may be a vcrr pffi<»pioua remf^jrlo 
arreftt it« further det'elopment and spread. By tbe aid of in, we do 
Dot always aoocccd in arrestiag the siippiinitton extending from tfae 
wound, but occasionally the tedematovs akin grow« redder, becomes 
painful, and, wbcn you press on it, a thin, serous, or sometime« quite 
consistent pus oocaaiouatly flows slowly frora somoof thcan^lea of tlic 
wound. I'ndcr such circumstances, the retained pus, especially if 
bad smelling' and ichorous, muxt be set free, and allowed to flow 
ODobstnictedly ; for this ]>urpose, df^ep inciaioua aliould be made in tbo 
eoft parte, aod then kept open. Wficn this ebovdd be done, and how 
it may best be done in iiidividua] cases, you will have to learn in tbe 
clinic For probing such suppurating caritiea, I prefer a sUghtly-curvtxl 
silver catlieter, which I pa&a throagh the wound to the end of the 
canal, then proea the end up against the ^kin and here make the itt* 
cision, Fur enlarging these sO'^allcd cotmtei^openings, just m in 
other wound», you use a tokumhly long probc-poiulcd knife, straight 
or curved (I'itlt'a knife). As a rule, the caunteropening ihouM not 
exceed an inch in length ; if neocRSary, we may make teToral of this 
length; in such cases there is ueiially »o use in dividing the soft {mits 
of tfaefoteorm or leg longitudinally, as wa« formerly tai^t. To pr«%nt 
these new openings from closing again too soon, which, 1ioweTer,ru*dy 
happens, you mny lut rmIul-c several Bilk threads Ibrouftb the pua caula, 
tic the cod« together, and leave them for a time. In placo of the» 
scions of silk or linen threads, caoutchouc tulies, \nth numerous lateral 
openings, hare n-ccntly been usctl; lliey ha\-c received tlic name of 
ffrftiH/j/jt-tHbfy an expression taken from agrioultural lecbnulo^^ 
Minirtimeft, at le.-iEt, these tubes facilitato the escape nf pus Tcr^ well 
but their priiiriple is not new, nor can wo accomplish mcK wonüi 
with Ibein as ia cluiined by OfnutaisMtt, their invcotor, who 
«Tiiten a book in two thick volumM about them. In ninking 
count cropcniogs, you will not unfrcquentljr strike on dead »hrvds 
tendon or fascia, wluch should Uien be remoreU. 



TOEATMENT OF CONTUSED VTOIWDA 



177 



lÄc skilful use of the nlwTC renjcdics is an art of pxperi^mc*; 
i yxxa cattnot ACCompUsli with tUcm in suppiuxition, ^ou will not 
kocoraplish vnth any tiling else. 

One of our colleagues of former dap would »hake his head doubt- 
fully, if be heard that tto h»d talked so long about tko Ireatmont of 
contusod wound» and seoondiuy guppuraLion.«^ witliout having- men- 
tioned cataptaitM. "Tempora mvtatitur/** Formerly cataplasms 
belonged to suppurating wounds as luidoubtc^Uy as tho liil tn the bor, 
and now, throe or four weeka may pass in my wards without oata- 
plasma being once employed for their original ns«i. The employ« 
meut of moiut warmth, whcllicr in Iho form of cataplasms or of thick 
cloths dipped in warm water, ia usrJoJia in the treatment of contused 
wotinds, atKl, in tlia treatment of secondary suppurnttoos, it is ocea- 
sJooally injurious ; under them the wounds heoome permanently n> 
laxfid, tho soft pan« swell, and Jwaling is not advanced. Moreover, 
cataplasms only truly act as moist warmth when often renewed ; tbeit 
renewal is tiresome, tijc poultice eawly sours, or may be scorched, and 
finally, tlio whole mess cannot be carefully watched in a hospital ; a 
cataplasm covered with pus may be removfd, new poulticQ added, 
^^uid it may theo be placed on auuther patient. In some hospitals at 
^Hrast half of the «urgic«! patieula wear poultices ; hundred-weights of 
^^pits and flaxseed, etc., for poultictrs, arc oaed monthly in the Burgieal 
^^prardsj they are almost banished from my wnnls; na oocasion oAen, 
^K shall show you tJie cases where tliey may be used with adrantage. 
Hence, little as I C4n recommend the use of moist warmth as 
the ordinary treatment of wounds, I considur it very suitable in 
those where there is au extensive hard (fibrinous diphtheritic) Iniil' 
tration of the cellular lissue. In tliese cases the motiit wnrmtb is not 
only pleaaant to ttie patient, hy rendering the tense skin soft and 
pUablo, but it appears to aid n>m<.ivitl of thu Imrlened tuflammutory 
products, cither hy their rcabftorptiou or breaking down into pus. 
In such cases 1 apply warm nwist cloths eovercd by some waterproof 
matariaL 

Hitherto 1 Lave not mentioned that the afntoluto rest of an injured 
pirt is always ncecsjMiry ; it may seem singular that I should mention 
I ii at all ; you may think tliia should he eunsidcn^d a matter of raurse. 
Ua; particular atrcss on it, because injurious substances are taken 
I biMitli« wound into the bluod; hence every muscvdar movement, »nd 
^L ffoy consequent congestion of the wound, in short, everything that 
^H drirai the blood and lymph more strongly into the vicinity of the 
^^ in;uod,iiuiy eventually prove injtuious. 




\19 C0KTÜ5ED ANT» LACERATED irorN'DS OF TITE SOrT PARTS 

Nor is an elevated position of Uie uijur«il pur t to be negleciod vbcro 
it can be triiHL You ma^ nvidily prove oa jourselTeft that gmvity ba< 
Eomethiug to tlo with llie movement of the blood; if j'ou let jour ana 
bsutfr purffctij rctaxcti for five miiiutus, you will feci ■ licavioesa in the 
bnad, and llic rein» on tbc back of Hie hand ^ill look ewollea; il^ oa 
the contrary, you elei'sta tho hniiil for a Linie, it will becoiDe whiter 
and smaller. While dehiUtnted persons are lying in bcd^ in Üie inoni» 
inj;, fur instance, their faces look fuller than when tlieybsre bornr 
tlio bead orei't for the day, Il©c*'ntly, VoU:mann baa sttonglj reoom- 
uieodc«! viTtical siispcntiion of tbe ann aa n powtTTnl anttjiblugistta 
in inflammationa of the band ; oonscqucntly» I have employed tbü 
niethod, and in cases of cutaneous Juflammatiotts liave found it very 
efr:cariouH; it appears to do less good in deep iuAammatioRS, aa of the 
n-rist. 

Hereafter, the vatcr^bath, ico-trcatmont, and catnplnitnis, will prob- 
ably give ptac« to tbe oj>fn Cre.ftt>nent of wounds, from whioh I bare 
seen Tcry good results ia contused as veil as io incited woumls (p. 9i), 
I did not 8iy this at the oommooocnicnt of tbe sectioo, because I do 
not oonsidcr my ex[ierieDoe of this mode of treatment sufltoicntly ex- 
tensive for mo to give a final judgment. . Tlie dreaded aoccs« of air 
to the «uifaec of tlie wound, even the ajrofbadly^^-vntilatod bosfiital«, 
is not, in my ojiiuiou, so injurious as dressings and sponges oT doubu 
ful clcauUnnss; the idea that air is injunoos to siip[niniting Tromids 
rcaU chiefly on tbo obserralion that tho entrance of iiir to abaoCM 
cavitiea with rijipd walla, and into iteroua sacs, usually induces sap- 
purmtioR ; apart from tbe fact that, iu many of these cases, it Is not 
proved tbat it ia indeed the entrance of air whicli excites tbo ioflam 
tnalion, we luust also attribute much of the blame to lb« fact tbat in 
the pus-sac<3 tbe air is «armed and impregnated with watery vapor 
from tbe pits; tbJa enclotied air now becomes a true batcbln^ilaco tta 
tlio«c minute organisms which cauiw decomposition, and whicb we 
nhi*a\'5 more or less |)ro«ciit in tbo atmoqibere. Ei-cry observing 
housekeeper knows that meat or game banging in the oj>en air spoils 
br leas readily than when shut up in a cupboüd, even wbco Ibe «if 
in tbe latter ia kept cool by ice. FW>eair does no hsmi to tbe wound, 
bnprisonod air is rery dangerous, I have already loenllooed (]i. flA), 
tbat a wound treated openly />■(»» the start bos no bad smell, uolt-as 
large shreds of tissue on it become gsogrenoua ; ia aecordaoce with 
this also, äies do not deposit their eg^ in open wounds, while tbn 
are apt to creep into dressings to do ao ; I must «ny thcso o' 
tions EUqH-Lsed me very agreeably, because I feared that fttos 
render tbe open tmitment of wounds impoMihlc in sunogner, 
longer I carefully try tbe open treatment of woundi, the mofC H sat- 



TBEATMENT OF CONTUSED WOÜXDS. 



179 



.5c« tee. No metbod guarantees a. perfect iininunitj from acoi> 
droCal traanuiüc clueftses, aod CTOD in tbe open lr«atia«iit of wx>und8 
than soay be su|M>r6<.'lul adhcsioos and fonnation of pooltcl« iii which 
daeompoiiiion of tbu secrutioa maj occur. We must learu to antici« 
pate tncb tbin;^. 

Itlntiv aurgooofl non* prefer tbc method oro(>e1urioa by thoroughly 
iütifcctcMl dressing« aud oi>rty appliciition of dmirutgc-tubcs for cur- 
ing uff sccreLiOQ, otter JUeter'i mclbod. It is asscrk'd that by this 
a mUd«r oooise is secured, as id subcutaneous contusions ; 
at tbe shr«d« of dead tiuue do not deoompoae, but dry up without 
and arc throw» olT with very little suppuration; that tbe 
lood-olota are nilhcr directly oi;Kaiiized or csc;t|>e from ibu wouud 
u odorier ffray crambs ; that acute ecpticfemta anil progressiro nip- 
pai»tioRs ni}vor occur; und that the severe accidental tmunuttic dis* 
eaaec, of wLioL we shall bereoiftcr epeak, are Dcvor dorclopcd. I 
I re«o(xiaieuil this method to you most wnrmly. 
^^ In gpneral I would advise you, as students and practitioners, to 
^HRudy and accurately Icam one of the modes of treatmoni rucoiD' 
^Hnundrd to you, aad not to bo easily led oS from your thcra|KUti(! 
^^^Hnciplt'». In your practice employ what yoti baro ncll and thur* 
ougbly learned. BeHeve mc» your patient« mud yourselres will thus 
oonw out the best. 

Jo tbe treatment of ««oondnry inflammation, moat careful propby- 
Isxi« is to be recDuiRKndcd ; avoidanoo of congestion of tbe wound, 
cmtctiing cotd, all mechanical and ohemical irritations, and especially 
infection. Hereafter, vben speaking of accidental traumatic diaeasea 
,', w« »hall atato what iniiy bo done in the latter respect by 
\ III and proper uae of llic room iu the hoRpitAi. For avoiding 

loc*] inflation of the wound by diesainga or instruments, wo would 
^T« ibe following advice: Be exoeadingly careful in the dressings, 
cleaiuing Ihc wound, choice of compr4>gjwK,charpie, and wadrliiig; al- 
ways see to Ihe most perfectcleanlincss of the mattresses, straw beds, 
coTcrins», oih>d muslin, parchment- paper, and in abort of every tiling 
about the pntitfnt. The bleeding of the wound on dressing should bo 
nrutJcd hr carefully syringing il with ßoHwrcA'Jr wound-douche, of 
which tlier^.' should be two or three in every ward ; we should never 
apply dry eotnproMe«, churpie, or wadding to tho wound, but should 
prerioudy wel all these articles in solutionof chloride of lime or other 
antiaeptic, and later, when tho wound bogins to ui«itri»e, wirh le«d- 
wnler; and for remoring the pus wo should never ose sponge», nor 
ahould we use thom in operating, but do it all by syringing or by 
nipiog ffT with wadding wet with water or chlorine-water ; if we 
eaoDot avoid the ose of sponge», they should be new ones, aud dieinfoct 




180 COVTUfiED AND LACERATED WOCXDS OP THE SOFT PARTS. 



Üictn ac oacu with liypennangaiia.te of poUsli or carbolic actcL 
ganic btings ncror ilcvclop in cblnrinc-watcr (aqua cUlori, with eqii 
parts of water), sutulioii of chlorido of lime (cblorido of lime tirti 
druclims, water one piiiL), »or do tbejr lo leucj-water, iu milutioii' 
of acetate of slumin» (&liini 20, aceUite of lead 35, wnU'r «lOO), nf 
permaoirttnat« of pola^b, or id sulphide of soda 50, glj'ccrioc H, 
vraMr 4W (PoUS, Minnich). ZUter bas recomoHänded catholic aci^ [ 
as a pcculiurly «^fficaciouB antiseptic; it may be diliilfd with oil, 
glycerine, or water, or mudo iulo a past« with cballc, and ibvn iprtii | 
ou tin-foil, to tnak« an air-tight covering for tbo wound. " Deoil)r>j 
icing powder" (coal-tar and plaxtorof Paris), nprinUcd dnr on pnti 
fyiof; BOTvs, is nliso good wbero the wound is not too <lc<^p. 
(Iiffi'n.-nt mo'lea of application, under the name of '* Lialer'* dfw- 
iog," bar« been regularly tri«d, and it is a good thing for tba jn»— 
fesaion to study and become tliorouglilyacquaintud with nnyoM^ui^i 
of trcatni<>Dt. Lister Itas aceoiuplisbcd ou« good, at Icfl'l, in Itavii 
directed atlontion to tbo aDti9q>tic treatment, aad given it a defrtiil« 
practicul Taluc. I consider carbulic acid as a rej-y serriccaMe aMi 
Mptic, but have nut found it to posscsH any s]x-cial advantage ni 
the roraodios und mo<1c8 of trt-atmvnt nbovo mculioncd. Vou uuit^ 
I>«y special attention to the instruinents with which you touch lb 
wound, auch as probes, forceps, knives, seizor«; every thing ehoul 
be wiped before being uacd, or, if it be at all auspidou«, it 
be quickly rubbed with cleaning pcwder. In order to nirpfully 
acrre all these precautions, you must be perfectly satialied of ibci 
seoesnty. 

If, in »pile of all our rare, di-eoniposilion, gaogrcne, or phi« 
monous inflammation has sLurted in tbo contused wound or il« riria^ 
ity, we must abandon the prolcctiTc diesiniig directly applied to 
wound; thfl cftvitiea.of the wound and abscesses should Ix* diUt» 
and fillt'd with wads of charpie or wadding dipped in a strong anii-ji 
BOpUo solution. After nuiiieroun experin>cnte 1 always rrlum 
acetate of lead and alumina ; it is a rery aotir« desiccant and d« 
ant, without disagreeable odor. It is true, the dirty dark-gray i 
due to sniphiirct of load from tbo sulphuretted bydro^a lo 
aauics and thf: lead in the antiseptic solution, is disagrecabl«, but 
is harmless. Till the mortified tissues have been entirely satural 
with tbe solution of acetMe of alumina and lead, the dressing tni 
be frequently changed, or the solution may be pourMl over tbe d«- =55 
ing «very two hours. When the wound begin« I0 clean up, ir; 
dressing daily is enough ; on »imple granulating wounds tbbaolut^. 
is loo drying, irritating, ami painful ; later we use protectirc di 
ingaor Milves. Kext to acetate of alumina and load, chloride of]'. 





LACEIUTEÜ WOÜNI& 



181 



solmioQ is nwet active; but us its effect is dac to development of 

ohlorirw, it is T«r}- tempontry, and dressings ^vitU tliia subetance 

^^Boust be tretiuently rüuewed tu dewlurize or disinfect well. Gly* 

^■Berino b a good disinfectant, and acts excellently if poured freely on 

Hlfae drMsiiiK L:vt-ry two boura. If applied early, it withdraws ho 

Vnach water trom tlio necrosed sltrods of tianie tbit tberti is no smell ; 

but if decompostttoa has onco begun, its deodorizing effect is very 

slow. After using it freely for tlirm or four <biys, the wound often 

become« so red and sensitive that tve must refraiD from further np- 

plications. Solutions of chloride of zinc are also rccouimundeil fur 

vasliing out purulent cavities ; I have rarely found its Hupevfioitd 

cauterizing efleot very obatioute. Strong solutions of carbolic acid 

JHio oil or wuter (five per cent, and over), wht^n applit^d to hiTge »ur- 

j^ftacei^ not uafreqiteiitly cause dangerous symptoms of poi-ioiüng, and 

are not ao effectual for deodorizing, mummifying necrosed tissues, 

and limiting putrefaction, ns aoetate of ahitniua and lead. I liuve 

no |HTsoiiaI L-xpenonop of tl>o antiseptic properties of salicylic acid 

(njcommcndcd by Koibe and ThUrech), or of sulphite of" soda (reo- 

oianiendod by PoUi and M*nn\<:h). 

If, hoirever, secondary iDtUmmatioDS attack the ffound, they 
rixHild be treated ns already advised ; retained pin sliould be removed, 
fisreign bodies extracted, etc., then tba wound treated vritb ice, per- 
haps, till all ia brought inonler again, and the patient free from fever. 
In such cases shall we prescribe any thing for our patients besides 
I cooling drinks and mcdiciacs^ regulating theit diet, etc. P Tho fobria 
^bemittcna not unfrc<iiiently aoootnpaoying such suppurations renders 
H^lhe patient dull, peevish, und often Eleeplesa. Two remedies are 
^proper here — quinine and opium ; quinine as a tonic and febrifuge, 
opium as a narcotic, especially in the evening, to secure a night's 
teat. With auch patients I usually pursue the following motli'^id: 
A» long as ihey are little if at all feveriBh, I give nothing; if tbey 
jrrow fercrisb toward evening. In the afternoon I givn two doses of 
<l<iinine (five grains eaeb) in solntion or powder, and in the evening 
^■liefun) be^llime from tlto eighth to half a grain of tnuriate of morphia, 
Bora grain of opium. As soon as the fever ceases, I stop tfaeac raedi- 
Pctaes; you mist especially avoid liberality vitb opiunt, vbcn it U 
■ot reqnired, for It is constipating. 



f 



Now a few words about lacerated wounds. In general, these ar« 
leu dangerous than contused wounds, because ihey are more exposed, 
and wc bare no need to fear that tho injury is deeper than wc can 
•ee ; we perceive bow tbe skin, muaole«, nerve«, and vessels are torn ; 



182 COSTÜSED AKD LACEBiTED WODSDS OF THE SOFT FABTS. 



bcoling by Gf»t intention ma; he tried for auJ suoccods oocasioiully^ 

»Itliough SHppumtion goaoruUy oocar», But slay, ruptures arc not 
alwav« oiposed', there art* ulao aubcultmeotu rujMare» of miwcrU's, ten- 
dons, or PTcii of bones, without thore li&ring liectt any ooiiCuiüoQ. A 
per&OQ wiälica to lea]» & «litcli, and uiakea a start, but fniU in bis at- 
tempt ; ho falls, and focia a sever« pain in ono h>g, and limps on it, 
ODexainiiitttiüti,ju»t u.bov« thchoel (tbv tubero«tascAlcan«i),we 6d«1 
a (IcpruMton iu which the thuuih may l>f laid ; the motions of (he foot 
aro inipurfi'ct, ospot-iälly extt'DBiuti, What hoB happened ? The l<;ntlo 
Achillis hiia been torn from the caJcaneua by tbo ^reat nitntcuUr ao 
tion. Tlie same thing oocura with ibe tendon of Ibo quadricviis 
femorU, which is attached to tltc patella, with the patella itscif, which 
may be torn io two, with the ligaroentum patollH.% with the triceps 
biaobit, which may be torn from tlie olecranon, and generally camea 
a pi«o« of the latter along with it. Here you have a few example of 
such 5ubeutaniH>us ruptures of tendons; I havo seen fubcuu 
rupture of lhc> rectus abdominis, of the vnattia extemis cniria, 
other mufidos. Theee simple suboutonoous ruptures of muscles aro 
not aerious injuries ; they are r^ndily rcco^izcd by th« diaturbanc« of 
function, by the depression, whicti may be wen and sUll Ix-tter frit, 
-which at oucc occurs, but subsequently i» niniiked by ihe effused blood. 
The trentroent is simple : rest of the part, placing it so that the nip- 
turt'd cuds mav be brought in contact by relaxation of the muscle, 
cohl cotnpreM(!Ji, lead-water lotions for feveral days; after eight or 
ten daya the patient can gcoorally rise without pain ; at first tbcrc is 
a co&aectivc-tioauc intermediate subBtauco, which aooo eondcnses so 
mucb, by sliortening and atrophy, that a firm tendinous cicatrix Fonna; 
the course is just the same as in subcutaoeoiifi division of tendons, of 
vhicb we shall spciik io the chapter on deformities. 

Functional disturbaiieoa of any oonstderable amount rarely r«> 
main ; orca&ionally there is somt; wcskueas of the extremity and loaa 
of delicate uwveinents, eapeoially in the hand. 

For such aubcntaiicoua niplure of niusdea and tendons to be 
caused by contusion, the crushing force would bare to Im very great; 
auch a contusion wouJd probably run a bud oouree ; extensive suppu- 
rations and neoro&i^sof l«ndons might be expected, llerv, again, you 
Me liow varied may be the course of injuries ai>parently the aame, 
according to tlie mode of their origin. In injuries by machinery 
there is often such a wonderful combination of crushing, twisting, and 
laoemtiug, tliut even with great experience it ta very difficult to give 
any aocuratc prc^nosis of their counse. The favorable courer of casea, 
vbere small or even laiige portions of a limb (as the hand) are torn 
off, is espeoially worthy of mcDtioo. I have seen two caws wbera 





9om-««t dUiR* Bi>f«r, wUliia tu Ann loin «O, wltti toptU 



181 C0STV8ED AN'D LACERATE» WOÜ.VDä OP THE ßOFT PAHTS. 



from tlie roof of the hous« agünsl trhicli tlto scaffold r«8te4 tbere 

hung a. toop; tlie fulling man gnuped ihw, but uuly succeeded in gfU ^ ^^ 

ting the middle fidgcr of the riglit tiniiil through the liKip ; he hung «,^ ^*'' 

moment and then fell to iho ground. Fortunttely, the hcij^lit wm not»-—- ^S» 

great, und he was not injured, but the mtddiG finger of the right hnoi^—^^*^^ 

was gone; H was torn out at Iho joint between tlie first pbulaux noo ^-^ "^"d 

the metacarpal bono, and it stili hung in th« loop, Tbo two tendooc« "^^iiij 

of ibo flexors and that of the. extensor romnineil attached to the Ri».^^ ^ 

ger ; they bad bwn torn ofT just al the inscitioo of tbo rauitclea; <i^,^. ^ 

man diied his fingvr with tbo tvudoiu, and subscquentl; carried it ^^ . 

hia purse aa a meumnlo of the cirL'umstnnoe. I saw a aimitar cu« ^^ ,** 

the diuic at Zllridi (Fig. 41). Curo ro&ulled without much inllar-, '" 

raatioo of the faienrui, and actually no treatment was required. 

Zurich I aaw ttro c*gcs wUfrc the hand wan torn out ; in one ct^ 

there was enough skin reinainiiig to loai'c the liealing to itself, in ^e 

other caae an amputation of the forearm wait necessary. Both 

termiiiatetl fuvornbly. In war it is not Tcry rare for anna aod Icga f^ 

ho toni from their sockets by large cannon-balls. I hare klso «aeta m. 

case where n boy fourteen ye^ir^ old had tho right arm witb the crs;> — 

ubi and clavicle &o tont fioni the thorax, by % wfaool of nuehitiny^ 

that it was only attacbud at the shoulder by a strip of akin twi^>-' 

inches wide (Fig. 42). The axillary artery dkl not ttee^l a tlrcp^ 

both uuda were closed by tuniion (Fig. 40). The unfortunate fellow 

died soon after tlic injury. Tearing out of entirfl extrcmitiM is wt 

ally quickly fulaL , 



■*)■ 
Ü 



CHAPTER V. 
SIMPLE FÜÄCTUJXES OF JBO^'ES, 



LECTURE XIV. 

I, DUhnalTaftvtlHoTFntttunM.— Armptdm*, Di«gDo«l«.— Ciuru ind Kxtamil 
117 ofHaalUig, rormitiou of Cktliu.— Soqtim of tba In4«Bimit- 
tagy OaMOOS K«ir VoroMion.— lllnolo^/. 

GtSTLKiOQr: HiUtcrto w« have been exclusively oceupioci TriUi 

I jurips of the soft parts ; it in time to ooHüider the bones. You will 

ind Umt ÜIC pTOoessca lliKt Nuturc excites for the rtätorntion of tbe 

L Bwrti ore ewcntüUy the same ttuit jou abeadjr know ; but the ctrcum* 

yCJUHict ara more complicstcd, nnil ran only be fully undorslurul whcu 

voru «re peHectlj aciiuaiot(!il with tlie mode of tiraling la the soft 

parts, Kvery pcrsoo knows tliat bones maj be broken, and agftin bo 

fim\y noited; this can only Iw done by bony tissue, as yoii wUI at 

on<?e Be^; henoe it follo\rs that new bony substauco must b« formed; 

tbo oicfttrix in bone is usunlly bone ; a very importAtit iact, for, if this 

WOT« Dot the case, if tlio broken cods only grew together by conoeo- 

Hvo tisBu«, aa divided muscles do, the lon;^ Imnes partieutarly \rould 

>t l»p nniU^ finnly enough to Bupport the body, and after Ü10 aim- 

^^ t frrictures nany meo would be crtpplo j for life. StiQ, before to\- 

lag the prooeu of tiie healing of bones to its more minute details, 

study that has alwnys been punned with great zeal by surgeons, 

• tniul tell vou somethiug about tbo origin and symptoma of eiraple 

I flay " simple or sulKiiitancouR fmctures " in oontrsdialino- , 

to those aecompaaiod by wounds of llie soft parts. 

Man may crcn oooM into tbo world with broken bones : tJie bono* 

Iho foeta§ may be broken, while in the uterus, by abtwrmal 000- 

tinns of that organ, or by blows or kioka on the pn^gnaot abdomen, 

^^ such iotn-uterine fractures generally bcnl wilb consEdernble dislo- 

caLiaQ ; as w« ahnll se« in Other instances, the vU medieatrix naturtF 



Leo 



SUPLB FBACTCRE5 OF BONES. 




•n], 



Fis a better pliysician tlinn sur;gcon. Of oouRO, frocturps of tbe bone« 
'iiiiLjr occur ut nur age, but tbcy arc most frequent bctvreeti tbo tgci 
of twcntv-fivo and sixty years, for the foDowing rcasooa : Tfae liiiiii^a,^ 
of chilfbcn are stUl plinble, snd beniw do not break so emäiyi if a» 
diild fallii, it does not fnll Iicavil/. Old pcopl« bare, afi is commnnl^ x^«- 
remarked, brittle, friable bones ; or, aoatoniically expressed, in old ag -;*-^ rmm'*^ 
the ni<?dullary cavity grows larger, the oortieol nibsianoc thinner; btr^r^^^T^*' 
old pentoiu are U>ss in dang«!r of iractureti of tlie boiie% becaun ibr^^^^^^/^ 
lack of strength prevents their doing bard ami dan^roua work. It ^r^ .'''* 
during the »go when men aro most exposed to hard work that injttri» ^ ^j"* 
generally and fractur«s especially are most liable (o ooour. The 1^^^. 
frcquency of fnctitres among women is due to the variety of thr~^_^ 
occupation. It is also due entircly to external drcmn^tance« that i'-A^ 
long bon«s of tlic oxtrcuiilics, especially of the right side, break mo.rt? 
fn?qucntly than those of the tnink. It is cridünt that discaaed Kfmrn_ n 
wliich are «Irendy weak, break more easily than hcnithy one» ; hcfi(g * 
certaiu (liBt.*its<>s uf tbu bouea greatly predtspoae to firactures, e»>peäal}jr 
tbo so<all(Hl EngUith disease, " rickets," vbich is due to deBdeot i)^ 
posit of Ume-solts in the boucs, and onlj occurs in children; also ' 

Boficning nf tlie bones or " osteomolnciB,'* which depends on ab- 
Domiul dilatation of tbo medullary cavity, sod tliiiiniug of tlie cor» 
licnl substance, and which is, to a great extent, accoiu|aniL-d by 
a ■* fi-agilitas ossium,'* and erai by total softnots and flexibility of the 
bone& 

Afl special causes of fmcturco, wo hara the two following : L The 
action of external forces, tlK most frequent cause ; this action irwy •< 

vary in tbo following ways: tlio force — fur instance, a blow ur kiek — — 
mceta the bone directly, so that it is crushed or broken ; or iho booc, 
especially a long bone, is boot more tlinn its eUsticity pennit«, sod 
breaks Uke a stick that is bent too much ; here tbo force acta fmff- 
rtcdy OD the point of fracture. In the roecliani«m of the lattrr rnrioly, ^ - yj 
insU,-nd of ibu siiij^e hollow boac, you may consider awhole extrtsntty '^^-St 
or the entira spinal column as a stick, (lexiblo to a certnin oxtent, *nAm^ ^^ 
oa this supposition found your Me« of the indirect action of th« foroe^^^k^ 
X<et us have aoouploof examples to explain this: If »heavy body **■***». yp|| 
on a forparm at rost, the I>onea are broken by direct totvv \ i( a jimiw ■_ j|. 
blls on tlie sbcniUlcr, and the clannle is broken obliquely througti tb> 
middle, this is the result of indirect force. In both ca»es tbeire is 
lUly contusion of th« soft parts ■ but in the latter eoaii it is mora —a u 
le«« removed fVom tlie point of fnclitre ; in tlie former at that poln^^nf 
which evidently is to be regarded as less rarDral)le.^ 

8. Muscular actio« may, though mrcly, be tbo canse of b«ctti^^=« 
As I already indicated, when speaking of the subcutaneous ru]Hiire 



•SO 







TARirrrEs op eibiple fractcrcs. 



1S7 



auudes, tbo patella, tbo olccnmoD, aad part of tlio cnlcaocus also, may 

be torn off by mownilar action, tbut is, obliquely ijacturetL 

H Tbe way in wliicb tlic boat-s bmak under tJif sc nu-iod applications 

^ of force Toiies, but some types bare been Tormctl tbat you should 

know. First, wo diatJD^uish coinplet« and incooiplet« fracturofl. 

/nco/nfiUle /raetures arc again sulHlivided into ßmuro^ I e., dells, 

cracks ; tbcy aro moot inM^ucnt in tbo fiat boDCS, but occur also ia tbe 

loo^ booos, eepeoially as longitudinal fi&eur«s acoompanying otber 

fracturrs; tbe deft may gape or nppoar simply as a crack in gUuia. 

Infrttctimi^ or bending, is a partial finctaro, which, as a rulfl, only 

ocoofs in very elngtio, soft bones, aitd especially in mchiiio cbitdreo; 

you may best imitate this fracture by bending a tiuUl till it» concave 

side breaks in. Id obildrcn, such iaCnctions uf the clavicle ar« not 

fare. Wliat ve mean by $pl{ntering ia ovidcot; the most Erequcat 

causes are mochine-c-utton, sabre-atrokes, etc. Lastly, thu bone may 

be perforated without entire aolutioD of /»ottnuitr, ua by n punctured 

«roood through the scapula, or a cl«aa shot through tbe b«ad of lb« 

^numenitL The latter variety of injury is called a perforated fraeUtn. 

^H Complete fratAnrea are sulxliviüed lot« iraiutveney odtlqaa, tooffi- 

^MW^oJ^ dentat«, aiiitplc^ or muttij>li fractures of the Home booc, cOTn- 

^piAwCed/ all of theso expressions explain tlicinselvc», Lnstly, vre 

' must mention that pcisons as old aa twenty years muy also bare a 

flolutioQ of continuity iu tlieepiphysoil cartilages, although this is rare, 

and tbe long bone» break more resdily at some othpr point 

^L Frequently it is eiuty to recogaiüe tbut a bone is broken, and a 

^EBon-inofesaioual persuu muy make ilia diagnosis ivitb certainty'; ia 

other cases tbo diagnosis may be very difficult, and occaHOnally can 

only be a probable one;. 

Let us tukc \ip the symptoms one after another. First, accustom 
yonraeU to eianiino every injured part accurately, and compare it 

Iwitli bealtby parts ; this is particularly importaat in thß extremities. 
Tou may not unfroqucntty know what the injury is by simple ob- 
BervatioD of the injured extremity. You Bsk the patient how it hap. 
peaed, having Itiin undre&iied meantime, or, if tliis be p&inful, have his 
dothescut off, that you may aoouratcly examine the injured purU The 
■H (aUDCr and severity of tbe injury, the wcij^^ht of any body that hot 
^^&lloti on the l>*rt, may Iiidivatu about \r)iat you have to expect. If 
jaa find tlio exircinily crooked, thu thigh bent outward, for iaatoncn, 
ud swollen, if stiggillAlions appear under the skin, if the patient cao- 
asC novo Ibe estreiuity wittwut groat pain, you may with certainty 
<lectdo on a Aacturc ; here rou tteod no further examination to decide 
<a tbo simple Uct of a fracture, it is not oeoesaary to put the patient 
lo any pain od this aooount ; you have only to examine with th« 




188 



SIKTLE FRACTCnES OF BOXES. 



bsQck to find bow nnd where tlie fracture ning ; this is le« ocoewuit^, 
on »coouut of dcttiiniiiiiiig tlie trcaUuciil, tliuii to be able to deoide 
nhctfaor und ttour recoTtrr^* will result. In this onM yen hnre nuule 
t1ie dia^iOMS il a glano?, uixl iu surgiol pructicu tl will often be caaj 
for jou to ivcogiitzu very quickly tho true Btato of affuts, wben jou 
are a«cti»toiucd to use your cyps thoughtfully, and when you have to- 
qaired s certain habit in judging of normal forms of the body. "Sever* 
ihelees, you should know perfectly how you arrired at tlds Budd«ii 
diatom. The first point was tho mode of tho injury, th«« the de- 
fumiity ; the tatt4!r is rau^ed by two or more pioces of bone (frag 
uivnUt) tiaving been displaced, Tliis dulocation of the irngmcnls is 
duo partly (o the injury itself (they are driren in the dircotJon Uiat 
they maintnin, from the bending of tlic bone), partly to the muaeular 
action which no longer bITcl-Is the <.'ntire bunc, but only a pu't ; tho 
muscles are c-xcitcd to cdntriiction, partly by the pain from tho injury, 
partly by llic pointed ends of the bone ; for instaooc, tho upper por- 
tion of a Jractured thigfa-booe is elemted by the flexors, the lower po^■ 
tion is drjiwn up near or behind the upper fragment by other muscles, 
and thus the thigh is shortened and deformed. The »ledling is consed 
by Ihp effusion of blood (we speak liere of • fracture lliat has just oo 
curred) ; the blood coihos chiefly from the mcchitlary cavity uf the 
boDO, and also firom the vessels of tho suirounding soft p«rts wlik-li 
have beoD crushed or torn by the ends of the boni> ; it looks blubb 
tjirough the skin, if it works up to the sldn, as it gradually riocs. Hic 
patient can only luovo tlie extremity with great p«in ; tlie wise of 
tliis (liaturbance of ßuictUm Is evident, wc need waste na wonU on 
it. If we examine ench of the above symptoms »e])ar<itely, none of 
them, either the modu of injury, the dcfbunity, »welliag, duutioo of 
blood, or functional dislurbanoe, will alone be evidcnoo of a fractore, 
but the combination is reiy dcdsirc; and you will often have to 
make such a diagnosis in practi^.^^. But all Uieao eymplnms may he 
absent when iheto is fracture. If there has been an injuiy,aDd non« 
of llie above üymptomg are well dereloprd, or ouly ooe or otlier of them 
diälinotly exiat», manual enutunatioD must aid ii». \Vliat will you 
fed with your hands ? Von should leant this thoroughly nt oocc I 
K> often see practitioners feci about the injured part fur a long time 
with both hands, causing the patients unspcaksblo pain, und aft^T all 
finding out nothing by their examination, Dy the touch you may 
perocivo three things in fractures: 1. Abnormal tnohilitif, \\m oa\^ 
patliognomonia sign of fracture ; S. You may oAea detect the ootine 
of the fracture, and often whether tberc are more thun two fnigmeate ; 
3. By moving the fragments you wiU often experu*ncc a rubbing and 
cracking of the fragments against each other, the socnlled " aiplUb 



SYMPTOUS or aiUPLE FRIC 



180 



twjn*'^lnctlj to crepitate mcao» to cratJtlc; tliU Is a sound, andstill 

1*9 aay, we fevl crc|>ilattoa ; it id uo uctu to object to thi« ; thi» is an 

abuse of llie word, ivliicb has so gone into practice, hnw^rer, llmt it 

cannot l>e rooted out, nnd everj- one kiK>n-s »liut it meaniL An edu- 

Mted toudi ufiimll/ fci:U ut oticu all tliut can hr dcl<vle<) \iy tlio 

Uiurli; licnco it is unneocfiaarj to muli«' the patient eiiffcr lon^ under 

this exscninatioa. ^cpitation maj' be absent or very indistinct ; of 

cuurac, It txnljr exists vltco the fragmenta can be mo\'ed, nnil wltett 

iiu^y are quite near each other; if ihcy be eonaidenbly dixplaecd 

lateruDy or be drawn far apart hjr miucular ooDlnictioR, or if there be 

blood Itetweco Uie iragtnenta, no crc-pltalion can be felt» and it is 

often diSeult to detect when the bont« lie deep. Hence, if we 

detect DO crepitation, this, ill 0|i|K>sitton to all the other s^mptoia», 

doe» not pro»-c that there is no fnicturc. Still, even where there ia crep- 

itattoo, you nay mistako its origin ; 7011 may bave a feeling of frio- 

tioa under other eirciimstanccfi ; (or inetance, the comprcRsion of blood 

DMpjliL or fibrinous ezudiilioos may give a fL-eling* of crepitation ; 

tliis toft crepitation, which ia analu^us to plcuritio friction, you 

ikould uot and will not mistake for bony cnrpittiii after ^onie vxperi- 

oree in cxaniination; when opportunity offers, t shall hcreafter calt 

yonr «tietitjoa to other soft Jiriction-souads which occur especially in 

tho aboulder-joiiit in children and old persons. For experienced sttr- 

g&*mMt in certain fractures scf-erc pain at a fixed point is enough for a 

ootfTDct diagnoedti, especially as ia oootusions the jiüin on graaping thu 

It^Mte ia tnoatly diSiuie, and rarely so severe as in fracture. If we lire 

!■■ Miiiiiiiim an extremity, it is heat to ttvixc it witb both hands at th<> 

ata^Mipectcd poinl, nod attempt motion here; this manipulation should 

b^9 Knn, but not rough, of course. I must add something about tho 

lis— 1(11 atiiiii iif llir ÜRagtneiits ; tbis may vary, Iwt the disjikcemeuts 

ok«^jbe diWded in varioua claasea, which from limo immeraoHal have 

h^^^3 occtein technical deeignatioris, which «re still used, and whieh 

(I > ■ imiii iillji must bo explained. Siinpl« kteml ilbptaoement J« 

oi^Uod diatoeatio ad latus ; if the fraj^ineutH form an angle like a half* 

bs-^c^aJuB sticlCf it is c<ül«d dM<Katio ad axin. IT a fragment bo rotated 

B»«3afl or Ices on its axis, we call it dülocatto ad jterijyhmam ; if the 

ÜK-<^eD ends bo ahm-od past each other rcrticully, it is » ditlocaiio cut 

lif'^m^yiiudintm. Tlie expresaions are short and Oi^tinetiTe, and cosily 

tf^KsMnaborod, cspocifelly if you represent to yountelvea the displaoe- 

■ft^^^ti by dtagran». 

Wo now jiass to a dest-riptiuD of the eoume of hcaliug of a frnc- 

i»J»^. Vou will rarely have the opportunity of seeing what happetn 

vikcii 00 biuulagc is apptietl, as the patient generally scuds caily fur 

t- «arg«on. But occnaloually Uie Inity undrrvalue the importunoc vf 

U 



100 



BUIPLE PRACTDBES OF SOKES. 



scirw 



tbo injar}- ; several dij% pasn before Uie psin and dantion of 
KfTuctioo ut luat cause Uie [Mtient to appljr to a autgeoit. lit 
cases, besides tlic ej-mpton» of friKAure nlrciuljr giren, yaa find gt^ 
csdema, aad in soino tv\r cases iuflftmmntory redness of Uie skin nbo 
Üie puiiiL of frncture ; under such oirounistances the exuninatioa 
be very difG<:iilt; occasioQitlly the swelling is so coosiderublo that 
L'snc-t diagiiusi« as to tlic oours« «rid vuriiil^' of tlio frecLure to uut 
till! questton. Ucocc Uie earlier wc sec a &ticturo tlie boUer. 
»iib6<K{U0Qt external change« at the point of fracture may be«t 
studied on bones that Via superGciaUy, and u-hidi cannot bo 
rouodcd with a tnndage, its on fracture of tbo clavicle. AfUi^t 
to niue daySj the iaUaiuioatory oedcmatoiis swelling of the ekia liaa 
subsided, the extrava^ated blood ba^i nin llirougli it^ disnoloratiaiw 
and goea oa to reabsorptloa, and a fimi, imntovahle, bard tumor 
around tbe poiot of &acture; tbis is Wgcr or anudler acoordinf^ t# 
dislocation of the brngmonte ; It is, as it were, pourvl around tbe tng- 
mevtSf and in tJie course of eight days becomes as hard as carlila^; 
this is called caliua. Prc&surc on it (the fragments can witb diSculty 
bo felt tbrough it) is painful, though less so than prenouslyj sabw* 
quently the callus becomes absolutdy &nn, tbe biv>ken end« ar« no 
longer movable, the bncture tnay be regarded as healed ; fur tbe cbir* 
tele this rcquiroa three weeks, in smaller bonce a shorter, and in 
ones a much longer time. But this docs not end tbe external di: 
tbe callus docs not remain as tlticjc aa it was; for months or j^mn 
it grows tbinncr, and, if tbere vas no ^sloestion of the fragmeols 
after a time no trace of the fracture will remain ; if tbere wna ■. di»- 
}ucatJou that could nut be reduced by trcstiitent, tbe etidi« <>f tha bnne 
mdU) obliquely and after ubsvrptiou of the odlus tbo bono remains 
crooked. 

To find out tbe chang«^ that take place in tbe derper part«, 
the fractured ends unite, wc try ex[x;rimcnl8 on antmalii. We 
artificial &actun» on dogs or rabbits, appl^' a dressing, kill tbe 
roals at various stages, and iben examine tbe fracture ; WQ majr 
obtain a perfect rcpreBentslion of the prooras. Tbeae 
have be<m mad« innumemblc time». The results have ainays 
essc-ntially tbe eumej but, if wo speak of rabbits alone, tbm 
c<Ttain variations which, as prcrred by numerous experitnents, depe 
on the amount of dislocation and of estrarasatioii of blood. IIk» 
before sbowing you a seines of sucb prcparatioR», I must gxvD yoa 
rcstdt of tliose luvcsiigattuns, and exemplify them by a fiuTr 
titen you will hereafter readily understand tbe sligbt modificaüoas* 

Wo slisIL first confine ourselves to wliatwo can see witb the Di 
t-yo and a lens. If you examine a rabbit*» leg three or four day« aft 



FOBMAHON OP CALLUS. 

K^ ondl^ while it b firralr Md In a vice, aavr the botie long!« 

^ ^^oa 6tut the follomng^ : tlie soft parta «bout the fnieture aro 

I And plastic; the tnuftcles imd suboutaneous celliilar tissue look 

'fiCKf ; the sw-ullcn »oft parta form « spiodlc-shnpcJ^ not vcrjr tliick 

tumor olxnit the A«atof fracture. About the brolccn ends wo find 

BOBU) daik oxtravnsat«^«] blooti, aixl Dm tn^'tlullary cavitj* it the saine 

ifoinfe is Homenhat infiltratod with blorxL The oniouiit of this cücaped 

i Tirkfl, being sometimes very stig-tit, again oonsiderable. At tlie 

][nt of fructure the periosloiini may be readily recognized, and t» in- 

itcljr roDoectcd wiih the oUier swollen soft pnrts (whtcli are the 

of pUutUo iafiltrntion). Oecosionallj it is nuncwhat dclocbcd 

tha bono at the point of fnifturo. Tbo wholo thing looks about 

iUk>W8(Fig. 43): 



ru.«& 



. _ «MllOB of • frt'tOT* «I • 

MlAU*« ban«. Io«ir lt«t* old;ii. an- 
HiMiwl nfliu ; A rcftMteata. 



Diunin or* innslindliiBl »uniuii of a 
SftDfu-dtjoIil fnMurv'if • luimbons ; 
a, Ikiipnial tallus; A, luiinr, t.tmtBt 
tanr or o»^ttatitm at tha »sMmaJ 
culni I d. new farlMUam, Tbo dt 
iiiiHitlan* uf tlucalLcu, in proporlloo 
to the ontlni took of dlalaoMlm of 
Ihu tnciuiniiB. uv repnaeiit«! M hr 
1*0 KK^t, btit IhU ftiHUiMM Uw pr*- 
UnluBi; uuiloHUiKlliii; uf Ibo taao. 



IB If we now cjumioc a fracture in a Tabbit after ten or twelve daya. 
we find that the extni^'asalioa has cither entirely disappeared, at that 
Italy a tJigbt amount n>nisina. I -will not niifte tlic <iiie8tion as to 
whrthpr it has been entirely reabsorbed, or has partly ofgnnized to 
»Iltu. The Bpii^dlc-sbaiwd swelling of tlic eott parts has mostly the 
[tpeonincc and consistence of carlilBf^, and has also the samo micro 
jital characteristics; in the mixlulliir>' cavity alao wo find yottng 




1&2 



SUirLC FRACTCBES OF OOKES. 



cvtilage fbrmatioQS in the vtcinity of tbe fractBt^. Tlie broken bone 
sticks ill tbU cartilage as if tlie two fragments bad bcm dipped in 
sculing-wax uud stuck tugellier; tlie periosteum ia still tolentblj dis- 
tinct JQ tlio cartilaginous tnae«, but it u »woUcn, and iU oontour« in 
indisliDct Although tbcre aro traces of cstificatioD eren dow, ifaejT 
do not become very decided or evident to tbc onkcd cjrc for some dajs 
(pcrlmi»s the fuurtecuth to tbe twcnlicth day aft«r tbc fracturs), 
Tlion wc sec the following (Fig. 44) : 

In the liciuitj of tbc fracture there is yomig soft bone : 1. Tn tbe 
incduUnry cjivity {a). 2. ImmcdiaLclv on the cortical layer {(), and 
some distance up and dovro beneath the pcrioateuni, which bus disap- 
peared in ibe whole sptndte-sbaped callus tumor, 3. In tbc petipbeij 
of tJie cttlluR, which is 6lill iiiOAtly curtilnginous (c). Tlie perieelctim 
vliicb prvviowily \xy within the ciiihis has non* dÜHippcured ; in its 
place a thickened layer of Uhsuo bns formed on tbe outside of tbe 
callna, which rcprcfionta tbc pcnoetoum fd). Tie ymnig bon(!>«ub- 
slwice ia soft, vhil«, and in it wo may see a bind of structure ; for 
Binal) panillel piece* of bone, corresponding to ibe transver*« axis oT 
tbu boue, may be diätinctly seen, especially on exomiiiation with a 
Ions. The cartilaginous callus formed from tbc surrounding soft perfs, 
into which the periosteum also liaH been partly trausformed, now 
fontift an enclpM^l whole, and nftsilie» entirety, partly from wittiout (s), 
portly from within (&), Uli finiüly tlic ends of the boiic stick in bony, 
a« they prcv-iously did in the cartilaginous caUus. Tliis bony callus, 
which consists entirety of siK>ngy bocMMuhtitance, is called by ^U- 
puytrf.it ^j/rovmtmat caUiif." As it is completed, the bone is 
usually firm enough to bo again capnble of function ; but tli« callus 
does not remain in its present condition any more than a reccut cjca- 
triz of the soft ijarta does. A avrifs of cbunges occun in It in the 
course of month» or years, for up to ibis poiut you may still oomjmn . 
Uie unioa to that by sealing-wax, which is not a true organie ttnioOL 
So fur tbc firm cortical substonoe is only united by loose young- boo«' 
substance; tbe uedullury ca\-ity is plugged nitti bone; tlie hcoUitg 
is not yet solid* Nature does far more. AVc shnll novr* study tbe 
subsequent changes; tliey are confined to the spongy snbstaace 
of the callus. At a certain time tbis ccnai» to incTC&se, and then 
change«, by rcabsorptioo of the bony substanoe tbat has forme«! in 
the medullary cavity (Fig. 45), and by the disappeamnce of a gfMt 
■part of the cxtemnl callua Mcantinte, formnlion of aev booe has 
»mmenoed between the fractured oorticnl layers, so that this has 
bsoome solid by the time the external mid internal iidlus disa{>- 
pewB. This connecting bony substance between tbc fragments grad- 
aally increases in density, totucb an extait that it becomes as bard aa 



VSimt OP rRACTOnES. 



1ft3 



rM.4& 







SKaa 
n*. Ketian- 
. iIkii III iIm tn«lalla>i' csvliy, 
natu nl at» I tfiut ffuriL 



the boAe iu the aonn&l cortical subatanco. Iii aux there has been 
liida Of no displuoetDent of the frnj^cnbi, tlic bono is thus so fuUj 
rrstored tliiit we ain no longer determine 
the point of &3cturc, cither on the liring 
perann or the smatomioi prc^paration. 

Tbc nhore changes oocur in a long 
bona of s nbbtt, wfaero there has been 

■little di8pU«>n)ent, in about ttreoty-six 
or tweul^''«glit w««ks, but in the long 
^ bonos of man Just mach langte, su Qu* as 
^Kilfe CAa jo'lgo from pn>p«rftttons that we 
^^W'eitlonlaliy huve Ihe opporluuity of ex- 
amining. 

The entire I)^JceH■*, st> exoeUenUy cou- 

tiveA hy Niitnn', Is esseiitiiilly tlie tniiic 

what wc obä<.'r\'(^ ia tlie tiormn} dervl* 

n9pmGnt of tho lonir boiirs : for there, loo, IäbsHh-ii™! »»pit"" or ■ rnMaM 

.•^ , " , ' , , . !>""« '""^ ■ niMili, «nor twm»- 

tbo tame rcnvaorptioa and condensation i^ir «"^k* p^<gK>■lvo km- 

take {ilaoo in the lucdullurj* cxaiH ami tlio 

■1 biyeni of the long bones, as we 

ive just »liklved in foimfttioa of callus Except the regenentton 

no Sfich Cücnplüti; roätomfiun of n ih^troy») piirt iuUva 

iu suj yllier part uf ih« humuu hjily ua wc have seen occurs 

Btill add a few n-marks about Uie healing nf flat and spoogy 

booea. In tlie catae of tlio finit, which we sec most freituently hi the 

healing of fia^ures of tlie cranial bones, the devdopiuent of ]»t>vi- 

^^Monal e*llm i» very KÜghl, and oeejuiionallj nppcors to ho entirely 

^^piuitbig. In tbf) S'^puhi, whero dialooitiuu of small, or half or 

^^■^rita^|tacbc«l fraf^ents U more; ajtt to oocur, cxtcroul rallus fortns 

^^^^^^^Btly, altliough even hero it never becomes rcry thick. On tlie 

uutsa of sjMMigy hones, tou, in which, as a rule, there is nhui but tittJa 

dialooaUon, there 13 lese derelopmcnl of external csllus than in tlie 

I><ng bonM ; while, on the other himd, tbe cnvitica of the spoogy sul^ 

«tmce in the immetlinte rieinity of the rriKnture aru ßlied witJi boQjr 

nbataooCf of which part, nt leoAt, aubscqucntly disappe«ni, 

I Jka may rCttdUy b« Ima^ocd, tho conditions will be somewhat 

.. .T .'< ..|.': -aed when the ends of the bono are muoh dislocated, 01 

w< :i :' -I 'Ills are entirely broken off and dinploi't-d. In »udb caM8 

■iiOrre is »uvh a ridi developmeuL of rallua, partly from the entire tar- 

L^fCseuf Ih« diaiw-iil«-«! fragmonlR unil from the mcdnllary cnvity, and 

^^^nly in the soft |iart« betnt'eu the fragmuuts, tltat fur somf distance 

tl^ the £ra£itionts an; embedded la bony mass, and orgiuii«a!1y glued 




SIMPLE nxonmsB ot Bona 

together. The larger tbu circle of ImUttoo from tbe dMoosted b^ 
rnenta, the more eztensivo the {ormatire leactlon. 

In man vre most frequently bare the opportunity of Keii^ cttUoi 
fonitatioii Ju greitly dislocated fnctures of the clnridc, wbero it is 
very t:%-ulctit tlutt the t-xtcnt ot Üie new turmiiUon of bony substoDoe 
is directly proportional to tb« amouat of dislocation. Vou may r«»J- 
ily uml4-rstand liow, io tbia wsy, with extensive formution of neo- 
pkatie boue-substmico, tbcre may be perfect finnnc^s, crcn with great 
dofonaily ut the poiut of (jmuture. Still, one would biirdly bclicYC, 
wtthout satisfying liiinsclf on the point, from preparations, that witli 
time, eren in suob case«, Nature baa tbe power of rcstoring^, not onljr 
Llic outn-ar«] shape of tlio bone (except tbe curvature and rotAtioo), 
but tUo the medullary carity, by rcnbsorptioo and condeoftatioo. 



na. u 




Fm «t 




raciiiracrUuidfitaoramilill. «Iiti 
■nal dlalMAIIon. wlili mUuiIi* 
bmauhm of wIidk ntXtr >I il it«. 
Ntuinl •Im. ahi-r St-O/A. 
lOitrtrtTmaitea.iol.l, p.iWJ 



OU united obllqu« fnicura of * tnii 

Ui« amU or Uut ln.riuaaU I 

(«u>dod eff bf MXDipliMi, iba Httnul 
nna» itatxniiol i bnaaUoa nf Uhim»- 






«I* dlnl»- 



Numbcrs of pointii, nudulL-s, iiiLt]uabtics aud roii^hiiMssM of all «urt^ 
that arc fociucd on Ibc youn^ callus iu reocnt »«a», so diiiappear in 
tbo course of months and years, that in their place there ia only leA 
«omc dciue, compact^ cortical Bub«tanc«. 



TORMATIOK OF SEW BONE. 



105 



It will now be intcrcsling to invostigutc tlie true Q ii^iii of tbe 
»wIj-foniic4 boDy s-jbstance ; is it produced by ibe boue ilaulT, by 
bo pefiosteunt, by tlii> eurroundhag soft ports, or is tbe extmvasutcd 
blood transformed into booc, «s wus believed by old observers? 
Most {bnnBtJiHi of CBTtilago always prcecdu tbit of booc, or is this 
unnocessutj? These questions luvii received variotus answers, till 
quit« reoently. To th e perio steum, especially, greut power of pro- 
ducing booe has at one time been ascribed, at anotlier denied. lu 
what follows, I vill brielly gire you tbe results of my invcitigations 
Wjb this subject. 

Ute new fui3a»lion Lbat result« from tbe fracture occurs ia the 

medulla aod Haye wJMI e>nal i of tbe bono, in ll>e per io stoum, and in- 

filtistcd la tbe adjactiat musdoti and teodum ; ])Oä6ibly thu esltava- 

saicd blood may also bsrc something, but reiy little, to do Kith the 

fonnatioti of the callus ; a large extnvasatioii is disturbing here, as in 

healing of wounds of the soft parts, for part of it must be organizml, 

vbQe tbe reioaioder ia absorbed. Ttic innamntatory new romiaiioti 

der«, aiaOy at first coiuistejiX-amall rouiul oells, wliicb increase greatly 

in number, and infiltrate tlio tissues mentioned, and then almost take 

tiicir pUcr. Bcfure following tlie fate of this ccll-fonnation further, I 

>st briefly eoosidor its course in tbo nnvensian canals. The cell-in- 

xtiau in the oooueclivc tissue of tbe medullary cavity offers 

ling peculiar, except that tlie fat-cells of the medulla disappear 

the tnaas as the wundeiing- o-lls tiike pi)»<ii-nAinn of the territory. 

Stippos0 tbe following figure {ilg, 4K) to r4>proii^nt the surface, or the 

Cncturad surface, of a bone on which, as you know, the Haversian 

jiwiiila open ; in thno canals Bo btood-vessela, surrounded by »ome 

^1 If this bony surfaoe be in the vktmty of a fraüturv, numcroua 




rn.ta. 




«ttnwUwIkatl ••KIloo Uimiiirti Uie »Hkiil wl»»«»* of » Wnir bmi". ».tuf»-:-: 
■wtontSMK »Uli likH*l-vra»U linl «aslwcUM ttanu: a perluiuuiii. Ila0i\tui 
imntriL 




190 



8IUPLE FRACTDBX Of BONES. 



eells firstcotue between Uteaxuv^ctivatuimeiii ibu HiLvenUn cuiab; 
shoulJ liiid cell-infiltration lie very rapid, it would cnttrclj oompreai 
the blood-resseU, ind cous« the d««th of the boöe, n prooon vrhkifa 
we shin hereafter leara. Jim, if tlie cell-increase in tliene oaiuls gocv 
on slowly, their wulLi nrv gnulually abetoched, u it woiil<l appmr, hf 
(bo infUmmatwy otsw rornmüoii tt««U; tbccaoftU «re dikccd, the cells 
fill Üu>ni, und at the sanm lirac the blood-veeseU increase by fofmliig 
loop«. 

Frvm the obsen'atiotis of Co/utfttim, we must 8U]>po60 Ui 
infl&mtnation of bono, lUso, the y<)ung cells in the Haveraiui cuuli 
are not newly funned, but arü while Mood-colls escaped from the rt^ 
sela. This has no clft^ot on the eubacqucat course 

Now, let us Iura to tho changes of form that w« obsfrro in the 
ossooiis tissue. An the conneotivo tissue of the osseous raDaJs is coo- 
tjououä, both with the ])erioftteuni ami medulhi, tlic rell-infiltratiou 
into tho boDc, periosteum, itnd moitulln, is »Iso continuous. Tlic cauw 
of tlio iitrophy of bone along the walls of tho Haversian canaU, 
which takes place In this, aa in iDost other new formations in the boDp, 
b difficult to vxjJain; the disappenraiioe of Uie conueclive tidsue «aid 
niiiM'iilar BubHtanoe, ns well ns of other soft structun?», when tho itH 
flammator^- nvw fonuatioii occura In them, ts less «tmige; but it b 
tmly rcmarkablo that bard bony subAtancc ahoulil thus be ttisaolnd. 
This proo^fis might be rcpire«anted by the fullowiug diagram (Fig, iO) : 



rw.4ft 




I>li;f*ma(lnaMimMnrrB«>tonaufoalilb*B«<nrrtineiHd*. a.anrfta: tt.\ 
0kiuk.4ikC»d,lIlad«itbwllaM4BnrvaM«l«i«,r«()MlwuB. H^alded«»/ 

Vou sec that the dilatation of the otwoouft cuuUs is not i 
bot of UQRriMi widths ; tho bone looks as if gnawed out ; tills is : 
Deocssarily so, the atrophy of the booe may be more regular; oc 
iag to my idea, th(»c irrcgularittcs result &om the oolloctiou of oe~ 
in ffTOu^ or from toopiog of the vosscla, which preas agnin«! 



FOBMATIOy OP CALtüa 



t»7 



bone and cmusc its atroph/. Virc/iow and others bclicFC that theao 
pRxtobenooos «nrespond to the nutrient territory of n^rtain bone- 
oüUa, wliU^ in tUis prfxrow iiiil in mibsorpiioQ of the bone. 1 tliiiik I 
fcave refuted tliis, bj alrawitig Diivl cvirii Jead portions of bone oiid 
imry Krs abo affected by th« in(1«i»DiAtory new fomution ; ttc «hoU 
Bpeuk more of lliis wlion ürr->atiiig of psuudiLrlliTOEU. At pn.*»(Mit it u 
not known bow tJic limo-salta are ilis&olvcd in thia process; I tliinic 
or^biibljr tlic ncvr furotatioii in tbv bone develops kctic acid, irhicb 
chimges the carbonate and pliospiiate of liinc into soluble Inctntc of 
lioic^ and that this is taki^ up and rt-nioved bjr thti TCssels ; but this 
i» only b)-polli«si& It would aUo be possible for the organio baeifl of 
tbe born;, tUc ao-ealled 063eoi» cortUuge, to be fiist dissolTed bv the 
inflamiDatory oeopluMo, and tbeo there would be a brenking-down of 
tbo «halky aubatuncc, w)to»c muk-culL-a would be subsequently to 
taorcd, etCQ if uudi&solvcd. AllLou^li I have couveraed with uauy 
diewutj and plt^<siologi»ts on Has point, none of tbeni have given me 
gi simple cx]»Ianalion of tbta pnx!«^.^ nor could tboy indiL-aLe any mode 
^ expcriuicntiiig that might aid in KolTing the question. 

In th4S above diagrams, if we suppose the fractured surfiico when* 

•cbcre Is DO periosteum, in place of tbe surface of the bone, you wiU 

«understand how tiie new formation (the young callus) grow» {mm it 

of tlio Hsvenion caoala a« above described, «imilur ncoplusin 

^^koD tbe whet fia^ent meets and nnites with it, a» iu healing uf 

^Jin soft part& It is etidcot tliat fhc Ixino through which the inilam- 

»Ion,' nc-opbuia thus grows must beoomc porous, CrQm the reabsorp- 

foo I hat tokea place on the walla of the canal; if you luaocmte a 

YMtiif^ia tbtt otog«, till llio young ncojil»»in dccom[K)se8, llie dry bonu 

will appear roogb, porous, gnawed, while young boue^ubstauoo b 

defvcaäted on it and in its medullary cavity. I must again repent 

tluafe In drawings and deaoriptioos wo Imvc, for the sake of cicaroess, 

m^^d« tb« callous fonnation appear much more cxtensi^-e than it really 

i«, ^uid tliat berv, as In wouikU of llic soft parts, the regenerative 

procscsaei do not usually extend very fiir or very deep, but are merely 

*?o^K2gll for healing, rarely in excess. In this whole explanation wo 

bav«» not mentioned tUo bonp-cella or stellate bone-corpuscles; I am 

fx>ra-vioc«d tliat they hare as little to do with these processes as the 

fix<^<J cotmeetire-tisaoo cclhi, and that the bone-substance, like the soft 

pioda, is dixsoh-ed by a certain amounl of inflamraation, and replaced 

So far we only know tlic neoplasia in the stale where it ooausb 

^^■ttQtially of cells and vessels, 0« the »oft parts do undnr the sanu 

ctnounutances ; if Uiirre was retro^'Miun to n ooaiiective-ti^sue cica- 

^Hvlienca« tlien; is there, wc should InTcno aulid bone formed, but a 




108 



SIMPLE FKjLCTCKB OP BONSa 



oonDcctivc-tts5uu uuion, pae\uIarthroiU (from ^evSiK, tikhe ; tipQpntat^, 
}<Miit), & false joint ; we shall hereafter desoribti tlic«€ oxceptiotut com«, 
Dnder normal circumstunues the neoplasia now o«Rißcf>, as jron olreadr 
know. Tlib ossification ma^ ciüter occur directly* or after Itie iDflamn»- 
iory oeoplaaia liaa been trauafuruieJ to cartilage. Vou koow that botli 
or Uiesa modes ktc s«ca in norma] growtii of tlic Ixino ; direct oaxifius- 
tioo of jrtniug cvll-forniation, for iiistauoe. In tbe peiiosleum of the 
(growing hone, or funnuüoD of ciutihigc with »uLec<|uait n&sificatioii, 
as at iirst in tho eiitir« bkvleluii and fa growtli of the hoties Icnglb- 
wise. Oollus from fractures varies grcattjr in tbis rtwpect id uea awl 
ttuiniiils. In rabbit« tbe callus is always changed io cartilage before 
Mtißcalioo, lu it also is in children. In old dogs the c«Ilua niuftUy 
ouIfieB ilirvcUy, as in the human adult ; ue are far fium Imowing tbe 
eaaaes of th««e diiTcrcnccs. To obtain a bistokigical roprcaentatlon 
of Üiuau pixKieasefl, let us return to our former diagram (Fig. 40) ; now 
ianginc t)iat tbe c«lls, Ijring in tlie spttces mused \rf reabsorplioQ in 
lbs Baversiuu canals and aiu-race of the bone, soon oasif/ and first fill 
Uiesc Epaccs (Fig. SO), then collect on the suHtice and in tbe mcduUo, 

Pw. [>*. 






mU 



1^ 















^fSV. 



^&!^^^5*5? 






>iv^ 



^tt r^:r^ 



%^ 



'^. 






^; 






" "f Inflnmniimpr qn^vla'taxn Ih* ■itribM of llwVnM aa^ k* iWI 



and thu« form Oie external and internal callus. Periostitis m: 
Mtitis, which lead chiefljr or exdusively to the formation of Dc 
bone, we call oetooploaÜc ; in the present caw the callus ia tho 
of thin. 



voEUA-nox or callus. 



1»9 



i}y rcmaHced, t)ie pcrioelcum ia used up in Üic neopla- 
lia and ia OMifyiiig callus, in its pUce, cxlemallj' around the collua, ■ 
ooonfictivo- tissue layer devclnpfi, from which new porinstcurn 
lecL I vritt »liow vou a few ciuru pri'iiumtiikns fit cxplanatloa 
tn.u. 



V 



Balani-1vl«rln] riUrul aflnii. of «IlcU iM rt a«*». on 'b» «nifta* of k nbbll'ii UbU, IoUm 



Pw.Ba 



*//■ 



*Bi 



'-'^J 



[tlie process in tbc prriostcuni. ' Vou »ee (Fig. 31) tli« peculiar 
uf Uic rcAscU almost Jit right angles to tiio boni', wliiub enter 
the boQC through tho young callus. 
TliQ ossification oC the callus begin», 
mantlc-likc, arouDd tliese vc9iscl-<>t and 
Ute little coIumQS which fir^l ft[^-iir 
in theexU>miilrjilhi9 aro thu« forined 
t^^^^^BK'C/. /H (dee rciiiaris on i'ig. 44). 

Vou have a good representation of 
the formatiuu of external (periosteal) 
and ioteniBl (endosteal) callus in the 
tollowio^ (incomplete) tiansverae 8er- 
tJoa of the tihia of a dog, fmm the 
Inunediate vicinity of iin eiglittlay- 
old Cneture, In wluuli you must uImi 
observe the vcswls of the cortiad sul> 
stance, which are couaidorahly dihitul 
OS compared with nonnul (Fig. 53). 

L«stiv,*>hscrvotho following prcfka- 

tatii»). It is an eight-dav-ohl, already 

oasifiecl, external callus on the surface 

".^ti?'ÄS"?"r5.,'T;t:Sa^' of t*»e tibia of a doff, moffuificd 350 

' ' tS'^Si^V^U^?; timoH (Fig. 53). 

If we DOW view the process as n 

whole, we sec that tho cell infiltnt- 

Itbe bone tlwlf^ na well »a in nil tho »ummiiiliiig parts, aids 

an of callus, and tliat hcticc th« periosteum playa no ci- 

ivo otftvoplastic r<3«. This might have been concluded a priori^ 



t**i|l 



h 



t 



2U0 



aMPLE PnAtTÜRR 07 DOSES. 



bectiusc ir Ü1C pcrioslimni alone formed tbc external cnJIiM, ss was 
formerlj Buppoe»], tlio portione of tlio htaia free of jXTiosUrum, u 
ihOM plftpes wliere teadoiis aro utta<-hi!d lo the bone, fouM 
no cmUfts; tliis is ditt-rily contrndicKxl by obaerratioa. lu 
grotrlli, kIso, ^^ l>«riort4>um dnes not hy anj ncaiu play llic id- 
]H>rtant part un-ibed to it in the formulion tif 1k>ii<>; for we nuijr jiiM 
as correctly regard tbc biycr of yotuiK ccIUi lying irn the iniT&cc c( 
UM boue, and extcoding into tbc Havcrüau conala, u l>eloiigtaglo 
tito iMMie, as to refer it lo tbc periosteum. 

fta.Si. 



m 



s<^*W 






i.y!!r 



^s- 









Becent invest if^t ions concerning the growth of bone-s, inawle by 
•^ 1}'ö{(f, remler it viTy probable that thcy^ inoreoiie in all direetiont 
by iatcrstiliul deposit of young owieoii« tjaeiie, and lieoro lltat 
growth by apposition through thf. epiphytteal nirlilnpes and pcrioe- 
teum can no longer be regarded as the sole Source of increase ta 
lengtli und tbickuese; sucb a mode of growth is placed beyond a 



TR£ATlfeN-T OP FIUUTUU& 



201 






lubt bjr Wefftier^i exoellimL work on tli« o&tooplu&tic action of phos- 
phorus oo growing bones. 

I will not coooeal from ;uu that tlic view wlii<-1] I Imrc obsliiiately 
jDniiitaincd, ituit tbc booc-ccllii in new osseous formations do not pro- 
iforat«, but rcmaia fjuite passire, is muob disputed ^ »ioce Cohn- 
liAs shown the passii-eocES of the etabllo connective-timue coc^ 
es in iaflammatioa, tlicro docs not seem so much atrangeness 
»bout vxj view, vhiob was adnncccl yeara ago, and ivos founded oo 
namerous observations; still, the explnnation of the preporutions in 
question b not simple enough to permit only one view, Ris-'oatly, 
bf Tef7 careful inrestigations about the liialulogicnl changes duriiig 
the txsnsfomiatkm of provisional into detinilive calUi«, Loi^n has tried 
to sbow tiiat the booe«olls in tbo former take an actire part in tlie 
loctnattoo of vascular caniüs in the latter hy enlarging and dianging 
{Kxition. I can agroo with this entirt.'ly without abandoning Uie 
abovo vicvrs, for tbc prorision-callus is like the young osteophytes of 
oalcäfied oooneotivc tiftsue, like certain boundary-layers between oar> 
tüage and bono. I have no doubt that the cells of this " osteoid car- 
tiUgo^ ( FtrcAoto), like the cells of hyaline cartilagR, pmliferale to 
tnie bone. Bat thi» is not tba place to enter more deeply into the 
faiscologtc^ details, which, great ns is their intrinno intcrcstt, have tto 
anential tnfiuence on the definitive formation of tlie new devclopmeat 

booo. 




LECTURE XV. 

oT Slai|ito rrHtur««.— Bedurtloa.— Tim« for apiiTring tK« ][>r«Mlnj, It« 
iM,— PluUr «f Pirlii and Standi Drawls^, Spllnta, PrainuMiie Sataadfriu— 
Btifaüiiine Uu Uoih in Pocitioti.— IndjotUon* fot rMn^viog Uii DraMiiiff 

^H Wb fliall pan at onee to the treatment of simple oi subcutaneous 
^nacturta^ eepccially fiaciureft of the t^xl n>niitwB, for these are by far tW 
V RK>ro frequent, and tliov poHiiHilurly r<y|uire treatnient by dressings. 

«bile those of tb« head or trunk are to be treated less by dressing» 

tlun by appro(mat« position, as is taught in the lectures on epectul 

Mrgery und in tbe surgical clinic 

Tbe indientions we have to consider are, simply to remove any 

dillocatjoiisaiul to keep the fmnturcd extremity in the correct onu- 

Umieal position till llie fnioturc is healed. 

Firat, iLe fngmenU are to be replaced; sometimes this may 




808 



SIMPLE FlUCTnK£ OF BOKE& 



bo uQoeocMarf, u whon tticre U no dUloeatton, Tor iiielAniTc, In scow 
frfict tires of Üieutnii,fibulii, etc. In other cases it U rety dIi5cu1t,aiMl 
mnnot a]ws>-a be done perfectly. Tbc obstacles to tbc repoeition eis/ 
be ill the position of llio fragmcnls themselves; one fngtnent may be 
wedged into anotbcr, or a small &agtnent lies between tlie cliief ones, 
so that llic litlcr caoDot b« broiiglit together accurately ; (rsctora 
of the lower articular extremity of tlic himienM are TCfy obstinate n 
iMs respect, for small fragments may \» so dislocated that ueither 
llesioit nor uxtt-naioa of tbc «Ibovjoint can be peribrtncd perfectly ; 
lumM its functione remain pcmuLnontly impftirod. Muscular mu- 
traclion forms a seeond obstacle to tlie repomtioa of the. fragnteols; 
the patient inroluntarily contracts tbe muBclcs of tbe brdten limb, 
tbus hibs tlie firajfments together or presses them into tJie soft paiti, 
causing screrc pitin ; tliis ntiKCiilar cootimctlon is oocasionally almon 
tctanlC} BO tbut^ creii by greut force, it id bunfly posnble to orcroomc 
tbc opposition. Indeed, Comterly tbese difficulties wore, to some ex.— 
teD^ insurmountable; and, sltliouglt attempts were ik>w aod 
made to attain tlio object by diWding tendons and muscles, it 
often only poswble to attain an impcrfe«! reposition. All tiicso 
euliies were at once removed by Die introduelion of (^loroform im 
anKSlhetic Nuw, In all cases where we do not readily succeed ii 
repontion, ire aoa^thetizo tlic patient with cblorofonn, till bis nn 
dea are perfectly relaxed, and we can then usitally place the fng- 
menta in position without difficulty. Some BuigeoDS go »0 lar ai to 
use chloroform in almost uU cases of fracture, partly for the examlna* 
tion, partly for it)« application of the dressing, Tbis is unncecMaiy, 
und may even pnivo very uupleasant, for some pcrsou9,0(!i)e«'tully those 
in tbo lutbit of drinking, at a certain stage of the anie&thcsia arc 
allected with spüamodic coiilntctiona of the extremities, so tbat, in 
spilo of being carefully held by strong nRsistanta, they rub tlio frae- 
hired ends against eacli other with fearful force, and wc must Ije very 
oarcful that u shnr|> fragment dot» not pierce tbe skin. Tlüs should 
iK>t frigbu'd jou from using diloroforin in fmeturcs, when it is neoea- 
sary, but sunpty warn you against being too free with it. The metl»* 
od of [t-position is usually as follows : Tbc fractured purl is grasped 
hy two strong assistants at the joints above and below the point of 
ftacture, and rf^;itlar, quiet ttactloQ employed, while the Riii;gecrD 
holds the cxtrctnity at tbc point of fracture, and, by gentle preaailT«, 
attempt« to fot^;o tbo fragments into position. All sadden, impal' 
sive, forced tmction is useless, and should be avoided. Berti you 
have to notice two t-^chniral expressions ; wo tenn tbo trnciion on 
tbo lower part of tie extretoity, extwtion^ that on the upper part« 
eottnter-txfen»io». In fructures, iheRC are both made bv the hands 



i 



TRUTXSKT 09 FUCTUBCS. 308 

itocAtions we miMt oocAsionnny resort to tHSorent mechnn- 

By ibe aboTc niethoil accwraie repfiüilion will only 

bo ImpoMible wlicn, from cxc<«svc swclliu^ or &vin pcculutrly un- 

ftvorable dislocaliuu o( tho fm^ciils, wo nrc tinsblc to corrocUy 

rcoogniie the rariety of t)io dispUcciDcnt. 

From our preeeot iOeaJt, whioli are baaed on a ki^ number of 
ohoervKtioiu, tlic sooner repoaitioQ is made after the oceammce of 
tlio fimctiire, tbe better ; wt> llieo at onoe apply the bamlagie. , Tliti 
was not aJvaya tfac brlicf, but formerly tlic adjintnwut of th» frao 
tureaadtb« application of thcdrcR^ing vrerc delayed till the disnppear- 
vun of the sweUing, wbiub uJmost alwayB occurs if a Unsssmg a not 
at oooe appli««!. It was i«arcd that under tho pressure of tlie dresft- 
iog tlie extremity mi^t mortify^ and tl>c (bcmatioa of callus would 
beMndcred; with certain cautions in the application of the drc«f 
tag, tho fbrnier may very rctulily he avoided, and tliere is little 
trutli in tlio latter helicL Regarding the choice of the droasiiig also, 
Biii;geoiu have of Ute reached an almost imanimous o|uniMn. It may 
ht ngardei tu a rvU, thai a »tAtd,ßrfn drtMtng sAotikt be uppiifd as 
Mrly a* pMatUs in aU case« of thnpt« tubeu/weoiit /ractura of th« 
urtremiiUs/ tltis may be uhangod altogether two or tbnH! times, but 
io nany cases docs not need renewal This mode of dresatng is 
aallod tho immotxAU or ßiud, iu routradistinction to ibo r»ora^ 

»^Fttsinfff, wliich must be renewed ei'Cry couple of days, and are 
Duly provisional dressingB. 

There arc B<?%~era) variL'tics of lirm drcasings, of vrbidi the most 

»erric«alJc arc the piaster of Paris, starcli, aod liquid glass. I shall 

first describe the plaster dressing, and sfaow its sppliration, as it is 

^ulhe one most frequently used, and answers all rctiuircmcntfi in a way 

^Mbat oaa scareely be improved. 

^K JtatUr qf Parii Bandagt. — After adjitstmrnt of the fragments, 
B|1)B broken limb is extended ami counteT-extendcd by two assistant«, 
then one or more layers of wadding applied OTCr tbo point of fracture, 
■nd over parts wb^ro tlie ^in lios diroctiy over tlie bone, ns orer the 
craM of the tibia, tbo ooudylcs, aud malltMlt. Now it is best to en- 
velop tbo limb with a new fine flaoDcl roller-bandage, so ad to make 
^■rvcmlar pressure on it, and «n-c-r all partjt that are to be surrounded 
^Khy tbe plaster-bandage. In boapital and poor praotioe, wb«re we ckii> 
^fcot always liaro fianucl, we may use soft oottoo or gaoie banda^-H. 
^ftfow cemea tbe applioation of the plaster-bandages prepared for the 
pntpoiie; tbo pbistcr-baadage tlut I here hareia cut from a rery tliln 
gaaie-Üke stuff; it is prepared by fiprinkling finvly-powdcm] plitstcr 
(nodeUing plaster) over the unrolled bandage and then rolling it. In 
prlrate prartk» a number of these bandages of various sizes may be 




204 



SlUFLE FRACTORE OF BONES. 



prepared beroreliand and kept in a well^loeed Un box. Hece io titt 
boe{ütal, wbcro tkeso plaster-bandagc« are much used, Üiej ftre pn- 
pored tvro or tbrcc Limo5 a week. This bandftge you plme m k bum 
ofouM ivutcraiid lut il sunk tLrougli, ihvn appl^ it liku any roller- 
buudngc to llic extremity prepared aa aborc described. Three or at 
most four thicknesses of this plftstcr-bonda^ sutGc« to give tlie dre«»- 
iog the requisite firmtuss. In about ten mUiutes good plaster be- 
comes stiff enoiigti for ira to lay the extremity loose on the bed ; in 
half ail huur or an hour, tbo dreesiiig beoomeo ua Uanl aa itone und 
i|uitcdry; tho time required for hardening dcpci»U partly oa the 
quality of the plaster, partly on how much you hare moistt^ned tbe 
bandage. Aftrr ittaiiy miitporisous with other nxxlca of applying ibo 
pUstcr-bandnge, I hare found this tho most practical; but I must 
mention «ome niodilifationn of the way »f handling the ploAtcr and t^ 
tlie material of the bllIllhlg(^. For iii»lauoe, we may rub tbo |ilartnr 
Int« th« oommon muslio or flannel baoJagcs, wltlcli makes (bo droi»- 
ing somewhat bearior and firmer ; but tfais is not neceesarj and tho 
I006C gauzo is very much cheaper than musJin-lsndage. If tbc band- 
age docs not appear sufTicicutly rinii, we may apply a layer of [iJaatcr- 
paste over thn dressing ; this pla.iti>r-pa»l« is to be mnd« witli water» 
and spread on tlie bandage very quickly with the band or a spoon ; it 
aboukl not bo prepared till we wish to use it, as it etUTcns \*eiy qutdi- 
ly. The plastei^re«8iiig as made with roller-bandages was first in- 
tmduned by a Dutch surgeon, jtfat/iyneji j this nieüiod was first pi^ 
lished in 1833 ; but il has only buconieweU known iiinoe 18S0; it has 
been spr«<ul through Germany obioSy by the Berlin ecbool. A differ- 
ent tnodo of applying ibo plasI(>i^n>sKing is by difTcn^nt strips of 
bandage ; ISroffOjf first hit on this mctliod from lock of bandagoi 
in the army ; all kinds of mulcriaJ M'ere cut into the abape of splint^ 
then drawn through thin plnater-paAle and laid on tlie broken limb, 
then tbc wliolo was coated with plastcr-pasto and a firm capaul« «aa 
tliiis mode. Subsequently llic same Hurgi^on made a iipOcial inctbot^ 
of this; he cut old conrso sail-cloth into certain paltom« for f>ach liml 
and applied it in tbe above manocr. Lastly, the so-calle<l niany>t«it< 
bandage of ^utMus was u&ed in tho same way as a plnnter-l 
The foundation of tho bondage has also been modified in 
ways; it has even becti used without wadtUng or any undor>! 
the whole limb beitig »mply covered with oil IK> that tho pUat^s^ 
bandage, iH-iiig applied dir<>ctly, might not adhere to tlio «kin by 
ßne haire. Otlicra luivu employed lliick layers of wa'kltng wil 
any under- bondage. Lastly, tliin woo«ten splints nr strips of tin 
been lately used in it, aswa shall herenflcr see ; this mav have 
advantages in fcnefitrntcd bandages. 





TB£i.TVENT OF FRA.t:n:R^ 



306 



bare iotcQtionaUy roprvMntod all (bcM modificationa of Uie 
läge M only exccptiouuUy Ufti'ful, aU of tliem baring oer- 
10 objecUoaa u compared witb the method first described. A more 
. critidsm of dieM modiiicatioos here would lead us too far. 

For pemoos unBkilled in Üie mutter, the rcmovul of tlw plaster 
taodage is quite difRcult, but you may see tbat toy of my uurses will 
do it with ustooitfliiii^ quickncae. It i» simply done as foUows : wiib 
a. sharp, stnmg garden-knife wo divido Ibo plaster^bonda^, not per- 
pen^colariy biit mtlicr obliquely, as fur as tbc undrr-bandage, then 
mnore the bandage eotirei lilco a shell ; wo may aim employ Iho 
pU»ter*cis5oni proposed by Szt/manmetki or those o£ JBnmt. We 
Ute this capsule in some other ca»e8 a.» a provittloual dreasiug. 

Starc/i-Jiantiagcs. — Il«foru plobtcr-bandugcs were known, wc had 
in the starcb-baodagc an c:tcollcnt mAtorial for tbc immoTabl« dr^sding. 
Tba atarch-boodage ttus pcHectcd und introduced L-hiclly by the Belgi- 
ma curgeon SaUin (f 1SG2) ; it is only during the last tvredre je»,n 
that it has given plaoo to tji<> plafit«cslre8«i&g, but it is «till used oc- 
cukiaally. Tbo applicstioo of tho wadding and undcr-bondage is the 
nme aa In the plaatcr-dresdng, but then wc apply splitttt, cut Jrom 
RMxleratdy thick pAstcboard and «ofioocd inwa(cr,to tl)e1imb,aQdlw- 
len tbem on with beuidugt>8 tboroughly soaked in stHrcfa-past«*; «enow 
apply wooden splints till tho dressmg has hanlened, u'h!eli at the ordi- 
nary temperature reiqiiirf » about twenty-four liuuni, Compared to the 
plaster-drcesiog tlila has llie diiadvnntnge of hardening much more 
Jowly* we maylmproTe tlils somewhat if wo use ^(iH(r-/>«rcAa.xp&iC» 
iofltcad of pasteboard, these may bo »oftfnicd in hot wntcr, and 
adaptod to the «xtremity, Gutta-poroha hands, such aa are tised in 
lacturics, are very use^ as splints. It cannot be dentt^d that the 
istnxltictiuti of giilta^rcha into surgory i» to be regarded as a great 
Mlranlage ; but it is too eoetly to be used in pnictic« for erciy simple 
fracture, although t>iick »plints of this material linrdeo oveu quicker 
iWn planter. The dressing with roIlcr-lMiudages prepared with plaa- 
ter is ao cheap and iirm that it will certainly not be displaced again 
by stareb-hondages, now that it has been introduped into practice. 

Instead of plaster, solutioos of dextrine, pure white of egg, or 
simple itiixturo of flour und water, were formerly employed; they 
ktave all gone out of u.10, but it ia well for you to know tlte usofulnesa 
tjf these subttanoM, whiefa are In ereiy hooae, and which we nay 
well «ii|doy as proriaional dressings. 

Xiit/uitt^lau jMvtting*. — lostcod of starch, we may employ the 
liqokl glass of llio »Iio|)s (silicate of potash). On applying llic dres^ 
iug, we paint this ou the muslio*bandagus with a large brush, after 
hanng miKle a substratiun of wadding as abor« described. Hie Uquid 



soo 



SniPLB FRACTCRB OF BOKE& 



.glnss dries qiiiclccr tlifta stardt, but DOt >o toon a» plutcr, nor doe* it 

'become ms hanl as tlie latter; tbis (Iressing does for fiaciures vrltli no 
tpodcDcytodispIaccnicot; ifwc wlsb tofixdülocat^tl&ugmcnlsof bone 
by Üie liquid-gUss dressing, vc mtist strengthen it by applying' epUnU, 
I doubt not the time will soon come when erefy fxnmtry physicUa 
will always k«ep a few plastor^pHnls read/ prep*re(! ; tti spile of 
IbcDi, provitiorüü drcmtt^t rciuuiu lUcfuL Tliese coomt ot band- 

[ages, oompreSM«, and splint«, of various raatcriaU. You may male 
apliat« of ihm IxMirds, aliioglcs, oigar-bozc«, pasteboard, IJn, lostlier, 
&mly-pIaitod atravr, tbo bark of trees, etc., and, for bandage«, onat 
ofttiu ooDteut youreolrcs witlt old rags, muslin, torn into strips and 
•ewed together; hence, in tbo practicid courses on bandaging, it\a 

'■ aeceasary for you to leam to make use of tl>e most Taried materials. 

It is not our iotentinn here to introduce to you every thing Ih^^*^ 
may be used in the way of dressing, but I must still speak, briefly c^*^ 
t few things. As may be readily seen, the object of the splints is f^^*^ 
make the bone Immovitblo by supporting it Srmly on various side^^*** 
this may be attiÜDod by external, internal, anterior, and posterioc-^C^» 
nnrrow wnodcn splbits; ne may, however, rjnploy hollow qtUnt^^- 
BO-c«lled gulters. Hollow aplmts are only good whea made of 
ble material, as leather, thin sbect-iron, vire-gaun, etc. ; an abeolutd^l 
stiff, hollow splint would only do for ccrtuln persona. Besides 
mechanical aids, there is another method of keeping hrokeo limba it 

^ pomuon, niunely, permanent tateneion. Thig is particuUrly indicat 
in oases where there Is great tendency to shortening, to dittoeotto i 
t^nffthtdinern. Attempts have been made to attain this estcosoo 
attaoliing weight« by various mechanical oontrivanocs, by oontini 
tnctlou made by weiglits hung to the injured Umb, by the douUe-- 
inclined plunc, wheriT t!ic weight of the leg is used as the eitcndiog ' 
weight. Since, during tlio post two years, I have unexpectedly kco 
such excellent eflect tn>m permanent extension with weights in ptüa> 

(|Ail oontracttons at the hip and knee joints, I nm oorapelkxl to believe 

, tbat this method mny also e\'ent*jnlly prove very somocable for Ibft -. 

L gradual adjiLilmf^nt of dUlocated fntgniouts of bone. Amon^^ tlis 

[wraogements of this nature with which I am acquainted, K Dun^ 
reie/t^''» ao-eollcd railroad apparatus best fidliU the object of penoa- 
ncnt extension, but it is too costly and complicated to cume into 
extensive une in private praotioe ; it is, doubtless, tlic iotcutJoa of the 
inventor to employ it olucfiy in cases where the dislocatJon is difficult 
to overoomc. [Ur. Gtirdon £»<'/-> apparatus for fractured thigh ia 
about as efficacious and much 8im]i1cr.] The double-inclined plan«, 

' tepreaooted by a thick r<^cr<:usktutt applied under the hollow of the 




TREATilFST OF FBACTl'REa 



fiÖ? 



Ol 

I 



leo, msy Ocxasionallj be craplojrod as a suitable fixation apparatus 
fa wr tur c of tbc nock of the femur in old persons. 
Wo tauBl still mcntioQ eomo auxiliaiy sppliaDces vrliicli vre have 
emploj to keep the broken limb in good po«itioR after it lint bcoQ 
; for tiie upper extremity, in most cnaes, n aimplOf properij* 
dotli, a mUelh, or elinff, in -n-bJcb tlic sna is kid, su^cca. 
'nHents iriti fractured um or fotwirm nwy be pcfmitted to go about 
niib D plnstor-twodsge and a sling during the entire Ireatment, wiüi- 
out inU^fnring nitb tbc £trnrablc healing. 

For keeping broken lower CKtromitios in position, tlicro arc a 
lumber of tnedianiml aids, of wbicb tbc following arc the most 
■ BT T lo e a ble: taitd'baffs, oairow sucks filled with sand, about Ibe length 
«f tbo leg ; tkcsc aro placed both sides of tbo ßmi dressing, so tbat 
the limb tnny not move from side to aide ; for the same purpone we 
intj ose long, tbrec-sidcd pieces of vrood, cut priamatically^ vrhkh are 
laid together, so as to form a gutter. For some cases a sack, loosely 
filled with cbafi' or oats, is sutficieRt - we nralco a liolloir in it length- 
tHse, and tl>e leg is to be plnced in this. If we desire finnc-r supports, 
wc luc Jraciurt^KfX^ cairow, long, wooden boxes, open at tbo upper 
end, eo that the teg may bo placed in them ; and titc aides at« 
fltad« to turn down, so that ttie extremity may be carefully ins|}cctod, 
witiioat moriog It; the cleratJon of these fraeture'bozea may bo 
tiiit«d to the convenience of tbc p&lien^ Lastly, wc must mention 
the MPin^, whidi ia usually luiule n itii n gullows, or strong bow, 
tfast is bnmgbt over the foot of the bed, and to vbidi the limb ■■ 
fuspendcd in any sort of a firooturc-box, or hollow ^1int [or I>r. 
'atfrnn Stiiif/i^i anterior splint], bo that it may swing about; in 
patients espedulty, this has certfliu adTantugL*«. All these 
ftppaiatuäes, which, although more rarely employed than lornierly, 
ai« BtiQ occasionally useful, you must Iciun to apply; you will have 
Cfiportuuity for this in the surgtcat elinic. Of late wo mn>ly apply 
ibrse npparatusea in the lower extrcniitr, as my fonner asdislAnl, 
r. JiU^ who hat brought the ai^lieation and elegance of tlio 
iidngc to an ejitmonlinary stiitc of perfection, applies a 
eD*padded wooden Hpliut, three or four inclies wide, to llio under 
side of tbc leg, making it reach somewhat below t))c bee! and as 
high as the knee, or, in Erneturcs of tbo thigh, iis higli as the middle 
(if the tbigh. The Hmb lies firmly on this boaid, if tlic mattrcüS be tMt 
too imerca ; if wc wish to »ttuin still ^t-iiler fiminess, we may lay ■ 
board tlie width of the bed over the lowt-r ihinl of tlie niatlress, and oo 
ibis fJaoe the Hmb, with ita plaster<lrcssing and supporting spUnL In 
the DUmennis double fractures of both lower extremities that come to 
Üie Zurich boqrital, this supporting apparatus did excellent service. 



tint is 

J^Hfuspemj 

H»tlen 
^KatifMnit 




208 



SUO-LB FJUCTUBE OF DONES. 




The old fono of [^Mt«^raoutd0 tas been rcccnlljr atj^nglj- adi-o 
catod aguio by Dr. JT JUüOer; vo havo 1 HmI it aguin, but it bean do 
comparison irilb the plftstcr-bnotlagc. 

Setäin tried to )n«m)60 tho &dvaii1agcs of firtu drcsun^ hygixiaf 
Kills that might enable palietits nith fmrturcd lower litnbüt U 
about to soma extent. For imlanc«, a piitieiit with a broken 
mny have a broad leather eirap iMssiiig OTCr tlic shoulder, and bi 
just abnre the knee, so that tlie foot will not touch the floor, and thai 
let him go on ccutcJies. But I mlvise you not to carrjr these experi- 
moot« with jour patioata too &ir ; at all cvoata, I only allow mj 
|)((tii<nl8 to make such attoiiipts three weeks after the oceurreaoo rf 
llio fracture, otherwise oodomn rcadiljr ocoun tn the broken limb, aad 
»ocne ]>atici)t« are ao clumsy in the uao of crutches, that they ore apt 
to fiUl, and, nlthnug-h this may only cause slight coneuasion of tJie 
liinb^ it is still injurious. 

Lastly, vre have to discuss ho» long the dressing sliould be Idl 
on, and the causes Ihnt might indued us io remove it before tlic cuk 
is eomplete. Tho decision as tu whether a dressing is too tiglitly 
apfilicd ia cntin^ly n matter of experience ; tlie following erymptoins 
must guide the surgtioa: If there b« svreUing of the lonrcr pott of 
the limb, as of Ute toes or fingvrs, which are usualljr left oxpoecdj if 
these ports bcooinu hluiali red, cold, or even sensdecs, the dreaaia^ 
« Khontd bo romorcd at oiicf. If the patient oomj^inB of severe pen» 
under the dressing, it is irell to remwe it, even if wo can see nothinp 
to cause It. In judging of tlie eihlbitiuns of pain, wo sliould knovr 
the patients; aome always complain, others arc \ery indnleot^and 
show their focliogs but little ; however, it ia better to reapply (be 
bandage several times uselessly than onoo to neglect its removal at 
the light time. I coonot too stron^y urge you always to visit, with- 
in twenty-four hours at most, every patient to whom jou apply a fixed 
dressing; then your patient will oertaioly not come to griefj as vn- 
brtuDstely too often happens, from the carelesaoess and laxiness ctT 
his surgeon. A aeiiee of oases has been puhlishtxl where, after the 
applicatioQ of a firtn dressing, the aflectcd limb mortified, and re- 
quirad amputation ; from these cases It was decided that firm dress- 
ings wore always improjirr, while the fault was clüefly due to the 
surgeon. Just think bow Utile trouble wc have in treating fractures 
now, compared to former times, when the splints had to be renewed 
every three or four dsj-s ; now you need only apply a drtashig oQoe 
But jrott must not think you have got rid of all trouble iu the sjipli- 
catioQ of dressings The njiplieatiuu of the firm dressing requires 
jnsi ae much praclii-e, dexterity, and care, as did drosaing with 
»plinti. If you or« ftret called to a Craetuie when it ia two or three 



TREIATllEiVT OF FRACTCREä 



sod 



dnys old, wben there t5 nlrcudj considerable inflammatory sveUiag, 
joa »fty even tbcn applj the finii dri>»«in^, but must apply it more 
tooadj", and u'iUi plenty of waddiii}^. Tliis drcBsiug tilll W loo looeo, 
■od should be renewed in ten or twclrc du%*B, wbc-o tbi; swelling boa 
left Ibe soft partft. It n-lU clilefly depend on the looseness of tbo 
bandage, and the greater or less tendency to disltxiation, wboa and 
bow often tlie dressing sbould be reaiorcd during the trcatnicat. 
SweUing, if not accompanied by ooosiderablö coatusioo, U oo conlra- 
iadicatioQ to a carcfully-appliod firm bnndngc ; nor do large or sitiull 
Teaiclee, full of clear or sligbtly-bloody »cruin, present any great ob- 
joctioD ; such f csiclcs result not unfrcquetitly finnn oontuAcd &aoturoa 
with oxteosi\'e rupture of the deep veiuB, Bince, from obstructioo to 
the flow of reoous blood, the senun readily escapes from the capilln* 
rieSi and elevates Die ban] layer of tlto epidermis into a vcaide; we 
pnnctiuN} these reticles frith a needle, gently prai-i out tbe fluid, and 
apply some wadding, and they »oon diy up. It \a the same with 
alight fluporRciiü excuriations of tbe skin ; wc an; unly nuvly obliged 
10 remove the dAiisiiig aiid apply another, when new Tcsicic* form, 
w we may know by the jrain. 

Tbc length of time tlint a firm drrsaing munt rcrauiii on for Üie 
«Jiflcfcnt fraclur«» you will le&m pftrtly in tbe clinic, partly from spe- 
«JjU surgery ; I »imply mentioD here, as tbe limit^ ttinl a finger may 
jnequire a fortuiglitf a tbigb sixty di>ys, or more, for healing. If yuu 
apply tbo pUstcTKlrcssing immediately after the fracture, dlslocotioa 
baving boon completely removed, tlio provisional csillus will always 
be lew, and hence firmness result Inter, than wbcre there is some di»- 
loc^ation and the drcasing is »pplied later; but ibis has oo eflcct ou 
tb ^ formation of definitive callus, and the nctuU nnlon of tbe &aO- 
riar«d enda of tlie bone. 



CHAPTER VL 
OPEir FEACTTTRES AND SUPPTTRATION- OF BON% 

Differenoe b«twe«u SubouUneooa knd Op«n Frsoturea ia regard to Prognosi». — ThV- 
«tioi of Cues. — InilioBtioiu for Primary Amputation, — SeooudatT' Ampntatioii.— 
Coarse of the Cure.— Buppomtion of Bone.— Necrosis of the End« of Fngmonb. 

We Bhall now pass to complicated or open fractures. 

When we speak simply of complicated Jractttret, we uaually 
mean only those accompanied by wounds of the skin. Strictly speak- 
ing, this is not exact, because there are other compUcations, Bome of 
them much more important than wounds of the skin. If the skull btf 
fractured, and part of the brain-substance crushed, or some rib» 
broken and the lung wounded, these are also complicated fractures, 
even though the sldn should remain uninjured. But, since in these cases 
the complications themselves are more important for the organism 
than the fracture is, we usually tenn such cases contusion of the brain, 
or injury of the lung, with fractiu^ of the skull or ribs. But we shall 
not here enter on the subject of injuries of internal organs by frag^ 
ments of bone, because very complicated states of disease are occa- 
sionally induced in this way, whose analysis you would not now un- 
derstand. For the present let us limit ourselves to fractures of the 
extremities, accompanied by wounds of the skin, which we shall call 
open fractures, and which ^nll give us trouble enough in their course 
and treatment. 

In speaking of the course of simple contusions without wounds, 
and of contused wounds, I have already shown you how readily reab- 
sorption of extravasated blood and the healing of oontused parts go 
on, as long as the process is subcutaneous, but how much the condi- 
tions change if the skin also be destroyed. The chief dangers in such 
oases are, as you may remember, decomposition in the wound, exten- 
sive necrosis of crushed or dead parts, progressive suppuration, and 
accompanying protracted, exhausting fever, while we have scarcely 



FE0GS08IS IN OPEX f BACTÜRES. 



Sil 



itioned tlie tcrerc gcti<-n] dmascs, erysipelas, putrid-blood poison- 

f, priraua, tcianus, and delirium Ircmcns, The diObrcnca between 

' cualusion» and eoutused wouiids is eve» mom strongly marked ia 

siinple «nd compouad (rsctures, a» regards course and prognosU. 

M^iJe in maoy cases ve can soaroelj coll a person witb simple tno- 

tan »ok (vQ have not spoken of fever there, for it rarely occurs), nnd 

under tbe pres«Dt conveoient treatment such an injury is rallior an 

incoorenieuoc than a niWortune, a Compound fracture of a largi; bouc 

j^^ el an extremity, or sometime« even of a fin^r, may induce severe, 

^■«ad too frequently frtal, dlseaso. But, not to alann you too mueb, 1 

^^*ill at oooe add that there are many grades of dunfrcr even m open 

fmctures, aod, morooTCr, that tbi-ir ircotincot has bccu itiucli improved 

ti Ule. 

It b very <fiJI>culc and important, but not always poaKb]c,to make 
i correoC pn>gnofiis about an open fracture at once, Tbe life or death 
of tbe patient may oocasionnlly hang on the choice of the treatment 
^liie Girat fV-w days, so that we must study Üäi subject more accurately. 
^Hho «ytnptoma of an opoa fracture arc of course essentially the same 
^ftft of the suboutAOOOUS, except tltiit diieeoloratirin from extmvosated 
^^lood in ofim wanting, because at least piirtof the blood escapes 
'tbrot^b tbe wound. ITic frnciurcd ends not iutrcqucntly project fivm 
Ihtt wound, ut lie exposed in it, so that a glauco may suffice for the 
«iJagTMMis of an open fracture. But this is not enough. Wc must do 
Ciur bet>t to aw^nnin how ttio Dartiire was caused, wbotbcr by direct 
<v ifwlircct foree, and how great the force ; if it was aooompanied by 
c^rustiing and twttttiog ; whether arteries and nerves have boen torn; 
if tlie patient toet mucb blood, and what i.^ his condition at preheat. 
Tlicre arc «mi-$ wlicro we can say, at the firet ghinoc, healing is im- 
possible ; ampuintiofi iniist lie reported tn. AVben a locomotive has 
Tua over tJic kaoc of an unfortunate railroad hand, when a baud or 
forearm baa been caught in the wheels or mlleni of macbinerr, when 
m premature explooon in blasting stone has crushed or torn off a limb, 
or liuDdrcd-woighta hava oomplctcly mashed a foot or lo;r, it is not 
diffionlt for Ibe Kurgeon to decide at once on pniniLty amputation, and 
asnaUy in aocb cases the state of the limb is such tluit the patients 
also, tbougii with a sad heart, quickly coneent to the Operation. These 
nnt ihn dif&inilt cafteH, And in other cases it may bo jiut ns easy 
fijretell, with considerable certainty, the piohabilily of a fiivoiabla 
For inetanoc, if fracture of tbe leg from indirect force bo« &)U 
ml t/>o groat bonding of the bon«, the broken pointed end of tlHl 
Icreat at the tibia may puncture and force tbnn^b tbe skin ; in sacb 
tberc is no ooutuAion, but simply a tear through tlic skin. 
body strike* (brdbly against a small portion of a , 



218 



OPEN FRlCTimES AND SDrPDOATION' OF BON'S. 



limb, nod iojtircs bone and skin, the wholo cxtmnitjr mnj' Ijc gnstljr 
flliakeo; but tho extent of the injury ta not grvftl, uui laoet of »ucb 
flsaea tarminate fiivorablj- under suitable treatment. The question* 
nUe cues lie between tliesc two extremes. In cases wbcro tbrro 
ta some cootusioo, bul oulj' a »li^lit stuoujat erideut, and Uie akia i* ' 
only injured at a small npot, it will be very difficult to deode «rbetber^ 
hcaling^ should be attempted or amputation be resorted to, and tl»e 
pecuUantj of the individual ca«e alone cnu scltlc tlic question. Of 
late the tendency 1« incroMgiug tnthcr to trj- to pntsciru ttio limb ia 
tbeM doubtful cauu« than to amputate one that migtit poodbly hare 
been sarcd. This principle is ccxtaicly justified on buniaac ground»} 
but it oinnot be denied that this oonecrrstive Burgery may be prae» ' 
tised at tlie cost of life, and that we cannot inth impunity vary too 
much from the princäploa of the older Bin^geiKis, vrbo geueraUy iive- 
ferred nmpulaüon in tlicse doubtful cases. Bciwlos mode of origin 
of the injury, and the »mount of accompanying contusion, tlie uaptK^ 
tanoo in any i^rcn case depends on whether we have to tloal witb ' 
deep wound«, with frtcturod bones lying far down among the niusolea, 
or witii bone« lying near the skin, as tho danger of suppuratioo de- 
pends greatly on the depth and extent of the bone-injury. Thus, an 
ty^ti fracture at the anterior part of the leg is of more farorablr 
prognosJs than a similar injury of the nmi or foreann. Open fructum 
of the tliigh are the moat uiifarorable ; Indeed, some surgeons always 
umpiilatc fur aoch injuries. Lai^ noTTD-truuka arc rwcly torn a 
rntclnreA, and, when tboy are, it does not seoni to liavc much effect ' 
the cure; and experiment« on animslH, as vcU as obsen-atious 
man, show that bones may unite nonnally in pamlyzed limbo. lujit 
of large venoos tnmlcs, as of the femond vein, oauses btemor 
which may be readily dieelced by a compressing^baodage, H is 
but ina^r prore daogcrous when the blood effused between than» 
and under the skin begins to deoonposa Rupture of tlio iirlniiM n^l 
trunk of a limb occasionally leads at onee to oonsidenble 





hEemorrbagcs ; but this is not a necessary sequence ; for, as prerJoual^H^ 
sliown, a thrombus quickly forms in tho crushed artery, so that ire ^^■<j 

not always have extensive hiemorrhnge. But, if, fWn» tlie naUir*« -f 

the hipmorrhage, ire recognize the rupture of an artery, acconlir- , 

prindplas already laid down, we should cither attempt to ligAt'_ 
srtery at the wound, or else at the point of clociioD. Buptore of . 
fetnorml artery with fracture of the femur is found by cxperienott 
be followed by gangrene, and ia an imperative indicalioQ for «n^ 
tatioQ ; in a oofTe^rnnding injury of tiie arm, recovery may 
or gangrene mny follow. In fractures of tlie forearm or leg, 
one or both artcrie« bo ruptured, recovery may take place. La& 






! 




POOGNOSIS IS' orsN nuoTURsa 



SI8 



*n the quesUoQ ss to wliother we shall try for union, or proceed to 
^anputatioo, ve must consider 1h>w uteful tlie limb can be if udioq 
and «11 unraromble cliaiice» Imve been overcome. In conipU* 
it««] Cmeturcn of the foot nnd loivt^r fuirt of the leg thi» question 
iiiBj be particularly importnot, aod it bus frequviitly bven nccetssor^ 
** smputftt« n fuot becniuic of llic chan^ of (brm ooU puutton rcsolt- 
i ^ig mhor naion of »n open, comminuted fracture, which rendered it 
less far vaXking, The same thing is to be considered wlien, in a 
r^^MS of moderately extensive gangrene of the foot, wc wi&h to decide 
%-i it should be amputatod or not. The dead portion of the foot may 
"■>« detached in sarh an inoonvenient shope that tlie remaining stump 
neither uaeful for walking nor for the Adaptation of nn urtifioiid 
limb, la swdi oases ve ^ould amputate, for all our methods of am- 
nuiating are designed for the future ttpplicatioii of nrtilieiol limbs. 

Sine« the nature of the subject hns led us dijectly to the indica« 

täoo8 fur «mpuUtion in injuries, I »hall at onee proceed to tbo sub- 

j<?ct of aeeirndary amputations. In tlie question aa to whollicr a 

complicated fracture should be amputated or not, you might readily 

aaataAfy younelf with the idea that it might be done at auy future 

tixatf if the feais of an unfavorable course should be realized. On this 

pcilut ■ttentii'e ob(«ervation shows that there are two periods for this 

»eoondary nntpulation. Tbo first dan^r tbroatcoa the patient from 

a,¥a B<ntt« decomposition about tbo wound and tlie consequent putrid 

l«itxuiic9ttoa of lite blood. The question as to this danger is settled 

daarizig tltc fir^t (i>ur days; if it arise», and you then aaipuLate (this 

isavtst be done far above the point of piitrefaetion),itis just at the moat 

unfATotablo pcrioil fur the Operation, for yuu will rtr*/ rutvhj succeed 

tzs sarttig your patient. Somewhat more favorubk-, hut still un&vop> 

tk-ljlo RS compared witlt primary amputations (those mudo within tlie 

Bx«t forty-eight hours), are the resolta of amputations made from the 

ci^^itli lo the fourteenth day; they are particularly unfavorable if the 

symptoms of acute purulent infootion, pyeemia, aro distinctly pi-cscnL 

X.C tbe patient bus survived two or three weehe, and profiisc cxh»usb- 

inf{ aiqipuratiun or other local iDdieatioii for amputation arise, the 

r^sMulta arc again relatively favorable. When some surgeons havo 

wgiul«! that eeeondary ainputattuns give better results than primary, 

fcbcjr bare almost exclusively oonstdcrcd these later sccoodai^ ampu* 

t^aftioiub But, if we hear in inind how many patients with open &ae- 

tMMrt*m die (luring the first three weeks, that is, how few of them live till 

f>«^ CiTotable time for seooodarj* amputations, it aeems to me we can 

'k^ve BO doubt about the dedd&d Bi.lvtiQt«ges of primary amjHitationa. 

^7*2» t^ the present time I have rarely found indications for late seeond- 

■^3^ amputations. 



SU 



OFEX rRACTUBES AND SOPrCRATION OF BOKE. 



An open fncture nuty unite iß Tarious wa^ Tbc skiii-wound, m 
ircU as tfav dcL-pvr part«, ooatsioiiitlly hcais hy first iotuntiou ; tlib ü titc 
ii>08t furomble case. Uiulvr modern trcattuenl tbU occurs more tn^ 
tfuciiLl^' thaa formeily, altbougli, from the oatur« of the esse, the »■ 
([uiremeDts for tliis lesult arc not often pccBont. Far more frtsqueotij 
(and this ia also iavOTable) the vroand only ffttppDiBtflS superfidall/, 
and not between and around the ends of tbe booe, but union of ibe 
bone Ukes place as in simple subcutaneous fnsiare. The cases wberv 
the wound onlj affects Uie skin, and does not oommunicata vitli t&« 
fracture, should not be counted among complicated frectum^but tlie 
limita arc difficult to trace. 

The proccES of cure must of course differ grcfttlj Crom the above, 
if the skin-wound be large, the soft part« groatljr oou(u8«d, so ttuA 
fragments «re detached from them ; if the suppuration extends do«? 
between the muscle« and around the boue,&nd e>'ea intöiu mcduUeT? 
cavity; if tlic fragments are bathed in pus; if balf-lnose picoü9 "^ 
boiie lie aliout, ain] longitudinal fissures extend into ilic \tow. '^- "* 
nctirily of tbo soft parts will rcmaia nscotjally ibc sonie as in «ul**^* 
taiiA>us fractures, except that iu this case the inHammatory new fiwi*^**' 
tioa does not directly become callus, but, after dt-tuchniCRt of t^^*? 
crusltcd, necnwed tJireds of tissue, granulations and pu> oro form^^^^ 
the former of which are trarisforaied to oRai^ng callua. Tlie form ^ 
tlje cttUus will not be much clianged, except that, where tho of»^ "^ 
suppurating wound ciisls for n long time, there will 1k^ a gap in t^^— ^ 
callus-ring lill it is closed by the aftor-growth of deep osaifying gran' ^^ 
latioDS, Henoß the process will tanninste fax moro slowly tlian 0^-"* 
stibctitniifotis fracture, just as healing by suppuiatioo takes lodj^ti*'*^ 
tlian heulitig by Srst iutuution. 

Now, what bcoomos of the oods of the fragmenls which, portly o^^* 
entirely denuded of periosteum, lie in the wound? What lieconw^^* 
of pieces detached from the bone, und only loosely allftched to Ih4 tnt^^ 
parts f As in tho soft paris, so hero ono of two Ihii^ may bappen^^ 
according as the cmls of the bone arc liring or deud. Id il>e first aaiV 
mobX frequent case, gronulaüoiLs grow directly from the eur&oe of th» 
bone. In the latter, as in the soft parts, ptastto activity iu the bon«- 
occurs on the bovden of the lirlng; interstitial grauulatiuus oud pus 
form ; the bouu melts away ; the dead cud of the bone, the ttqveitrvm^ 
blls off. The extent to which tlits proocM of detachment gne* ontn- 
rally depends on the extent to which the booe ia dead, or. cxprened 
wore pbyaiologically, on the extent to which the circoloti- 
from stoppog« of the vessels. This extent may voiy grr 
possibly extend only to tlio superficial layer of the injured 
since the whole prooess Is called JMTOti«, Ibia sui>erGcv1 



rxios or open fbacttber 



915 



* 



of a pUte of booe itt termed fiMroats supe^/hkUUf wbile (Imt of the 
vhok; Erncturcd end of the boDO may bo «died fuurom totaHs / bul 
the latter terai is more tuuol for iodicating that tlie entire diapliysis 
of a long booe, or at least tbc greater pni-L of it, is deUcluNi, and tlie 
oppottit« of tbia iti ntcrosia partiaiU. Tlie opposite of the above- 
mvQtioned aocTO«is supcHtciolis, which ü also tinned exfoliation, it 
prtjpeHy neero»it eentrati», tbul is, detaelinient of an iuuer portioD of 
booie. Nocroeis superficialis and neorosm of the bmkcn coda and 
partJjr-detkolied Gmgraeuts of iLc boac uro so ofVeu cvmbiucd n-ith sup- 
purating frncturet^ of which wc bare to treat here, that n-e mtist treat 
of tliem in tbia place. It will at fint seem Btrunge to you that vasca* 
W gniatilatioiis should epfing from the liard, smooth cortical substance 
of a long bone. From what has already been said, it will Bcem pos- 
fiblo that, ander the inäuence of thin plastie process, the liard o«i)eous 
tissue should be so dissolved that there may be a spontnneous solu- 
Uon of continuity between the dead imd healthy bone. Wc sludl now 
•mdy mure t>xactly those processes of furmatioa of grauuUtions and 
of soppuralion in bone. 

You viU remember, from the fiill deecripUon of iroumatic suppu- 
'fation of tiw soft parts, that in tmnmatie inflflmnmuon the proCGSB 
cbielly depends on free suppuration and cxlcn&ivc formatioo uf new 
fcsscU, as well «a on direct ccU-in titration from the blood» whilo the 
interceUolar substanoo assumes a gclalioous or fluid oonsistenceb 
Doth of these processes can only lake place to a slight extent in bone, 
especially in the Brm cortical substance of a long booe, because Uie 
firm (UMons substance pre%'cnU much dilatation of the capillnrios 
whidi ore enclosed in tlio lilaventiun canals. I may at once cull your 
sttentton to the fact that, from this slight distcnalNlitT' of the vcsnels 
in UM osseous canals, portions of bone may more readily die than 
weald be the ease with the soft ports, because, in ease of coagulation 
of blood, CTen in ihc smaller resscts, tlic nutrition can bo only impci^ 
(botlj kept up by collateral circuLttioo. Moreover, th« ooimectivo 
le and tlie vessels in the Hitvenian canals may be entirely de- 

lyud by siippura.tian, bo that necrosis at the ends of the friigment« 

ill he itioritable. Should a vascular grnnulation-tiesuo dnv<;lop on 

le surface of the bono or in its «nnpaot sul)9tance, this can only occur 

prenously dcscnbctl, after the osseous substance (lime-salu as well 

orgaiiitj muiter) 1ms disappeared at the point where the new tissue 
la to appear; hence tJicn> roust b* solution and atrophy of the bone- 
tissue, jii«t na ihfT« aitt of tho soft parts under Minilar uircuinstanoes 
J^g, 33). The —**" '— ICO appears chiefly in the difference 

', for the < •tioDS on and in tho bono takes 

loDgerl ^'■■- already stated tliat the 




I Ü«»»,: 



::I0 



satiiö process requires iiiucli longer io the tenJons and [its4il0, wbkli 
have tew vessels, tban in tbu oumiuc-lire Uüsue, aiusolt«, and skin ; lu 
the bone it requires even nxtre time tliMi in tbc tendons. Tbe con- 
»litutidunl power uf tbo iudividuiU, aiMl tlie cooaequeut Bo-cslkid 
vitality of Uie tUsucjij are alw to be utkeD into oootkiefBtion. 



LECTURE XVI. 




IHvelopuent ot Ommv QnonlaUoiu. — IliaUlocT'. — DctocbaeDtorUi« SeqvMlnnB.— 

liiiuAtgj. — DaKous N«w FottnatiDn >rauikd th« Dotiabod SaqoMUuiD. — (UIm Ui -^^^_ 
Sappuniinf f motutoL.— 6appuntive PBräMliiiaand OkImkütvIUIi.— Gaoin] Coo-^^ 
dttiou. — Fever.— Trcntmont; F<oMtnt«d, Cloaod, SpUtDrataiiifK.— Aadpt 
BcuimUc*.— iBimcnlni).— lUletkboQi BoiM-aplinwo*.— After-TrcMmeBt. 

Whex a tlvnwlcd porliou of boiie begins 1« tlirotr out grut' 
Uons on its surCice (nliicb in coniplicatod fractuiea ve con aoiy 
when ttic ends of tlie Irafcineuta ure exposed bj a Iwge nKn inTTini^ i 
on tJie interior surface of the leg, for iustance), vo recognise tliis '~ 
lliu iiukod cyu by tb« fc^owriiig cliang«« : For ttto first nigltt or 
days after being denuded of )x:rioatcuin, the bouc musUjr prcacrvoi i 
pure rcUonish color, wbidi, eve» during the last daj of tbc abo 
period, ehangeii towonl brij^lit ros«KH>lar. If wo Uten exanüoe tr 
avT^ux of liic bone wilh o. li'iis« wc mnj* notkc oumbcra ot xctj 
red points and irtnie, wbicli a few days later become riaible to 
naked oyc ilIk» ; these mpidly increase in nx«, groir in leogtb a. «^^rzad 
breadth, till tb<.-y uniio and then present a perfect granulAtlng — ' — ^ 
wbicb passes imoicdiatcljr into tbc granulatiaos of tbc surrouu&x^ry 
soft part«, and siibs^uontly ])artiutpatce in Uie cieatTizntJott, so tJk^ 
audi a cicatrix adbures firmly to the bone; 

If we follow this pmcef« in it« finer histokigiral detaila, «tai 
must he chiefly done experimentally, by aid of iiijectod bones 
prired of thrar Ume, we have tke following result : If the dnnilati 
in the bone is maintaiood near to tbe sorfaoe, there is a nob Enfil 
don of oells into the oonoectlTO tissue accompanying the Teasel* ii 
tlw Hnventan canals; this tissue grom, with tbe rasonUr loops c^.^ 
velopmg toward the surface, out of the bone at tke poiuta whera t-Ar 
Harersian cuials open ottcmnlly. Tbo dcvolopmoot of tbis yoiLXD^ 
gnnuUtkiD-masi kterally rLttults at tlie expense of reabsotbisd bos f.-. 
If ve nsoerato one of these bonca with tiqierfioinl gnnalstaoas, -r-i 
sui&eo will appear gnawed and rough ; in tho living bone, granuIatA-ji 
tissue fills the numecous small boles, whidi all ooonnunloata witb ^Kl» 
HaTcniaa csoals. The surGice of tlie bono docs not, howcrer, rci 



-u 



-mi, 




ie stmte, but, while the osseous granulatjQDs on Üici surface con- 
a to oonncctirc tissue and cic»lrize, in tlic deeper pnrts (bej- 
f quiti^ rapidlj', so tbat at tbc termination of tbe jirocvAd of bL-iU- 
ho Burbce of tbe injured bone doc« not show ■ dcficicncjr, but 
m denser from deposit of new bone. Y<M.»ee Ibiit hi-ro too ifae 
BUfauCGS are cxactl^f llie same as iaaubcutuueousdt^rclopmcutof 
nSitminatMjr Dcopliuia. If jrou look nt Fig. 4(), and suppose Itie 
«teum remored from the surface of tbe bone, tbc new fomistion 
lis CA«C as gianulntione) will grow futigous-likc out of tbe ÜxTer 
oanals, 

*ou wiE omkirstaod tbis better if we aavr follow more cnrcruU; 
■rocean of detadimenl of necrosed portions of bone. ]>t us re- 
to what tr« SCO with th« nalced eyc^ nnd let us gtippoii« wc bore 
« IK aportioo of tlic pnrtcLs! bono denuded of t.o(t jMirts; tiit-ii, 
I ^ninnlaljons, nx above: dc9crib(.-d, grow from tbo bone, wc shall 

tbo foDowiug sjmplonts: \Miilo the surrounding soft parts and 
lortion of bone still covered with periosteum have abeady pro- 
i numerous granulations and secrete pus, tbe dead portion of 

toauÜDs pure trbito or boooDies gray or uven blackisJt. It re 
I tome weeks, Moiethncs two months or more ; nost proliferant 
ibitions grow arouDd it ; cicatrixation bas Hlreiidjr begun in tJic 
ibcrr of Uio wound, and wo cmmot decide how tbc ca^c nill tcr- 
for to til« sixth week tbe aurfaee of the bone may look jaiL as 
day after injury'. Soino day we feel the bone and find it 




I ««pMflFta) ptn* «f » 0*1 b«D« (M «f OD* »r th« <rubl t«ll«\ oWdl bM Vn «■ 

-Ti» miTWl. Vttfiim ■nffUMjIta ; m. ibacnjintatlnrB irttlDclhmi 

. aBdMDllwF tha dstd partUklba HtfaMtivn ('hnArA rrrtlMll»): 

^mn bM W« «DuMcrabtjr mIh •wqr bjr Iho iinuubtloiii. «Uta 

■ fMM. Dlwnu, utanl dM. 



S18 



OPES' FRACrC&ES AKD SVPPÜAATIOy OP DONE. 



mornblo ; aflor a few atlcmpta onc Usdo of the forceju tnny bo iDtn>- 
dui:^ undfv it otid wi; lift off a tbia plnte of bone^ ander vrliiirb wei 
find luxuriant granulations ; tLo under euriaoe of this plsl« ia tctj 
tQUf^t ts if «at«n awaj. Xow bcnling gooi on nptdlj. It fs olteo 
long before the dcnttii becomes permaoeat and st^id pnougli to ic> ' 
eist nil injuries, auch as pressure and friction, but bcaling often («Tni- 
natce favombly. TliB ia tho procoss that we t<nn necrorH tvpeifi- 
eiati$ or exfoliation of boD& We are alread}* acquainted «ith Ibb 
proceee b the soflparts; during the first week targe shreds of lisrae 
fall from the contused vound, since on tbc border of tho licmlthy im- 
sue there is ui tnterstilial development of granulaüoo, bjr which the 
tissue is detached ; tlie process is the same bete, la % bone drptmd 
of its limo wc majrcadllj examine tbcseprooesMsanntomicKlljr. Tbr 
inflammatorj- ncoplaaa, or gianulatloD tlsson, develops on the ma^ 
gin of tlie kealtby bone in tbc HaTersiaD canals. The accompanjring 
figure (Fig. &5) may represent to you tho dctoiU of this prooess. 

If yoti have fully understood wbat has been said, it onlv rtxiairH 
u slight stretch of imagination to sec liow the snnie process of detach» 
mcnt of a fragment ma/ extend tlirough the entire thidoieas of bene; 
that is, bow (nod here wc come back to oomplfcated fnict\tres) ft vaif- 
able length of the fractured end of a bom.' may be entirely detached, 
wL«n it ia iiicnpnble of living, 
AVhcQ the boQC io question is 
thick, this process require« ser^ 
cml months; but at lost ure 
may 6nd oven largo pieces of 
bono movable in the wound, and 
remove tlicm as we would a su- 
peHicial bony plate. 

Aa regards spUaters entirely 
detadiod from the bono, and only 
attached to the soft parts, tbeir 
fttturo &te, as regard^ living or 
not, depends on bow &r their 
circulation is prceenrcd. If tbey 
are not capable of li\*ing, tbey 
at last become entirely detach- 
ed by suppuration of tbc soft 
parts attached to thorn, and of- 
ten, as foreign bodies, keep up 
irriLation and suppuration of tbc 
wound. If ihcy are capoble of 
living, they produce granula- 



Pra. u. 




DlMiWB of MacbDMal of * natmmA pMtloti «f 
Wn*. «<gM»< »•. «. MCrOMd Mrtlun •< 
ikiB 



; r, mrtr hinMl 
r will' 
tKb«d. CuBpan Kg. at. 



btnte; Allttns bo*«: r, nvw hinMlloB !■ iba 
llkTtnlaa taSÄ. to triiteb tb* boai (a dh 



DETACDlIEKr OF TOE SEQCESTRÜ1L 



SI 9 



OD tbu &ce surface ; tlieae subseciuently ouiTy atid unite with the 
eftUiu, fonnlDg arouDit Ike fractured eiida. 
To represent tltu reluüoii of tlic fünnatSon of rullus tolhis process 
of detachment of tlir nccicecd oodd of tbc Inictured bone, I proscnt 
tbe following figure (Fig. 56). 

The fangiDentii of tbu broken bone src not scciiratvtj' oiljiuted, 

but dtft{ditood Mmewhat Uitcralljr; tlie cods of the fragmcoU hare 

botli become neoroMd^ and nearly detached by intotstitial prolUeration 

of gmnulatwna OD the borders of the liring bone. The whnle wound 

19 llnnl vrtth gnuiulations, whicb socxete pun that escape» nt d. In 

both frafcments, an inner callus {b b) has fornied, whioh, boverer, from 

avy p ur alioa of tlw fractured surfaoea, bau not yet been soldered to- 

gedicr. The out«r calKis (c«) is bregular, nttd iutcrruptcd at d^ be- 

CWM6 tl>c pus cecnpeil here from the first. Wlien the gTvnulations 

grow so strongly aa to fill the entire cnvity, and subsequently ouil^', 

healii^ ia oomplctcd, and tbo final result is just the same aa in the 

heaUDg f>f subcutancooB fractures. For this to take place the necrosed 

portioni of bone must be removed, for experience shows they cannot 

heal op In the ooseoua cicatrix. This elimination of tltc sequestrated 



/■<"i 



Pi«.ai. 



-d. 



^ 



/lU 



Slvtam oT fr*n«n W a InM twM wlUi 
•Ufraal «nHmd. iMUtladUal «anlnn. 

of Uia amb; oaio. i>rrni»rilBbi1i nf 
>B W . 'llM AutiMimteA part npn- 
M«ia dw j^MlalloMk obKb ita« {fi 
VU tMlmS Uml cneu oiuiiinUr. ind 
m t n U pB* ; kt, fnUnal vdlu* In U< 



•acaluo. 



land* or bona; «« «st» 



Ampatmloii itgmp of 
tbe ttilifh, «I III ii»cn)> 
•I* of lb« med *ll^ 



320 



OraS FHACTUBE5 AND En*PrR4TI0N OF DOXE- 



Iragments («kcs place citlicr b^ rcabsorptioo or hy luiiGciol re' 
outwardly; ütc former is the more licqueal in einall, iho littl«r in 
large scqueatm; but uniun will not result as long aa tbe »equestniin 
ntnoins bctwecu tiiv gmaulatloiu of the üragmeata; Since tbe open- 
ing St d may bo much oootraclcd l^ Üie tlOTdopmouC of czt«rtia] 
cnllua, tlic opcintivu rcmoral of tlte necroBod end» h often Tcrj 
cult. Wc find, bj examination witJi the probe, -whellHir such »ei])jefr 
Irn in the deeper parts really existed, mid if tbej ore dct^died. U 
you fiuppase the aequestnim, a a (Fig. 56), removed from the wound, 
tliere is no obstAcle to the filling of tJic wound vritli granulatwni wm) 
to their Rtih<if!qiient 0!>ailic*tion. Such sef|iicfftra in (wtnpliiailcd trtiy 
lures »re fn?qiii>nlly the raune, not only of nev exaoerliatiaiu of tbe 
ocute siippuntive inflaminntiun, but ulso of subacute uid chronic ptfv 
ostitiit, with protmctcd firm oodenm of the eztr«roitT luid »rmoyag 
eoemntouK eniptior» on the skin, ns well us of lonj^^onlinued boH 
fiatul» and ulcvmtiuuH of the unds of the frugntcnU The action o( 
this scqucstnim combines the double effect of a foreign hn.'ir ("mI 
tlmt of local or genctsi purulent infcctioQ. «^ 

Wc maj speak bcrc of conditions us they exist In tKc bone iba 
tniputation. Imagine Fig. OQ divided tmnuversoly at tbe point <f 
fracture and the lower half removed, then the oonditioa wQl be Jim 
the same as after amputation. Granulations either grow dnedlf 
from the wounded surface, or a portion (the sitwcd surlace) ta DNMHd 
to a greater or less extent (Fig. 57). I-et this b« as it may, bi tie 
medulbiry cavity, us well as on tiie ontsidc of tlie bone, a occfiladh . 
(a half callus) is fonned; this subsc^nently citifies; if you cxMaiaeiim- 
amputaÜOD stump several months okl, you will lind the medullu^ 
epBCC In the atuinp of the bone closed by osseous deposit«, ns wdt i^^ 
«■xtomal thickening of the bono, Wc may hero remark that the Hinr^l 
callus is used almost exclusively for tlie bony now formation in (no ™ 
turns, while the young bony formatioos on the outside ocrarriniria 
Tarious ways are called " osteophyte« ** (IWim 6<rH«v, I»n<, rihI ^I'f«, 
tunwr) ; callus and ostaopbyt«a are not then very dilTereat, but both 
are dedgnalions for young osseous formatioos. 



Jn oonsidcring the proec*» of suppuration, wo have left. o»t of «»• 
aiderntion tn-o of the constituents of bone, namely, the periottomn and J 
medulla. In (Aufcrring the development of cnllus, wc nw that tlw 
periosteum also bnd something to do with the formation of new boOb 1 
But, ii^ in open suppurating fractures, tbe suppurative inflammation I 
spreads greatly as a result of extensive contusion^ a larg« anxHiBi a(i 



süPPCRATirB rERiosnnä 



sei 



;rio«tciim nt*y Dccroeo or euppurat«, aod io bucIi a^vs we find 

eaiX gupptn-alive perioatitia • thß great«r part of a king bone, 

libiu, TOtkj be bathixl in pti.^ TIm; botie tliu» losing its coonec- 

iIÜi the soft port», it« supply of blood \a vithdnnii, oad from 

Mauue Uiero mny Im extensive DCcrosU of tlieboDO MS b result of 

ippumtirc p^riustiUs. Tlut Üie&c locsl dangcnt arc »liglit in com* 

JO to the daiifT«» tu the orgKoism at larffc froDi these deep sup- 

puntkn»; we iball Iierenftcr Lrc»t fully of lhc-8L>, 

lu llie Mmo vay the mitluUa cither of a long or «pougy bone may 

p«rtictpatc in th« suppuralioo. From nhat has alresdy been eaid, you 

IciKnr that, in tlio ooim« of the norma) iiaion of fmeture, neu- boncv 

lime loroM, in tlie medullary ovily, and clt^sei; it for Home time. In 

open, sappunting fractures there b ul^ occoAionully Huppuration of 

tJbe medulla, titat may cxt«nd more or 1ms. Such a attppiirativo 06- 

I tcomyelitia !s quite as dasgerotu, both for th« life of the K'oo and foi 

^B^ entire organism, as suppumtivc periostitis, Prom Torious causes, 

^Hm, it may asaaume a putrid cliaractcr; the larger veins of the bone, 

^Hpiat eome from the medulla, may participate io the sappurattoo, and 

HUs diaeaae ia the more destructive because of its deep oiiuaUOD ; tl It 

^nift«a fiist recognized «t the autopsy. Purulent osteomyelitis alou 

may also lead to partial and eren to total necrosis of a bone, the mora 

fio wbcn combine«! witji suppuTati%-c pcrioaütis. 

Although it was noccsKUy to mako you acquainted with all tbe 
above local oomplieations of open fraetures, I may say for your relief 
tl^l they rarely occur so extennivety as aborc descrilied ; ocither total 
aecTDsb of both ende of the fracture, nor exlemiiTe puruleut perios- 
ad Osteomyelitis are frequent result« of th<«e ^etiircs ; Init, for- 
tly, licatiiig of tlie dLi.*]ier jKirts often taken pluc« very »imply, 
and auppurfttioo oidy oontlnueti cxtumally. 
^H WbctJior a troumatio Enfiammation leading to suppuntioo bIuiU 
^Bst<:Dd beyond the borders of the irritation (of the injtuy) depends, as 
^^Bl simple contu&eil woutuls, on tlie ^riulc of tlie local iufcctinn by 
^■moittf^iiig tisdue la the vround, and later on all the OKunutanees 
that we liare learned u direct or indirect causes of secoadary in- 
llanmiftt*'»! of voutids. Tbe greater the Hhaltering of the Imoc (espe- 
cially in guosbot-woumU), the greater «re all mediAlc and immediat« 
results of the injury. 

Now a few words about the genomlconditioa of the patient, e^x^ 
dally OS topper. While in subcutaneous fracturcsitts to he regarded 
as s r»rily for a patient to have ferer, tbe reverse ts tniu in open fnio> 
turcL If ever the fercr evidently depends oc tbe extent and intoosityof 
the local process, it does so here. As we hare already menttooed, in con- 
lased wounds, eveiy extenüon of Uie inflammation is aecompaoied by 
1< 




228 



OPBX FRACTURES AKD SCPPinUT[05 OF BOXE, 



an Incicaso of fcver, and, geoerallj speaking, this i« Iho mors decMod 
Uic deeper til«; suppuratiuu. In lociclental OKtcam^-etitiii and pcrio» 
Utia tlic ovoniu^ Uinipcraturc of tlie body Dotua&eqaoDtly tiscsabof« 
one huiidnHl and Cbur dugroc!» Fiilirunhoil ; rapid dwatioa of leat- 
pcratur« wiüiohillsis, unfurtunatdj,afttx]ueDts]nnptom; septicarmis 
and pjcmia, trismus, and d«liriuni poUitorum, a» especially apt to 
accompany euppuratiog fracture«, so that 1 can only n*po9t hen>, 
wtint I »aid at tlic beginning o( the chapter, that any opi^n fmctiire 
inny be or uiay become a severe and dangecoua injury. IIuucc, the 
greatest ctrciimsp<!<:tion nnd care are neoessuiy. I can tell you, fratn 
my own i')t[KTicune, lliat tbe most suooessful operstton oevcr gave ne 
Eucli pltuisuru as tlic suoocasful unioo of a severe complicated bBCtuic 
Let u» now psss to tlie treatme>U of op«n /h$cturet. After tlw 
sdrantages oE firm drossings luvl become apparent, it was natural tn 
try ihent in modißcd funns in open fractures ; indeed, some time stooe, 
SetttiA, the inrf^ntor of the etdrcb-bandage, used tbe so-caUod Jhtet- 
fraud bandage, i. e., in tlie ßrui slarcli-bandage he made an opotüng 
ooircsponding to tbe wound in ibe eofk parts, so as to leave tbe lattoi 
open to Observation during treatment. Theprimilivo forms of Cbese 
fonestRited starvli und pluicr bandages also^vbidi are itow often osed, 
had great objections, that may now be considered as ovcivoiue. Tbe 
cbicf ohjcctiun to tlic fenestrated baodage vu tbot tbe uader-faattil- 
ngo and tlie wadding vrere rcudily saturated with pus, whidi doaoBi- 
putted and bccanto olTensiTe. Ezlensire experieooe has 
that these objections nmy be overcome; it is only oocessscy to 
(ho openings large enough, to round off tbe edges with strips trf 
muslin attached by plaster, to make the dressing finn by ineatu of 
Hi«''« pu&ition-spliutis 1'/ introducing strips of wood, etc, and to oaldi 
the McrctioD from the wound in basins placed bcoeatfa. If this drc* 
ing remain tirni and clean, the trouble of its £rst a]*|iUcatioo Is 
wvU repaid, not only by tbu brilliant suoccss of this mode t^ ti«at* 
meat, but also by the grcnt suring of time in the subsequent cant o( 
the wound. For some time I cm]Joyed plastur-buudagcs in open 
frncturrs in this way ; at first I applied them closed, just as jn nn^il» 
fractures, and soon slit them up lengthwise, opened them, and ill witij 
the wound crery day or two aa rrquired, wiüiout mortiig the 6s^ 
neots, and continued llii« till the wound was healed, then applied s 
new closed baaduge. IW method is good for sone oaaes, «od sbowt 
«ime good results. The essential Uilog in them dreaelngs is 
ufter deciding not to umimtntc, ci*en the inoafc oomplirati-d fmrtarr? 
■tbuukl be ploood in Ibc plastcr^lrosstng immediately uiler the injury -^ 
just as in the ease of simple fracture, only with tlie difference 
the wound should first be covered nitli charpic or comprewes 
ously dipped io lead-water or solution of ohloriüe of Ume^ and 





TltBATMEXr or OrES FRACTl'REH. 



22a 



vradding 



Dgcr-brendtlia 






ck) should be laid on 
_ even if tlicre sIiödM 
be *-K^'mg, tlie limb vany not bu strutigulatiMl br tbo dressing. 

The difficulty of BpjjIjiDg any Grm dressing In innreaneil hy ihc 
■pntcaco of « lutgv wound or of several wouiulg at tbti satne tune, 
Shonld tiiece bo exleusirc >nc) deopauppunition in such cmcs^m Uirit 
numemos countciHipcnings 111119L 1>c made, and llie number of llw 
^wuods Uius iucrcaaed, it will be tiiii>OäsiI>lu to köcp tbc same dreiis- 
inj loQg, und wo may tbm be obligtid (empomrily to relHrn to )>j>lint» 
■nil ftacturc-lK>]i08, »liicb miwt be oom|>lctfIy rcncuud yvvry day. 
Uureo^'cr, ta you n>iiy gather from what has b«;n said, these severe 
taat» ottea Bland on the bonlera of amputnltön, !. c, tlicir union ia 
Terjr proUematicaL The more practice onn bnü in tliE^ appltcalinn of 
tbo pl«stcr<ircss<nKi the more rarely will 1>ad ao-^ident« Lnppen. 
Siaoe I huvo applii-d tJiu drüssin^ in the »bore mnnncr to complicated 
fracttucs, I see difi'usc Sfplic indammutions and secondnry suppura- 
tians Diuch more rarely. I am ODovinoed tliat tbc treatment of open 
frwrturea by pla-^ter-dressings is tho best; but tliis tnctliod must b« 

udied, we must not suppose we know it apriori. 
Should a suigcoQ of the old school svc our present tn-almuiit of 
frncinrM, simple as well as eompltcatcd, be woiikl cotmider it not only 
irraLiuuaJ but foulhardy, for formeriy fractures, like all other injuries, 
were treated Gist by aDlipliIogislict«, every thing else being secottdiuy. 

cnce it was coaaider«d nece»sary lo apply leeches to the limb in the 
y of tlie fracture, to keep oa euki compres^e.'i or blnddnrs of ice, 
to purge the patient frct^ly. Subs4y]ucntly, whcu auppuratitin 
Irom tbo opco iracturo began, they usually resorted to cataploscns, 
wldbli were ooutiuued till healing was almost completed. Besides 
lUa, Bpliota were applied and changctl aWnt every tito or three days, 
socordiiig as tl>e wound was dretsied more or less fTcqueatly on ai> 
Kiunt of tbo suppuration. Lwrrey %vn!t one of tlie Srst to speak 
igaioit this fretjucut change of dreiisiiig« in wounds, e8i>ecinUy in opeti 
Gnsotures ; if nc may trust his nolu5, he curried thia idea to on unju5- 
tifiable extent, for he did not always remove the dressings eveti whei> 
i|uantlties of maggots had derelo]>ed under them. Of late, the gen 
ml opiuiuQ is tliat, in the treatment of open as well as of simple frae- 
toraif the accumt« li.\atioa of the fragments is the first requirement fcir 
fiivormbte union, and that DOthing is mnre apt to excite inllammnttun • 
amuid tho wound tlian movement of tho fragments. ITenee a firm 
Jreaeiiig is tlte most import«jit and cfUcocious antiphlog^tio that wo 
CKD use. We here repeat a |ffc-vious lemark, that cold and abslrao- 
tkio of MijyA ha^-e no prophylactic and untiphlo^tic action, as wan for- 
ly supposed. If, OB account of commencing progressive inflamma- 





2U 



OPES FRACTURES AND BlTPFtTRATIOS OF BOSE. 



tion arotind tlic wound, I contiidor it necoss&i^ to applj* ice, I remove 
a pj<M!A from tbo pliuter-dressing, ooneepondiii^ to the point wbon 
llie ir«^hladder is to be applied. In case of Btippuratiüu aWut tlie 
ivouiid, openings are to be made ibx tbe csi^pc of pus. Tltc gcacrmi 
principles as to Üie choice oi the point for the opening is to make tbo 
tminteropeniiig' where fluctuation Ia moat dLstioot, and whi:-n: the soft 
jHirls uro thinnest, where llie pas will eftoapc most readily without 
pretntre from the finger. If «e bare to cut opening« <n the bandage, 
this may be done most easily two or three hours after it« application. 
After makitij; openings in tbc plastct^bondaft^ corresponding to tha 
wound, without distiirbing the limb, wc s^piirat« the wiidding, rvtoofe 
tbo charpiü, and bind tbe oppoing carefully ; ibt-n with a »patula we 
introduce wadding under the edges of the opening to prerrnt tlie 
secretkm from tbo wound getting under the dresaing. J^ mort 
theai a year I have b«en Uaning them wound» open also, and hoot 
been aatoniahfd at the Buccrta of this mttfiod of trcaiment. In 
treatment of complicated friiclurcs with plaattf-diesänga, tcs7 
All mnnipulatioa and the knowk-dgc of a large number of details 
which ran only be acquired at the bedside of the patient^ are nooo» 
Bvy ; tbe gift of iovcuting otodÜicalioas of rarioua tuna» of dmiring 
Is also nuccsaaiy. Tbo trea.tment of open fractures is often vciy iSffi* 
cult ; erery one employs in practice tbe inetbod he baa laamed ; U 
makes Utile difference wbeibor we employ plaster, stordi, or GquJd- 
glass dressing«; the e&scnliol thing is for the fmgmi-uts to Uc qn(»t 
and liim, and not to be moved by tbe dressing», then the patient will 
rcoo%*er well and without p<iin. llie brorablo cxporioaco of iauner- 
•ion in onnttised wound* of the hand and foot lins Induced »ome sur- 
geons to tivnl coiiipliciitcd fmcturcüt, of the leg and forearm at least, 
in the tome way. In the Berlin surgiool dinio tbey hare tried keep- 
ing the fractured limb dressed with a fenestrated ptaster-bnndage, io 
a permanent water-bath ; for tliis purpose the plaster must be made 
water-tiglit with cement, solution of shcUnc, liquid glaag, oollodlujnior 
something of that sort. Tbc results of tlds Irestment ars eelebraled. 
Uut, should any suppuratire inflammation oocur about the woutid, ta 
which the water-bath \a injurious, this method would appoar to me 
less suitable than any other. 

In tbo treatment of open fractures witli splints, we generally use 
straight, narrow wooden splints; in the lower cztiemity tbese arc pro-' 
vided with a auitabl« foot-piece. 

As we oommciiccd speaking of tbc treatment of complicated fn< 
turos by dcscribbg tho dressings, I must add a few words about tb* 
Itrst examination. The diagnosis of oompHcated fractures it 
bite that of simple fmctures. Pasaing ibe fingers bto tbe woand h 





TREATMENT OF OVKS FRACTCRE& 



S20 



uQDeceasar^ and injurious; we sliould only dniw out Hptintera 

'boiiu wlien »e tliiuk vre feel or »e« lliem ciitiri:)^ loose; Utc tcsa 

examine the n'ound tJie better. We leave nl) lulherc&t splintcfS 

of bone ; rawing ofl* pointed cuds of tntgineut'i (primnrr nwuction of 

tho Inp^mts) I cousiJcrunneoesuryiuidgCDcnUly injurious; I bavo 

only done it wlien, even under cbloroTorm, they projeew-d »a that il 

-vfoa impoMJUe to replnce anil keep thcin in position. Tlio rcpositloa 

^■f tlio fn^mcots should be accurately made bcforo the application of 

^Bke dreaBinp ; subsequent bending and trrtction ebüuld be dccidcdijr 

^KroMed, luid, if it should be necessary on scoount of great dislocation, 

^ftitmld be postpoocil till healing of the wound. In tlie siuno way 

(iarly tmctioQ on bolf-di^tached ^linters of bone is enlirelj in3ppfo> 

|irUle «nd usdeta ; a juece of deul bone adherent to the periosteum 

or olliar suFl parts is gnuliially detadicd spontaocously, nod may tboQ 

he rcointed. Wc should not examine till quite Inte, when tlie wound 

is fistulous, t4 see tf fragment« iüluat»d deeply are neetrosed» and 

ihooM then do it very uarefully and Trith very clean instrument«; If 

Ibere bo extensive necrosis of one or both frftctuied end«, their e«- 

traction may be veiy difficult ; wo then resort to the same openliuus 

u for DecTTwis from any cause ; wo sliall speak of this vrhcv toting 

of <UsMS«A of the bones, but this should not be done till the process 

■ hu beoome dmnic. 

^H The uniOQ of coniplicntcd fractures always requires longer than In 
^^«mplo fractures ; indeed, in protracted suppuration« it may toko doublo 
y the time. ATe have to deinde this by mannol examination, and not 
allovr tlie patient to attempt walking till the fracture is perfectly con- 
solidated. Tlte diuappcaraacc of the cailua, its ooDdCDäatioo, its atio- 
pliy MttcmaQy and JU roabeorptiiwi till tho roedttllary cavity is je- 
stored, go on junt as in simple subcutaneous fractures. The treat- 
ment of oompUcatcd fractures is ono of the most difficult tilings ia 
watgerj ; we never cease learning on this point. 



APPENDIX TO CHAPTERS V. AKD VL 



LECTUKE XVII. 



1. ReUrdcd FoniMlIaii «f CtXiiM tad I>«T«l9ptiwM of PtouduthrMb.— CauM < 
«■knovn.— trfx»! CaiiM«. — CmHiitMlttul Cmum.— AaatMnb»! Cmti 
Truuacnt: intcnik), i>p«rativ*: OritldiB of HotlKMla. t. ObUqndj 
rrattnn«; BcbrMkiim, Bloodjr Opcntknu.— AlnonMl S«ralopDi«nt'af Ctßm. 

L-ÄETAHDEP WEVELOPMBNT OF CALLUS AK1> FOBKATIOK OF i RO- 
CALLED I'ALtJi; JUINT-A BO-CALLEP 1«I£V1>ARTUR09I.1. 

• 

UxDUB some cireumsUinccs. «rliicli we do not always safEciüiitlT 
imdcrsbiDiJ, a fracture is not ooosolidntcd after Ihc lapse of the umal 
lime; indeed, it may not consolidate at all, but tlie Brat of fracture 
tns^ nmuün palnlesa and tnorablo, wbidi of oounte intpoirs the fum> 
Uoo of the limby even to the point of entire useleasnem. A '«hort 
lim« sino«, a strong iaimer-boj, villi simple subontumiUB (melure of 
tbe leg witltoiit dislocation, enteret llio tiospital ; w nmal, ■ plasliv- 
bandage whb uppliud and itMicw^d In fourteon da^va. Six trceks after 
tbe fracture th« drcasing* woa rumored nltogctbor, in tlio cxpoctatJon 
tbat union had taken pUoe; but the point of (raelure was still pa^ 
fectl^ inorahip, nor could iiny cnllus be fcH. I hi-re Cricil the ^im- 
pleat remedy in such ca»cA, I nnrcotixed the pationt, nnil theu rubbed 
the fragmenta stTonglj togetlter till cicpitatioa «mid be dlathieÜy 
perceived; then I applied another plaster^reasing, and on ramairtiig 
Uli« in four vreeht» fvriiml t-lie frneture tolemUj firm. I ptitoed the pa- 
tient in a fradurt^lwx, and, without placing any bnntlage on the leg, 
had it« anterior mirfiice painted daily vritli strung tiiictiir« of Iodine. 
After this bad been continued a fortnight, the frnrtur« was porTcctly 
firm ; th« patient now ptrvxl wilh the aid of erat«tie*, and in a sbnn 
time was diamiKSMl cunxL I ktHjw of two olhrr cum-s from iho prae> 
tico of ooUcagocfl, where Bimjilc fncturea in very hmlfhy young pn* 
KKU did not consolidate, Init formed pseudnrthroses. SwA occur 
rencea are to be regarded as very rare ; iisunlly there is some pec 



FSEITDARTaitOSia 



837 



BMBse, »ucb u diaease of tbc boue, Uiat iaduccs fatsü joint. Tbcrc ara 

o«rtaia frooturM of Uie humjiti skeleton wlikb firom vftrious cause« 

rarely tinitc hy bony csUiis; among Lli(>«i>, arc iutranpsular frno- 

iru» uf tbc neck of tiie fvinur, aixk of tlic humerus, anil fractures ol 

to olocnuM» and patella, Wbcnfrncturedtraosrencly tbGtu'oUtt«r 

bones Beponit« so fiu- that tbe obsvuus substance formed on the two 

^^^ds cannot meet, so that oaljr a 4%nnicotou3 union can take place bi^ 

^t*c«n lliesc two part« of bouc. AVTien fractured within tlio capsule 

the bead of the femur has, it H true, a supply* of blood through a 

small artery which mtcra it through the ligamctituni tere«, but thia 

source of nutritioo iaverj slight, oonacqucntl/ the production of bona 

from the enioll tngmeot» i» slight. Jo ftucturc of the bead of tb« 

lunncrm within l)ie capsule, in the lare ease of part of the hcud be- 

iDg cntirclT ÜL-ioched fxuni the rest of the booc» this portioa of booo 

vill reeeive oo supply of blood, aud will ^et as a furngn body; its 

mioo can scarcely be expected. la bho above cxumplcs, wo rrganl 

aon-unlOQ so much as the rule that we do not usually call them cases 

of pseudarthtosis. But I wish to show you that there may be purely 

^^|i>csl causes that predispoiie to pseudirthrons; among- these c$p^ 

^■cially belongs oomplote loss of Urge pieces of boae, after the remoral 

^H^dUebi in Optra fracturt«, ther^ may be so large a defect tfmt it nut 

^^^^Ab again fiUml by new iHirie-lissue. Protnicted suppuration with 

oleefsttv« destruction, and cxtcnairc dctiichmcut of tbc ends of the 

(fagnonts, may also Ictul to pficudarthrosis. Morcorer, the treatment 

b ooaukmally blamed; too loose a dressing, or none at nil, and too 

aarljr motion, are ocasionally sccu^chL On the other hand, it has 

Pbcen ••9ert«d that too continued application of cold, the timultancous 
ligalk»! of large arteries, and, lastly, too light u dressing, may ititet» 
Ebto with proper development of bony callus. All this alone docs not 
acceaearily lead to pseudarthrons, but miiy act as a second oause wben 
the goooenl oonditioas of nutrition in tbo organism predispose to it. 
Of tliegeacral predispOAJtiüus and boiiudieouw-^tlie following inay 
bo mcnttoned as disposing to pseudarthrosis : bad nutrition, debility 
fron repeated losses of blood, specific discuses of the blood, such as 
seorbutis, or ouicerous cachexia. Of the disosEos of the bones, it is 
diiefly osteomalacia, atrophy of the cortical substance, with enlarge- 
mentof tlie tneduUary cavity, in\vhich,a9nlrvudy menlionc^l, in certuia 
stages there is not only dt'<!ide<l frngilitnaoiuitim, but in which also the 
ohanues furreunio« are slight. I have »ta(*Ml all thii«, because it isgrn* 
erally accepted, although, on sharp critical examinatioo, sotiic of the 
iborie-cnentioncd prcdisposiug cat»«« for p«c«diirtl»ro«iji are of very 
different raliic, vhile the BlgnlTicancc of otliers 1.4 entirely doubtful, 
tbo aatnc way it is a oominon belief that fraclures are not oonsoli- 



as 



AFfENDU TO OlUrrEBS V. ASD VI 



dated in pregnant femutcs. This is out true in «11 UMs; I limve my- 
self seen nunierot» fractures tinile in pregnant womra, only ooce 
Iiardcnin]^ uf Llic callus was drlujcd a (evr urcclts in n fracture of tbc 
lower c»d of tlie radius, wbicb was recognised late, as niiglit also 
cxwur i» n'omen not pregniuit, or in num. 

Tbc abnormity of tlie licaling process In caso of pscudartbrosU ta 
not diio to tbc non-furmution of callus, but to the failure of ossificor 
tiua in the neve fin-ioutiuu. The substiuias CDnnooliog tlio frugmeats 
becomes a more or less rigid cumcctirc tissnc, hy wbicli llic coda of 
the bono are beld mora or leas closdy together. IT tbo fragtocnta lie 
ao close that they come in contact on motion of tlie liinh, a oarilj 
wltli smootb wqIIh, filled tritb acro-miicous Until, fonns b«!lwoen them 
iu ttie uniting ttetiuc ; and, on tbe fracturetl etida, curUIa^ bas been 
found, to that tbrrc was, in fact, a sort of new joint This doM not^ 
Iiowevcr, occur very often, but io most caw« we Iiato rimpty a ßira 
connecting muas, wbicb sinks directly into tbc fragments like a 
tendon, Wbco audi a pscudarLlirosifi is in a small bono^ sucb aa tbe 
clavicle, or one of the bones of ttie forearm, tbe dUturbanoe of fiuie* 
tjoa is always 1)earabte ; but, if it be located in tlie arm, tbigli, or 
leg, of course there must be considemblo impairmcat of fuoctioQ. 
tn some cases it ia poasibl«, by suitable snppocting ajipiuiitiiB, to gin» 
the limb the necessary fiminess ; in otlicr cases wc cannot do thia St 
all, or Only incompletely, so that for a long time attempts bare been 
made to cure this disease by opcraliuu, Ibat is, by inducing ossifiea- 
tioo. Before piis»ing to tbe loetbods U3C<1 for tliis purpose, wo moat 
mention the attcuipts ntade to prereot fiilse joint, and to cure U, wfaoi 
onen establi.-^bc«!, by internal reraedica. Prepantions of Umo 
chiefly u»ed for lliU puqMse. Pliospbatc of lime was giren in: 
in tbe fibapc of powilur; limo-wotcr was ^vcn in milk, but vrithotrt 
much boncGt. Of the lime given in this way, little is abacwbed, and, 
of tliia auperfluous lime takeu into the blood, roudi was excreted 
tbrou^ tbo kidneys eo that the pseudarthrosis bad little good fron 
it. Wts may expect mora from geneml n^nlatioa of diet, «ad pra- 
BcriUng articles of food that contain lime. Reaidonoo in pun country 
lir, and milk-diet, arc to bo rocommemleil ; but you mu- ' »-ct 

much from these remedies, especially in a fulty-funoi'. j 'int 

that haa eiisted for yeanfc In a reeently-published and wry intcresfr 
ing work by Wejner, it h shown, by a nurabo- of experiments!, thai 
b}- continued administration of small dose« of phOEpboms the £WBU- 
tioncf callus about fractures is particularlyluxorious and hard, as well 
as that in growing animals the portion of bone formed during the ad- 
ministration of pbospbonis is unusually den«e and hard, aaid TCi 
rich in cbfllky salts. These experiment« would lead us to 




PSEITDARXEIROSIS. 

piiQcus io patients witb pscudorihroais, cspcdollj' in Uie earlier 
■tajfcfl ; of coun«, wc »houli be very careful of UiU (entody, wbidl 
cna^ be sodangenms u-hen cawleasly UAcd. Tlie lofial remcdicf «11 
»im at indudng iDäammation in the ends of Oie bone aod jMrl« 
nrouad, becnuae experieooo abciwa Uiat ntust iuflnuimations ia tbo 
Ixjtie, especially subcutaaeoua traunialio ones, induoo formatton of 
bone in their Immediate vicinitjr. The reniedi« employed vaiy very 
^rofttlj. VTc bsro already mentioned the proposals to leave tlie 
Umb without dreseing, so as to avoid intprfenog wiib tli« formation 
of the estenul caDus by pressure, also tbe ntbbiog togvtbor of tbo 
fimgmcnts, and painting with iodine ; with tl>e aame view (viz., of 
iiTttating the fragments), we may apply btüta-t and tho Aot iron to 
tbe part of the limb oonespondiiig to the fractiiro. Ity Uie fallowing 
remedies we act moru on tho iotcnnediatc lij^mcntou» tissue : long, 
thin acvpvnctKre-nttdlti are puacd into tiic ligamontoiu band, ond 
U*ft there for a few dnys to exdto irritatkin; wo may coancot the 
ends of two of these aocdlcs with the poles of a galvaoio battery, and 
pftsa HD doctrical carreot as an irritaDt. Ulis proceeding is called ttee- 
tn>-puHetun / it is little used. We may also pass a thin, smnll tape, or 
aemsal threads of stlk {a so-caUetl attcn or a strong ligatiav)^ through 
tho ligamentous tissue, and love it there till llier« is free snppuralioD 
iDd it. Tbc following openliona attack the bone mora directly ; 
«re quite numerous : For inatanoe, a narrow but strong knife is 
as deep as tho fracture, and tho ligamentous tissue ts shaved 
bom tho end of one fragment, then from the (.ther, without en- 
larging tlie skln>WDund. Q*hls is colled the subrutaniow Uoodj/frah- 
eninff of tho fragments. Or wc may make sn incifiioo down to the 
booe, dissect out tli« two fragments, pcribratc ihcm close to Ibo fmct- 
ttred end, and pass a stifficiently thick lead wira through tho perfora* 
tiooa, twist tbe ends together, so as to approximate the frogmcDtn, or 
dao, after maldng on inciaion, we may saw off a thin piece from each 
fragment, find treat tbo resulting wound like nn open frneture; and to 
ibti opentw», resection of tJie fragments, wc may add Uie application 
of a »ulurt o/tht boti*. The following operation originates with Die/- 
ftrAaeh : Corresponding to Üie en^ of the fragments bo makee two 

Ismail incisiota down to llto boiie, then lie perforate» the ends of th« 
(louo rloiu; to its borders, und wilh n liammcr drives ivory p«y9^ of 
Stable thickness, into the perforation*. The conscqaenco ia, a for^ 
matioa around tliese foreign bodies of new bone, which, when ex- 
IcnsiiT ciiouyh, OS it may alwaj-s bo made in the c«iiröe of time by 
tepcalntg tlic operation, causes lirm union. 1 will here Tnenlion that, 
*hra extracted in a few weeks, these ivory pegs look ruugli and 





SSO 



APPENDIX TO COAPTBES V. ASD VL 



oonoded at the points trbcre they were in oootact witli the Ijonr, 
while the perforation In which thejr lay is mostly filled with gnmula- 
ttODs; o(K&aiotiall5 the pegs are not reniorcd ; the openings through 
wliich thoy n'frc introduccil heal. Tliis proves abeolutrly that dtad 
hone, amoafi wliich Jt-ory is to be clafised, ma^ bi dieeolv(ti and reatt- 
Bori^d by the fftxnriny Mwoui ffranuiaticru. W'c shall hetvaHer ham 
frequent oocasion to return to this muctHoontcKtod qiiexlion, whidi it 
veiy important in some bonc-distase» ; we have ahcadjr spoken of 
tbo theorelicat causes of tLu reabeorptioo (p, IQ7). JB, o. Langm' 
beeil has modified this c^ieratioQ of DU^tnhaeh hy u&inff mvtal 
aurewi instead of ivory pegs; immcdjatcly after the Operation he 
bstena Uteee screws to ao apparatus, which hc«ps tfa« b«gmei)te hn- 
moi'able. After all these opemtioos, a suitable dressing must be 
applied to kocp the fragments fu^i. 

llic hkhIcs of operatioD iu psöudiirthrosia, of which I hare only 
nootioDcd the principal ooce, are, as you nx*, quite numcrou» ; and, if 
the results of treatment correspoiidod to the number of remedies, this 
would belong to the most curoblc class of discuses. But in roodiöm 
you may generally take it that, with the iaor««so in number of reme- 
dies for a disease, their value dt-crcascs. Easy and certain bb aone 
fonns of pscudarUiosis are to cure, others aro just as diiTicult ; nor are 
all the diBeretit metluxla suited to the same atsc In the luvt placv, 
tlie operations vuvy greatly aa to danger, being much more daiignona 
in liinbs with thick »oft parkt, cs])L-ciaIly in the thigh, thuu in utben; 
and, as may be readily supposcil, the non-bloody operations arc less 
dangerous than the bloody ; those made with a small «round less so 
than those with larger. As regards cfBoocy and certainty, I cooaider 
the introduction of a hone »utun and reatetion as those which, even 
in the worst coseii, give proportionately the rjuickcst reaulu, but 
which still have all the elcnienta of diuigcr of a fnictun- conipltcnied 
bj a wound. The treatment with ivorj- pegs is less dtuiKercua, e»* 
cept iu the tliigli, where every false joint is dangrrotiB, and I think it 
would ncoompliah the object iu most cases, if the ojwfmtioa «eve 
rqxated ofLca cnougti. I have seen good results f^n this tna^ 
iDont, and from Von jMngtnbeel^a screw aftparatuB, as well as from 
the bone euturc. 

In pseudarthrosia of the tliigh tlic quci^tion may s^^owljr bo 
asked, if we should not prefer amputation at the point of the Eais« 
joint (which is of favorable pro^osin) to any other dangerous or 
doubtful operatjoo. lliis cgui-stion only tlic peculiarities of <be in- 
dividual case cnn dcddc. In some eases the safe aid of a sttttaU» 
splint apparatus, iwule by a skilful instnimeDt-mukor, is prefcnble to 
any- opcntion. 



4 
\ 



OBUQD£LirDSIT£D FRACTURES. 



S31 



1-OBUQCKI.T.CMITF.B PRACTDRHS. 

Aitbotigti, irith the ])ro^e»» niiul« iii tha ircstmCDt of fmcUire!«, It 
is now rare for union to ocicnir ia so ohliqiti> n dircotioc as to render 
III« limb eitltrely usdeaa, still, esses rroni linio to time arise where, 
ia Fpit« of tlic grcatCBt caxc of the Burfri»n, in fracturca will) opeu 
wminds, di«loe>tion cnnnot he avoided, or ds«, from carelcaeoess or 
grett rMtlsesoeas of the paUent ami looso application nf tlie dress- 
ings, n ooDsideraUc obliquity ia the position of the fractnro remains. 
Tn rosDj cased tiiis is so slight that the patients do not aire to get 
rid of the deformitjr * improrement of the position would only be 
desired ia Cftses where, from considerable obliqiiiiy or abort^nioj; of a 
foot or log, the moTement^ arc decidedly impaired. There ore vari- 
ou« mraina by wbieh wo may greatly imjiroTe or entirely get rid of 
these defonnitics. If, duriDg Uie process of utiloii, wu notice that the 
fragniems arc not exactly conptod, wo may undortaUe the (idjiiitmcnt 
at «ny lime in aimple subcutaneous fructuroti. If, iii an open frnL-lurt', 
obliquity of the fiagioeiitft has tnkca place under the first dressing, I 
etnwgly urge you not to try to rectify it before the wound bae healed ; 
jou would thus break up the deeper gninulations, and tbn fi(>vercst 
Inflanidatiüa might again be excited. In fractures that have long 
suppurated, the callus long remains soft, eo that you may always sub- 
soqaently accomplish a gradual improvement in position by properly 
poddii^ the splints first in one place, then in another, or perliaps by 
oontinuctl cxtcnsioa with weighls. If tbe Iracturo be fully oouaoli- 

I dated in aa obIi<:[uö position, we have the follon'iag rcme<lies for its 
ement: 
^1. OarrcctioD by bending the callus, by ir^raction ; for this pur- 
pose we anafitliclizc the patient, and with the hands attempt to bend 
lb« limb at the point of fracture ; if we succeed in so doing, we apply 
■ Cmi<lru)tüiigwitli the Smb in the improved position. This method, 
eo Irc^ Ijuai danger, caa only be suoccssful while llie callus ts stJll soft 
enou^i tobe bent; hence it can only be done soou aftor tlio fmotur«. 
iL Complete breaking up of, tin ossified callus. This also may 
I bo done by the bands alone, but frequently other niccbaD' 

*Scml nflstis will have t« be resorted to. For this purpose varioua ap- 
p»rmtiiiM have been oooslriicted, sncb aa lever and scrnwmacliincs of 

, ronaidenUe power ; one of llie moat terrible beats the name of " dys- 

I mmpbosteopoIinklaAtoii.*' All these appamtust^ should only be used 
with the gr>?äteAt care, so as not to cause too much bruising and con- 
•equeot nccroeia of the akin at the point where the machine is applied 
on which the limb »sts. For the not unfrcquent obliquely-tmited 
fnictum of tbo thigh, the/ororrf exte/uion of A. Warner (by the 



23'^ 



APPENDIX TO CHAPTEBS V. IKD TI. 



itpparatus of ScJtneider and Mefid, vrliich we also emplov fur reduc- 
ing old flislocattons) bos been retorted to irith miocesa. The follow- 
mg illuAtrnlion will fully expluin ilie mcchantcal effsot of thu «ct«o- 
aion: If jou have a bent rod, and let n strong man take bold of eaA 
end anri draw, Üio roil will break at Uie point wbere it is bent most. 
If n new Oacture of the thigh has boon cauAed by indirect foroe at the 
bent pnrt, and the fmgments be adjusted in a straifi^ht poaltion, you 
apply a pUstcr^rossiog at oncn while tbo limb i'^ siill held in the xtUß 
chine. Ab &r as our present oxpeiicnc« gocft, tiiis mctbod appears to 
bo entirely free fxora danger, but only euil^d for the thigh ; in s eaae 
of very angidar union of a fracture of the leg, wbere I adriaed this 
treatuHTiit, the Itfi-j^ caused hy the cxtcnüon was not in the old »mt 
of fracture, but near it. 

3. The bloody opemtton« on ttte booe, of whidi there are two in 
UAo, arc mora dangerous ; the first of thcto is tie Mt^uufaMecnM 09U- 
otoiny of Ä V. Lanffcnheck. This consists in makhtg a small 'mä^ 
ion don-n to the- bono at l)ic lient part, introducing a tnediuTn-«is«l 
gimlet ilirougb tliis opening sud performing tbe bonc^ without, bow- 
evt^, piercing tbe soft parts on tbe opposite side ; then draw otit tli« 
perforator, and pass a sniall, fine a»w through the perfomtion, and «aw 
the bono trans^-unwly, first to one Bide,'tlicn to tlie other, till you can 
bresk the Test of the booc with your band; now tbo bone is to be 
straightened and the injury treated as a complicated franturix This 
operation hii» only bron done on the leg, but, so far as I Icnow, always 
with good result. It may also be done by not making the adjnatr 
tnent till suppuration begins, and the cbUii« has thin been goAoDC«} 
and p&Hly reabsoTbcil. For V. Tiangmbt^t instraments we remj 
adrantageuusly substitute fme chisels, aa recOnUDCodcd by Groaty tot 
dividing the callus from a small exposed portino of tbe bone. 

•i. Lastly, wc may employ the mctliod of 2iAea Jiarton, whloli 
consists in exposing the bone by a large inciaion through the skin at 
the point of etir\iiture, and sawing out a wedge-»liu]x?d piec« in 
a way tlint the broad part of tbe wedge shall correspond lo tlie i 
Tcxity, the point to the ooncarit^ of the abnormal ourvalurcoTthr 
bono. This method also shows good rcEults, 

On tbo n-hoh', tlie non-bloody arc to be- preferred to th«} bloody 
method», if they do not cau»e too much contusion ; but the latter ate 
less dangcrouK than br«>nVing up fraetUTM willi stroogly-oontuäng ' 
apparatuses. 

If the deformity, csp<-d.i!ly of s fimt, to bo great, in diffcTrat 
direction«, that none of the al>ore mothods offer moch prospect of t 
we may have to resort to amputation in some cases. 



OPERATIONS FOR FSEUDARTDBOSIS. 235 

Id some few cases the callus is abnonnalty tliick and extensive, 
just as happens in cicatrices of the skin and nerves. Do nofbe too 
tasty about operating in such cases, for slow subsequent reabsorption 
isually takes place in every callus. The removal of such callus masses 
»old onlj be effected with chisel or saw, and I should be unwilling 
o decide on such an operation. 



CHAPTER VIl 
lAVVHrSS OF THE JOINTS, 

OdoUilMi.— DUtntios.— Opming af tb« J«ini, uJ A«aU Tnnouil« Artlaüu Ia£U8t- 
BmUoo.— T»ri«tf af Cobim, utd KmsIu.— TrMtBMt— Anatomi««! Cbaagtm. 



HiraXBTO wc liavc sludttiil injuries of siin[Je tiasuc^lemcnis ; oow 
vre must occupy ourselves with moro «omplleatcrl nppanituK«. 

As is woU known, tlie )i>iuU are composed of two cmla of boocia 
coreiod with cartilage ; of a sac frcqtwatly contunitig tnan^ appen- 
^Mgea, poc^ts, and bulgiogs ; llie synovial iiicmbraite, wbich a rltnnrl 
among the serous mcrabraneii ; and of the lihrous capsule of the jotnt 
with it« strengthening ligaiutiuti. Under some circumttaaocs, all 
these ports participate ia tlic diseases of tlic joint, m that at tliotatae 
time wo may faavu diaoitaa of a serous membrane, of a fibrous oapsulv, 
as well as of cartilage and l>on& The participation of tliese dUrsreni 
paiia varies exooodiogl; in intensity and extent ; but I nmjr stats at 
OQoe that the synorial itwmbrane pln^ the most important part, and 
tlint the peculiarity of joint-diseases is chiefly due to tin closed and 
irrojfular form of llie synovial sac. 

First, a few irords about crushinj^ and contusion of t/>e Joint, 1/ 
one rcoeives a, heavy blow agaiost tiie joint, it may swell inoderaldy • 
but in most cases, after a fuw days of rest and appltcattons of LBäil> 
water or simple cold water, the swelling and pain subside, and Ibe 
funutioos of til« jotut are restored. In other easel, sUglit pain sod 
stiffness remain ; a chronio inflnmmatioa dcrclups, whioh amy load to 
scFioasdisease^ofwhioh wo cannot af present spoiüc more fully. If 
we have a chanoo to examine a modciatdyHjootased joint, tbo paiieoC 
having died pcdtaps of a sc:rioiu injury rcccircd at tlic Bamo time, 
shall Snd extra rasat ions of blood ia the synovial membnne, and 
blood in the cavity of the joint itself; ia these oontusJoos wi 
fnctitre the eSusiona of blood arc rarely so oxtenstro tliat ttie joint i 
tcaady filled with blood; but this may ooour. This eoaditjon i 
called hoemarthron {from alfta, blood, and ap9pop, joint). If a joia 
that has swollen greatly just after an injury remains painful for 




orBXI>'08 OP THE JOINTS. 



S88 




tap 



time, aod fi^eh bot, a soniewtiat more active antiplilogistic treatment 
ia iadicatciL Hit» couötsts iu tlio a[>pIicaliou of leediea, regular cd* 
velopment c*f Uic joint in wet bandn^ü, causing moderate ootnjyre«- 
«ion, and in appl^-ing an ioe-blailtk'r to tlic joiut, äXs a rale, iiijlant- 
nittioD of this ^rwic ttuiy bo reodilj rclicrcd, altbougU cbronto di»- 
coftes and a certain irritability of tlie joint tfaat has been injured not 
OD&QqneDtlj follow. It is very important to determine wbeth«r the 
hhtg of Uw joint be accompnnied b; fracture or fusGurc at the end 
the bone, in irhich caae, it would bo nercssary to aj^ly a plaater- 
\g, and give a guarded prognosis as to the future usefulness of 
I« joint. If the oontiiiiiod appli:'alton of cold incrvxaes the pain, 
ke inuDCtioD» of mercurial ointment, i»nd apply moist, warm com- 
'S9i?9 eovered with gutta-pcreha and wadding. 
A fcnn of injury peculiar to joints is distortion (literally, twtst- 
'). TUia a su injury tbat occurs especially often in ike foot, and 
bidi is commonty called *' turning tlie foot." Such a distortion, 
bich \i possible in almost any joint, oon.<unts essentially in a tension, 
too great stretcliing nad even piLrlial rupture, of the capsular ltg»> 
mcDtf^ witli escape of tome blood into ibc joint and surrounding ti»* 
sue. The injury may be rery puinful at the time, hikI its oooscquences 
are not ua&c<iui:utly lediuus, eapcoiuUy if the tieatmcnt bo Hot 
itlj oooductod. Usually alHtlractiou of blood and oold arc resorted 
la tlteae cases also, but witb ouly tcmpomiy benefit. It is mucb 
m important to keep the joint perfectly motionless after such in- 
juM», n tbat, if any of Lbeliganients be ruptured, they may heal and 
■c^tdre their iirevlout firmness. Tlie simplest way of attaining tliis 
fi^X is by npplyiug a finn dressing, such aa the ptn»ter-l»odage, 
•illi nliirb vfc iniiy |>ermit the patient to go alxnit, if it gives bim no 
Hin. After ten, twelve, or fourteen Any», acconliug to tlio sevori^ 
of iIh mjoTT, wc may remuTe the dressing, but renew it nt onoe if tbc 
it has pnin on walking. It may sometimes be neees<iiity to wesr 
Shia (Inssing tliröJ or four weel«. niis appears a long lime for such 
«Dtsjiuy; but I can assure you that, without the application of n firm 
lUuaiilifl, the oonsequcnees of tliesc sprains often eontinue for months, 
at the tame time tho danger of subse<}uenl chronic inflammation of 
til« Jphit is iiuTfeascd. Bence you must not promise too speedy a cure, 
«a<I must always treat thc«c, often apparently insignificant injuries, 
«Dtncicnlkiu^ly sikI cnrefully.* 

orsjrutiM or niB jouvx«, axo acute TRinixno AtrnctTLAn 
nn^ijuniATioxR. 

now pawing to wounds of the jc»nt, w« make uu immense 
as r^ards tlie ImporUmce of the Injury. While a contusion 




S3« 



INJURIES or TUE JOINTS. 



andeprain of Üic joiutuc scared}' notkcdb/insD^' poticDts, tbeap«ii> 
iag of a synovisl sac, '^tlt escape of eyDovi«, cvcu if ike wound be 
not large, alwa}-E has a sorimis effect on tbc functioa of the joint, aod 
is not unlrcqucntly dangerous lo life. Here, again, we linre tlic «lifitir^ 
cuce between eubcul&neous traumatic ioflamxaatioD» ami tboee wbicb 
open outwardly, of wbicb wo spoke when on the sulijcet of cod* 
fusions, nrul wbicb we sIm saw In aubcutaneous and opvo fractttreok 
Moreover, in tbc joiuts, we bare closed irrcgularly-sluipod sacs, in 
wtiicli till) pus, once funnod, rein»ius, ami, besides inflaniniatioo of the 
MTOUS membranes, may result in vctj tedious processes, but in Its 
acute state often has a bad elTcct on tbe general bealtb of üte patient. 
I think the quickest way to deeoribe tbs pTocess will be lo give 
you a few cxnniple». 'We are here «pealung only of »ntple punctuml. 
incised, or cub wounds, without complications from sprains or frao- 
turo«, and choose as our example tbc knee-joint ; at tho satn« time we 
must remark tliat injuries of tbis joint aro regarded as the moitt 80> 
Tcrc A man comes to you, who, io cutting wood, bus received a 
wound half an inch long, near the patella, and which has bled but 
lilÜe. This may have happened some bouts before, or erca tbc iw>- 
vious day. The patient p»ya little attention to tbe wound, and only 
asks your advice about a proper dressing. You Inspect the wouad, 
linil that from its position it coiresponds to the kneo^joint, and around 
it you may perhaps see sumo serous, thin, mucwis, clear fiuid, wbtcb 
oscapes in greater (luantltics when Uic joint Is moved. This will coD 
your attention particularly (o tbe injury; you esamine the patieDt, 
and learn tnaa liim tbat, immediately after tbe injuiy, tlicrc was not 
much blceding^, but a fluid like white of egg escaped. In sikJi caeca 
you may he- e4?rtnin that the joittt baa been opened, otlierwis« tbe 
üynövia could not bnve escaped. In small joints tbe escape of 
synovia is so slight as to be scarcely noticeable, hence, in injuria of 
tbe finger-j<nnt, and cren of tho ankle, elbow, and wrist, it may for JL 
time be doublfiil whether tbe wound has penetrated the joint or not 
^^1)cn a ppnetriiling wound of tlio joint is orrtain, tbo folluwiii^ 
sliould at ODcc be pursued : The patient should keep quiet in bcd_^ 
tbe wound should be united as quickly as posxiblr, to prevent ibe 
cape of more eynovl«, which would interfere witli healing of 
wound by first intention; hence we dose the skin-wound, if it has 
tendency to g»pc. Tl lis may Itcst be done by sutures accurately appli 
in some small wounds, curefuUy-applied adhesive plaster, or iditb, 
collii-plitster, painted with collodion, may suffice Kow the joint is 
lie kept absolutely quiet; this can only be dcxic by firmly band: 
the limb, from below, with wet bandages. In the cnse before 
t})e whole teg should be kept securely and Gnnly «xtendcd on a 



OPENINGS OF TBE JOINTS. 



837 



lour B|>titit, or between two sius of BtiotL If, bcsiJes tbis, you g}TC 
■oiite iiilvroitl rcmclj, iudi iia n mild purgative, I IhiBlc enough haa 
tx-LMi Joiie for llic lime. In most loxt-books oa surgery, it is true, you 
nill find the advice to put oo n number of leccbci, iLiid to keep a 
bladder of ico «00910011/ applied, to preveut too muub inßaninuitioii. 
Uut I can assure you that Inral abstraction »f blood and cold do not 
area here bare thU propbjlaotic, aiuiplilo-^istio action, anti tbat it ia 
time onoi^ to riMort to ice iu a later stage, ultbou^^b I will not blamo 
any one for wing ice from ilie first in iiilliLninntion of the joint. Tli« 
abore dres^g'I Uave of lat« rejjlat-ed by tht? plustirr^in'uicig ; I apply 
as for a (htcturc of tbc knee-joint, from llic fuot to above tUo mid- 
dle of the thigh, with a position-eplitit, then cut an opening oorre- 
^Ktnding totheantetior sur&ce of the knee and the wound; the results 
of this troatnieot, as (»MniiurtHi to the olil rc^lar anliphlogisUc Ireat- 
nent, are very brilliant. Let us return to nur patient. You will find 
thai, oa the third or fourth day, be will complain M>inevrh»t of burning 
poio in tlie joint, au<l be slightly Feverish ; ou applying ymir band, 
the joint fed« wanner than the hcaltliy one. "Wbco you hare ro 
Bnved the suturea, on the fifth or sixth day, in tho followiTtg two clan's 
the course may be iu ooc of two vciy different dircctiona. Lot us 
first take tbo fovorahle case, which is frequent undor early treatment 
firm drp-ssynpt; the wound will heal entirely by first intention, 
ighb »welling wid puln in tlie joint will diminish during ilic fol- 
wio^ <Kys, xiul fuially disappear cutirely. If ^-ou remove tbc drcs3- 
(D from four to six weeks, tlie joint will be again movable; tli« 
■y is eomplctc. 

t in other cases, especially where tbc patient comes under 
trmtmimt ULo, things turn out woree. Toward the end of the first 
week Ibcre are not only great swelling and beat In the junt, but Ibore 
ia <a<lefaa of the leg; Uio patient baa severe pain on being touched, 
m» well a.i| on every attempt at motion ; toward evening he hi.1 high 
ver, he loses bU appetite, and begins to etnadat«. At this time the 
ound may be closed, or a scro-mucous nnd subsequently purulent 
:ul<] eeeapes from it. But even If this be not (ho case, the al>o\-e symp- 
lu, cspcditlly the swelling of the joint, with distinct flu dun I ion, tho 
in(aT:35cd temperature, ccdcma of the teg, tbc increase of fever, 
tnt to an acut«, intense inSammation of tho joint. If in such coses 
lb he not fix«], it gradually a&sumea a flexed position, which in 
■joint may increase to an acute angle. It is not easy to give 
for thiH flexed posilion nf inflamed jointe ; it Sfema to me 
bable tltaC it arises, in « roflex inaiiner, hy a tran.sffT of the 
irritation of the soniüble nerves of the inllunitid ajTiovia to the motor 
Dcnre« of the Hoxor muscles. Another explanation i«, that every 
U 




S88 



LVJCRtBS or TUB JOIlfTS. 



joint niAjr ochiUJd more fluid in the flpxcd ihao in the extended (Kni 
lion, wbtcli liiu been prorcd experimentally by Bonnet^^ who uiuiilt 
brought the juinLs in Ihu codarar to ft floxed position, hy tnjocting llwl 
into tbem. But tbcac cxperimciita do not seem to mc to proT« oaf 
thing «bout the abore-montloincd flexed position, for tbcao aUo ocoa 
til nrlicular inflaminutioDa where Uiere is QO fiuiU in tbe joint; on tb« 
ullicr hand, they »re often absent where there is a great deal of Buü 
ObAenmtion Abows (bat aeutt pairt/ut syooritia OMSt dispose* t» 
flexion of tlte joint 

If Ih« abo\-e 8}-niptonis have presented tbcnuelres, aatJpUaglilie 
remedies shuuv their hiätcric raluc, but wo oiuat oot Garget lh*t M 
tbe sane time the position of tbo limb should not be neglect«d, n 
tJint if absolute stifFheKS of th« joint shouH occur, Hüb nay reanh in 
tlic pof>ilioii rrtativcly moet ^rotmble for its usefulocstt, fiiat i«, id Üie 
kneo-j'^int fullv estcn<led, in the foot and elbow at a right oaglö, ele. 
If attention lo thi« point was neglected at the commenerment of tbf 
troatmcnt, you should repair Uie error by anoesthetiziug tbe patinit, 
BO tbaC]*ou may, witliout diffietitty, give the limb the proper positi«. 
Among th« antiphlogislio remedies, I attnch muMt Jniportanoe to pit* 
elug one or mure icc-bUddürs on the inflamed joint, and painting El 
with conoontrstcd tincture of iodine, which shotUd bo used til) » «40- 
sidcnthle extent of epidermis is ele^sled into a vwsjcle. 

If the fluid in the joint increases rcr^' raptdly, and tbe ten^oa 
becomes iasupporlAhle, and if there is no free escape for the pue 
Ihrougli tlic itound, so that there ia dnHgur of ulceration of tbe csfH 
sulc {ram wilhia, and of the pus Sawing from the jtfint into tfie oct- 
lular tieaur, wo may carefully draw olT llio pus with a trocw, nf 
course f^onling against tlie eolroooe of air into the joint, TIda tap- 
ping of tlie jcnnt, which of late has been spedally recoaiuicouldd by 
ß, folkinann, I furmerly used with good results, and hjr it curoJ, as 
I iK^Iicre, four suooeEsiTo eases of severe, acute, trauinntjo iuflaonna» 
tion of the kneo-joiut, witli perfect rüstoratk» of imibUItr. Sine« I 
hare applied Ü)o plastcr4»sndago in simple pcncttnting wounds of 
the joint also, T luire not resorted to tupping. If Üw potietit is kept 
i^wake at night by pain, he should have a dose of moqitiioe in the 
fTcning, and antiphlogistic diet and cooling drinks during tbe day. 
By this treatment we may succeod in cutting short tbe acuteness of 
tbe disease, even in this stage ; but e\'en tJteu t)ie funirtion uf the 
joint may not be ftilly n;»tor«I, although this is iK>.SHib1e in ca^e the 
■uppurativ^n of the B^-noTial membrane tomahu chiefly suporCdil 
{cntarrltnl). Frequently, however, the ^scos« passes from an sente 
to a clirouie course, the eupfmration nttaclm ihc tiEsuc more deeply, 
lliea after rocorery there remaiiiB more or loss stiffness. 



TRXDSUTIO JiRTICITLAB KFLAHIlAnoN. 



«36 ■ 



un fort untidy, the iuflatiimatioo in and around the joint occn- 
lalljr i>sleiuls uQControUabty. And, finally, the only thing to be 
b Ü to cnlsTgc tlic wound, to make new openings in Tarion« 
jH; w« Üicn bavo complelo suppuration and destruction of llie 
^ial ma. All the coniintiniontiiig (Lynovial eaca do not partici- 
f eciunHy lo the supjjunittun ; on ttipjiing', you may nt one pnrt of 
'joint evmcuato Knun, at anothcr, pus ; this is proluilily hccauM 
BwoIlvQ synovial nKtmbrand clo^s, like a ralvc, the openings of 
Inunicatjoo, which are often narrow betwe<>n the cavity of the 
|t iumI the adjacent sacs In bud cases the »uppunitkiu oxl^mds 
lie soft parts of the thigti and teg, the po-flcnt is thus exhausted 
k and more a» he hIso is by «etx>re fuver and eliillm, his c-Iivl'Ics eiulc, 
f wj fceailato about our treatment. Itcoovcry b possible, even in 
stag« • the »eutc Biippiwations gradually cease, and the disease 
tmea chronio, and sHer Bcvcral months may terminate in complete 
bess ot the joint. In many cases we strive in rain to keep up 
stren^b of the patictitwith totitca and streuf^hcuing remedies, 
'he diea of eslianstioii m a ivsult uf new »uppunitiöns n-liich 
I occur ai point« having co oonneclloo with the wound. This 
trtuoato tcnnination wo can only prcront by amputalon; this 
hly wfait-h is so deplorable, but wfaidi in these cases (hMjucntly 
Ü life. T!ie difBailty here lies in the chuioe of the proper time for 
llftiJDg. ObMrn'sttoiU! at the bedside, which r^u wilt make in tiie 
tBiut teach you bow miKh you mny trust the etrcngth of your 
t in individual cases, bo thst you may dctcrmiue whon the luet 
for the operation baa «rome. In hospital, you will always 
Inaoy such casee die of purulent infection (pyannta), with or 
unputatioD. 

', in describing tnumatio arttnilar inflamnialion, we Held to 

tattoo of a special CAAC, and let tb« treatment follow the 

I«, wr must adil a few remarks aliout tlic palbologieal ana^ 

, M It has been accurately ittudit-d on the cadaver, on ninpiilnletl 

% and by aid of cxi>(>rimcnt*, Tlio <li»ca$e affect« cliiefty, and at 

cxcIu&iTely, the synovial membnitio. If this has not bticu »ecu- 

ly obeerrod, aa I know from my oivn experience, we art; apt to 

lUer it loo tliin and delicate. But, by examining a knee-joint, 

nay readily Batisfyyouiselrea that at mostpiiinls it ia thiLkLt 

more BUCculrnt titan ibe pleura and peritonirum, and ia separated 

1 Ike fibrOtts arUcular capsule by a loose subserous cellular tisauc, 

eh MnietJmes ccvnlains miteh fal, so tliat you may detach the synu- 

■cof a knee joint from tlio ciu-ttlage as an independent mom* 

De. A> is well known, it conAiets of coaneotive tissue, hoB oa its 

pw pavement epithelium^ and containg a eott»i<IerabI(> cnpillnr; net* 





SM 



IXJOBIES OP THE JOINTS. 




work BBK ibs surijtce. AVe lave tti e iavesUgations of Mutter, tbau Ik 
IjnnphstÄo Tcsaole of the sjmovtni membrane ; »ocording to then dn 
Uicmbran« it«elf contains no Ijmplmtice, -while the Bub^yootnal tissue 
u saiil to be very rich in them. This result is surprising, and beooe 
requires repetition with all tlic aids of modem auatoiiiicul art. Siaiv 
the sjnorial mcs a» serous mcmbnac!), it is most probable that ütj 
contain Ijmpbatio Testeli», sui^h as have lieen described io the perito- 
iiicata and other serous membmnca, by Von RecUinffKauaeti, fonniig 
supor&cial net« «ovcrod with epithelium, and partly opening oa t^ 
sur&oe of the membmiic. Tho surfaco of the s^-norisl mcmbmnc, c» 
peciuUy at tlie sides of the joint, shows a number of tuflcd proocsscs; 
these have well-furmed aod often oomplicated capilbry neU. Syafr 
«■iftl morobraacs sharo with other acrooi mcmbniiies the pcculiarily oT 
wscrctiufT a cuiiaidi.-rjkbte qiianlity of scnim. oti bi;in<r irritated. ,M 
tlic same time the rcssvis bucome diluted and begin to groir tortuotu 
toward tlie surface, the mornbraiie loftus its lustre und smootlmoss, aai 
first grows cloudy yelloMneh-red, and later more red and veliely m 
ibe stirfucc. In most oases of acute iaflamniiLtion a more nr lea 
tbiak fibrous deposit forms on this surface, a ito-callod pücudo-mcts- 
braue, liku that in iuHaminutioa of tlio pleuni and pcrilomeum. &li- 
croscopictU cxamiuutton of the s>*novial mcmbniuc in tJiie stafco ihtm 
that its euLire tissue is grcatlj' iußltraU.'d Tvilli plikstic luattcr, and that 
ua the BUi'fiLce the collecrtion of cells is so considerable lltat the Hamm 
here consbts almost exclusively of smalt, round cells, of which the 
moro aupcrliciul have the cbantotoristics of pus-ccUs; in tbo immedh 
«to viciiiity of tlic gTcat]y>di]ated vi.'SMtU we find the eoUeotioD of 
waikdering cells jKuticularly great, which is prDlmhly bMsne in acute 
sysoritis numerous white blood-oclls wander tlirougb tlio viUts of the 
voaaels into the tissue, und collect in the vioiuity of tbe resKcIs ; in 
thifl process red blooiWiqHiscW seem also to escape from the Tes&cit 
in great quantities. Tbe päeudo-membranes era oomposed callrely of 
small, round cells, held U^ther by coagulated fibrine, of whose ori^ 
from fibrugODOUii and fibrino-phtslie substance we bare n'- >k:en 

(p. G3). The oonncctivc tisjsuu of the roombrane boa \- : its 

striated character, and has a gelatinous miicoua oonsütency, 80 that it 
greatly resembles the intercellular substance of grBaulntina>(Jssiip; 
in tlie fluid in llie joint, which is constantly becoming more cloody and 
puruloiil, there arc at first a few pus-corfiusulc», which constantly in- 
crease in nunilwr till llie fluid has nil the eliaractorislics of pus. Still 
later the wirfuee of the synovial membrane is so ^-uscular that erc-n to 
ibc naked eye it looks like a spongy, slightly-Dodular granulation- 
surface, on which piiB in coiiiitaiitly forming, as on an orJiiuiiy grana- 
lattng surface. The condition into which tlie synovial mcmbran« 



surrcRATioNS op joints. 



ill 






ID the lirat BtagcSy most rcscmlilcs acute catarrh pf ibe muoous 
mes. Jia long m tbörc has been ou\y supcrGcial suppuntloa 
without (iisiat^ratiwi of tissue (without utceraiioii), ttin momlirano 
may return to tbc aocmal state ; but, if the irritation be niilTioioiit not 
only Jbr tlic fortuaUoo of pseudo-meuibnuic (wbicli innj almi be agiua 
(lisiategfiitcd), but to cause suppuration of tlie sjrnovi»! mcmljniTie it- 
self, tlie only result will be fomuitioa of dcitrix. In dL-scribiog a 
{ticai case of suppumtioQ of the Lncc-joiut, wc have already shown 
t the pus pcrforat«« from tlKi knc<;-joint into ihc subcutaneous cel- 
lular tissue ; this undoubtciUjr occurs, but pori&rticular subcutaneous 
euppurationa, after penetrating wounds of joints, also oocur occa- 
sioually without depondiog on pcrioratioos of pus; ve see tb<^ni 
both in acute and chronic suppurations of joints, without being able 
detect a dinvt coinmuDioatton with the cavityoftlic joint. From 
ly experiments on the phlogistic action of pmü, I think thit must bo 
due to the rvabsorptioa of quickly-furmi-d jxiiisonous pus by the lyiD- 
jihatio vessels of the synovial mcmbriuic, aud ita conduction to the 
perforticulai- cellular tissue ; at the satoe time the neighboring lyio- 
|Ant3C glands arc always swollen. When tienting of lymphnngitis, 
we stuill have to rclum to this subject The carlilage does nob pai> 
Dcipato in the iuOaminatioa for some time; its surDtce beoomes 
i-louilr, and, when the process is very acut«, it begins to disintegrute 
lo fine molecules, or even to become nccrosccl in large fragments, and 
to bo detached from the bone by tho occurrcnoo of inilanunatioa and 
tupporatioQ between cartilage and bono (subchoadnü osüüa). At- 
tJioagh the cartilage with it-i cells is not wholly inactiire in these 
iafluinutions — for, froui vutioiis obecn'ations, wo can scarcely avoid 
Denog that tl)c cnrtiUgc-cells may al.<«o pnxluoe pun — alill, I ooniidcr 
state of the cartilage is ««sentially a passive softening, a sort of 
such as noLun nuder like circunislancca in the comca when 
is severe bicnnorrhini of ihc eonjunctiviu Indeed, tliero are 
mif tvro parts of the huuuin body so analogous in llieir rdaliona 
as the eoojunclivn in its relations to tho pomca, and tlie synovial 
tnomlm&o in it« relatious to the cartilage. We shall frequently hare 
oecation to retum to tliis point, and shall here ceafle tho oocwidoro- 
tSoni, «rhidi trc sbati rcsamc more particularly hereafter. If the acute 
proeenbecomos chronic, aud a stiff joint result«, an anehyloai» (from 
li : «rAij, bent^ it always oectirs in the sama way in all suppurative 
in tUim nation» of the joint«. We shall inve<itigato tliis more exactly 
hvn treating of cltronic 'articular inflammatious. 





MS 



IHJDRIES OF THE JOISia 



LECTURE XViri. 

Slaipl« IMaloeMloM; Tnnmulo, Ooogmlul, Puheloigtotl LonUODi, SuUMWiofc- 
Edotoyj.— DlfflMltiM In Bodnouon, TrotiaiMit; BedvetlMt, AtUr-TttamMiL- 
Hkbiluil LunOaiM.— Old Louttoiu, TraaUMBt.— OomfUflUtd LiiMill<an -C* 
pmttul LnxailMw. 

SIUPLE DISLOCATIUNS. 

Bt a dislocation {tvxatiu), no understand that oooditios oft 
^intio wbick the two articuUreniUaro entirely, or fortLe moat [art, 
thrown out of their mutual rchiUonü, the arlicniUr capsule beii^ gco> 
cnillj' panly ruptured &l the sunc time; iti Iea»t,thi8 Isalmoatftlwij» 
the CMC in traumatic luxaiiont, i, e^ io those that b»re oocurrcd b ■ 
hmlUiy juiut as u rusult of iho tppUcktiou of force, Besides these,«« 
di&liiigulUi eongatiUxl, oud tpontaruous or pathvloglcai tvaatUm. 
The latter remit fiom gradual ulocratirc dc&tructioo of the articvlu 
extnnnitics and ligaments, since thcro is no longer the Datuml oppo- 
shioa to musculur contraction ; we sluiU »pcslc of ttiis hereHAer, u it. 
t»a«utjijly belongs aiuoiig iLu result« of oertain ditteaaes of the jcöati 
At the cod of this section wo ühitll say soineUung about congemul 
luxations. At present we sball epcik uuly of traaioatio dislocatlou 
We oocssioiially hear aLto of »ubtuxattotia ; hy Üüa oxprcssioo ire 
imply thm the articular surfftocs bsTC not »opnrsted entirely, to tbit 
Um luxntiuu i« iui.-oiupli.'tf.'. By eomplicattd liutatious wc niMn thoM 
nuuuiupaiiiud by frocturrs of buues, wouimIa of tho ebiii, or niptorcs ol 
Ur;^ e TciAcls, or ncrrc», or (dl of tlic»c. You nittft lü^ ohserv« that 
it \x eusluniury Lu dostirnatti the lower part of tlie liiub as Uiu |)arl 
luxated ; as fur tostamx: at the shoulder-joint, not to npcnk of a lui- 
ated Hapula, but of dislocation of the htuuenu ; at the ktifv-joiot, not 
of luxation of the femur, but of the titua, etc. 

Dislocations generally arc i-arc injuricü ; iu iminc joints tliey are so 
rare that the whole nuuibor of oases known is scarcely half a doxco. 
It is mid that fmcturcs arc dght tiincs as ircquent as disloeattoos y it 
socms to mo that oreo this is too largfl a propurttoo for dislocations. 
Hw dt»tnl>utioa of luxations antoog tho diHurcnt joints Tories my 
gre^itly ; let mo show you this by some fijfurcs ; According to Mai- 
ffaiffne*» statistics, among 4£d dislocations there wem 8 of the trank, 
S2 of tbo lower and 41'J of the upper extremity, and nitiong Ü>e lal- 
la there were 331 of the slioulder. Hence you see ttiat the should« 
is a reiy &iTorite joint fur diislocatioiis, which is readily explained bj 
Its oonstmction and free inobilily. Dislocatiuos arc more fifxiuenl 
among men tiuin women, for the same reasons that wo have alrrads 
shown fractun» to bo nioro fntiucut io men. 



J 



DISLOCATIOKä 



84« 



Am iaducing cauws for diKloeations, ve biive external applicatioiia 
of foroo umI musculBr actiou ; Uie liiU^r nre nre, but oa.tes Iiare beeo 
«baetred wbere dislocntious were caua«,'«], in epileptic«, for inatunce, by 
T!nm^T*T oontnctioiut. As in fractures, ibe pjttomal «ine« sro diiidad 
{nto dirtct aad öi(//rvcf. l'Vr iiisüincv, if one gets a Ijuition by 
UiUing <M the ehouldcr, it ie due to di^^ct force; HtQ 8«tnc luxation 
isigfat cKxiir indirec'tJj by a. person witli ouUitrctch<xl arm fulling' oa 
the band bikI elbow. Wbetlier s dtslocalion or a fracture will result, 
tliqtcixt» cUiefly on tbä iKMitiu» of tlic joiut and tira oature of the 
OMUO; but muob aIko depends on whether tlic bones or the orticukr 
ligatiimu gire way tbe more readily; furiusUuice, by tbcsamemanoeii* 
rvr, on dilff^nrat dead bodies wo may somctioica cause fracture, some- 
times dialocation. As io fractttrcH, thcno aro mitnoroug sytiiptoiDs of 
luxatioD, of vliieh noine may be very noticeable, and are the more so 
tfce sooner we see the case, and tbe leea the diaplaccmcnt of the ar- 
tieular ends ü bidden by infianiTDatory swelling of tlie st^perjacent 
■ofk pnrtft. Tbe altered fonn of tlie joint is one of tbe raoüL important 
and striking »ymptomg, but wbtcb ooly leads quickly aiid certainly to 
4 diAgtMieu wbcn tltc eye bos been accustomed to teadily reeogoize 
dlffcretices frum tbe normal form. Correct measurement witb tb« eye, 
aooont«; knowlrd^c of the normal forDi, in sbort, some tuslc for sculp* 
ttare »ik] sculptural aootoniyf »o-cuUed artistic anatomy, arc bcrc very 
QtefuL ]( tbem i« i-ery slight change of form, even the meet prao- 
IJaed wtU Dot be able to di^ix-uM; witb a com))eri»oa with tbe opposite 
fide, Bdid bencc I comeally urge yuu, if you would avoid error, always 
la cipose (be upper or lower half of tbu body, as the case may be, 
nod to compare the two sideSL You may best follow with the eye 
tbe directioa of tbe appureutly lU^plaood boiic, and if thif> lino doc» 
Dot strike tbu arti^^uliu- cavity 8<»<untt«Iy, there will moat probably be 
a dislocation, if there 1» not n Iraclure, clo«« bflow the ajrtioulaLing 
ItCMd ot tbe bone, whicb muitt be dctennincd by manual exninination. 
The b-njjtbpninfj of shortcninjf of a Hmb, it« position to the trunk, 
tlic diitUiii;« of cert^iiu pruminctit points of tbe ski-tuton from uaub 
other, often aid us io making at least a probable diugnmia rcry 
<]aicktj. Another ei,*mptom perceptible to the sight is cochymoas of 
the soft ports, or suggiltution. This is rarely distinct at ürst, because 
tbe blood, escaping from the torn capniilo only gradually, perhiijK) not 
tar •e^'erml days, rised near the »kin and becomes visible ; in aomo 
«■Ma the efltisioQ of blood is so tnconsidonible tliat it is not perceived, 
^le flympt'jni« given by the p»t!mt art-, piuu and inability to mov-c the 
Vmb DormAllr. The pain ia nercr so great a.s io fractures, and only 
appears on Dtt(.>nipting to more the limb. In son» eases, patients 
wttb lusatjous may perfonn some motions with tlie limb, but only i» 



»44 



IXJCBIE3 or THE JOINTS. 



»1« 
-id. 



tsertftin dircotiona, and to a rcrj limited cxtcni. Usntul ciAtnlniUioi^ 
iRual finally settle tlic qu«8tioo in moat C8«ee ; it must show th«t tlv .^^^ 
iu-Li<Hil«r onvity is empty, and that tbe bead of tbe bone is at som«.^ 
other ]K>int, at one siiic, aljove or below. If ibe »oft parts bo consi».^ 
cAblj ewulWii, tbis exaiiiiiiittiuu may he quite difficult, atid tbe ^-^^^^^ 
of mnsiJStiicsJa i» ofn'ti necessiiry for a oorrcet diagnosis, especiallj" ^ 

lltu cxbibittonB of pniu and tbo motions of tliu patient interfei«. ( 
moving the citretuitj-, wbicb wc find springj or alighllj moval 
tHoro is »ocaiuoDally a. fiM}]ing uf friction, uii tndiHtinct, soft crcfdtat)^,^ 
TUis may result partly from rubbing of tbe head of tbe booe on t^^Z!]/" 
capsular li^menls and tendons, partly from the compmsion of f^^T* 
biood-«aagula. Hence, in such vnrietiea of 49«pitation,we ehoold ^^ 
«I once corcliMle on a fnietuiv, but W urged to more careful exam, j 
tion. Fntcturus uf cvrttiin paris of tbe articular ends, with dislo^ 
Uon, arc most readily mi»talccn for lunatioDS. And formerly the t^oi^ 
of ('![pTV.-ssion on tliis point u'us not exaot, fur di>ip1s<x.'mi-nta ahoot 
thr joint, combined with fractures, and rauscd cntin;ly by tbcio, wn^ 
oIeo termed lusation&. At present vre distitigoiBh tbcso fnctare* 
witliin tbe joint, witb clisloeatioos, more sharply from liuati 
premier, _ 

Should you be in doubt :is to whether the caic a one of diaboMe^V 
articular fntolure or of luxation, you may easUy decide tbe qtMC(io^:3 
by ftu atlcm]>t at rcductioD. If such a dislocation is mdily vedota^^ 
by mofk-ntlu tniction, but at once reiurus vrbcn you leave off tli^^ 
tnuAion, it is n oaxo of frnctntej foro otTlnin art a nece-Moiry tolb^^B 
reduction of a dislocation, aiKl,wbea oaro reduced, it downot rcodil^^y 
recur, nltboi^b there oro cxceptiona to this rule. 

A contusion and spmin of ihc joint may aUo be mhtaken (or bna' " ' - 
ation, but tbia error may lie avoided by carßful examination. OI^mk^I 
traumatic luxations nny sumctimea be mislaken fiudislocatiopgcsauc igt 
by coolraction. Lastly, ia pamlyzcd limb», M-hcrc there ii at tW ^ 
■sme time n>luKiition of lliu urlitnilar esp«iilo, the joint may be iO rer~-;^^ 
movable that in certiiiu positiuoa it vill look as if dislocated E~n 
tiiese casetv also, tho history of tbe case and careful local cxamlDatic»-« 
will lead us to a oocrcct conolnsion. 

Hej^nling Uie state of the injured part« Immediately after the L«»- 
jury, in catK-a when; there has betiu a eluince to exiunine them, it U ^r 
been found that the eapAttle of the joint and the syno^^ol mombrs-*sv 
are torn. Tbe capsular o]ientng ia of rariable size ; occaaiooally iL iM 
a slit like a button-hole, Eomctimoa it is triangular, iTtth more or l^tas 
ragged edges ^ niptures of museles and tctidona immediately afOtaa^S 
tb« joint bav« aUö bf^m obtterred. Tlie contufiioti of the parts Tsrä«9 
lirrenlly, as does alao tJie cfftiaion of blood. Tbc bead of lite booo 



nBDncriQX or diblocitioksl 



24S 



not tUvrmy* remain at ifie potnt wlicro it «tcnpus from the ruptiirod 
vnpsuli*, but in many cubcs it is bigbcr, lower, or lo one »ide, lui Ibu 
musolcs nttadiol to it contract and dispboe it. It ii important to 
Lnonr tliat vre must trt-quently brin^ the luxated 1ic>ad of tli« bone info 
a diiGercnt position before we on cnrry it bark tliruiigb llic ojxming 
ia tbe capsule into tli« articiilnr cnriiy. 

Occasionally, by «oiue accidi>ntal muscular action, tbc diBlonition 

b spontnncously reduced. In iLo »boulder, utpccially, tlii» bas been 

ob*en-cd several tim(^s, But 8\icb epootaocous redactiona are very 

mr«, berausc tbere nro usually certain niGcIiiinical ubatxutrtiotiH (o ttw? 

n-duction, nbicb must bo overcome by skilful mampulaüon. Tliese 

^^^ndcrances consist partly in contraction of tlio muscles, by wbiob the 

^Head of tbc bone may bo cauglit between tu-o contracted muscles ; 

^Knodipr far more frequent oWtade is a small capsular ojiening, or ita 

^■Kolusioii by tbc vutranvc of tlic soft purls. E^istly, nrrlain tCDslons 

of the cnpsulor or slrcnglbcning ligamcnta may Iihuler tb« reposition 

of recent traumalic luxations. 

In trcatit^ a lu.vation it must lirst be skilfully reduced, and then 
gfieftos bo employed for rcBtoring tlio funetion of th« injured limb. 
•^V« shall here only «peak of the reduction of recent diRlocntions, by 
«rbich wo mciui those that are at most eight days old. The moft 
^vonble time for reducing- a dii>1ocation i« immediately aflor Ihe in- 
^i.irj' ; then we have tbe lea«t swelling of the soft parts, und little or 
^o d^ilocctiicnt of the luxated head of tho bone; tlic patient is still 
"ly and pbj&icatly relaxed from the accident', so that the rcposi- 
,.:» is not nnfrequently vctv easy ; later, we sliall often have to &cili- 
(ellieopi?nitionby rasorting^ to anT'stlicUrs to remove tbcoppontlon 
tlw »uwli;?. Regarding Ibc proper msnonivres for tho reduction, 
«ream say but littlii in general terms, for tbia of course depends en- 
tirety cw the meeliaitisra of the different juiiits. Formerly, it was a 
p=n«al rule, fiu- Üic reduction of dislocations, that the limb should be 
liirooglit into tlie poftitien in wlueb it was at the moment of the dislo- 
cntJoa, to that by traction the head of the bone might be replaced as 
it lad escaped. This nila is only important in a few casca ; at present, 
in tlie different dislocationa we are more apt to resort to reij- diSorcnt 
motion«, Kueb ns flexion, byper-extensiun, abduction, adduction, eleva- 
tion^ PIC Usually, tlie aurgcon directs tbc assistants to make these 
"»otioo», mjd bmiaelf puivhea the head of the bone into place when it 
i^«B Wen brought before tlio articular eavity. 

SWqucntly the surgeon alone can accomplich the reduction. I 

often tbiM reduced a dislocation of tbc thigh over wbiob i-arious 

'l*otlMgoes, aided by muscular laborers, had worked In vain for Itoura, 

'*> AcK oaaea, eveiy thing depends on correct aoatomieat knowledge. 




810 



DIJCRIES OF THE JOINTS. 



TLod you miiy readily understand tliat in a certain dinwtioo yon oaj 
uot uiifrvqucnlly slip the bend of Übe bono Into place witfa vay liUw 
foroc^ ■Khüti in uioUicr positioa it might be entirely tmpoBsiblc. Wim 
tlu) head of tlio bono enters tlie arLicitlor cavity, it oocmBiooally exaaet 
a perceptible snap; but this docs not slwnya occur; we nro onlypo- 
fcctly assured of successful reposition by tbo rüstoration of nonnil 
mobility. 

It' we do not succeed alonr-, or witb a few aasistaots, uro hiR 
vuriuiu nid», by npplyjni; Jong- aiiuffi to Ute limb, and having sovonl 
assiittant« draw in one direction. This traction, which of course nnat 
be opposed by a couater«xteB5ion of tlw body, must bo regular, M 
by slarts. If wc do not Slioceed, even in this way, wc call in the üi 
of machinery to increiM the power For this purpose ranom instiu- 
inentA were formerly employed, suoh as the lever, screw, ladders, &c. 
Xow tbe multiplying^ pulleys, or ScAneldar-Xisnei't estcusioD^ppon- 
hu, ia almost exclusively uslhI. Tbc multiplying pulleys, an instn- 
ment that you nlrna^Iy Itnow from your .itudics in phyüos, bir inore«- 
tag power, and wliieb Is greatly retturted to in medumtn, arc used H 
fullows ; Oiic end of the rope is fiiatcn<xl to a strong hook in tbo wiH 
whild the otltor is applied to the bmb by stmps ami ImicUIca. Couatar 
extension ia made on the body of the patient, so that It shall DOl 
be moved by tlio extension. An aulslaut draws on tbe pulley«, 
M-hose power of couTM inereoaes with tlie number of collan employed. 
Schneider-MeneCt npp«mtus consifits of a strong gallows, to the inner 
aide of ouc post of which is attached a movable windlass, wbidi mar 
be turned by a handle and held by a tootbcd wheel ; ovet tbia wiud- 
liiES nmti a strap wbieh is attached by a boolc (o a bandage applied 
oiound the luxated extrcniily. In luxation of the lower extremity the 
{Ntticnt lies on a tabic plaocd IcngtliwLae between the posts uT the gal- 
lows, or for reduction of an arm he may be seated on a chair placed 
the same way; the counler^xteuston is made by 8tn|» by wbiob the 
patient is fjuttened to tlic other post of Hia gnllows. Botb uf thcs« 
apparatuses have oertaiu advantages, but both arc troublesome to ap- 
ply. In your praetioe you will have little to do with tlicin, as they 
are almost oxclusivcly employed in old (ÜHlooitions wlioMs tntatinent 
ia more rarely undertaken in private praotioe than in hiMpit^li ant! 
surgical clinics. 

At prceentf when wc undertake this forcible reduction, it is alwaj*» 
ander the influence of nnoslhctics. To produce complete relaxation 
tili» an.-i^thesia must be vt>ry jirofuund, and, as tbe eli'<«t is ofloa cov- 
ered witb straps ai)d girdles for countcrcstension, thu anjostbctio 
must be very carcTully employed to avoid dangerous rosult«L But 
there are also other dangers whioli were loiown to tbe older suf^coiw, 




REDDCTION Üf PtStOCATlUXä 



M7 



rlio did Dot u:e chlorofbna. Tliese are ss Ibllaws: If tlio paUuot is 

too long with Ibcsc powerful rcntedies, he maj' siidctetil/ collapse 

die ; morcovof, ibe Umb aitiy becouio guogn'ouua froin Uic preao- 

■ of tbe Straps, or tJiere mav be Rubcutancous ruptur« of \iixge nerves 

veaacli, and consequent pamlysis, tmumatio uiieuiisin, exteiiRiv« 

>anlion, and olber dun^croiu local accidents. The rcjsulta of 

prcMure from the appliances mar best be avoided b; applying a moist 

roUer-baoiUgc! from below upward, and fastening tlie straps over this. 

a regular pressure is Üiiis mailc over Üic eiilirc l!mh, tlic prc&s- 

' of tlie apf^iance doea above tbc joint docs not prove so injurious. 

lie time dnriog wliidi we ninv eoiitintio ilic«c forcible attempts at 

laoemeoi abould be at most half nu hour; if wu do not sucetxMl lu 

bis time, wo may be pretty certain of not doing so at aU. If wc 

to try further in such oases, wo shotild resort to sumo otlier 

stliod. Until recently, we hnd no measure of (be force that could 

used without danger, and liad to couteut ourselves with estimating 

It soeinf scarcely possible, by Uic abore means, to tear out an 

or a leg j but not lotig since this did occur In Paris, and in a case 

odly manaal cxtcoaion was employed I OcncraJly, llie stnips 

sooner, or tba buokloa bond. Subeulaneou» mplurea of tbe ncrre» 

veswU would scaroely be caused in a healthy ann by regular trao- 

oa tbo whole extremity ; but Ibcy may tear, when adherent to 

sp cicatrices, and arc 60 atropluod os to have tost their normal eins- 

ity. If, under audi drcumstancCfi, the oonditious could slunys br; 

stcly ap)xeciated bofofcltand, wc should frequently entirely ab- 

. Croia attcmpla at reduction ; lor. in sudi caso^ rtipturo of a nerve 

' reAsel Duy fi^w attempts at repo&itioo with the Iiaud, and wu 

it refer tlie occtdeot to tlie macbincr}'. An instrument has been 

ranted, by whose aid the fum: employed in extension may bo meaa- 

Tiiis instrument should be inserted in the extension-appamtug, 

the furcQ etnpluycd in wulglit, as is cii.'<tomaiy in physics. 

ag to jlfaf'jaign^ wc should nut go above two hundred kilo- 

. with tills dynamometer; but such directions arc of counM! 

sly approiiinatire. 



If tbc reduction has been socompliahcd, the main point has cor- 

Jy been gained, but some time ia still required for full return of 

fisnetion of tbe limb. . The wound in the capsule nuist beul, fr>r 

jch purpow perfect t^^t of the joint for « longer or »liwter time is 

«itc. After rcpoeiUun tbcic is always niodcnttu inflaninuilion of 

1 8/noriiil metpbrane, with a EJigbt effusion of tluid into the joint, 

the latter remains for a time painful, stiff, and unwieldy. If re- 

L-tiriQ bascloaely followed the injury,tho joint must first Iw kept per- 



348 



INJÜBIBS OF TUE JOINTS. 



fectlxi^'C^t '^ ^ siirrounilixt with moist bondages» and coM comptcsu 
Bre Applied; the swelling 19 rarely so gre«l as to demuid otbcf uti> 
phlogifttic rem<^ies. Tn ilie shimlder-jViiut after ten to Iburtceu 0»yt we 
be^io pBAsive motion mid coiitiuue it till ai.'livc uiovument« ru be 
made and tho ano w fully useful ; frcqucDtly, it is manjmonths Met« 
niürüiuotita ara quit« free, atid t.'lL>raliiig tliu arm in tlio lust niotioo to 
i\:tum. In other joints that liarc Icsa mobility, active moTcmciil« 
may bc penuiltcd much sooner ; tlius they are restored especially cariy 
in the elbow and bipjoints, and io the latter joints ire may permit 
«tlcnipta a), motion tlje earlier, because there luialions do not H 
itiodily recur. 

If active tnot-ioDs bo permitted too soon after reduction ot a di» 
location, especially in those joints where dislocation readily recurf^M 
in tho bhoiildrr tu>d lon'cr jaiv, and If the luxation recurs once or ser- 
cml times before the cnpftular opening has healed, occmsionally th« 
wpsule does not heal completely, or Üiere is so much di^teiisibnily tt 
the copsutar cicatrix that tJic patient only hua to make a oorclcM 
nwtioa to luxate tho part ngsin. Then wo bare the state called 
habitual lujcatio», a reiy annoying elate, pspecjaljy in the lower jaw. 
I knew a woman wlio had a dislocation of the jaw and did oot lake 
care of hcraelf long^ enough afterward, so (bat it sooa relumed and 
Itail to be reduced nguiir ; the enpsulo waa eo mneh etn_>tohed that, K, 
ill eating, she took too large a morsel of food bctncL-o thv back teeth, 
ahc at once luxated the jaw ; she accustomed herself to the tnanatane 
of slipping it into place, so tliat she could do it with the grenteet 
fiicility. Sui'h an habitual luxation of tlie alioulflcj- may occur In tbe 
same way. I have eecn a younf; man, who, when ^esticulattnfr vio 
Icntly, had c«rofuIly to avoid mising his arm quickly, as ho almoct 
always dislocated it by thi« motion j such a state is vucy anDoyin^, 
and is difficult to cure; rcroTciy would only bc posable by long^ 
rest of tlio joint, but patients rarely have inclination or patience ft« 
this treatment. It t» welt for eueb patients to wear a bondage thai 
will prevent Ufiinjf or throwing back the arm too much ; if iJie laxa- 
tioo be avoided for a few years, it will not recur BO readily. 

If a simple du^loeation be not peeogtiizcd and reilueed, or i^ for 
various reasons, we cannot reduce it, a certain amount of mobiUtjr is 
oerertlidess restored, which may be considerably increased by regu- 
lar tne. From the relation of Die head of the bone to adjnocnt bouy 
processes, and from displacement of muscl««, it may be readily uoder- 
stood UuLt, for purely niechuuiail reasons, certwn motions will be iin- 
poMible, while otbera mny approximate tJie normal nvobillty. But, 
if the movements be not methodically restored, the limb remains slitT, 
the muscles become atroj>hied, and tlic limb is of Uttlo use. Tint 



OflAVGES m OLD LUXATIONS. 



340 



aoatomiciU rhaiifri-a iti tlie joiitt and purls arouDtl arc as follows : the 
estnTSMted blood U roabaorbod; the cnpeulo folds togeUier and 
•trophies ; iha head of the bono rests iigiiiiist some bone in the TidD- 
ity of the articulating c-tritj ; for instance, in luiatioa of the biiinenM 
inirard against tbe Hba under the pcctonlis major, tlio soft part« 
about tbe dislomled bead bcconi« infiltrated with plaütic Ijrtnph nntl 
transforai to dcatricial connective tissue, whidt partly oAsiJies, bo 
th»t a eovt of bony articular cavity again forms, wbilo tbc liend is 
surrounded by a newly-formed conneetire-tissue cnpe>^i(.\ lu tbu 
fmrtUogc of the head of the bone, tJie falloving cbnngcs vlsililc io Uic 
lukcd eye ooour: the cartQaf^ bcoomcs rough, fibrous, aud gmvn 
mdhentul to llta parts on wlmib it lie«, by a äcotxiclulj finn connective 
ttraoc. Id lb« course of time tkis adlii'^ion brocmes wtj fimi, espe- 
cially if not dieturbcd by uoTcmcpte. The tactanior]>liosis of carlilage 
to oonneeti ve tissue, followed loicroacopiciJIy, tskes place as fuUows : 
the cartflnge-tissuc diridcs dirootly into fine filnmentA, so that tbß 
Uasue ac<|uirca lirst the appcarsnce of fibrous cartilage, ihon of ordi- 
nary eicatrii^iid conneotire tissue, which unit»i witli the ports around 
anci receires veMels from tbcm. Tbe surrounding muscles, as far as 
tlicy aru not torn, loae a large juari of tbcir lUanents, partly from 
moleculiu- dicinte^ration, partly from fatty metamorphosis of the oon- 
trartilc sobslam^' ; ftiilis«t)ueiilly, new iinj:»cular filiimenta funn in 
tbeac niu5CuUr cicat fid's. 

This is what wo call an old laxstion, and it is in sacli cases espe- 
cially that the above methods of Ebroible reduction are employed. 
Tbe (luesiioo, how long a Inxatifin nnust ha%'e existed before ii« rcpo- 
sit>oii is to be oocLtidercd impossible, cannot be answered tinec tlio 
introduction of chlorofonn, and is to be dilTerenlly answered lor the 
Tiiriou5 joints. Thus, dislocalions of the shoulder may be reduced after 
existing for years, wbüo those of the hip-joint two or three months 
«Id are reduced with difficulty. The chief obstacle lies in the firm 
adbealona of the bend of tbe bone in its new position, ami in the loos 
of oonlractUity of the mu»cles, and their degeneration to connective 
tissue. Another question is, whether, wben such old dislocatiuns an* 
Tcduppd, we attain the dcurcd effect on the funeb'oo, especially in the 
shoulder. Imagine that the small arlieuUting eerily is tilled by the 
atjophied capsuli), and tliat the head of the bone lias to6t its cartilage, . 
then, f*Ten if we sueoccd in baringini; the he-jid to Us nonuul poeiUoDf : 
wsJoratioii of function may still be impossiltle, and I cnn assure you, 
from my own experieaec, tliat the finid result of a very tireicjiiiu uud 
long aficr-lJcatm>N)t in such nmaea docs not always rcjHiy the paticoce 
•nd perseverance of the jialieiit and surgeoa. In such cascs, the result 
wiQ icarrely be mme lavornhli? Uiau if the jialicnt trie-«, by nietbodtcal 



S50 



CfJtnUBS OP TOB JOINTS. 



cxcTciso, to malto his limb m useful 83 poe&ible tn it« new poettio^ 
which it may have occupied for montli» or yeuK Vi'e majr &cÜitale 
this exercise bybrealdng^up the adh<'«ion8 about tbc bead of the Voc^ 
by rotating it forcibly while tbc patient is aiuMlbctizcd. li^ u oo» 
Bionally happras in ahouldcr-dtslocstions, tho bfs<I of ihe bono fal id 
nbaononl positinn so presses on the braohial plexus as to cause psnlj;^ 
eis of tbo um, if rciluction be impnesililc, it niay be advifiablo to moke 
un incisioa down to the bead of tho booe to dissect it out and sa« \H 
ofT, L e., to nudte a regular resertion of the bead of the bumfnn. 1 
Iiuvc ei>i'ii a ease wbcre,in annplcto paralyiris of tbe nnn nfcor a luu- 
fion of the liiimenis downward and iamud, decided iraprorcmeRt e( 
(he fuQction of the arm wax attained by tlie above Operation, altboo^ 
there wna Dot complete rtwn-cry of tbc paralysis. 



COMPLICATED DISLOCATIONS. 

A dinlocatioa may be ootnplicnted in vniioos ways ; most tr» 
qucntly witb partial or entire fracture of the bead of tbe bone, irUdi 
is difficult to cure, luid lu which repOsiüoa is often only partly sue- 
eessful; in trentineiil, nCleDtion must a)tvu^-8 be paid to tlie fracture; 
i. e., a dressing must bo worn till the fracture baa united. At tht 
same time it is advisable to renew tbe dressing frequently, i^y tmrj 
week, and to sjiply it in a different poaition each time, bo that tbe 
joint may not lircome stiff". Nevertheless, we cannot always «uooetd 
iu attaining p(;rfect mobility, so that I can only adviuo you io jMir 
practice always to give a douhtfiil prognosis in such eases. 

Another complication is a ooincidcnt wound of the Joint, JVjr 
instanc-t:, tbii broad itriicultir surface of the lower ei^iphyais of the 
bumcTUs or of llie mditi« may be rlriren nut of tl*e joint with swlt 
force as to tear through the soft parts ami skin, and tie exposed. 

Of conrsc the diafiiuoeis is easy in such rases ; icpositioo is aooofo* 
pushed according to the above rules, but vrr; still hare a wound of tbe 
jotut; and we are liable to all the chances spoken of under wounds 
of joints, so tbat for the pro^osis, the Tarieties of the poeaihlo rcaults 
and the tj<?otmc»t, I refer you to what has nlrondy been said (p. 284). 
Of course, it is worse whnn llion) is nn open fi-aetiu«tliroiigh tbe joilii; 
hero wc can neither expect mpid eloeiirL- of the wound nor restoratron 
of the function of the joint, and wc run all tbc dangers that threaten 
ooniplicBted open fractures and wounds of joints. "Hie deciskio as to 
what must be done in such cases is cn^y, whcti there is at tbc same 
time considerable cmahing or tearing of the soft parts; under such 
otrcumstances, priinary atnputatiou must bo done. If the injurj' of 



J 



CONOSKITAL LCXATIOXS. 



Ml 



' «oA parta be not great, wo maj eomctimcs bopc for a cure hy 
' ItgipunititKi, with a subsequent stiff joint; but, u pxpcnence shows, 
this is always a tlaiigtrroua cxpcritncntt According to the principles 
of mociera txti^cry, in eiich caecs vre avoid amputation by dissecting 
ODt and aan-iug ufT the fractured articular ends of thß hones tm as to 
Hake ■ simple wound. Tttia in llie regular (otai resection of a joint, 
an opcratioo coaccminj; whieK very vxtenaive obscrvntioiui Lore been 
made during the last twenty jcars, and of which modem times i« 
justly proud ; by its mean» tnaoy limbs have been preserved, which, 
acocrdiug to th« old rule« of surgery, should unlicsitaliugly have bci-n 
amputated. 

In regard to their danger, tlicse resections vary greatly according 
to the joint on which tbey are tmide, so that It is diilicult to make any 
genenl remarks about tbrm. But, in a suljscqtiont s<>ation (in the 
tveetment of chronie fungous disease« of the joiuts), we sbnll study 
this roty importitnt jmint more carefully ; -wliat has been said will giro 
J-OÖ a general idea of a resection of the joint. 



COirOEXrFAL LUXATIOA-8. 

Congenital luxations arc rare, and we must dUtlnguinh them from 

inter partum aegm-tit<f, i. e., those that have resulted at 

birth from manceurres in ejctraeting the ebild, and whieh ate merely 

ipio tmumaUc luxation» which may he rwhice*! and ewred. Al- 

congentlAl litxat*oa& have been observed in moat of the jnints 

' the extremities, they are pnrtieularly frequent in tiie tliigh, and not 

ifrequently occur on bolli sides nt the same time. The head of the 

■Viae stands somewhat above and behind the acetabulum, hut in many 

. It ean readily bo replaced. As a rule, the disease is flntt notice«! 

^^hen the child begins tu walk. 'I'he most noticeable sinnptom is a 

^Becoliu wabbling gait, which is caused by the bead of the bone 

standing behind the aeotabulum so thiit the pelvis ini.-lineH fom-ard, 

aiid also because in walking the head of the thigh mores up and down ; 

ere ia never any pain. To examine the child more accurately, yc u 

Bay uiielottie it entirely ami watch its gait ; then lay it on the bock 

!id contpwe the length and [losition of the exlremitii^ If the luxa 

OQ be oue-oideil, the luxulcd limb will be shorter than the other.and 

foot tumod inward ; If you fix the pelvis, you may often reduce 

the dialni-ation by simple tinetiou downward, l^ic anatomical exami- 

aatioa of such joints has led to the following results : not only la the 

liead of the bone out uf the socket, but the socket is irregularly 

IbcBied— ton shallop- ; later in life, in adults, it is greatly comprrsaed 





»52 



1KJÜBIE8 OP TBK JOISTS. 



and filkid witli (at ; ulicn tiitiligamonluin teres exists, ft U abnotnuJI^ 
long ; tbc head of tbc bone is not propurtjr developed ; in »ome cam 
it u not luilf as largo as itorm«l ; ttia artieular e&itUago ia uatMOy 
completely form«], tbe oapBulo very large and relaxed. 

Uiuler such circumstances, jou ma/ understand that it is eic«M^ 
inj^j- dilljcull, in must cases tiupo&sible, to effect a cure. If tbe brad 
he onlj partialljr dcrcloped, tbo upper bordßr of llie njietabulum kI> 
Bcot, and tlio capsule enontioti»Iy dist«iif1ei1, how sliall we restore Um 
normal copditJoiu ¥ A» to tbe caucus of tliis malfonaation, tbo moat 
varied hypotheses hare been adranced ; the oj^rtiinity has never 
iMMurred of atud^'io^ it in tbe embryo. There is sn arrest of develc^ 
nient from some cause. It is assunicd that these disturbanore Collownl 
prcTJous pathologic»! proees»«« in the foetus, and the most probable 
hypotbesB is that, in verf earty embryonal life, tbo joint was Gllad 
with an nbiiomial qtiantitj- of fluid» and so dialcndcd as to indace np- 
tiirc or at least great dilatation of the capitule. AoMj>thin1c« that 
abuomml intn-utorinc positions nuij- give rise to tlicso Inxatioiw. 

Cure of this state Itas been attempted in those cases vberc dinct 
examination has shown tbo existence of a tolembly-dcvclopcd beail 
In such cnscs the luxation has bi>en rttluced, and attempts made to 
preserve tlic normal position of the thigh hy aid of dressing or botut 
af:«s — the child beinj; kept quiet for a year or more. The result «I 
this treatment, which requires great patience on the part of tbe sur- • 
geon and parents of the child, in shown by experience to be only 
partially satisfactory, as after this ti-catmont there has only been 
impraretncnt of the gait, but nrely a perfect core ; and, vben you 
in ortbopcdic pamphlets of the frequent cure of congenita] luxation^ 
yon may be sure thai In most cose« tbere bare been errors uf 
nods, or there is intcutiooal deception. 

Congenital luxations of the thigh are never dangerous to life, 
since they are accompanied by a change in the centre of gravity 
tbc body, in tbc course of time they have an effect on tbe 
and curvature of the ve-rtebrol column ; this, and a liraj^g, wn' 
gail, are tlie only inconveniences tliey caiiite. There can only 
hope of Buoocssfol treatmeat in vciy early youth ; but, oa the w 
cannot promise ft suoocssfid result iu less ttuin one to throe years, 
patients arc put under treatment. 

I will here mention a very rare orcurrenoe, irliirli I batr i 
met with oitoe. In certain movements the tendon of the lonj; hv^ 
of the bicrpa bntchii may slip out of it« groove afid hang un Üio bop. 
der nf tlic greati-r or h-sacr tubercle ; then the arm stands filed !n ■ 
plightly abducted position. If wo hold the shoulder-blade steaify 
Bod relax the tendon by slowly misiog tbe arm, then by sJigfaily 



CONÖEITITAL LÜXATIONa 2S3 

rotfttiog the arm we can easily slip the tendon into place ; the pain 
ceasea at once, and all motions are free. For this luxation to occur, 
the Cascia-like memhrane vhich covers the sulcus must tear or be 
mach relaxed. The former is improbable ; where the latter is the 
case, the accident readily recurs. Some persons have the covering 
of the sulcus, in which the tibialis poaticua muscle lies, so relaxed 
that they can voluntarily luxate this tendon and let it snap into 
place with an audible sound. 

[Cases where the tendon of the quadriceps femoris and patella 
nuy be voluntarily luxated and snapped back into place are prob- 
tbly less rare. The translator, among other cases, has had one pa- 
teat 18 months old who could do this at pleasure, and when irritated 
tbout any thing would snap his patella even if his leg were firmly 
held. This leg having been placed in a plaster dressing, he began 
the »nie performance with the other leg. Then both legs were left 
ttee, and after some weeks, when his general health and temper im- 
proved, the phenomenon ceased,] 



18 



\ 



cnAPiER via 

G UN8S0TW0 UND 8. 



LECTURE XIX. 

bialcricol Bcniukdi.— Iiqnrüa ftom Iatk" UIuIIm.— Taiiou Fent» of BullBt-lToai^ 
— Troiupnuüon tää Can »t ih» Wonsded in the Tlilil Tiiiliiiiwl. Ciilil» 
ted Gunslio^FVMtiiTM. 

Ik war many injuries ocour that &re to bo cUs8«d atooof; sim^ile 
incised, cut, punctured, nnd contused wounds ; gun!ihot*wounda tl«D> 
selves must be classed witli contused wouii<la; but Uie/ baw tone 
peculiarities that entitle thein to sepurul« ooiui<Ieratioii, io doing 
wbich wo must Lriufly come in ountaot with the domain of mililDj 
surgery. Siucc 6rc-anns wore £rat used in warfare (133d), gundtfr 
wounds havo roceired special attention from surgical writei», eo lUt 
the literature on this mbjoot liaa Iteoooie Teij eztcosive ; of Ute, it- 
deed, military surgeiy ha« been made almost a sqwiate branch, whU 
includes ifae care of Boldicrs in peace and war, aod the special brKittK 
and dictctjc rules which are so important in barracks, in etationtij 
and Beld hospitals, also the olothing and food. Although the RotuU) 
u was mentioned in the introductioD, bad sorgeons appoiotod 1ft tltt 
«täte nilh the anny, in tho middle ages it was more oonmon for tnoj 
leader of a troop to have a private doctor, whn, with one or tf*t 
sasistaDts, very imperfectly took care of the soldiers sfltr a baUlr, 
aad thes uttuüly went on with the army, teariug tbo wouadcd to Um 
care of compas^onato people, wllhout th« eonunnnder or tho trsj 
taking the respoDsihiltty. 

It was not till Btanding armies were formed that (Hirgeou mn 
detailed to certain hattnlJons niid cotniwiii«», and certain (still WT 
imperfect) mica and rcgulotiona were made for the care of tk* 
wounded. Tbc poeition of military surgeon was, in those dsjSi T^T 
if^noble, and such aa we do not hear of now ; for, eren in the tine of tke 
fiither of Frederick the Grcat^ tlio army surgeon wa« publidy flogg^ 
if be permitted one of the long grenadiers to die. At that time, irli^ 




VARIOUS PORÄS OF BUlLBT-WOimML 



S«» 



tlic troops marcbcd to meet the cocmj at a parade-step, the nio?e- 
ment« of the anay were very tedious auil s?(nr ; tlio large armies bad 
unmenae traiiu ; for iostaocc, in the Tliirt/ Vcura' Wilt, tlto Innoera cax- 
ried along Uteir wives and cliildrea tu muuiuvrable wagons; lieuce, in 
the medical arrangements pertaining to tlie train, tliere was no ne- 
oeaaity for greater faoilities of motion, l^ie tftcLics started hj FVed> 
ericlc tUc Great Tcquiicd greater luuliility of tho bcarj trains, whicli, 
bovercr, was only practically earned out in tlie French army iiiular 
^apdeoo. As long as a small province remained tli« seat of war 
(loring a wbole campaign, a Sew largo Iiospitals in neighboring cities 
uigfat suffice ; but, when armies moved about rapidly and bsd a fight 
now liere now ibere, it became necessary to fumisli more movable, 
sooallcd field boapitals, not far from the field of battle, and wliicli 
oould be rcndily moved from place to place. These ambulances, or 
6ying boepilols, aro tbe idc« of Goe of the greatest of surgeon», Xar* 
ny, of whom wc baro already spoken. As I slioll shortly tell you 
what is done irith the wounded from the time they arc injured tül 
they enter tit« general hospital, I will here dismiss this subject, and 
only oKBlJaD some of the ntany cjicellcnt works on military surgeay. 
£«pecuUy interceting, tK>t only medically but liiatoricoUy, ore the 
somevhat lengtliy " Memoirs of Larrey," iu which I especially recom- 
tneod to you the Egyptian und Itussiau campaijrua. These memoirs 
tontain all Nupolcou'e campaigns. Another excellent work we have 
^^in Engliäh literature, Jo/m JTeitnvnU "Principles of Military Sui^ 
^■|ery ;" and in Gemian, besides many other excellent wotlcs, wc hare 
^"*The Maxims of Military Surgery," by StromeycTt which is composed 
chicily of experience« in the Sohleawig^HoIstoin TrVar ; and, lastly, 
'* Principles of Gential Military Surgery, from Reiiiinisoenoes in the 
nad Caucoeu*, and in the Hoopital," by Jh. Jpiroffoff. 
'Wounds caused by largo missiles, such a« cannon-balls, grcnndc8| 
dIs, sbmpnel, etc., are partly of such a nature that they kill iit once, 
olhcr cases tear off whole c^tit^mtics, or so ahattcr them tlint oto- 
poialxm is the only remedy. The extensive tearing and crushing 
uMSilfrt by these shot do not differ firom other large crushed wounds 
allied by mwhinery, which unfortunately now ho often occur in 
k^pnetice. 

Musket-balU used in modem warfare «fiffer in some tespcot«: 
wUle the small copper bullet« with whEch Ute Ctroa&siaiis shoot are 
wuedy larger than our KHsllcd buckshot, large, hoQow, leaden bii)> 
Irtivcre used in llie late Ilaliuu W'ur; these were amcli larger than 
IIa old-faahioDed ones, and were particularly danf^rouft, because they 
MdUy broke npoo striking a bono or tenso tendon. Besides these, 
the solid round ai>d coniual bullet are tiscd, but their cQects do not 




inniasoT-woimD& 

Pw. in. 






» CbMNf^*; ft, B»«d> H Ba; • ■Hw I»»q»« |t s)9i ll lwi EManI M» 

diffr-r inueh. Tim Prusaian loog buUct, tvliicb la bnld in tlie ouiiidjg« 
of tlie noedlc-gun, i» u solid bullvt of the form xiid sue of aa 
You must Dot tliiok that the projectile^ as found iii the wound, baa 
Bame eliape as wbcn put in the gun ; but it is changed ia Cmid u b 
comes out of the nfles of tlio gtm, a»d is also Battened iq the wout dF-»^ 7 

so tbat wc ofwn find it a shapeless mass of lead,iirbiah scarooly' ^ 

tbe form of tbo projectile. M'e shall now bricflj oonsklcr the 
injuries tbat may be caused by a bullet ; to doing wfakb, we 
usturally confine ouraeJrei to the cblef hum. 

In one act of oases tbe buUot make« do wound, but simply a n^^^ 
(uHon of the Aoft parts, accompanied br freat suggillation awl 00*«^ 
sionally by subcutaneous fracture. According to recent autbociti,^ 
ahi^lo subcutaneous Iracturca arc not very unooimnoii in war. Tlk«ev 
injuries arc Cnused by spent bullet«, i. e., such as cOmc from a long d» 
tanco and bare not force enough to peoetnito tbe skin ; such a bolJi^ 
strikiiig orer tbo liver, may push t)ie skin before it and make a depf- 
sionin or a rupturcof tli«livc-r,and then tdl bade without prodoeiai; 1.1 
external wound. Like injuries are caused by bullots striking the li 
at a veiy oblique angle. Firm bodies, such ss nstcbcs, pocket-buoU. 
ootiis, leather straps on Ibo unifonn, etc, may also arrest the boUn. 
Those oODtosed wounds, which, especially when aOeotiiig tba abdoaxA 
or thorax, mey prove very dangerous, hare always excited the atlai> 
ttoR of surgeons and soldiers; formerly tbey were always rcferrod 
the so-called " wind of the ball," atMl it was thought that tbry n 
caused by tbo bullet passing very close to tbe body, lite idea 
injuries could bo caused in this way was so firmly ostabliahed, 
oven very weI14nformcd persons worried thems<-lTes in trjing lo 
plain theoretically how they resulted from the wind of the bnll. ' 
said that the air in front of and near tbe bullet was ao com] 



I 



VARIOUä F0SM8 OF BÜLLET-WOrXDS. Uf 

ifluiDJuiy was due to this pressure; anotiier thought Ibat, from 
the frictioD in the barrel of tho gun, tbo bullet tns charged 'with 
«Icctricitj, and could in some unknown manner cause contusioa tnd 
bumiug at a certain distance. If the ooaclusion tliat the whole id«« 
of the wind of balb vras a Cablo hjid been Arrived at sooner, Uiesc 
Aotutio theories vould oot have arisen. Contustoos from spent and 
oblique bullets are to be treated like other contuHions. 

In the second case, the btiliet ilix's not enter the soft parts de^y, 
1>ut carrici tnuj part of the skin from the Burfiaoe of the body, l«aring 
« gutter or fnrrow. l^iis variety of gunshot-uTiund b one of the 
eü;jrfatr3t, unlthss, as nuij happen in the head, thu bone is i^rozcd bj 
<ho bidlcl, and portions of lend romiiin in tlic skiilL 

The tbifd ca&e is where tbo bullet enters the skin wil-buiit escap- 
ing agun ; tbo buUct enters and generally remains in the soft parts ; 
it mokes a tubular wound. Various other foreign bodies may be cnr- 
Tic^d into these wounds, such as portions of umform, clotl^ leather, 
Itultoos, etc ; a booo may also be spUutcrcd, and t he splinters driven 
Into the wound and tear it. After perforating the »kin and soft 
jiarts, the bullet niight rebound from a bone and fnll out of the some 
opening, so that you would not find it in Llie wound, in spite of there 
iKiDg only DDO opening. The wound that tlic bullet mi^cs on entering 
the Ixxly is osually round, corresponding to the shape of the; ball ; its 
«dges are contused, occasionally blu»h-black, and somewhat inverted. 
Tliesa characteristics hold in the majority of cases, but are not sb> 

The fourth and last ease is where the bullet enters at one point and 
at another. If the oounio of the wound is entirely throogh 
soft parts, sod the bidlet baa carried in do foreign body, the point 
axit is osoally smaller than tlie entmnce, and is more like a tear. 
If tbe bullet has stnick a bone and dr!\*eD hone-spIintcrs or other tor* 
ögn body bc£i>re it, the point of exit is oocssiouulty much larger than 
(he entrance ; there may also bo two or more points of exit frum 
limiting of the bullet into several pieces or from scTcml splintcra of 
bone Lastly, splinters of bon« may make openings of exit like those 
from a buDet, while the latter, or jurt of i1, remains in the wound. 
Too much valnc has been attucbcd to the distinction of the openings 
t/f cntranoe and exit ; this is only important in forensic cases, where 
xt may be desirable to know from wliich side the bullet came, as this 
inay give a dew to the author of tlie injury. The course of the bullet 
tlraough the deep parte is occttsiooally very peculiar i its course is some* 
Ifanea deviated by booes or .tense tendons and faücim, so that we 
should be greatly mistaken In supposing that the union of the pomta 
ttl entrsDOe and exit by a straight line always represented the coarse 





2118 



GDMeOT-WOUNTJÄ 



nf Uic bullet. Id lliis respect, Ute enciraling of tlie akull and tJioru 
is most pcCTiliar : for ioalaac«, a buUct strikes llift »teraum obliqudj, 
but without sufficient force to perforate this bone; tlie btilleL taa,j 
nin iiluiig a Hb HiiiJer ilie akin to the side of tbc thorax, or cvan to 
the Rpiiml column, before escaping ftgniii ; from tbc poeitioD of Um 
points of entry and exit, we might suppose llie bullet had passed, 
dhvciljr through Uie cheet, and be grcottj ostoabbcd wbcn «nb 
pnticnts come, witltout Any difftcultjr of breathing, to bara their wound 
dress«]. 

The coinplicatluu of guoshot'wounds with bun» by powder, fucli 
IB result« from ehoottng at close quarters, rurcly occurs iu war. li ä 
not nire iu esses of accidenta trom CArelef^s hnndling or buTBUog- of 
firfsarniH, or from bUsLing, and nuiy cau:^ the g^cateal vnrietj- o( 
bum. The burnt pwHicUs of powder oft«n enter the skin. &ad bnl 
there, ginitg it a bluiith-btack appearance for tlic rest of life. Mora 
of thia in the diapluT uii bunu. 

1q giuufaot injuries, there is taid to bo »carccly any pftin ; the npidity 
of tbu Injury ix such tluit tho patient only feels a blow on tho side 
from wltich the bullet comcii, and docs not lor some time pcrcein the 
bleeding wound aod actual pain. There are numerous example» 
wbero conibulaTits haro received n shot, espednlly in the upper ex* 
trcmlt^, witliout knowing it till told by some OQC, or bantig tbeir 
attention attracted by t^e flow of blood. 

In gunshot, as in contused wotmds, the bleeding U usually IcM 
than in incised and punctured wounds ; but it would be a great n^ 
tukc to auppuso tiiat arteries which have boca shot through do oM 
bleed. On llie oontrnr)', many soldi«ra nei'cr leave the halUe-SeU, 
having died fiom rapid ha'inorrhage froui largo arteries. %Vhen one 
has Been a fully-divided carotid, subclavian, or fomotal artery Uecd, 
be will know that in s very short time the loas of blood will be e» 
great that the only hope of safety lies in immediate aid ; so that s 
hmuorrhage of two minutes* duration from on« of these arteries it 
certainly fktal. But arteries, even as Urge as the rndinl, often bleeJ 
but tittle. Tlie Gi«t surgeons wlio gave us descriptions of guoahot- 
wounds called attention to this poini. 

Before pas«ng to the treatment of gunshot-n*ounds, I would 
brii-lly pii-ture to you the transports tion of and first aid oSered to tlte 
wounded in bottk-. For the first aid there are uauaQy tHtabli^M^ 
certain tempomry plaecs for dressing the wo\ii»ic<1, in somo Bhelt«rcii 
place close bvliiud ihe lino of battle, usually in rear of the batteries i 
tliC6C arc designated by while Ahrs. Tbc wounded are first brough*^ 
to this spot, either by eoldiers or by a Iraiacd amlmlanee oorpe. Of 
course, those wounded slightly or in the upper extretiiitios walk to th^ 



CAEE OF THB WODKOED. 



ast 



cpot. 1ha ftmbulanc« corps has prorcd so cffioimt in bto wus Üint 
it will ocrtAinly bc more trusted to in future. It is cumpoecd of 
KiuTvcs trtiined to bring tlie wounded (rum Ibe field, iind, when ncccs- 
luy, to give tlicm tcmpwuj <"(!, as iu arrcstiiig bleeding from arte- 
riell anil wodDÜB, etCL They have becMi tnunod to cany a patioDt 
■bctwcco two of tbcm, citbcr witiiout other support, or oa an bnpro- 
-vised litter. For this latter purpose they usually cany a lanoo and a 
jileoe of cloth longer aod broader than the body. Tlie lanoea are 
jMXoed through hcma along the sidca of the cloth, and a barrow b 
tlius nitule ; bayonets or swords mny bo us«(l as pro\'isi(inal splints for 
snpporting a limb that has been badly shot. The wounded are thus 
1>roug{it to the dressbg-pUce, and the fint dressings are applied ; 
tbceo remain on till the patient teaches tlie ueanatfield-hoapituL At 
-the saiDQ time htemorrfaage Duat be securely arrested, and injured 
limbe 00 amngcd tlutt transportation may do »o harm; bullet», for^ 
oigD bodies, and l^ovo eptintccs of bone near the surfuce, should be 
rem o v e d, if it can be done quidtly and readily. IJmhs tlia.t bavo 
Iieea entirely cnisbcd by large shot should Ik* at oiioe ani]iulul<xl, if a 
Orraoiag caunot bc so applied as to render transportatius poesiblii. 
The chief object of tbi» drcsaixig-plnoo is to render the wuunded 
transportable ; hence it is not proper to do uuiny or tedious opcratiooB 
there. From tlic great pressure of the conataatly-iticroasiiig thraog 
from the front, only the most important cases can be attondcd to here, 
and Jfroj/ojf is right, though it seems cruel, when lie Bays die stir- 
geoDS should not cxluiust thvir strength on the mortally wounded and 
the dying. But, if possible, every pßticnt, when carried to the 
finld-hoüfütal, shouki receire a short written ocouuot of what wus 
^ibuntl at the fint cxaminatioo ; a card, containing a few wonls, llirust 
,feto one of Us pockets is enough. The chief point is to tell whetbet 
b«n has beoi extracted, whether a wound of the breast or abdo- 
lea Is perforating, elo., which will »nve lime to the surgeon at the 
ätal and pain to the patient. Part of the ambulance COrj» has 
the further duty of plsdng the wounded [Jpopcrly in wagons for fuN 
titer tnnsportatlon, xxmiei direction of the surgt'^a For this ptirpoee 
titere are special ambulances, coostntctcd most variously, which take 
some patients lying down, others Kitting up. There sre nircly enough 
of these, and it la often necessary to use oommoo wagons, covered 
.witb bay, stiaw, <>lc. Those wagons oourcy the wounded to the next 
'Id-hoApital, which is estaldished In a neighboring city or town - 
it (he larg««t »ttnlnahle rooms should bc taken. School-lioiiseti, 
iimdic«, or boms, may be seized, altbougli the latter ur« thii be»t. 
these places beds arc ptcparcd with straw, n few mattressc«, and 
lelothes. Surgooiu aod nurses await anxloualv Ike arrival of the 






200 



OülBHOT-WODÜI». 



first hwd of i>atieDts, having been a1r»adj^ noLiGcd of the coinmeooe- 
meat of the b*tt1e hy the thunder of the artillcT^. Here bt^oa tfe 
aocursto cxamiuAliuu of patieab, who were only temponrily dtesMd 
Otk the ßeld,aiMl her« operating gov» on mnaC KTtirely. AmputstioH; 
resections, extraelions uf bullets, etc, are dooe by irhok'sali?, xnd tit 
surgeon who lift» been anxious for his first operation on a liriog 
patient may opvralc till be 6top8 firotn cxhaustiott. Tiiis oonttoues 
till tat into ibc night ; the fight lusts till late in the evening, and it ii 
near tnoming bcfurc the last loads of «rotmded come in. "Widi bod 
lights, on a tcmpomry operating-table, and often with uosldlful DuriM 
for asustantfl, the surgeon must at oucc czainiue crery patient, down 
to tlie last, and then operate and dnss his wonnda. In tho fidd^H» 
pitala the wounded hayo a period of rest, aad, if possible, those irbo 
bsTO been operated on or are Beriouaty hurt should not be mored t9 
another hospital till healthy suppUTatloo h^ios and healing liai it 
least conunciiccd. "nita cuunot always be done. Owa&iomUly lb 
place where the field-hospital hns beea estaUifihod must be nested. 
If one helungs to the rai](ii)ishi>d party, and the enemy takes the plica 
where the field-hospital wius tustoblUhcd, thceurgeonaare usually tofca 
prisoners with their wounded- for, even when the enemy is u««! 
hunuine^ nfter n great battle there is often such a demand fur sn^geou 
that those! uf tho enemy caonot toko the pro{)er coro of woopded 
prisoners. A few yeara since, in Geneva, a oonvention of European 
poweiB detenmoed that xtirgeons und snnitiu-y xui^hca should be eon 
^Cred Beutral. Altliuugh there are some practical düBooltia i* 
carrying out this principle, it has don« great good in tiie wars of hte 
yean, and is capahlu of still further development. At all erenl«,(&e 
idea of considHring a wounded enemy as an enemy no longer, but u 
a patient, is lo be prized as a beautiful evidence of advaocing ht 
maoity. 

When the wounded have all been lirouglit under eovcr, bedded 
and the necessary operatioua done, and Ui« diet, etc, has been s^ 
tended to, arrangements should be made for their proper dlsposttiC'- 
Permanent oolleetJon of many wounded mou in one place is lujuriotA 
and, whim the scot of wax is a poor country, with few raürcMul et?"* 
neetioDs, tho care of the wounded is particularly diffictUt. Heo^^ 
tlioy should be sent off as soon as possible. This may he doac^ 
with the severely wounded, when there is a railroad hniuty ; whea 
transportation is less eonvenieat, the more slightly wouudcd at 
can be removed. Tliis system of seatteriog, wbic^ of lato luui 
conducted with eicellent rcsutts, requires great eircumspeotioa 
trouble itom the superior mcidicnl and military authorities, but It h. 
proved advantageous. If bouses (barracks), or, in summer, tents, 



TR£1TH£NT OP GÜN8nOT-WOÜSD9. 



201 



be creet«d for those remaimof;' — the severely Troundcd— tbnt Trill be 
best. If tbii be not practicable, tliey may be distributed in printe 
houseB ; it haa proved uo&dvissble to Icäre the wounded in sohool- 
hmises and cburches. 

The war Jo Vortli Ataerica, as well as that between Austria and 
Prussia in 184ß, abowcd that thcie were ntill tmpmrcraenta to be 
BMde io militArj sanitAry arrangement«. A factor has be«n added 
ibnt never Ix-fore came as an aid, namely, extensive asMstance from 
< tocictirs. Sisters of Cboritj, cdril surgeons, and many otlier persons 
■ who, either personally or bj money and »lores, aided iu tlic core of 
Htbewomidod. Wben this private aid ia pmperly oi^titzed, ander 
Hpropcr BWDagcraent of tlic military ofliccrB, it may bo very usefal. 
H Conocnüsj; the treatment of gunslioi-'n'ounds, views have i^rcAtly 
B cbaaged frooi time to time, aecordln^ to the point of view from whi^ 
H they were regarded. "ITic oldest suiecoos whose opiaions we have, 
~ eoftsidercd the« aa poisoned, and thought, cotiactioenlly^ that they 
ihciuld be livated with the hot imn oc boiling oil. The firrt to op- 
poeo this Ttew sucoe&sfully was Ambrose J\tri, whom you already 
know to bajo introduced tli« Uyiiture foe artenca. He relates that ia 
the campaign in Piedninnt (I53G) he ran short of oil for bumioj; the 
vounds, and be expected the death uf all llie p:iiieni3 who could not 
be treated ocoonling to the ntlca of tbo Umc But this did not bap- 
pen ; on the oontruiy, they did better than the chosen few on whom 
he used the remains of his oil. Thus a lurky aceident tnleisfaly Boon 
freed mediduc of this ai^rstition. I^ater it wa« very correctly ob- 
Brrred that the forest diffieul^ in healing gtinsbot-wonnda was due to 
lie narrowness of the canal, and attempts were miide to obviate this 
by pingging the wound with charpie or gentian-root. But sensible 
>Di sooo saw that tiät still more impeded the eseapo of pus 
im the deeper parts, uikI the correct view comineDced to make 
•omo headway, that a ^runahot-woimd was a tubular oonluacd wound. 
^Bbey sought to improve this in a peculiar way, by Inying down the 
^^Rile that every superficial gunshot-wound should bo laid open, the 
opraJng of a amal leading into the deeper parts was to be eittai^d 
by one or more indeions ; various tocthoda were propoeed for ohan- 
pstg the contused ivdund into a simple ineiscd wound by ihese in* 
ciaioiu, wbDe, in fiiet, the only thing that was done waa to add &u 
cised wound to tbe gunshot-wound. The case wu somewhat dif* 
lit when tbo rule was given to cut out tlic whole course of Iho 
and cIosR the rrauUing rnniil hr sutures and coinpreaees, so as 
obtain healing by first intention ; this proceeding cannot ofleo be 
applied, and obtain«! little reputation. Of late, since the treatment 
<k all wotmds is so much aimpUficd, tbc same thing lias hnitpened to 



S6S 



ODSSHOT-WOCJlDSi 



Fn. W. 



gunsliot-wounds whicb are trexlpil oq llie «ame gwoeral principleH as 
ooDtused wounds. In these, aa in otbcr woiioils, the first thing ts to 
arrest any artorial brrtnorrfiBgi;. Tbis is to be done noeontiag to the 
rules ntready givcit, ibt^ blne<]ing iirtory 
being tied eitlter iii the wound itaclf, or 
the ooireffponding- artonul trunk beiti^ 
ligatud in itti cuulinuitr ; toacfiotnpliab 
the former, it is generally iico-ssury to 
enlarge tlie opening uf fntnuice or exit, 
otlicrwisc we should not find the bleed- 
ing art«r;. If there he no hiemorrbiige, 
wc should examine the vruuiid, especially 
nay blind canal, for foreign bodice par- 
tirularly fur tlic bullet. Tills majr bu 
dull« most certainly with the finger; 
^ould it not be long enough, or sliould 
the dinal be too iinrrow, wc inay beat 
use n silver female catheter, with which 
Wc niuj tw] more certainly nnJ safely 
Uiuii Willi li ]nt»be; if wc fcfl the bullet, 
we try to remove it the shortest nay, 
that iti, either draw it out at the point 
of entrance, or, if it lies in a blind conal, 
close imder the bkiii, we uiukc an iiict- 
nion througb the skin and extraet it 
through this, thereby clian^iiig the blind 
ennal into a ooinplete one. The CKlrao- 
tion of bullets tlirougl» the opening of 
CDlraoce may he nindc by aid of apuon 
or forcopA-!tlin[>ed instrument«. Bullct- 
foreeps with lun;^, thin hiadea are often 
difficult to uac, because tbey euiinot be 
sufliuieutly opvued in the nurruw auial 
to seizft the bullet, bcnec many military 
aurgc-uns prefer the spoon-shaped iiislni- 
incut. Hueh a bullet scoop has lately 
been suggcstwl by Ä v, IiOngenbtck, 
and seems very practioal ; in it the 
spoon is movable eo aa to pass behind 

the bullet, and push it forwunl. Still bettor, it »ecm« to me, is 
recenüy-inveiiled American forceps, whuso peculiarity is that the^ 
can be o|K:ned even in a narrow canal, and they sehe very securely« 
If the bullet be lodged in u hone, wc may bore a bug gimlet into I 




It Co, of Bfar- Xart. «Kb 
prtnMfHrirlitirlriilMiI ~ 




TBEAIHENT OP COSSnOT-WOCXDa 



»8 



And try to eitract It in that w*y. If we do tx>t succeed in removing 
the bullet or other forci^ bodj b>- the opening of cDtruDoc, vre proceed 
to eoHargn it to gkia mora room >o u to ftpply ibo iostrumeDt« better. 
Tlie ezperieace tbat bullets nay oflen ramaUi In tbe bod^'witltout in- 
jiiTT shooM iram us against any violent opcrnlion tbat aims onl^ at 
tlieir extiaotioo. Hcnoo, lucmoribage and dÜEcult oxtracLion of for- 
mgD bodies ore tbe chief isdications for pritiury dilatation of gun&hot- 
woooda. later, other indications may arise to neceasitst« it ; but, in 
the gunshot-wound, auch ontargeiaent ia not neccflsary Jbr a cuie. Ulis 
lakes place by the throtrlng- off of a small ring-shaped cscbar, and the 
detachoKnt of gnng^ooua shreds from tbe track of tlie wound, till 
liealtfay in'anulation and mippuiuUoa b^to, ood the canal grnduaUy 
dose« from witbjn outward. In moAt eases the opening of exit 
cicatrizes before l)ie ontrunce, Ccrtuin obstacle« niuy stand in the 
vaj of this Donnal ooiii»o ; there may be deep progrcseirc iDltamma- 
tifloa, ivnderinfr nccessvy oew incisions and the einploytnent of lee, 
■8 ia other deep contosed voiinds. 

Tbe first dtcssiog of a fcunsbot-wound in the Seid is usually a 
Boist compress, covered with a bit of oiled muslin or puchmcnt- 
paper, held in place by a bandsgo or cloth. Frequently nothing 
further is required tlian simply keeping the wound moist and covered 
with chnrpie, lotions of lend-water, chlorine-water, etc. As yet there 
DO full obserrations of the treatment of gunshot-wounds without 
drrrssin<:^ They occasionally, though mrclr, heal by first intention ; 
IKS s rrile, tlic^ suppurate for a longer or shorter period. One of the 
erlief oames of dovp inflammation is the presence of foreign bodies, 
stich na bita of clothin;^, leather, etc. Tbc presence of the bullet, or 
a portion of it, is far less dangerous, for the cicatricial tissue may 
f^row atouDd and entirply enriapsuUte the load, while the wound 
dooes OTor tt; the patient keeps the bullet in him. But tbc»e bullota 
do itot always remain in the same spot; they parity sink, from their 
reight, partly are displactx], by muscular action, bo that after years 
jey «re found ut (liflcront ((jftierully lower) poiuts: tiT instance, a 
ItuUct may eoter tbe thigh, aod subsoquenUy, after bcitig almost foi^ 
fettem, may be lelt uudcT the skin of the eolf or hcci, and louy llieoee 
lie readily extracted. I faare told you the same thing about needles. 
XJut Don-mct«llic bodies seem never ablo to remain thus without 
^ijiijurj in the human body^ and hence should always be extracted 
^mrbcn discovered in a wound. 

^B In gnnshot-wouncts the fever generally depends on tbeir size and 

^rextenlj as well as on tbe accidental suppuration. In tbe excellently- 

directed liOApital of the Bai-arlan chief stiiff-siirgeon Sect, which I 

. ^nuiberhtacfaofisbeim (1886), the thurmometur was used fur 



_ wttl 



■2di 



OOSSHOT-WOCSI». 



dcttirmiuing the amount of fc%-er-, tlio rcetiltfl as to fcrcr genenüly 
oont«pond with tboKc in other injuries. 

[ßemargu/jif (quoted in tin Medic(U Times and Gazfite, St-ptPiD- 
hvTy 18(1) sajB that in all cas«fl obscn-cU, where the ttanperature fell 
below 95° Fabr., the ptttienta died.] 

The special rules to be obserred in perforating wounds of the 
skoU, thorax, «ai abdomen, are ^ven !a special suxgcry ; let us bere 
make a few remarks on the fracture« resulting from pmshot-woundi 
We bare alreadj- statod that sliDple subcutaneous fractures occur froni 
spent or obliqiiel^'-rolling bullets ; but, in mosfc oases, tho fractures an 
acoomponiod bj wounils of the soft ports. The eoft, spongy bones 
and the epiphyses may Ijo eiinpljr perforated hy bullets witboot any 
splintering. Iliis injury is coiiipantlivoty favorable; If tiie adjacent 
jcänt be not opened, the bullet may rcqiain ia tbo boD«, sod, if it 
csnnot be extracted, may heal lliora ; the track of the wotind to the 
bone suppurates, fills with granulations, which at least partly ossify, 
so that the Gmuicss of the boRc is not impaired. If tiic buUct stiikei 

Tut. tti. 



( -J 



ronmr of ■ fmnb to\iiiet. brokn 






TR&iTUEyr OF GUN'^OT-Womi». 



3SS 



rttie £kpliyais of a long bone, it ^ncrally splintci« it, and <loea bo 
^Braoh nmra extensirelj' than any otbor caiige. The tiuiiibi>rs of sharp 
»plinters, and the extent of the splintcrtog in proportion to the diamc* 
tAr of the projeotUet is the most noticeable feature that we obserra 
when fint «eeing a larg« number of giinshot-woiind«. 

I think It is necessary and rery important to examine erery gun* 
chot-woiind of the cztrcntttics with the Bagor quite coriy, and to 
remove fra^cnt« that are loose or slightly attach»! to the »oft parts; 
it may be odrisablo now and then to cut or saw off pointed freg- 
nenta whora it can be done without much new injury or extensive 
iociuons through tbe soft parts. But I woidd not reoommcad these 
n»eetion» m iKo eontinutty as a uflunl or necesnary Operation, for ex» 
perioDoe abows that many such cases go on briTrably without opcro- 
tioas. 

If the injury lias caused a ooinplicated fracture in a joint, we can- 

Bot hope lor much from an vzpcctant lit- atmcut, according to preeent 

o^terieDce, whicsh is biLscd on statistics ; the question riftbcr seems to 

I be^ wLetber priroaiy resection or amputation is prefc-rable; this eaci 

Konly bo decided by the peculiarities of oacb case. 

™^ Lastly, wo most ncntiOR that secondary bfnnorrhages are par- 

ticiUariy frequent in gunshot as in other contused wouurls. 

I oooaider tlie treatment of gtinshiit-fmcturc!«, by fi-nc5l.rala] pla»- 
ter-buidigee, as th« only proper meliod (excepting perbspa those in the 
upper part of the arm or thigh) ; the only thing against it Is, tJiat 
eorgcotis who have I30t already tn:atcd open fructurcs with plaster- 
dressings, sod are not adept« to tho appücution, should not make their 
£tst experiments on guoshot-&actutes, but should only apply drcBsbgs 
with which tbcy arc familiar. 

EeoodduT}' suppurative inflammatioDS occur in gunahot-wounda 
ereo more frequently tlian in other contused wounds; the same 
faaitses that we have already learned for these dangerous aceidentA, 
unfortonatoly often act in gunshoi-wounds alao, 

"We must satisfy outsdves with these few remariis on Uie subject 
of puQshol-wounds, glad aa I should be to continue the subject. Those 
wbo feci special interest in tbo subject, I refer to the worl&s already 
mentioned, and to a lilUe book of tny own, " Historical Studies on 
the CoosiderstioQ and Treatment of Gunshot- Wounila," in wliich you 
will find the old literature brought togothci. 



CHAPTER IL 
BUnifS AXD FROST'SIT-ES. 



LECTCHE XX. 

T Btnu: Onüe, Exteot, Tr««taBaDt,—8«aitn>ko.— Stroh» of Ugbtaxig,— & Fioit- 
btua: Orado.— OOMralFmilnc, ThwtDMBt— CUlbUna. 

Tub symptoms due to burns and £roat-btt«9 ore quite similar, bat 
■lesuflicicnU/disÜncttobe regarded separately ; weali»!! first trettof 

BÜSNS. 

These arc caused by tlie flatucs, wlie», fur ioKtancc, tbe clotliM bum, 
but more irequcntly hy liol fluid«, oa wlica obildrcn pull vesseU of bot 
water, cofTcc, »oiip, etc, off a table oo to themselves. And, tm&s» 
tuiuitcly, in factories, bums &«)u bot melaht, such as moltea lead, irom, 
etc., ore not mrc, and in cvcty-daj lifo sliglitcr burns from matcfacAi 
eealmg'wax, etc, ofWn occur, as yculiareaUdoubUcmsQCo. Beside 
tbc aborc, coQGCQtrstcd acids and cauilio alkalies not tmfrequcnA^! 
cause bums of various degrees, analogous to thoso from bot bodies. 

In burns tbe inteosi^ and extent of tbe injtirjr are to be regatdcT^' 
we shall hereafter study the Utter. The intensity of the bom c^^ 
peods ceaeatially on ilia grade of the beat and Uie duratioa o( ^^^ 
■ctioa • accordiag to tlie result of tbis actiott, bums bar« beea divid^^*^ 
into three grades, "niese pass into one another, but from tbc acecor^^ 
Iiaiiyingsymptomsmay be difltinf^uished without difficulty; tbeoiUyo^^ 
i«ot of tili« is torcndcr explanation easier. We assume three gradi.'-'^ 

J^rtt decree (hypenemia) : The skin Is nitich reddened, very potttft»-^ 
and sU^fbÜy svollon. Tbtiso symptotna are duo to dilatation of tl» ' 
capillftries, and slight exudation of ecruin in the tissue of the 
Thero is a mild grude of tu flam mat bn, in which there ia an iocraas^^ 
of cdls in tho rc(c Malpig'hÜ alone, wbicb is followed, in many iiiiin^ 
at least, by delaobmont of the epidennis. Redness and pain oocasior»' 




OZGREBS OF hUBSS. 



S0Y 




last a fev houn, in oUter «ues WTcml itya. But it is not neoeo* 
Bot at all practical, to make sereral gradm oq Lliis acoounL 
Second Jeffree (formatioa of xcsiclca) : Bcsidra tbc symptoma ot 
tho Bnt degree, vcsicJcs arise oalbe Eurfaccof the skin; before burst- 
ing these oinitaiD fitnim, clear or mixed with a little blood. These 
Tcsiclcs (arm immediatclj-, or in a. few hours after the reception of the 
bun, and may vnry ^natlj in vzc. Anatomically ve find thai ia 
moKt of these eases tiie homy lajrer is detached from the niuvous layer 
of tbe epidtirmls, ao that the iluid rnpidly escaping- from tlia i-apiUa- 
rio lies bctwcoo thcao tn-o layers, just as results from tho artion of a 
Uiatcr. Tho resich» rupture op arc puitctured ; from tiie remaining^ 
reto älüpigfaü a new Itomr layer of the epidermis fonca quirkly, and 
in aix or eight dnra the »kin is tlio panic us bcforr. It inüy also hap- 
peo that after removal of tho veaiele tli« denuded portion of nkin ia 
excesiirelj painful, and for sereral days, or even a fortntglil, there niKy 
be anpei&cisl suppurutioa ; tbu pus fiuollr drica to a scab, under whicb 
^the new epwlermis forma. Vou may induce this state also artificiailj 
h-aring a blister for a long time on one spot Here also it ia od« 
ry to moke new grade« of the»o ronatioDS, for llu^y only de- 
pend on a Uttle greater or less dastruclioo of tho rele Hulpighii, 
while llie greater or lesa pain corresponda to the amoimt of dcnuda- 
tioo of the uerrcs in the pajnlln of the akin. 

Third deffjw (fonoatioo d" eschars) : Bj thia term vre may dosig^ 
nate all those cases where there is fonuatiuo of eechars, L e., wber« 
port ioaa of tbe skin, and eren of the deeper aoft parts, are destroyod 
by ibo bum. Of course, tbe vaiictiea raiiy be ircry grea^ ua in one 
OBSO tli«r«may bo only bumbig and chnrring of tho epidermis and 
paptlbe, in another death of a portion of tltc cutis, in a third charring 
, of the skin nr of an entire limlx la all cases wbere the papillary layer, 
^bitb tbe rete Malpigbii, is destroyed, there will bo more or less sop- 
^BttrsUon, by whi(üi the mortified portiou will be detached, vrhicli of 
^■Donw; ivill le»ro a granulating wound, thai will ifJIow tbe ordiiiary 
oourso in healing. If only the epidermis and tho «nu-face of the pa- 
be diaired, then) is only slight suppuration, with rapid repla«!- 
st of lite cpidcnnio layer from the remains of the rctu Malpigbti. 
Fran wbat Itaa been said, you may understand bow from four to 
ren or more degrees might be fbrmcd ; but^ to make the subject com- 
lible, tlie three degrees of redness, vesicles, and eschars, arc 
in exlOQsii'e bums wo often find these tUffureut degrcea 
oolDbtoed, and, wlicn the injured part is eorered nith chnired epkler« 
mis and dirt, it is oflen dilTictiU to dHermine the degree at any point. 
If there bo suppumtion, it inuy be either superficial ordcjp; oecaaioD- 
ally it appears as if islands of young cicatricial tissue formed in th« 



2(18 



BURNS AND PB(Sr-BITESL 



midst of a granulating wound, and tlUa has given rise to tlie fube id«i 
tlmt tliQ ktler ooulil ctcabnae not only Srom the edges but from differ- 
ent points in tlie midst of tbe wotiiid. Hut ntch cicatneiiU ieload* 
never fonii witere there is total absence of tbe pajiiUtrjr bocUe» of the 
skin, but only from soiiio romnunts of the ntc Malpigbüi, as may hsp- 
pvu iu burog and oortain tdoenitioDS to be hereafter mentionedL 

Tbe prognosis for tbe function of bunit parts may be inferred Erant 
what baa been said. We should, bowei'er, add tlist after ext«nsire loes 
of tbe akin, as occurs »pedalty fiom bums of tbe neck and upper ei- 
tremilies hy hot lifjuids, tliere is very eonsiderablo eioatririal coatjuv 
tioD, by ivhioli, for iustonce, the head may be completely drawn to one 
iide of tlie neck, or anteriorly to the sternum, or tlie ami fixed in a 
fiex«d poutiou by a dcatrix in tbe bend of the elbow. In the oonrae 
of tinn these cicatrices become more distensible and pliable, but rarely 
to Suob ao extent as entirely to rc-move the disturbance of fimcttni 
and tbe disfigurement, so that in many case» plastic operatloDfl an 
neoeesary to improve these conditions. It «aa formerly asserted thst 
tbe oioatiicei lUter bums contracted more strongly than any otbcr 
(äeatriees. But tbis is only apparently so, for searcely any otiin- in- 
jury ever causes tiio loss of such large portiona of skin ; we nay 
readily peroeive that, when this docs occur (as in plastio opcntioai 
and after exteDiive destruction of the 6kin hy ulocfations), the eon» 
traction of the cicatrix is just as great. 

Entin-Iy npurt from the different d^igreee of bum», llidr eati£ 
of the frrcatcat importance, as regards tbw danger to life, Itiai 
enilly said that, if two-thirds of tbe sur&oe of the body be 
only in iht_- ürst dc^rrcc, death soon occurs, in a niaiincr that baa as 
yet received no physiological explanation. Persons thus injured läll 
into a state of ooliapsc, with small pulsc^ abnormally low temperature, 
and dy^mxa, and dio in a few hours or days. In other esses life 
lasla somewhat longer ■ death ooeasionally results from severe diai^ 
rhtea, wilb the formation of ulcers in the duodenum, tteortlie pylon», 
a complioatiou which aleo sometimes oomes in seplico-iiiia. Ttie rapid 
uccurrcitcc of death trom cxtcueivc bums boa received various ex- 
planations: lirsi, it was asserted thst simidLaneousinilaliou of almost 
all tlic periphcnd ncr\-e-tcTmtiiatiuns in tbe skin was too great an irri- 
tant for the onntral ncrvOUB Gvetcm, and hcnoo c&Uttd pQislySis ; ttoi 
that the cutaneoun perspiration waa nrTt'Rted, and death was to be ex- 
plained here, as in the case of animftU, wbo»e whole body baa hetn 
covered with an air^gfat layer of oil-paint, caout<liouc, or pitch, la 
llio latter hvpothcsis it is assumed tbai the excretion by tbe skin a( 
certain substances, especially uf ammonüi, is int(.Tfere<l with by liie 
impermeable coating (oa by the burning of the akin), and Lhnt a littal 



TBEAIKENT OF B0R.\9. 



S4» 



tng is tlius Lndueed. Lastly, the symptoms might be tlie 

formation of 
Should tho bum not prove fatal from its extent 



ftoaolt of an misuse ] 
escbmra) intoxlention. 
alone, die ^re*t loss of skin »nil consequent suppurslion mny prov4 
dangonnis, cspecially for cbildren and o\A persons ; in the same way 
tlio amputations neceesary from complete charring of sinj^le cxtrcmi- 
tiis involve certain dangcrfi, wliich are the more serious as tbi-y ufTocl 
persona olready greatly dcprcaacd by the burn. 

Id the treatment of bums in the first and second degrees, more 
depends on alleviating the pain than on any eneigetio treatment ; for 
we cannot hasten the retmn of the skin to its natural state, but must 
kare the courao of healing eutirely to Nature. If there are any vesl- 
dea, it ia not adcUable to remove the loosened epidermia, hut to open 
the vesicle by a couple of needle-punctures, and carefully prc^ out the 
wrum, to relieve the tense feeling. It would be QKMt natuml to cool 
the borot part, by applying oold compresses, or holding it in cold 
water. But this is not usually very popular with patient^i, as tlieoold 
sbonld be cüi^sitleiitble ami coritiuued, to relieve the pain very mudu 
Tbe «old-water compresses iriru too quickly, and immcr«ioo in cold 
^«ratcr Is only applicable to the estr&miiies, beuce cold is cumpara- 
^bircly little used in bums. Numerous remedies are osod in bum«, 
^■«bose only clTeci 13 to perlcctly cover the ttiflamed skin. Smearing 
Ftiie surface with oil and applpng watlding is a very common and pop- 
ular treatment. Mashed potutoe», starch, and collodion, arc ahio much 
taed ai protective coverings for tho burocd skin. The two former may 
ha r^ardcd as popular remedies ; for extensive hum« I canuot praiaa 
asQodion very much ; the oollodioQ covering cracks readily, aud in the 
emdca tbe skin becomes sore and very 8cn»ittv& Some surgeons use 
pMuliar salves and linimcnUi instead of <h1 ; such as a liniment of 
equal parts of lime-water and lineecd-oil, salve of etiiial part» of butter 
and wajc, lord, rind of buoon, etc Another pluu of treutment ia with 
a solution of nitrate of sUvcr, tea grain» to Ac ounce of water; this 
is to b« painted over the burnt part, and compresses wet with tbs 
«ine to be kept ooostantly applied. At first tho patu from the cau- 
terization of the parte denuded of epidermis is ooea«ionally very great, 
but a thin blackiah-brown crust soon fonns, and the pain theo ceases 
«ntirvly. I particularly recommend to you this plan of treatment 
>wlico all three degrees of hunts arc oomlwicd. 

In bums of the thir«! degree, if tlipro is only mortifientinn of tho 
cutis (when this ia DoC charred, but burned by boiling water, it gcn- 
eivUy becomes perfectly white), tlio treatment ia tho sainc as that 
alxive ^ren. Should it subsequently be desirable to hasten the de- 
tadiment of the esdiar, cataplasms may be employed to stimulate 



S70 



BtrajfS AXD MOST-BITES. 



mppuntion ; in ino«i cafl<>s, hoirevcr, Uiii will be utmeceaui^, ud 
til« treitnient tijr nitrute of uItct may be oontiaued till the ew-laru 
oomplctcij dctaclicJ. If large gnnulnting Buifaocs nnuiiu, rspccUDr 
OD parts of tbe eurfaco tbat are morcd macli, ftJid xrln-rc Uic ti^igH- 
boring «kill is not very moi-kble, it may take a loDg- time, oftoo moatha, 
for Ihem to bcoL Veiy luxuriaat gmnukitiona form, aotl their tco- 
dency to cicatrizo is always very slig^lit. Of tho rctu«diea airetdjT 
given fi^r promoting tlie healing of micb voundfi, I particularly rcoooi^ 
cnetxl to you tbe oouiprcssiou of tbe wound by stri|»3 of adkeairi 
piaster, wbicb aru of cxcoUoit service ia BOmo of Uiceo oa«c«. In tlw~ 
trvatmeiit of uisttrioial L>oiilniotioiiB resulting fruin tlicsc bunts, L'om- 
preasioQ of tli€ cicatricial baud» by ailbcsivc- pliuit«r ia one of tbe tnort 
important roin«dics, and you would alvaya do well lo tiy tJüa per- 
sistently before resorting to exoiaion of tbe ocatris, or to pUltic 
opemtionsL 

If, in a burn of Lbu tliird degree, Üiere baa bvvn cbarring of a 
limb, it may often be nih-isablo to am])ut«tc nt once ; not only bccaaw 
tbe detacbment of a large part of the body is not free from daager, 
but also because tbe atonips thus led arc unfit tor tie aptiticatioa U 
AD artifidiil limb. 

If called to a case where tticrc U a bunt of tbe greater put of ibo 
body, you must ^vc your whole atU^otion to the grncnil condilioa of 
the patient^aod try to prevent coUapee, by the use of stiuitilautSfWKfc 
aa wine, hot drioka, hot baths, ether, ammonia, etc Unfortiuatelj', 
in most of these cases, our efforts to prescrro life arc in vain. Siia 
praisea tbe treatmcat of eztenaive bums by tbe cootiuued wann batl^ 
which, under proper circuinstancca, may be kept up for wcclok. 



i 



Persona wiUi deK(.-«to aliiua, hsug exposed to tbe ttat'a rayt^ 
have alight degrees of hums of the üice aud neck. This is dUa 
served in persons tnvelütig on the mountauu, Wliea persoDs, esp^ 
dally women, who do not usually pass tbo day in tho «un, tmrd fit 
serroml brigltt days in summer, without carefuUy protecting the bee 
aud nei-k, ibe skin becomes red, swollen, and very painful ; after tbren 
or four days the skin dries to browD crusts, oacka, and peels off. lo 
other persons, with BtUl more iiritublc sklos, Teeicles fixin, whioh nib- 
sequently dry up, without, however, leaving any cicatrices («oem 
Bol&ie). Beeide« pmphyliixis by veils, aun-shades, etc., ibis well to 
Dover the skin of such mouutaia travoUors with cold cream «r glyw- 
fine ; the aame remedies may also bo used In developed euiibun); if 
llie burnt partd be very painful, we may Bpjily cold compresses. 

Here we must siso spcuk of «Hriativlt, or imiolatiOH, In our «It- 



J 



FBOST-BTTSa. 



271 



rte, Uli« tlioCA«« Ofturs almost ejclusivtly in jrtniag eolJicri!, wlio 
■ve to make (ktiguing' marcbes in full miifonn In TOry hot, Itrigbt 
^esther. There uc severe lieadacbe, dizztocgs, uacoaaciousacss, &ad 
xnetiinefi death ia a tcYr bours. In ilic Orient, cspcciollj io India, 
tis iliseAse is not rare among tlic Englisli soldient; somo cases are 
nite acute, cinUn^ with tutanic spasms; otliers 1x?giQ with long pro« 
KMoftt«, and drag on with aymptoms of sovcro licadaclic, burning 
Idn, oontJiiucd latiguo and depcessioa, palpitation of the heart, 
HJUhing of the muscles, etc; ; even wh«n this »täte foda in rccorerj, 
D Ü a p e e a are cotnmnn, I'uticnls with »unsiroke are to bo treated like 
bose vith congestion of the brain. Cold offiieions and bladders of 
cc to tlie head, rest in a cool cliambcr, purgatives, leeches behkid the 
lUS, Mnapbma to the nape of the neck, arc tlic proper rcmcdiw. Ac« 
fniiog to tlw experience of English surgeon», vencecction Is injari- 



VTn also have something to eaj about the effect of being alrtick 
kJightning. Probably all of jou have nt some time aeon liousea or 
I tliat had been abudc b^ liglilning; we uMinlly see a large rent, 
jrc with charred edges. Men and auimnb niay also be »tmck 
to lose &iDgie limbs, but ttits i» nut nlwap the case ; u&ually 
be lightaung travcja along the body, in at one place, out at anotlicr; 
ba olothes are rent, or even torn oE uihI cast onide ; peculiar, branched, 
i|*a^ bKmrniKh-rcd lines am found on the bodv; these bava been 
tgnrtled as representstEous of tlie nt^^rest tree, or as blood coagulated 
atke reeoels and aliining llirouRli; both I'icws arc incorrect; wo do 
ui know n-hy the lightning runs this pcmiliar course on the akin. If 
I penon btt diroctly etnick by lightning, he is usually killrd on (be 
tpA, If the lightning strike in bis immediate vicinity, it induce« 
mnptoma of commotion of the brain, paralysis of oerlaia limbs or or- 
pas of special senne, and oocaftional extravasationa and hums. The 
ktt4¥ bcal like other bums, according to their degree aiul extent. 
Piralyhi from lightuing ta not usually of bed prognosis ; the nervous 
> rautcuhu- activity nuy roturu after a longer or shorter time. 



JWMT-BTna. 

Te may oivide froet-bites into three grades analogous to those of 
the first of these is cltaracteriiEod by rcdncfls of the skin, the 
by formation of vcsclos, the third by eschnr«. The first degree 
b-bite is <iuilo well kuown ; we might rcgnnl the coealled dead« 
of the fing-jrs as ils mildest fonn ; probably each of you has some- 
:had this in a oold bath, oc in wintertime. The finger becomes 




PRaST-BlTES. 



978 



Generally do remedies are used ui these alight cases, but, 
rery piopcrl^, paticnU are vorned ngsinst wftrming tlio parta too 
rapidly*; rubbing witli snonr, tlicu gradually elevating tbe tempera- 
tuTL-, is recommended. 'Itc nbov« a^tnptoiua are thus explained: 
First, the c«pill«ric8 Me strongly contracted by the cold, and are tbeo 
paimlyzcd for a time. I Khali not here c]i.<)4tutut the leiuihilitj' of thii« 
hypothesis ; this explanation inFolves all tlie difRcullie» tljat we liave 
alt«ndy met in the theorica of iaflanimation. 

i Redness fuUovring a frost-bit« may soraetjines remain permanent, 
ei, tlte capillaries remain dilated. This is especially apt to occur 
in fnwt-bitc« of the nose and eara, and is usually incurable. In Ber- 
Un, 1 treated a young nuin vtio hod a dark-blue no»e, as n rciiult of 
frostrlMte, and wished at «U hniards to be relieved of the deformity. 
Be pcraiKtently pursued the difltTcut modL-a of tn.'atmL-nt ; firat, be hod 
tlie nose painted with collodion, afte» which it loobed 88 if raisifthed, 
aod,as long as tbe ooeting of collodion uMitiaued, it was somewhat paler, 
but tbe improvement was not permanent. Tlica the nose was painted 
with dilute nitric acid, vbich gave it a yellow tint. After detaduncnt 
of the opidermi» tlte evil again appean^d improved for a time ; biit it 
aoQO returned to ita fomier state. Then ve trie<l Irealmcut with 
tiactorc of iodine and itilratc of aiU-er, which {or a time gare tbe aoec 
A browoisb^od, then a brownii-h-blaek (M)lor. Tho patient bore all 
lieu changca of color hcpoically, but ihc perverse capiQarica continued 
dJUted, and the nose remained bluish red at the lu&t, just as it liad 
been. I still thought of trying cold, but feared tiie condition might 
to made worse, and, after several moniliH* treatment, bad to tell the 
liero of this tm^i-comical hiistoi^' tluit I could not euro turn. The 
treatment of chilblain) and the conaoqucnt ulcers, of which we shall 
ipeak tmntediately, may be just aa difTicult. 

tProEt'Iatc, where, bt-aidcs redness of the akin, there is formation of 
»des, is moro fc<r\-ere; it is often aceompaaicd by compluto loss of 
satioB of llio affected part, and there is alnttys danger of mortifini- 
». The formation of vcsiclca in frost-bite is prognoatically much 
«orae Ihsa it is in buma. Tbo serum contained in the vesicles is 
nrely clear, but usually bloody. A limb coniplclfly fro»™ is said to 
be perfectly auffand brittle, and small jiortions arc said to break <^ 
iko gUn, if cudeBsly handled I have bad no opportunity to reri^ 
these itatements, but r^MiiemlHT tlint, when t was a sludenl, a man waa 
brought to the Gutlingi-n surgicnl clinic with both feet frozen; 
ing transportation 1« tbe bo$pilal, they had beoome spontaneously 
ktadied at tbe ankle-joint, eo that they hung only by a couple of 
at. Double amputation of the leg nboTC the malleoli had to he 
"BAdc. How lor a limb may be entirely frozen, ao that thccirculntioii 




S7« 



BTJHXS AND FROST-BITEa 



is culirely «rrested, frequently «nnot be dcU'nniiicd for a lime; 
bcQoc wc must oot be too hasty about ampufatiog. Id Zoricb, I bsd 
two caws vrbero both feet wen? dork bluo and nitbout feeling, ud 
on being punotured witii a nei^le oiilj a diop of blade blood ettafei; 
nevertheic«, the foot lived, and only a few Ions were ioet. Iw a thint 
aaae,.in a rerj debilitated patient, where both foct as high u lb« 
calf wore dark blue and covered witli reaicln, tlicy becntne enliral/ 
giiagreuaua. If llirrti bt' exteoaiT« gangreoe of the cskin, beyond t 
doubt, we abould not delay ampatating, for thcM patients are vaj 
subject to pjsenua. A very sod case ootniired in the Zorioh hnphd. 
A powerful young niau bad both bands and botb feet (rosea, ao tlat 
alJ beoBPae gaDgreuous ; the patient could not make up lus mind to ifai 
four anijHitntions, nnr cnuM I bring myself to persuade bin to tbe 
fv»rful openitio». He died of pyn-ima. 

The cuds of tbo oxtrcmitica, the {>oiDt of the ooee, and tips uf Ibe 
ear«, are most liable to be frozen. Clofioly-fiuing eldhes, which iiii|»dB 
the circulation, increu&e thu prvdisposition. Cold wind, and oold a» 
txMnpaniod by mwetuic, induce froet-bito more rradily tlian very great 
atilt, dry cold. 

There in also a total fireezing or stiffening of the whole body, in 
wbicli tlie ]>aticnt loeea consciousneas, amt falls into a elate of tott 
Kmitwi virality. llic radial pulse can hardly bo felt, tho bcart-beat U 
scarcely audible, the raspirntion almost imperceptible, and tbe whole 
body is iry cold. This state miiy pass at once into death ; then all 
tho fluids harden into toe. This general freezing is eäp«ciolljr apt U> 
occur when the iDdividual, ovetcotne by fatigue and cold, lies down 
while freezing; lie aooii falls BAlecp, and sometimes noTcr wakes 
oi^u. It baa never been accurutely dvtcnniDod bow long ■ prtimt 
may ri'inaiti \a tliig stifT condition, wiUi very sliglit appc4u»iic« of Iifi% 
und again recover; wc Und mention of the state baring lasted mx 
days. Whether ttus be true or not, wc should continue our attempts 
at rPSUBtritstiun as long as a hearl-bt^iit con be detected. 

Let us commcnc« the treaimfnt of frosl-lüte with lliia slate of 
general olilTiief«. We must here avoid any sudden diange to higher 
tcmpCTBturc, but inoreaeo tho waimth gradually. Surb a patient 
should Im placed in a cool chamber, on a cold bed, and friutioas made 
for aevcnil hours. At tlic )iD.me lime, artificial reepirstioa sfaoakt Itc 
occasionally tried, if Ihe brcalliing bceoinos {tnperDcpttble. As sUgh* 
stimuliints that may do good, I would mention eoetnata of cold water, 
ind holding ammonia to the noettils. Very gradually, us tlio patirnt 
becomes conscious,wc raise Ihe surrounding temperature, keep him for 
i time in a altghtly-nanncd room, and at first give only tepid dili^ 
As the dilTeniit pari» of llic body, one by one, regain vitality^ there U 



TREATMEST Or FROST-DITE. 



S7« 



otcasiotialljr fiome poia in the limbs, cspeelullj if t)":}' ncrc wanned 
loo rapidly ; in th^e coms it U well to ciirclop tbo painful pari« ia 
ttoüis dipped in ootd wst«r. The patient may remain fur }iours or 
citjrs in a benumbed, scnsdeaa condition, which disappears gradualljr 
Of titti:, cxperimeDtö Iiare been mode ia resuscitating stiffened ani- 
maljf which appear to ahow that auinuJg are more ccrtaiitir mivixI 
fnnn death hy rapid tltau by slow warming, t should not rL-ndily do- 
cide» from these osperimcnta on animals, to depart from the rulca 
ah^ady empirically «mploycd for treatment of penonn froz(.-n stiff, and 
vUich appear to b« correct for local frostbites, but tlie question is 
worth fijrtbßr experiment. Su<^ caaoe of g:eneral freezing rarply 
ewape without loss of some limbs, or part« of theot, and, in regard to 
tbe troatinent of these froaen parts, I can giro you little advice. The 

• tf^eU-s arc punctured aiitl evaluated ; tile fuel or lumda may be 
wntf4M:d is cold, wet cloths ; thou wo must wait to m« vbetlter and 
ho» extensively gangreoe will occur. If the bluish-red ot^r paasas 
into a dark cherry-red, tlie chances of teatoratJon to li(c are altghb 
Gangren« will occur in the great majority of Buch oasea, Hy tc^tinx' 
the «eligibility witli a neeiUo, and noting tbe escape of blood from 
tiiese fine openings, we test buw far the limb has ocaslmI to livx' ; but 
thia only bcoomos ccrtaiu when the lino of dcmarkatioa forms ; that 
Ü, when the dead Is sharply b<%unde4 from the linoj*, and inflamma- 
tory' rcKbiess derelops on tlie border uf th« gaiif^-nuus parU. Rut 
Ibo general oooclitioo may bccomo dangcrouti before iJie line of de- 
wrkation is fully formed; hence amputation must not b« delayed 
too long if the inftammation after freezing assumes a phlegmonous 
cWarter. Tlie detachment of single toes or fingers we may leave 
1« itself; but whore there is gangrene of a large part of a limb, 
I jjnputation is decidedly prefomble.* 

I I win bere return to cliilblatits (pomionc»], not liecausc they may 

P kcomo particularly dangerous, but because tlicy are an exucodingly 

uinoying disease, and are in some oases vcrj' dilBcult to euro« and for 

irfaidi, as good faoiily docton*, you must liuve a scries of remodies. 

CTiilbhtni are cauttcd by pomlyais uf tlio rapiUurii-it, with seroua exu* 

>JiKt.ioa in tl>e tissue of the cutis; thoy are, as most of you know, 

UixJsb-red sweUinga on the hands and feet, which prove excessively 

*ou:aoying from thör severe burning end itching, and from the ocai- 

slonal funnatiou of ulcers. T\iey result from re|)«NtteU sliglit froL-ziiig 

«r tbe satna spot, and do not occur with erjual frc<|iicncy in nil per* 

*A«is ; they are leas annoying in very cold weatlier than during tlie 

< ^fc^ iigB trota oold to warm. At oiRht-, on going to bed, when the 

bkods and ft^et bcoomo wann, tlio itching oocasioDully becomes so 

trr^juhlesome that tbe patient has to scmtch them for hours. In gen* 

I, females are more dispoeed than males, and young pßrsons more 




37e 



BURNS AND FBOOT-BETE^ 



llian old, to diilbluiiu. Emplojincnte rec^uiriiig fre<}ucni tJiangeof 
tempcTKtun; puücularlj pnxliiiiKHi: to tb«iai cltirka uiil apothvoriei, 
who stay fi>r u titn« in a. wtmi ruoin, then in n cold cdUuror1raf^ 
lionse, are fruqiieut subject«. But uo station i» exempt; peo|Je wia 
aln-njs wear glorcs, and rarcljr go out in winter, may bo attackcdu 
well aa those who have never worn gloves. Among females, dblomti 
and disturbanoea of menstruatioD occasionally seem to predtapoie to 
them ; generally, frequent returns of froet-Ute appear to be coDBCCteJ 
with 9omc constitutional anomaly. 

As rcjgaids treatment, it is usually rviy difficult to oombal ik 
causes tlijo to constitution ond occupation ; bene« we arc clucfly lim- 
ited to locid remedies, lu Italy, where the disease is rory froqoeiil, 
if a cold winter orxjum, frictions with snow and ice oomprenes at 
rocommended. With u», theaa arc less used, and do no good, or at 
moat only aUcviate the itching for a timo. Salve of «hit« precqiiUk 
of mercury (one dnu.-hm to tlie ounce of IbrI), frictions with (ttA 
lemon-juice, pointing with nitric acid diluted with cinnamon-water (coe 
drachm to four ounces), solution of nitrat« of aQvor (ten gxaios to Ik 
ounce), and tincture of cantharidea, are remedies that you may resort 
to. Sometimes one answers, sometimes another; hand or toot bitb 
with muriatic ncid (about one and u half to two ounces to a foot-Ull^ 
use for too minutes), and washing witlt inftisioa oF mti5tard-«)ed,sre 
aUo celobratod. If the chilblnius open on the top, they tnar U 
dn-ss^d with ointment of ^uc or nitrate of silver (gr. j to 3 J fn)- ' 
have here giixn you only a small number of the remedtva recom- 
mended, the effect of most of which I hare myself proved, allhcw^ 
there are a number of others; at the commiencemcnt of your piactiM 
you will Gad thc&e enough foroomboting thisconuiM)n,tiifliDg disOtK 



CflAPTER X 

^VTE XOA'-TRA UMATIC XKFXÄMMÄTIOX OF THE 
SOFT JPAJtTS. 



LECTURE XXI. 



..-«nl KtUiIogi' of Arot« InflusmUlo««.— A«tiw InSunmaUoD : 1. Of tlio Cuti«. 

«, Kt7«l|xlat«tiB liduUDUlon ; k, f^nui«!« ; t, Cubnncl« (utbru), PiuHiU lift» 
Vtfnt. S. OrHtiltMmlSamimabK t. Of tbaCcUiil«rTiua«,A«uteAbMeMW. 
^m "A. Of Um Utvielw. ft. Of Ü>* 8«t««* UombniM«, Sheatlis of tb« Tcndcnw, *Bd 
^H £Bl>««sa«on» JIdmih Bsnw. 

^f Centlxxszt: So Cu- we bare treated only of injuries, now w« 

IsSkAkJJ pus 1o thfl arute infiammntiorui wliich aro of>-iion-lraiiinatia 

ormg^ Of these cases, tluwe belong' to euigerj* llmt occur oa Uie 

otxt'Cr pott of the bodjr ; aUo tboae wbidt, fx;curriDj; in tiitcruiü orgtns, 

are »till Acc(VKf^ib!o to sm^eat treatment, Althoiii^h I inust start with 

the- iilra Uiüt yon abcadjr know the causes of disease ia general, it 

Blfll Bccnts neoQBsarjr to malte book preliminary remarks with 8pccta.l 

r«fe*nuw to tb« subject of vhioh we are about to treat. 

The caoaea of acute noD-trsumatiR inHammatinns niaj- be divided 
into »bout the following' categories : 

3. Jifpeated Me^anteal or Ch«miial Jm'tdlion.— At tlie first 

^ance, Uiia «ecms to con» under lli» licnd of trauma, but it ni»kea 

tonaidcrable diflercnco whctlivr such an irritation acts onee on u tissue 

« wbethw it be frequently repc«tcd, for, in the latter case, each sue- 

ewdtog iiritatioa affects a tisaao alrcadj irritated. An example wtU 

Male tUs clear to rau. Suppn^e a person is rubbed contmuou^ly by 

a pKJectia^ abarp nail to bis boot or shoe ; at Grst there would bo a 

dl^t wnund with drcuniacribed tttflammation, but arterwanl the 

blumBatkin will spread and bcoonie more Intense as long aa llio irri- 

latiaii lasts. Let us take another esuniple of chcmicnl irritation : If 

a pnvnn not aeKnistomed to highIy-«L>:i«<.iiied food cats Spanish pepper 




278 ACUTE NON-TRACM.VTIC INFLAMMATIOS OF SOFT PlBTS. 



it would induce tcmporarj hjpcrannia and BwcUinx of tlic oral and 
gnstrio inucouA mcmbrauc ; ebould ono contiuuc tbe usa of »0 acr'iA » 
substance for ■ leo^tb of time, lie migbt exdte aaevere gmatrili». 
Except in cases oCthe first example, tbcse rapidlj'-nip«*tod initatjoM 
are not &equeot in pnoticG, but tbej hare a great deal to do with the 
origin of chronic inflamnudon ; wlkeo, of tbeniselrea insigmficaat, ibef 
act on parts more or leas veak. We Eaust again return to tlui 
point 

2. Catc/ilnff Cold. — You all koow that hj catdilng ooM one m*y 
aoquire Tarious discKiKCH, vspeciullj acute cstanli and inflammationit of 
t4ie joints or lungs ; but we do not know what is tlie particular iaju- 
riouN iiiflueace in calcliiDg cold, or n'lmt tinine<linte ctiaoges it cmdh 
in tbe tifunica. The npid cliaugc of temperature i» Maned aa the 
chief ouse of catching cold, but by lliia mean* we cannot cuipei^ 
mentiüly induce an iuflamnintion, or niiy similar disease. One eatchcs 
cold from being heated, and tla-n being exposed to a oold dmughc for 
a length of time ; by careful obscrralioa he may say just when he 
caught cold. The cold may have a purely local action; for instance, 
one sits for a time at tbe window, and the cold wind blows on tfae ndo 
of Ilia laoo toward the window ; after a fvw hour« bo is atbudted bjr 
paralysis of the facdal nerrei We may here assume that moleeular 
changes Iiavu occurred in the nerrfrcubatanoe, hy which llie ooedacU 
ing power of llic ncn-e is lost Another might get a oonjunatiritis 
from the aamo cau£e. TlieEC arc purely local colds. Another e»M is 
more frequent, rtz., that on catching cold that part is attacked wtaA 
in the person affcrtol is most liable to discasof tbo "foeiM mjnarü 
re$üte>UUs>*' Stune petsons, after catching cold in any way, hare 
acate catarrh of the nose (snuffles) ; othei^ bare gastric entarrh, CPtbcM 
muscular pains, and still otliera have inHamniiitions of tbe jdalh 
Now, SA these parts are not always directly affected hy the lojufj (at 
when one has nasal catarrh from getting his feet wpt), we must cup 
pose that the whole body is implioated, but the action of the injury is 
only shown at the hau» minorU tvtiOmtÜB. Whether this tranäfcr 
of Bueh iujuriuin iaflucnees to a spoehd part of Üie body La due to the 
nerves, or to tbe blood and olbcr fluid» of the btidy, is a question wUck 
cannot at present bo decided, and «bout whi(^ physioioo« «re diTldod 
into the two great bodies of neurojtathK and hnmcwnlists. IteMoas 
may be adduced for both views. I rnthej- iodine to (hebumoral view, 
and regard it aa possible that, for instance, ob«mloal cliatigea may 
occur or be prcrented in the slan while swoating, whidi may have • 
poisonous effect on tliC blood, and may act na nn irritant now on tMa, 
now on that organ. According to (be old form of (^ech, Ibesa in- 
fLiinmntloos due to eatoliing eoM are called **rbeumatio" (Iron jftrifM, 



HIASXAUC IXFBCTIOK. 



SM 



p) ; hut lliU cxprowion is m tnueh mimiscd, and has oonie into sudi 
eputc, tliut it stiouM not. be emplojed too often. 
3. 7'vxic an<i Mtcamatie Jnftdivn.—'W'Q Imvc already (p«gc 
107) stated that nioi&t ond drj', purulvut and putrid, subtttatioca 
brought 1q cotitact witb b wound iaducx; severe progtcssit-c inflamma* 
tiotu, if tbej enter the healthy tissue inuncdifttely after the iDJurjr or, 
voder certain previousl^-meotioned circumatanoes, pass tlirou^ the 
granulatiofu of a wound into the tiHgtie. It i» true, the Imdy is 
tdcrabljr prolcctvd on its eurfaLt: \>y tlie «pulennis, oa Uie niuoous 
coats yyf thick epithelium, Against th« entraooo of mich poisonous and 
Inflam ma tonr materials, but the ptntedion is not perfect. There are 
man/ poisonoua subetaaceB whicli enter tite body through the skin or 
nuooua membiane. Some of them vre tenn poison, sach as the secre- 
tion fmm glandcpulcers In the hor«c, or Troin the carbunoulous pus- 
tules in cattle ; otlicrs we only know from their eObcts, from aonie 
dranHCtance« of their origin. There arc inrisible bodiea which we 
term ** miosnutic poisons,*' or briefly '* niitiKm " (juaaiM^ unch^unnesa) ; 
it i& supposed thnt these miuams dtn'clop from decomposing organic 
bodiea. Some «oosider them ns gosce, others as dtist-Iike pArllcles, 
Othets as miante organisms or tJicir gcmu ; I think tlmt in many 
caaoa the latter is the cortcct view. The action of these poisona 
rariea, inasmuch as some of ihcm huve a direct phlogistic action; in 
otheis it ii more indirect. Hius lu^rae poisona, aa pus, cadaveria 
poiaoo, induce severe influuiustioa al the iK>iet where tbey enter the 
hodj (infeetiontatrium) f others excite no inihuniodtion at that point, 
bot are impcfceptibty taken into Uiw blood, and, although circulntiiij; 
through all the orguu, only hare na inflammalury effect on one or n 
finr parte of tbo body. Tlie«o poiaotis are, to a certoin extent, only 
Bjorioiia to rartain organs; they have a "gjweiSo" action. ] shall 
not hero Kprak of the primary sclion of this poison in tmnsfonning 
tlie blood. Wo d» not know the chemically active constitventa of 
OMMt of these poisons which aot Epocifically on ooe oigan or tissue ; 
aumot »oe them drculste, nor cnn we always see their cflecta. 
, jam may very justly a^k me how we can expra'^s ourselres 
with ßn niu<^h eertaioty on the nibject. We de<äde on the enuiu^s hy 
obeenring tlie inorbkl symptoms, and, in M> doing, sup^Kwt ourselves 
munly on tlieir analog to the vOcot« uf poisons intentionally ititio- 
I dt>ee<l inin the body, eapcoidlly to those of our most active medicines 
If we lake tlie group oE narcotics, they all have a more or lees be- 
Dtsmbiug ciTrct, diat is, a paialyzing elTect, on the psycbicnl function», 
bat thcT hare also the most peculiar spccISc effect«. BuUudonna acta 
DO the iriii, dtgitalia on tbo heart, opium on the intestinal cniuil, etc 
|> We MC the same thing in other remedies. By repented doses of can- 



«80 ACCTE KOS-TRAOMaTIC ISFLAMMATIOX OF SOJT FARTA. 

Uiarides we majr excite tnflninitistion of tite kidneyis hy mercury i» 
SiunmotiOQ of the an! muooiis membrane (in4 Mlivar; gluicU, «tc, 
u'bctlicr U'o iiilroduco ihoin luto the blood tlirougli tbo stouftdi, rec- 
tum, or skin. So ulso tbcrc i» an endless number of known aoj 
unkuowu organic scptio poisons, of wliicli many, if not »U, bave iIh 
s specific phiogo^Dous action. I mention onlj one example : if yno 
inject putrid fluid into the l)!oo«l of a dog, in many owes, besides tbt 
direct blood Lutoxic«tion, he will bave enteritis, ptcuritis, or pcric«h 
dili«. MiiRt we not bore »uppoiie tliat the injected fiuid coDlnln« om 
or morv matters wbicb bavc a specific [nflamiDatory ufTt-ct on tbr 
iutcstioAl mucous membrane, od tbo plcui» and pericardium ? If wc 
Icnoir the point of entrance of the poison, and have some cxperienot 
of the poison iuelf, tbere will rarely be mud) doubt »bout tbe casK 
ntid action. But bow many owes tberc may be wIk-ic nciilicr existsl 
1 behci'c that infection )9 a much more frequent source of inflatna*- 
tions, especially in eiirgt'n-, iban bus lutburto been suspected. 



I 



I would Btitl make a few gonornl rematlcs nbout tlio /itrm» ana 
eourm of aon*traumatic InflammatioiiB. I have already UAA you that 
tbe (^arocicristia of traumatic inilammatione is, that tbcy are Unöted 
to tbo wounded part ; if tbey become progreiaJTe, it is (t*'"^*"!')' 
llirougb mi^ch;iiiic»l or toxio (septic) irritation. Tliis would imply 
ibnt üiflamRiatiuna induced by mccbanicol irritations and toxic actions 
hare a tendency to progress, or at least to diffuseness ; this ia trtio of 
most inflnmmulioiis resulting from catcbing nold, vbicti allacic either 
a vrbole organ or a large seclJoii of one port of tlie body. In this 
rogard, much depends oa tbe intensity of ibe meebntiJcal irritation, 
and, in loxic inflaromntinn», on tb« quality and quantity of tlic poiMn, 
especially on ita more or Ictu intense fcnncoting action on tbe 
permeating tbe tissues. As regards iiiflammatiuas due to rc{ 
mecbAiücal irritation and cntobing cold, we do not always bav« reaaon 
to supfKise tliat their proclucta are more irritating than tboaeof drttplfl 
tmumutk inflamnuitiou; but if, during the Inttor, tbo afleotcd pari 
be kept absolutely quJot, and the lympliatio ve^gela and intcrsUet« 
bctn-oen thu tissue« are ulusvd by the inlittration of tlie parts about 
the wound, the extension of the producta of iaSammatJon into the 
surrounding parts in much interfered Trith. But in repeated m«^ian> 
ical Iiritations the tiKHue is not kept at mst, and consoqtiontly tbe 
products of inflammation extend unimpeded aroiind the irritated part, 
and excite new inflammation. Jti inflammation due to catching' cold, 
occording to my buniortil view, the materfa fttcean» ia poured to a 
whole organ or tissue ; hence, these iuflammatJons arc mostly diflbae 




ACUTE WPLAXMATIOS OF THE COTIS. 



8S1 



1. ACUTE INrLAllSLiTION OP THB CUTJ8. 



cement. If| From an existing point of inflftmmation, 
material enter the l»lood,anJ Uiciice specifically' affect 
■DJ other organ, wc call this sccoodnrj intlsDamatioa "metsstatic** 
But these metaftlntic inHamnuitioiiii may w^nir in another and mucll 
more eritlent manner, b^ meaiis of a bluoJ-clut in the vein», as w« 
abaU Bhotr in the iH^tiou ou tlironibotüs, cmboliam, nnil phlebitis, 
Kaa-traiimalio inßnmniRtions may terminate in resolution, in firm 
orgnntsatioa of the inflammatorj' protluci, in suppurntioa, or in mortt* 
Gcatioo. But wo will now ceaae treating- tlits siihject in genenl 
temw, and pass to tli« ioaamiiutioits ot tb« diUvrcnt tissues. 

be simple forms of aeute inflaniinuliun of tlic skin (spot^ irbcaTs 
,-^ -les, vesicles, pustules), which aro grouped under the common 
uame oE "acute exantbeioata,*^ bekm^ to tiitenuil medicine. Only 
cfjraipehitAas inflammation, funmcic, and on-rbundo, nro gcnenüly 
■pplcen of ns tni9 primafy inflainniations of tliu cutis, I will here 
nuiiul ytyu that veij frcqucntlj the skin is Eeoondarily afTectcd, fjwn 
^H iaflMnmation of the sulxrutancous cellular tissue and muficl^, or eves 
^B ot the periueteum ur bont». 

(a.) Eiysiprhitoua inflamraatkm is located cliiefly in tlio papillary 
hyw and in the rcte MalpigfaÜ. llie local symptoms arc great red* 
oeM and oedomalous swelling of llie skin, pain on Ixnag toucbod, and 
|ttcnt dvtai.'-hmcnt of epidermis; these arc ofxasionully acoora> 
by Twy hi^h fever, out of proportion to the extent of iho local 
Section. Tito diseuso lasts from one dar to three or fuur weelcs. 
kjr part of the skin or muooi» membrenes may be attacked, but 
ipathio erysipelas is particularly frequent in the bead and face 
ce the acute exantliemala of the skin, aocorcling to the i-iews rl 
' {Mthologlsl«, erysipelas of the head and face should also l)e to 
variM as a symplomatio cutaneous inBummation; that is, that the 
\ue«l tffection wag only one nymplom of an acute general disease. In 
ijiatcase, mirgery would have as little to do wHb ciysIpeUs as with 
icaristiDa, measles, etc ; but, as it occurs cspeciiiUy iu wounded per- 
toaSiOail particularly often arotmd wounds, we muitt study it more 
aUealtnily. I consider ej-i/xljxlaä traumaiicum not as a symptomatic 
inflsaunatioo of the ekin, but as a rapillary lymphangitis of the akin, 
wlöA is always due to infection. M'c ohiUI treat of this disease more 
c^OKfjr among tlto nct'^identnl tmiiinnlic diseases, and content ourselves 
Aae wi til baTiDg called attention to its n-Iationship. 

(%) The furuncle or pli1<^^on t« a peculinr form of mRammalion 
^t&e akin, usually of typical course. Some of yon may know it 




SSlj ACUTE NOX-TRACMATIC INFUHUATIOS' OP SOFT P4JtT& 

Etom personal obsciratloiL Fiist, a nodule ns laig« as a pe« or beui 
fonns iu Üic skin ; it is red and rnlbcr scustliTC Sooo ft «unit whil« 
point ionna st ils apes, tLu swelling spreads uruuntl Üiis <N>ntjef sod 
usuall/ attains »bout tbo size of a dollar ; somcüincs Üic furande re- 
mains quite »mall, about Üie aize of a cKeir}' ; tbe laij^ it is, tlia 
more painful it beconiex, and it may render iiritaUe persoiia ijuite 
feverish. If w« \vl it run its own course, toward tbe fifth dajr tbe 
centralf nliitc putut, bocumce loodcacd in tbe diape of a plug, and pu 
mixed with blood and detached shreds of Ixnuo is eviieualed ; threa 
or four days later suppuration ceases, tbe swelUog and redness gnulu* 
all}' disap)>car, end finally only a punctate, ecaively-visible cicatrix 
r«ninins. 

Wc raruly liara tlic opportunity of anatomkiitly ezaininlag lodi 
funincli'S in their (iret aingt-, aa iiiry arc not n fat&l diseaae ; but, from 
what wc 6CC of the dcvclopmcnl and from inci»ion, tb« death of a 
small portion of skiu (perbnj»! of n eutaueous gland) seems to be the 
filattjng-point and ocmltio of an inAammation, during which the blood 
finally stagnal«» in the dilated ca|>illancs ; by infiltratioD with plaatlo 
matter, tbe tJRsue of the cutis partly tiinis to pua, partly bceomei 
gnngrenoua. The peculiarity in all tlib Is, that 5ucli a ptünt of iw 
damnintion should, as A general rule, show no tendency to apreftd, but 
ehoutd tlirou^liDut ri'rasin eiroumtit-ribed, and terminate witb the d^ 
lodiincnt of (he little plug ulxiro mciitioued. 

There is no doubt that in many cases the cause of ainglo ftirunolea 
is purely lociiL Sumg parts where the aeeretion of tbe eutaMKM 
gknd» i.1 particuliu-ly strong, as the perinietmi, axilla, ele^ aro «p^ 
dally i>redi»[)0«ie4l lo furuncles ; they ore alao [tarliculnrly caamioB 
in persons who liave very largo Mbftooous glands and »n-rHlte«l pin»- 
pies, maggota, or ootDedoues. But tber» are ntso undoubtedly cuojCh 
tntional eoiHlition.-*, dii<easca of the blooct, irhttih iliitprac In tbn forma- 
tion of numcroim furuncles on i-arJous parts of the body. Thb tuorbtd 
diatbesiti is udled funmcvlctia; should iteouünue luuff, it may profe 
very cxhaitsting ; tbe patients grow thin, and arc greatly pulled down 
by pain and skeplees nights; children and weakly old penouauydN 
of the diaease. It it \-ery popular to refer furuncles Ui full-blooded* 
neos and faliiess ; it is l>elicved that fiitty food predisposes to thom. 
In my country (Pomcrania) they say that pcrtoua wbo Buffer andi 
bain pustules and furundea have " bad blomf I sliould rary tMUii 
doubt tlie truth of the supposiÜoti thnt fiitty food especially diipnaw 
hfarundca. Von will often find that mtacrabl«, atroplttcrliildroti, atid 

idated, sicldy people, nro frtjquontly attacked by furunde, and, 
although Die lock of care of tbo skin has something to do with Üüs, 
it is Dol the sole cause. On the other luuid, it is alao true tliat wvll* 



rURVNCLfi AN» CAItBUNOLK 



MS 



t 



1 butcbcra are often attacked hy fiinincliM ; but this may bo 
otberwiM cxpluined, for not unfi^quontly it mxy be fouud that iu 
tbem ttie fanindM ato due to poisoning by eoiiic uaimal iimller ; ne 
should at]eASi always cmudüiü for tliis (nu»4r. But I thiuk k is going 
too £u- to Hsaumc that every iuntnclu is caused 1>y infection, and ia 
iilwa\-s to \ye- regarded as ooe symptom of a general Euppuratire dia- 
tliesis — uf a pyneoua. 

llio tzcatnicat of iodividual furunclefl is very simple, Attempt« 

have been made to ciit sltort tlie proce»«, and pix-ront auppuration, by 

eaHy ai^jUoatkniB of ice. But this rardy surceti]», iiud is u T«ry tire- 

aoae trcutincnt, which is Dot oftvu p<)pulur wIlli tbc paticuL I prefei 

hastening suppuratioo by wann, moist compresses, and, if tlie funmcle 

docs not spread too mucb, to quietly await tbe detachm(>jit of the 

plug, tLeo to squeeso out tl»! furuncle, iiiul do aotliiog muf«. 

' tbe foniDclc be very large and painhil, \re roay make one incision, of 

two cToseing eauh otJier, lluougb the tumor ; then tlie iiatural courao 

the pnwcss is favored by the escape of blood, and tbc more rapid 

rjppuiation. 
General funinculosis is a difficult diEGiuw to treat suooessfuUy, es- 
pedalty if we know littkj of its caiisc Uaiially we give quinine, 
oioenil acid», und Iroti, interoally. Besides Uiese, wamt butbs oou- 
ttoaed pers*veriiigly are to bo rooommendotl. A porfwtly-regidaled 
(lii;t, especially nulntiuus meals witb good wiiic, is also advisable. 
The individual furuncles arc to bo treated as above advised. 

(c) Carbund« and carbunmUm« it^tammalivu {anthrax) anatotn- 
kmBy reaembles a group of sereral furuncles lying dose logetlier. 
Tlio wbole prooess is more extensive and intense, more inclined to 
progtTwa, so that otlicr parta may be affected by the extension of tiic in- 
BatntnaikuL Many «arbuocles, like nio»t boils, are origiiially a jMirely 
■^^^^ disease, Tlicir chief scut u llm bard skin of the back, eapociaJly 
^^^^■ftctly persons. Their origin nad Erst stage arc tiK! same as in 
ftimnda But aooa s number of wbito points fonn near each otber, 
•od the swelling, redoe.ss, and pain, in tbc peripher^', iDcrcaso in 

■OHM easee so mucb that the carbuncle may attain tbc size of a Eoup- 

^Bdbdi ; aiid, while the detaohmeot of the wliite plugs of skin goes on 

p^B the cwitre, tlie process not unfrequcntly extends in llie peripher)-. 

Hie detacbinoot of gaogrcDous shreds is much greater in carbuoclc 

(ban in funmele. After the Io«k of tbc plugx of eulis, the skin aj^ 

in pcrfumtcd like a aiuve, but BubK-qucntly not mifreqtK-nlly »\t\f 

»jnUeSfSo tbut after a carbuncle a large cicatrix i« always left. But, 

real when moat intense, Ibo procoss ia almost alwa^-s limited tu the 

ein and Rubeutancous cellular tissue ; it ia most rare for fn-scia: and 

IBwdea to be deatioycd, so that, when a largo carbuncle is iu the 





S8i ACTTK SON-TBAÜMaTIC INTLAHVIATIOS OF HOPT PABTS. 



vtciottjr of an artery, the danger of destraotioo of Ute uteiial valls 
is more appArent thaa roal, as is shown by experieoee." AAet the ex- 
lOQsivc tlirou-itig ofT of the cellular tissue, and tlie final anest of 1^ 
proooea iii the pcrijiliL-rj-, Waltlij and usually veiy luxuriant graaola- 
tiooB dcTclop; healing goes on in the usual niann«r, and ia sonnD- 
pltshud In a lime oonespouding to tho size of the granulating sur&cei 

You will haro already uottced tbat the pnweas of (bnnatmi of 
furuncloB and carbuodo dilTcrs from tho inflammalions irjtfa wbioh 
fou are already BCt|^uaiut«J, by tli« constant and peculiar doatli 
of portions of skin; and I bnvo mcntionod that this gu^reoc of Utr 
Bkin, at first very smaU, ia tho primary and local eanso of furunclM 
nod curbuDcIes. Of course, this must be induced by an early, pet^ 
haps primary, oocludon of small artcrli^s, possibly of tbo vasoulir 
net-work around the sebaceous glands, without our knowing on what 
final causa this latter depends. 

Tbc course of the onlinnry carbuncle no the back is tedious sod 
[wioful, althoi^b it rarely causes death. But tltere are cases, especially 
when the carbunole or a lUffuse earbunirulous inflonunation occur« ta 
the face or head, which are ac^companied by bigli fever ami septJo or, 
OS was formerly suid, " typhuus" symptom», and which pruvo dancer- 
ous and arc even generally fittal (carbunctilus maligna, pustula tDklfg- 
na). All Cfirhuneles of the face are not of tliis malignant character; 
eninc run the usuid course, and only leave a <lisfiguriiig ciratHx ; bat^ 
as it is difHoult and often impoosible to UJl how the ea*e will tun 
out, I would atJvise you always to be very careful about Ute piugno- 
sis. Uiifortutuitely, I haxe had auch sud expcricnoe in tbcae oarbtn- 
cle* of tlic face, that in any affection of the kind I am very solicitOBl 
nbotit the life of tho putieiit. Let me briefly narrate a case or twa 
In a young, strong, bc-nlthy man, on a journey to Berlin, from »ana 
uukoown cause a paiuful swcllitig began in the lon'crlip; it iocieaaed 
npidly, and soon spread to the whole lip, while tlic pati<<nt beoaiH 
very forcrish. The surgeon who was called applied nataplnuna, aad 
apparently undervalued the condition of tlie patient, as he di<l not sr» 
Ida for two days. The third day tlie Gtoo was greatly swiinea aad 
the patient had a severe chill, and was qtnio delirious when broq^ 
to tho cUuii:^ I found the Up diuk bluiab-rcd with numerous white gas 
grcnous patches in the skin. Sereral inoinonawereraadestonoe, tt« 
wounds were dressed with chlorine-water, rataplaams applied, ai^ n 
bladder of ice placed on tJie bend, nn nienin^lta waa bc^mung. As 
soon a« r saw tho patient, I declared his cocwlition boptios« ; be sooq 
fell into a deep stupor, and died twenty-four hours later, foor daja 
after the oonuncneemont of the carbuncle on the lower lip^ XJtihr* 
tunatcly, an autopsy was refused. 1 will mention nnvtlter Oftao : A 



OABDUKOB. 



S$6 



nt in >CUnoh received ft sword-cut on the left sMe of the bei4. 
Tbo wound liealed without utijT remarkable Ejrmptctns ; but it vu ■ 
loDg while befibre it closed entirely. For soiue time tliere wts a 
SDuil, open wound, which woa so slight (hut the piiUent paid do at- 
teatioa to it. Violent edraiitiDg' whilo feUL-iog, siiil jierhsps subse- 
quaiilly catching vtild, may hsTe been the cauHva uf lliu following 
catutropbc. Ono tnoniiiig the young man awftkcncd with coDÜd- 
erablu pain in the cicatrix, and a general feeling of illness; a rosy 
redness and moderate sn-elling of the !i«nlp rendered an attacic of 
simple erysipelas cajiitis probable. Hut the fever increased in an 
unusual manner, witiiout the redness spreading over the bend. The 
patieut bad a cliilt, ami beeaiiie delirtmis. Wbeu on tlie tliird day be 
was brought to the huepiuil, in the vieiuity of the cicatrix 1 Foiuid a 
mtajxr of small whit« spot«, whicji showed mo at once that there 
was carbuneulous infiammation ; aa the patient was entirely uocoa- 
•oiona, ami for seTeral reasMis tliere wna probably iiiflnmmation of the 
nenlBges of the braiu, I h^d little hope of a euro; 1 gave tbe ae- 
eMSaty dtructions, but the next day the patient was dead. Tho 
«utopay sbovrcd various vhite gangrenous points in tbc inflamed scalp 
cicatrix ; oa seeking furtiier^ Uie uciglilforing reins were fr>und plugged 
witb clots, and along them tlie cellular tissue was Bwollen and con- 
taioed potuts of pus. Anteriorly I oould follow this condition of tlie 
TctDS as far aa the orbit, but did Dot tiy to follow it farther, not wish- 
iag to iujarc tho eye. After opening the skull, as soon as tho brain 
was removed, we found in the laß. antcriur cranial fossa a moderately 
inflwDGd spot about as Urge as a dolliir ; the diaease affected boUi the 
dor» aod pia mater, and ereu entered tie bmiu-substaooe. There 
was no doubt that tJie infinmnialion starting from the eieatriK on tho 
bead bad travelled along a vein ttiio tlto cellular tissue of tlie oibit, 
tnd tbeoM through the optic fommcn and superior orlutal Gmutc into 

tiwskua" 

la miuiy cases of malignant carbuncle of tlic laoc, on caref\d ex- 
■minntioo we shall find such an extension of the inClatntiiatiou to the 
CfuEal earity, and conseqaeat disease of the brain. But 1 must to- 
mtDd you that the extent of tbia inflammation as found in the radarer 
ia ool at all in proporiioa tc the severity of the couatituUoual eymp* 
lotna, so tluit thfi hitter arc by no mrnns fully explained by Um pott 
mortan appevances. Indeed, tliere are cases, and }ii8t the niosl 
quicUy btal oucs, wbcra dcatb occurs without our being able to Snd 
any di»ea*e in the brain. Hero there is full room for Iiypotliosis ; in 
I the nptit, viuleiit ooiirae aixl thtr quick change of carbunoulous in- 
I Baaunatioa to gangrene vc »aspect a rapidly-occurring decomposition 
I of Uie blood, of which the carbunele itself va&y be either the cause oi 
^ 90 



SbÖ ACDTK NON-TRAVBATIO INPL.11IIUTI0M OF SOFT PARTS. 



result. But, as the dcoompoeiÜoiL of tlio Uood must luve üt 
it Iia« L)ccQ Buppottcd that so insect which has alighted on some 
rion, or od the aoso of a horso with glBoders, or a oow wIÜj <srt>ita- 
c)e, etc., lights soon after on a man and inftHjts tiim ; rou wUl bero- 
nftcr Icara ttmt mali^aot c^rbuDclca result pnrtlcularly from cutmn 
culous cattle. I kiiuir of bo tuscfl where this has bora actxujfy 
observed, but I do cot eonRidpr it impoMibte in certain ca«osj tlia 
Kup(io«itiOTi 18 8up|)orted hy llie £*vt tliat tbe«e carbuDoles are Bxat 
{rtitucnt oti parts of tbu bodj^ wliidi are usimllr rxpoecd. Ai 
events, the high fever and fatal blood-iorcctiOD arc ntoetly rcml 
the local disease; bene«, we must suppose tliat in these carbimdM, 
under oircuiostanocs which we do not exaci]jr uiidcntlaod, pccuUul^ 
inteo» potMDs are formed, whose reah»ofption into tho blood cnisca 
death, ßui the causes of iiutligiiant earbuoelc am in iDoat 
tody obscure." In diobvic» mellituii and ursmia carbuncle 
just aa sugar is observed in tho urine of persona otherwise healUir, 
who have funmcleB aud carhuude»; these are enigmatical faetic" Fer. 
tunately, airbunidea arrnnt Jxcqurnt; even simple hcnig-naiit <.'arbtH>- 
clea are to rare that in the extenaire surgical poticlinto d Bcriio, 
where every ycnr &ve or six thousand patients presented tbcmselY««, 
I only Mw » carbuncle once in two yean or so. In Zurit-h alao the 
wcrv rurr. Tic diagnotta of ordinarj oarbundc is Dot düGciJt, 
cially after you have seen one ; diffuse carbooeulous iiiBamntalioii 
otdy be recognized after a period of ohaervatioo ; at first it rtMublaa 
erysipelas. 

like treatment of earbuncle must be very energetic, K w« iroiüil 
prevent the advance of the disease. Aa in all inOauiiaatioiia diijw^Ml 
to gangrene, muncrons incisions should be made eorly, to permit the 
escape of the decomposed, putrid tissues and Siiids. Hcnc« in erefy^ 
oailniDcle you make large crucial incisions, dividing lbi> whole thiob^ 
DOSS of tho cutis, and lonj; enough to divide tbo infooicd skin door 
through to the healthy. If thif doc« not suffice, yoa add a few other 
indsioas, eepedally where from the white points you reeagnixs gaa> 
grenc of the sVin. The Mceding from these iudaioas b propq rth »- 
ately aligbt, as the blood is coagulated in most of th« veawls of tko 
earbuDoIe. Id the incisions you place chorfiie wot with ehlorioe.««!*^ 
aod renew it «reiy two or three hours; over thb warn cat^ilanB 
may be rr^ariy appbed to hasten suppaation by the moist warmllt. 
If the continued warmth bo not well borne, as in carboaele of ihr 
neck, where it may induce cerebral congestion, the calapUams raayba 
anitted and the antiseptic dressings continued alone, or erea ooU 
may be resorted ta If the tissue begins to detach, yoa d*ily piA of 
th« half<loc«e tags with the {oroepa, and so trr to keep the «ouiid aa 



ÄCÜTS KTLAMHATIONS OF THE MUCOrS HE U OR. IN E-^. 297 

deaa u poaribl& Strong graDuUtions will aoon appear here aod 
libera; fioally, the Ust shreda nie detached and a hoocTcotnbcd gnnvr 
kttog HirCioe U IcfL; t}iis soon etnootiis off, und »ubftetiueDtly cica- 
trizes ID tlic osuat mannvr, so thiit it oiitj requires a little oocaaiooal 
stimulation from oitrato of «Iror, Uko oLhcr granulating niiface. In 
tnklignanl csKiunelu the local ti«Httn<rnt Is tbo Btune tbat we have juat 
described. For the rapidly-occurring cerebral discaeo the otiljf Uiing 
we can do i« to applj- ico to tljo bead. Internally wo luuall^ give 
■{iitaiae, acids, and other aotiseptio remedies. But I must ai^cDOwU 
edje timt the resulta of tbu treatment arc very slight^ fnr in my own 
eqMsienoe I do not kuow a case where it lius succeeded iu averting 
destli wlieo septioiemia was nt ilII developed ; tlüs H the more depress- 
ing, because tfaeae malignant curbtiuolcs genenillj' attuck young, strong 
CNliriduaUt SrcD if the course bo favorable na regards life, tlicre will 
(m- ooostdenble loas of akin aod great disOgurement, oapocially In ear- 
iuiaculoiis iDflamioBtioa of the e/etJds or lips, aa they are mostly dc- 
itcojcd by gangrcae. Early indsioa, excisioo, and burning out of 
th t«. carbuncle, also have litüo effect on the furtber oourae of the di»- 
>^ u I bare proved to myself in a few malignant cases. But do 
In deterred, by these bopclcss vievrs of trcuttnent, from making 
ly indswii», for caws occur where carbuncles on the faoc nm the 
flcnne after oommi'ncing with bigU fever. Froocli surgeons 
htwe attahicd some good rcsulte by early burning out the malignant 
itnte. 



r 



t, ACÜTB ISFLA3C1U.TI0NS OP THB ttUCOUS MEMBSAKES. 



Whilo traumatic inflammatioa of the mucous mombranca presents 

»ithinj^ peculiar, " a<mte catarrh " or **acute oatairbal inflammation ** 

<)[ tbcM membranes b a poouliar form of diseaac which ta anatomically 

danclerized by great byperaBmia, oedemaboos awdling and free seore- 

äwof a&nid at first »wous and subsequeotly muco-pumlent, and is most 

ly eausod by catebing cold or by infection, " Dlennorrbtca " 

*a increase of catarrh to such a degree thai quantities of pure pus 

looeted. Catarrh and blennorrhoea may bcoomc ohronio. Simple 

of exposed Diuoous membranes aflected with ontarrh 

that it may be very sewru and loctj; continued, without the 

of the membrane suScring much ; the Burfooe of the mem- 

'loDS Is hyperiemic and swollen, somewhat thiclc and puffy ; in rare 

there are stipcrficial loss of epithelium and small ddbota of sub- 

tfaaee (catanhal uloera), but it is only in very mro cases that tlicao 

CBsse more extenalve destruction. "Hiis obserration is supported by 

^MSf-fncirfnn examination and biatological torestigation. Tlie opinion 

is, that there is only a rapid throiring off of the epitbeliol cells 




3S8 ACFTB KOK-TB&DMATIC INFLAUMATlON Of SOFT PA&m 



whicb upproacb Ihe sur&oc u pwocUo, and Uiat tlio rrmirrtf — '^li,^^. 
«lie lnyct of Uic inii«ou5 motubrane lakes no pRtt bi ttio prooeai. AI^^^aT^ 

tbough inuuy altcmpts bare been made to fiiitl segrrgaUoo of tt.^^^ 
oeiU in tlic dcL-pf-r cptlhclial layrrs of mucotLS mrnibruncs nffpctcij wi' a*^ 
cstairli, lliyy wem unsuMosaftJ lUl Htmal; Buhl, and Jtitufykit e^^ '" •' 
iliscovered large tnotlierK-ells in the cpitlirlisl \ayen of stwh id^siob^'^ 
brancE, 



Pw. «L 



iSg' 



t-i^ 




Hdlhallil hjH »r « coiüinicilTa ■(n<iM] wtih ranrrh otA» iEtatiMM«). Xackiaa« «II 

eltn. 

It u-»s iiio^t iintiinil to cxplitin tliis obsemtloa hy Msuiuing 
llic mutItLT<M:lIs were formed by erwlogciimis segrcgalkm of tb^ r 
topWm, and subsequently tunird out llicir broods (us pu£^ 
Siooe, ill i:>i>po»iüun to üii« Tiew, it wax rrppeatedlj ahawn Hk^ 
tbia were tbc cose, Uic molbtrr-cclls cbouJd alwajrs be found 00 
ihal mucous mcmbraneii, whil« Ihcy ttoto found ooly nt fint a: 
tben ii] smull numbura, of late, U>rjr hare been exj4ained quite 
fercDtly, Stcudcncr and Vbikmann first adranoed the idea that 
young cells do not form in tbc older ones, but that, under oeitait 
cbanicalljr dvonble iuSuenccs, the latter amy eater from witiiout, 
have nothing to da with the origin of the oalarrli. Altiioagli itaim 
rif^vr is very dil&mlt to prove, afti?r much consideration and wefgUiy 
of known fiiclx, I cotmider it as very prolmble. Tlita is not the phf 
to go into details on tho matter, but^ stnoc it has been prmrod bf tJ« 
rinnnbar mctliod that the white bIood-«c1l8 CMnpc from the reasda oT 
t)ie iiiflamed miipntis niembrmne, and not onlj wander betweO) lit 
i-pitheliiim, but urn also found as puft-cclls in tbc rnlxirHial Mcrrtwi 
I should Ibink catnrrhul ptu liod the same origin as otbrr pne, «u. 
that it camo directly from the blood. Besides catarrhal inflAmnutin, 
muooua mombrancs arc also subject to <roupotu and dlyhUitrUie i» 
llnmmations. When, in Inflamiuationof a mucous tuoDbnuie, llio pn^ 
URta of inflamnialion (cells and transtxlntion) appoarin^ on tbe tur 




m fibrine, aiid thus become a nieinbmne clinging to the sttrfeoe» 
after * time ilissolres into muoos and piis, or is U/tod up by 
ich is produced bcliiiid it from Ihe mucous uicaibrauc, vo call 
YKipoiuinSammation;" the mucous tn&mbran« and its epitbe- 
■antime remain intact, tlio juuia arc perfectly restored, Diplt- 
is exactly similar to the above profrcss, but tbo fibrinous layer 
only Attacbed more firmly to tlio tisAuc, but tbo acnun pcr- 
l tbe Bubstanoe of the membmne coa^lates; tlic rireuIuHon is 
paired bo much Uint uccawonally the alTected part becomes cn> 
angiBDona. In diphtbcna, the diBiQt4.-frn)iion and gangrene 
minent eymploms ; ibcy prohablj- d<.'[>cnd on very rapid dcvel- 

of genus of fungi and infusoria ia the diplitlicritic nieinbraoe. 
.Y tlicse fuDgtHia genua arc, as many euppo&e, llie cauae of 
ria, at present reiiuiins doubtful. I'he j^neral iifl<i>«tion, tbo 
lay bo YOry severe in extenaive croiipoua inflammation (as in 

bronchi and alvcolt of the lungs, croupuua pni-umonia), but in 
ria it is of a tnoro septio cbaractor ; the Inttcr diseasc is far 
St malignant. The mucous membrane of the pharjrnx and 

is often exposed to both fonns of the disease. Catanlml Gon- 
itis, whi^Jj is 80 Tcry common, may bet'ome diphtheritic, but 
>ecomes eroupoui«. I'he mucous membrane of tlio intealiwil 

seldom the seat of tfieae diseases, the Mtnrc ia tnic of the mu- 
tmbraiic of the geoitals, vbich are so often afTocted with con- 

bloonorrhceu (clap, gouorrbwa). 

7. ISFtAMUATION OF T»K CELLfLAK TlSfil-EL PllLEUUuKOCft 
ISrLAMMATWK. 

I term is pIcouoHtie, for i^ ^}^y^6vT\ mcaiui inflamnuitinn, but 
lUy it ia ao exclusively applied to infUimioatioD of tlio eel> 
Kuc tending to suppuration, that evei}' surgeon knows what 
is; auothcr onme for llie same disease is paoido-fri/aiiM^ 
is just na mueli used, but seen» to me less distinctive. 'Ilie 
if this inBamtnntioQ arc in many cases very obomre ; a severe 
n nuely bo prured to be the cause; frequently thi.-»c in* 
lions might result from infection, even if the cutis bo umn- 
^ul tili» ia only hj-pothesis; we have aln>ftdy seen tbo«e pn> 
) acute inflammations as a complication in injuries, CKpcctatly 
ult of local infection Jrom mortifying shreds of tissue in con- 
tnd contused wounds. Spontaneous tnllanimation of tbe eel- 
isae is most frequent in ibc cxtrcniilica, more frequent above 
low the faseise, especially prone to oifcct the £agcr8 and hand ; 
is oalhtd panaritium (comipted &om paronycbia, ioBammation 
nsti, from 6vv^ nail), and to distinguish it from deeper 




290 ACUTE NOV-TRäCMATIC IXPl.AMMATrON' ÜP SOFT PARTEL 



(iiflttmiiutttotu) «Iso ooRuniag lo the fingen und ]uutd, paoarilium m 
cutaneum. If ihe ioBatnmatioci affect tlie rioiniij of the noil, or 
nail-bod itael^ it ia termed panaritium aul) imgue. Let us first 
&i<l«r tliQ H^iiiptoms of pblegmoii of tlto foccann : it bt^pna wi^^ 
,.nin, swellinf];, and r^lncss of the sldo, and luunlly wiih high tere^^^., 
the skin of the arm is somewliat aedematout and very Icnnc. Wi%j 
Uiifl commcDoenieDt, wliicli alwu^-s announcco an acute tufiammali«^ 
of ihe arm, it« spat may rary grciitly, and in the firtt day of two yon 
tiiiiy bu imabi» to dvdile vrhelhßr it is u cnse of iuflatnmatitMi of tbp 
»ubcutancous ecUular tissue, of pcrimusoular iiiSiimtnntioa below ll» 
fMtfia, or 0T«a of pcrioetitis or ostitis. Hie greater tlto ccdcynt«, lite 
more considerable the pain, the less the redness of skin, nod the laa 
intcHHR the fovcr, the more probiibly you liaTO*to luiticipate a deep 
&Mted iiiDamDiattoa wbich will t<>nninato in suppuratiou. If tbö in- 
flaramatioD otlacks ouly tbo subcutaneous «ellulur tissue^ and gooi«B 
ti> auppuralion, as it does ia most cases (tliough rcsolutioa ia Br«n), 
this c%iDCe« it««U ia ii few days by tbc skin becoming red >t loiiia 
{)oiiit, aud disliDL't fluctuation oucurritig. TImju the pus cither per- 
fumtcs spoatascously, or is let out by an inciaioo. If the inBammo- 
lion afiect porta of the body where the hkia, and eipeciaUy the epi- 
dermis, i» pikrticularly tliick, as in the hands and feet, thcra is at fint 
little pcrrt'piiblc redacts, bs it would be hiddeo by the thick layer of 
epidennis. Pain, and a [wculiiir tenaio« and throbbing io the iafiniBml 
piirt, nnnoimcc the formation of pus under tlie skitL 

In some of these csses a portion of th« bViq becomes gsngrenuna, 
the rirculntion being disturbed by (be tonsioD of tbo tiastiQ, part of 
the skin loses Um vitality. Tho EaseiiB also arc ocoanonally threcl- 
ened by these iuflammaiions; in such cases they come throt^b the 
ojirninK^ nf the cutis as lugo, white, ronsistent, throsdy tago^ 
is particularly the case in inflammations of the Malp, whieb luA 
fVequently extend over the entire Hkull ; the whole galea aponoucoUta 
may thus be lost. 

Let ns now pn» to th« more minute anatomical change« tbal ukt 
]iixc.e in acute inflammntion of the cellular tissue; we shall not Imr 
return to tbe dispute as to wbethcr i-esseb, tissues, or ncrrcSr am firrt 
affeetcd^but shall only spcnk of what wo caa find on direct atiAtOBiical 
«UUDinatii»!. A series of ob^ervutions on the cadaver, where in rariont 
cues we sec infiammatian in dificrcnt stages, ^rea us sufllcJent infet^ 
mation on this subject. The first things we find are distentloa of Ilia 
capiUaties and swelling of tlie tissue by serous exudation fmm thl 
reascla, and a t'u:\i, plastic intiltnttion, rarylng frith Uie >tage^ L e, 
ibo connc«tivc tissue is filled with quantities of youog, rouxtd coDa. 
Tliis, then, is ttio nnntornicnl condittoa of the cellular ti&jtue under the 



raLEGHONOÜS INPLAUMATION. 



891 



reddc&iNl, paiuTul skiu ; subsequent!; the oullectioD of 
telU in the inflamed omncctivc tiwuc and fat [>coomea more promi* 
DeuU Tbc«e tissues becmue Icusc, and Uiere is slAgn^tkin of blood 
ia the vessels at various ]>oiiit^ espcdully iu tbo cajiillaries and veins ; 
■t socnc places tlic circulation ceasHS entirely. This stA^atioa of the 
Uood, which at Sret cau»«« a dnik-Uuc color, und Uicn uliitciwss frtmi 
the tapid disoolontion of the red blootl-coItK, tnnj ext<>ttd so far as to 
cause exteosivc gangrene of the tissue, a rusult nliicli wu bare alretidy 
tiiODtioDed. But in moat cas4» tUia docs not occur, but vrhilo the cells 
increase, the fibrillar iotcrcellular euhstancc disappear«, partlj hy the 
death of small tngs and particles, partly bj gradually becoming gelut- 
JBOM Bt aiid (itially changing to fluid pits. 

FW.« 



Tlww ft— > anil fciWiMwI lr*a tedatuiuMlaa. TV HhawttWrT IDirfllir IbnnHim of A« AiB» 

lwi« « WBfrdM»p p MrMl.«MiOi»i»»il«iiiiiflmpwic*QfiliB BjlaMf t BB M iiBMI ni» , Tlu mlli oT 

(fc* m«ds an rtkud wl tmHtr^u^L AffBÜBd aUml MO. 

Aa the inflamtnatioi) proffrcÄSt-s the ciitiro inflame<1 part ia finally 
idaogcd to pus, that is, tu fluiil tiaauc, consisting of cclU with som« 
serous intercellular fluid which is mixed with ^rc<lfl of drad tiesuc. 
If the pnxTSs goes on in the subcutaneous cellular tissiie, extending 
in «II directions (most mpidly where the üksuc ia most \'n8CuW and 
richest in ocIIh), the purulent destructloo of tissne or »uppuration 
riil ext«nd to the cutis from within, perforate it at some point, and 
ugh this perforation tbo pus n-jll cecopo outwardly; when this 
, the process often ceases to extend, Tlic tiHsuo Bunoundlng 
punilent collection in filled with cells and very rascular ; anatomi* 
caally it doocly resembles a gmimlattng mirface (vrithnut any dietinct 
gnuitilatiorui} lining the whole CAvily. ^^'ben the pus is all evacuated 





a92 ACUTE NON-TRAUIUTIC INJXAMMaTIOX OF SOFT FAKK. 



the tniÜB come togetLcr and usually unite qmcUj. llu piMtic tnCU 
tnitiaa ccputinurs for n timr, causing the ttkio to remam firmer lod 
more rigid than tisunL But, by disintc^Tatloa and rcabsorpHoo of the 
mAltratiDg colls, and traiisfbnnatioD of the connoctive-tisBi«* BaIi«tiLDr<r, 
tliis stutc also ret lima to the iiomuL 

You will n>a(lily pcn.'oii'O that, aaatomicallj', the piooeaa is mach 
the tnma wbetlier it be diffuse or droumscribed ; the Bner obu)g«a of 
ItsBue in tho tn-o arc just tbff same, Dut in pnctioc ire dislüiguisb 
between purvUtit injUtreUion and abaeeta. Hie first ezpTMsioii esc- 
plaitts itself: hj ao abscess we usually unilenrtand a (ürciun»crib(9^ 
oollcction of Jiufl, excltxliiig further progreea of ttie inllaniniatioa ; 
thoae (anamg rapidly, &om acuto inHammatiüo, arc called acute 
hot ab*r«.t*(fi, in contr»cli»tinclion to eoA/ ahtca»eSy or tliom due 
chronic iußiinimntioii. Tlic foUowiDg G^^uro O^g. 04) luuy render tb* 
formation of abscess more clear io you. 

You bero eet liovr tbe young cells grmdually collect at the poiat) 
wlicrc the conncctivo-tiaauo corpuBclca lay, while intcrmcdiato eiil 
stADCC conetantly dMn>nso8, and how in tho middle of tlie draningfit 
tho centre of the ioflaniGd spot, the groups of cells unite and Tonn ^^^ 
collection of pus ; every absocas at first oonsiata of such separate od — "U 
lectioiiA of pus; it grOM'S by pciiphcrul oslvntiion vf the suppuratioB.^ 
FonneWy, it u-n;« not duuhti_-J that, whurvver ]ii»-celU thus appeared 




ruhtH. 




nb(t«a) of pamlcot toSUnUfin «r Ih* call* coMc«a*B tlimtt, fbnrtac n 
miMMi. Jti^iflMl SU dUBK-lm, 



«bKMClaa« 



in groups, tht^y wi-re to be regarded us a production oC connoctivr- 
Ussue «Us ; oooordiug to our prt-st-at Tiews, there is no doubt that 
Üiese young ocUs are C8caj)-?<l white blood-cells, and are »imply grouped 



rilLEüUOyOUS INFX,i.UUATION. 



ssa 



(q^ctScr from mi^attical causes. Tlic Fat, whicli is nsitiilljr plcotifiil 
■ tbo (ubcutaacous Of Oiüm- tissue, is gcncrailj destroyed in aoito 



PM.U. 




. taOlUh'ioi of Uut MltalBr niMDbnno. M«nlili!<JBXidlamcit«T>: fron a pn|Mnttu 
haiAouMtntdoobbl. 

ildftioal&tiün, the fat-cells bciu^ comprvstnMl hy the dvw ceU-tuass«», 
aod tfac tat bocomiDg fluid ; subsequently, it is oocaalonallj fouoil in 
Ibe shape of oil-drops mixed with the pin. In tbiB pTCparatium ;ou 
ma^ lee tlie microscopic appeamiice in infUmmatiun of the cellular 
scmbrane. 

Id examiniog locb prcparntionx w« not unfrequently find fUamonts 
Qoagulsted fibrine infilrrated in Uic tissue; poosibly it is formed ui 
I oonmieDccment uf tliu iutliiminatiuii, as previously dcKribcd ; but 
is olso pouiblo tbat tlicso ^lamcnU Appertain only to tlic fully 

puB — possibly ttioy are produced by the alouhul. 

I must call your attention to ilio fact that, until the process is 

mcatcil, vr« alvntya liavc a progrcsairo softonin^^ of tlio tia»uc, or sup 

pundiOD, iu which it tliflere from a developed granulating surface, 

vhicli only fonns pus on its flurface. All suppurative parenchymatous 

iofivnmatiocu have a destructive or deleterious aetiou on the ti;<auc. 

^_ As regnrdfl llie relation of tlie bloo(l-vcs»el8 to tlic tien- fom)ution 

^n the yotittg tüsue aod its sjteedy disi[itcgration, it hau already been 

4ntcd lUat they arc at first dtlutvd, and then the blood stagnates in 

them ; if the drt.-tdatiou bu eiilirt-ly arrested io oertsin portions of 

tisnie, in vhicb case the comgulation in the veins occasiooallj extend; 

% oooAidcrable distance, the walls of tite vessels and the ciot suppu- 

''^te, or fall into shreds, as fur as the Itordcr where the drculatiaii 




294 ACUTE KOX-TSACUAnc CfFLAUXATIOX OF gon PART& 



<i,m. 




TmmI* (afttfldailr lalceled)' erih«v«Ili r< 
ft dag. Jl*it' 



•V 



begini again. As ve have »IroAdy wen vhen stiidjiDg tbe detadK 
UKrnt of utrcroAed slireds of tissue, rnscnlur loope must 6xm cn tUt 
bunlcr of Ibc Jiving tinne; tbftt is, tho wholo inner surfiwe of n 
abecoHs, in the arrangcmcnte oF its vessels, is analogous to a gtatula- 
iing Bur6un; folded up aaoUkc. 

In rcgurd to the lymphatic rcsscis, ve may conclude from analogt 
that licre, as in the riciuitj of wounds, thf^y are dtts^l hy the infian-. 
rnElorr neoplasia; special investigations on this suhjerL vrtMili] 
very dosujabic So soon and so long as an abscess u auiroumlod 
B ngon>iis ]ay«r of üssoe infiltrated vith {Mastic nutter, for 
■litädf mentiooed liiere will be do reabsorptioo of punik*ut or putrii^ 
BitbabuioCB from the canty of tlie abKCSS. I can give you pm 
evidonoe of this, if in llie clinic yon will smdl pus from an a 
DCar tho rectum or in the mouth ; this pus bos an piirepdingly 
tnting, putrid odor, still is not reabsorbed by tbe valla of the Tth 
or Is so tu only a rcrr stig-ht extent ; symptoms of general aepais 
ruvly occur. But at the commenoement of mflannnation, and fail 
whtui it is aooompaoied by rapid destmction of tiante, aa wcU as 
nme prDgre««ve inflammations aroond cootused wonnds, and 
phlqgmonout fuOamioatioa of tbe ecDular tlsBue, et«., if the lymph». 
Teasels are not yet slopped by ceD-farmatton, organized iollunins 
new fbrmatioit does wA occur, or comee on lat« as tbe gangreoo 



PHLEfiMONOFS IKFLAUMAnOX. 



sw 



LioQ i« bein^ ImuimI»] ; thcu the decompoaLu^ tissue oiiten 
llic opro lymphatic« and sots as a. fcnncot in Urn blood, cnusin^ fever. 
Allliougli infiamniutiun of tlic cellular tissue (ccllultiis) iniiy' oomir 
at any part vf the body, it is most frequflat in the hand, forearm, knee, 
loot, and leg. It is olVrn accompanied» and, when extending, preceded, 
by lymphangitis, of which we shnll speak among the aocidcntal tnu* 
matic diseases. 

Hie intensity and diinilion of th« fever, Accomponrin^ those in> 
AuBinatioiu, depend on the quantity and quality of the miitoriiü rc- 
abaorbcvl. At fint a quantity of Ihcso matters is Uirou-u into iho 
blood at oDcc, hence ul the onset there is usually hi^^h fei'or, eome- 
Ijmes chili; as the inflammation proj^resjec, the fever eontinucs; it 
eeues when further absorption of Dm iuflnmmatory produet is arrest- 
ed hy the aborc cltanges of tissue, when the process stops and the 
■faeoeM is fonned. TI>e quality of the inflammatory material formed 
in cellular inflammation cerlainly varies grcatlv j for instance, in some 
<!aaBS »lce[) in tlte neck in old )>eople there is sueh intense poisoning 
Htitmt the patients die without otitcr nj-inptoms. It is here the mdc 
Hh in carbimde — sotnc eases cause little fever, otliers produee fatal 
^Icptic fcrer. If a phlofrmon be due to a dangerous poison, such as that 
of gUnders, we do not wonder at the fatal termination; but for the 
^-RKmlaneoat cases it often seems very etrnogc why gome sliould be so 
^flKry aerere, while i»o«L of tlieni are relatively mild. 

The pro^osis of phlegmunoua iiiflumniiitious varies iniinensety 

with ihc loo^aiif^n, extent, and cause. M'hilc the disease, occurring as 

a metastasis in a general phlogistic or suppuratire diathesis, or iu 

glandeis, gircs little hopes of cure, while deeply-sealed abscesses in 

(be walls of the abdomen or in the pelvis are ver^' slow in their course 

and may prove dangerous from the locality, or, by destruction of fas- 

, die, tcDilons, ai>d tulin« may impair tlie funetiotis, most cases of phleg- 

DQD ou the fingers, hand, fureann, etc, ar« only moderate diseases of 

duration, nllliongh very pninful. Tlie sooner FuppumUon occurs 

lud the more eiretimscribed the iuflummutiun, the better tlic prognosis. 

As regards the treatment, at the conuncnecmcDt of the disease its 

is to arrest tbo development of the disease if possible, tliiit is, lo 

the earliest po^siblo rcabsorption of the serous and phistic tn- 

CltraliuQ. Fur this purpose there are various remedies: first, Uie ex- 

tenud use of mercury ; the iiiQamed port may bo smeared with me^ 

cuiiml ctntmenl, the jmtient plao.'d in bed, and the inflamed eitremity 

Cnvrloped bi warm, moist clolha or large cataplasmH, Ire niso may 

t»« employed at first, if tbo wliolo inflamed part can be covered with 

»agn r cja l bladders of ice. Compression by adhesive plaster imd band* 

^L^res is also s very cITeelivc remedy for siding nifsorptton, but It IS 





296 AUCTE XO.V-TRACMäTIC ISyLAHVATIOS' Of SOFT PARTS. 



litOe used ia these inflanunatinns, partly because of tbe pain ft aam* 
ia Bucli cases, partly IxxaiiM! the remedy is not fiec frora dnagct, t& 
g&ogrenc may be eaail^ imluccd by t little too much prouure. Ut^ 
proocM be not iitodersted soon alter the employment of lite abore 
remedies, but all tlie symptoms incicoae, ivc must give up tlte hope of 
resolution, and resort to remedies to hMtco tbc suppuration wbiA-w* 
uuiRot avert} tiw> chief of tbmc is tbo appltcatioa of moist wumtb, 
espccislly in Ibo shopc of cataplasms. Thirn, as soon as fluctustioa i* 
detected «t aay poiut, we do uot usually leave tbe perfonktioD to M^*- 
ture, but divide the ülciri to give vent to the matter; if the suppuntiam 
extends under lite akin, vre make several openings, at least I prcfic 
tliis to one very large inciviun, from the elbovr to tlie lia»d for iuataac^K* 
beeause io tbe Intter the »If in pipes widely, and takes a loDg time fc<o 
heal. If the pus escapes naturally from tlic openings, ereat tJesnÜitf 
is the onlv thinfif neccseorr; this is greatly assisted by local 
baths." 

Wliilo il is a rery simple thing to open subcutaneooa at 
" oncotomy '* of deep absccEsrs requires great attention to tbe mult- ^ 
my of the locaUty : for instanee, the dingnosis may bo vpry difficult i^^* 
8U])puratioii![ deep in tlie nocV, in tlie peliHs, in the abdominal wal^^Vt 
ctc„iuid can only t>e certainly made after a long period of obeemtioii -i 
still, partly for the relief of the patient, partly to avoid « ipontanao uag ** 
opening into tlie abdomen, perhaps it may be desirable to evacustü^i^ ■* 
tbe pus ciirly. In such cases we must not plunge n bistoury boldlj 
' (tt, but dissent up Inrcr after laver, till vc reach the fluctuating cover 
ing of the nbsoess ; llien iiiUxxluf'o a probe carefully, and dilate tbe 
oi)eniiig by extending Uie biiidesof forceps iotnxluced into it, »oi 
avoid luvmurrliago lix»a thu deeper parts, Ocoasiooally dewmpo-- 
I Ktlioa of tlie pus ill uu abtujcss causes so much gas as to give rite • 
[to n tympanitic pcrcusalon-sound; after being opened, liiese puirid 
^nbsooaBGS should be syringed out and dressed with chlorioo'vratflr. 



4. ACUTE INi-LAMMATIOS OF TUE MUSCLES. 

Idiopathic acute ioflammation of muscular suhstsnoe is 
tively rare. It occurs in the muscles of the tongue, in tbe 

and gluteul muscles, and in ihose of the tbigb and calS^-BT 
^of the leg; the usuid tenulnalion ist in abscexs, although y«eo\v^«^--^::ys 
has beea observed. Metastatic muscular abscesaes are vuiy fifwpigo^ ^m t 
in glanders. Regarding the special laistdoi^cul conditions, the ' 
'torstltial connective tiisue of the musdM, the pcrimysimn is fa« 
as iu tmumalie myositis, the chief scat of the purulent infiltration"' -^1 
&om the Tory acute disease, the nuclei of the musoulur filsn 




1VFLAUUATI0.S' OF TUE SBEATDS OF TESDOSS. 297 

uo deatrojed, witli tho contractilo Bubetaneo ant! thn sarcolemma ; 

rmly on the stumps of t\m muscular filamcnLs in tlie capsule of 

tbo sbAoeas do we fiiul Ute iuii»cuUr nuclei (musoular corpusci«) 

in groups ud adherent to the cicatrix ; in such cnscs, nccordtng' to O, 

W^etf then) is a oonsiderable n«\v formslioti of yourij^ iniisck<-ceUs. 

Tbo symptoms of an abscess in the muscle are (be Bame as those of 

»ny deep abscess; tbcir periods of development and pcrforatioo vajy 

tvith their siae and extent. Id many cases there is oontraction of the 

muscles in whose substance the abooesa derelops, as id psc^tia. I ahall 

tv>t discus» whether this is the phyvological result of the inflammatoiy 

irritaüon, or whether it ia half voluntary, nnrl inndc instinct! I'cly by 

(lie patient, btil am rather ineline<l to the latter rjew, fur iu amall 

^nd not TOry painful abscvsscs and in tmumatic inflummalioDS of tho 

ffjiBcIc«, tliere is usually no ountniction, but this oceurs only in Urge ab- 

^oensca, which arc compressed by strong fascia;." Absccatca in muj^lcs 

gitouii bo opened as soon as fluoluation ia felt, and tho diaguoais 

A very peculiar form of dUease of Uie miiseleit, wliich, secoiiding to 
tnir '^'iew, should be claascd among aubcutaneouA infiommatioas, boa 
(yeo^KK teoentiy disoorered and described by Zenker; It occurs chiefly in 
t3rr»boi<l ferer, )u the adductor miisclus of the thigti; in it the oontrao 
lilc eubsiuice io the ftorcolemm» crumble.^ ami is gradually »hnnrbcd, 
tvtLJ-l« neir mtiscular rilameiits form to rcpUice the old. Thus, iv^ most 
eas^sA, the parta are fidly restored ; in other eaaes permanent atrophy 
of ^Jbe muscle n.-muiiis. 'I'here is uooccunt« knowledge as to whether 
tlai^ diseaao may lend to suppuration, although abscesses of the ab- 
do>ixa,lnul musch>B have been obeert-ed alter typhus. 



I- 



OCTE IXFLAMMATIOM O? THE SHEATHS OF TENDONS AND SUB- 
CUTANEOUS MCCOCS BUÄä.B (SEEOL'8 MEMBRANES). 



-As is well known, the eheJitha of tendons form shut sacs, which 
.C3K some of the tcudous uf the hands and feet. They may be- 
come acutely inflamed from «ontu«ion, mid in Sümc few ca««i aUo 
■pon taneou&ly . Like aJl sctitely-intläuied sL-niufi incmbrunea, these 
Bacs at first cxudo a quantity of fibrinous scram ; recent Gbrinuus 
pseudo-membnaDOB compoeed of wandering cells may again dUsoWe, 
Wt ihcy may also induce teinporaty or permanent adhesions of the 
*wiath to Üie tendon ; lastly, there is not uafrcfinently suppurn- 
lloca of the membrane, and at this Umo the tendon may become 
nocroaed. E^iii on motion and slight swelling are the finst eigna 
^H oC 9vt.il inftammiiljou ; oo(-»»iona.1ly there is friction-soimd, a grating 
^H üt itio sheath of thu tendon, wliieh muy bo pcroeit-cd by tJie hand, 
« <v, «till belter, by the ear. This noiso is due to the aiirfaoea of 

1 '" "• 



S98 ACUTE NON-TIUCHATIO INIXAUUATIOX Or SUFT PABT& 



fibrine and rubMn^ agsiost cneli oUier, whon th« tcndau ata 
tili» rorm of subcutaneous influtnmntiaa is most cointnon on tite 
of (be liand, ami almost al^rays tonuiDslcs in resolution. The rrr^ 
»cut« inflnoimations of tb« shoatha of the tendons« arising from niVi 
kucnvn cau»es and going on to nuppuration, are rare ; Üi«>y b^;iD Uk« | 
an ucut« plile^iiion ; llio suliciitmieouK oelluliu- Ilssuq qutrkly partici- 
patM in th« inflnromation ; Die limb sn-eJls grMtly, and the adjaoeil 
fing«r or wrisUjoInt may be drawn Into llie iDflammutloii. Lik« tie 
synorial mcinbruiiu of tlie joints, tliut of the tcndinooa ahcatlis ooof 
nooallr eccms to furnish product« that int«nMly affect tbo »ummBi- 1 
ing parts. If, under suitable trvatment, the dis«ue does not go on lo 
euppumlion, or, if tbis bo only partial, resolution slowly occtus ; tbe ' 
limb remains stiff a long while; tho adbenoos between llie tfodon 
and its abeatU do not breaV down till s/ler month» of use. If there be: 
extensive mppumlion of the »heaths of tho tendon (which, in the bwid^' 
has been termed "panaritinm tendinosum"), the tendons usually bw 
oome necrosed, and o^er a time may be drawn out of the abaoen 
openings as white thrends and shreds; the membmnc tlien degeoer-i 
si« to «pongy granulation«. If tlie process be now arrested, OO» Ofl 
mote lingers will be stifT, and remain so for life. If the joints be sIm" 
attacked in tbe niigcm, there may be reoorery with anchylosis ; but, if 
the wrist or ankle-joint be nflccted, its cxi«tL''nc«will be greatly «ndsa- 
geml. lu uaite Buppuratire iufluinniuliuu of the Ivudinous shfAths, 
tlic Jirer is occasionally alight at first, but in severe cases the discUQ' 
may begin with a. chill. Tho further the ioflamoiation and nippuntkwi 
extend, the less the process tends to funnution of an abecess, the mOi^ 
oontinued the fever hccnnic!!, and it assumes a distinctly remittcati 
form; at the saise time the patients are rsptdly pulled down; inafe»l 
week« the strongest men emadat« to skeletoas. Tbe pcognosts i^ 
biid uhen thi; fcvtr runs on with inlermifleiit attai-ks and cbilla. 

Tho (reatmcnt of eubcutaueous, crt- pital iug iiithimmationa of lli^ 
abealhs of tbo tendons consists in keeping the part quiet on a splinl^ 
and painting it with tJncturc of iodine; if this does not nffonl speed.^ 
relief, a blietcr may bo applinl ; under this treatment I haro oiwawj 
seen this form of inflsmmation disappear in a few days. If the syngri 
toms are sever« from the first, quiet of the part is the first rrniiiritJ 
this shotitd he eccoiHlcd by mercurial ointment and bladders of ic=q 
This treatment should be persistently pursued ; in these cases I i3ri 
cidedly i>ref«-r it to cataplasms and local warm baths, which are rt rnt 
common. If abscescs form, incisionii and plenty of oounteropcain^ 
should be mnde ; in theS:eca«esdraiaago-tut)e8 arcveiyiuHiil, beesL:^ 
the gmnuhitioDs prujc-cting fttjin the openings ofton oltstruct t^ 
escape of tho pus. If the suppuration will not stop, if the spoiagn 




INPLiMMATlONS OF SIBCCTANEOCÖ MUCOUS BlTHaA'. 2fifi 

^^^lling of tI«J limb continues, if crepitation nppears in ttio joint be- 
g^»D the bones of th« wrist (showing lliat the cartilftgiiionit coverings 
linv^ fiUppural«il), ttad if t]ie patient oontiiiueA to eiiik, tlicru is UtUo 
i^Qp0 of a termination in unchylaitis of tlie hand, but the danger to 
life i^ ^ fcat tliat aniputntioti of tbo fureann should bo made ; tlie 
_(it^>nt maj thus escape vritb bia life, and ivill soon recover hia 

3.cute tnflammaüons of tho »ulcuian60U$ mucou» hurne are less 
jnurtfvouB ; tbe bursa pncp«tcllans and anconea arc moat frerpK'titly 
•ftetoi citber from injury or spontaneously; Uiey are coiiucc-tcd 
tlfitfx^' with t]te joint nor with tti« sheathji of tlie tendnn» ; titey biv 
ixmtp jaioTul, fiU with Gbrloous aenim, tlie ekin reddeos, and tlio eel* 
lulitr -tiHae in the rieioi^ p«rtieipat«8 in tbo inflnmniation ; but sup- 
ptinEt»*" nircly oociirg if tbe patiejit is treated early. TIio rometUo« 

are xxvcunnl ointment or tincture of iodine, keeping the limb quiet, 

•Ad cTOcnpressing the swollen bitrsa by Applying vet bandages. 

ARKf^rufe is unnecesGsrjr, and may bo injivious, from being followed by 

■l)|mxj.ration and a tedious sttppurating fiatula. 



CflAHER XL 

ACUTE I2irFZ.\y[MATroyS OF THE BOyES. PEnr- 
OSTBUX, A!n> JOINTS. 



LECTURE XXII. 

AaUomr.— A«aM PtftottiHi «id OiteomTditi« tt tb« Imi; Boomc S^puai, ' 
■iift*ti6iL( la BCMhtton, BnpitonttbMt, N««v«U, I'ioxdm]«, Traic 
Ottttb in Sponcj' Boom.— Aonl« latMunutioiM of Uii Jmiita.— lljdtof« Aaatai 
Brnptoia», TrvubMOtv— A«ato SuppuntiT« lalamaiatkn* of Jolnu: Sfwip 
Co«m), Traftbnant, Aattotnjr.— AouU ArtUwIu RhMmattm.— Arthriu«.- 
latio laflABSBtiODi «r Joint« (Ookonliaal, PfMiioi l*iMrp»ral). 

Tbb periosteum and the \joaat are pbjsiologically bo inttnialHl, 
cwnnected ttuit diaease of one geaerally afTecU the other ; altboagti^L^ 
ID spit« of UiU, we ore, for practical reasons, obligod to oonawlor ■rwt ^; 
and ehroaio infiammation of th« pmoAtcuni aod of bone tepBfale)3r, 
etin we fllutU often liare to refer to their oonneotion. t mimt liom raaW« 
a icw prcliniiaarj aualomical remarks, aa tlicy aro imjiorULOt fcr tl>«i 
eoinprehi-niion of tlio fullowing prooejw: \Mjon ftponking farisC^of 
the periosti.<uin, wc iisuuHy mc»ii, simply, thv whiu>, glislratnz', thin 
lucmbniQc, poor in rcssfb, which immcdiatol^r eurrouiula Uic Lua& i 
must here rvtnark that thi« n>pn>scnt8 ouLj a p«rt of tlio pwi fltf gu w 
*hal is pnlhologicallir of lillle ri?Iati\-c importance, Upon thisjoM 
described üiacr Ujcr of the pcrioateum lies, at points wlicio DO tes 
donft or Uj^menta are ioscrtod, a layer of loos« ceQuIar tissue, whir6 
U also to be considered as periodt^um, and in which principallj ßo th> 
vcflflcls tlut enter the tmne. Ilils outer layer of pt-rlost«uiD u Ifa 
most froqiwnt Boat of priTmiry inHammatioos, either acute or chraolt; 
tlie looflo cellular tis.sue of which tliis layer conM«u ia very rid ■ 
OoUs and Tcssels, henoo nmrc inclined to inllainnuition than is Iha la» 
dioDua portion, poor in cell» and Teasel«, whk'h liPS irnniMüilelf <• 
tbe Inne. As to nutrient vesaetft, espocially in Ih^ lung b<iai%tW 
rfupbyscs have their own supply, which, as long a» the epiphyseal e* 



ACUTE PEJllOSTm& 



901 



tiligcs a>atiDue,do notcommunirate iritli tbe vesseb of tlie dinpbjFBis, 
wliuiii liave tbeir own uutriciit aricrivs. Iltis dutnLution of tbc rc»- 
iebeiplüus vlij düu>aiiO!( of tb« diivp))yst>s in j-oimg persons rsroly 
fast to Ü)C epij^^-s and (lie n.-verBO. Gtnietk'ally the arlicular cap* 
■ule ia k oDiitinuntioii of 1\m [>t.-riostvuEn, nud s certuiii cnnncctimi is 
ofitoobsenocl botwoon irtieiilur ftn<l jxTiostc»! ()i«eusi.i), ihc dUcasca 
of cot readilj passing' to tlia other. Ia the course of the following 
ubsemtiaas wo sball have oocfuion to recur to Üioso anatomical con- 

tüUSDä 

Fintf let ua speak of aetite periaaiitU and Osteomyelitis, of nbich 

jm have already lieard sonietliing in the remarks on Btipfitiralion 

of Lone in Uie chapter on op«a fraclurea (p. S21). Tliis diAea«« 

U Dot yeiy frequent ; it occurs chiefly in young person«, and in iis 

Ijpica] form» almost exclueircly in thc! long boncH. Ttiu fL-niur la 

BKBt farqucauy nttadicd, next the tibin, nvyrc rarcJy the hnnicnis and 

(■ones of the forearm. I havo ai-cn tbu diMnise oocur priuinrily or 

f Momdarily id the vicinity of acutdy-inflanwxl joint*, after catching 

CdU, and afi£>r severe oooeussions aod oontusiooB of the booee. It ia 

poMJble that the extrnvasation into the medulla from eniHltinj; or eon- 

tttiiun of a bono may be n?absorbcd, williout the oci;nrrenco of any 

■ynjAom but a continued pain as the rMult of the injury ; but suvb 

"'jurii?s may occaEDORolly iotluce clironio aflcctions of various »oris. 

In many ca»cs we oaanot düooi'er whether only the periosteum or 

^6 medulla of the hone is aScctcd ; the distinct iun is usually only rcn- 

*ifir«(I certain by the suliBiHitiuut course and hy the (crrnitiitlioii. Tlie 

■5Tnptoms are ok foUowa : The disease bcpina with hijrh fi-vcr, «ot un- 

''^ut^itly witli a ohili ; there ia severe pain in. the affected limb, which 

«■Wtilla at first without redness. The eevcre pain prevents motion of 

'lui limh; every touch or the slightest jarring is very painful; the 

^^n ia teutie, usually oedomalous, and ovcasiooally the diüteudcd 8ul>- 

culaAeous veins ahow tlirough, a ^i^^n tliat the flow of blood to the 

*Joeper parts is obstruct«!. The iiiflamiration may affect ihe wbole 

'3'' Only port of a bont^ 13ut these symptoms aimply indiivtu the ex- 

••t^noe of an iiitojise defply-scstcd aeut« iiißunn tuition. Uiit as idio- 

P^l^ic iuflainmatioa of the perimuacular and perileudtnous cellular 

"**tie is very im&cqacDt, ond rarely begins with 80 much pnin, we 

*'"«all ntit err in most cases if^with the above symjitoms, we diiigitoati- 

'^'»■t«^ amite periostiliB, peihaps accompanied by astcomyt-ditis. If, while 

••»«5r«-w are great jiam and fever, or complete inability to move the limb 

**•* ^u«annt ef pain, swelling doe« not ooomr ft» several days, we may 

■•*«':jaiict that the prininiy seat of the inflammation is the meduQiiry 

J^ ^"^ ty of the bone, and that at first the periosteum participntea but 

^. To this stage the diseased part is in abont the follotviog eun- 

Si 



302 ACUTE WtXAMMATIONS OF TUE BONES, rERIOSTETM. KTC. 



dttioD : Tbc vessels of the medulla aotl jtcnoctoum are greatly dllstoc/ 
And distcmlöd wttli bloud ; poHiiips there may b« abuis of blood u 
tliSerent {loinltL The metlnlla, instesd of tU ttwiiil brigfat-jdlor 
color, ia dork blue, »ml pcnncatcU with cxtnvnsatiuiis; Um peri» 
leum is greatly iofiltnited, and on microscopies! ejciuninittioii of it ^ 
ÜikI nuiulters of yoimg^ cells, as you aUo do in Iho uiL-dulU ; tbst ii^ 
ÜiL-re i& p\asiia iiiltUnillon. lu tbtii stage, a complete return to the 
Qormal stato is possible, and, if proper trcfttmcat is bcguo e*r\y, tliis 
IB not so Ttuv, purt ioularl jr in the more suhocut« oaoca. The ft.-Ter 
fall», tho swelling decreases, and the pain ceases ; a fortalght after the 
comRK'ticvinCDt of the disease the patient may be recovered. Erai 
irhca lliä ]>ruce«s is sotncwhnt further advanced, it may stop; then • 
part of the odvr fomiation on the sur&oe of tb« bone osstfips, and tlnii, 
for a time at Irost, there is thickening of the affected bouo, wfaidi nay 
again be abäorbeJ in the course of montlis. 

Ill m>Ht casi^-s the course of periostitis is not so fiironble, but the 
process goi;s od, and l^nniiiates in mippurution, the symptoms hdof 
as follon-s : The skin of the evroUen, tense, and painful limb a at fiat 
reddish, then brownish rvd ; the atlcmn extends further and further; 
the neighboring jouita become painful, an<l swell ; the fever . 
at the 8Ame point; tb« chills are not infrequently repeAt«d. 
patient Is much exhausted, as tic cats little^ and nt iilgbt 1* 
awake by the puin. Toward the twelfVb or fourteenth day of tho • 
easCf rarely earlier, but often later, we may dearly distinguish Su 
ation, and may then greatly alleviate the sufferings of the patieot b>B 
tetttng out the pus through one or more opeuings,if tlie ^iu over tfc^ 
ubscesK ia suHicieutly tJiiunud; for the ojiciiinf? of dcc[), »tiffwaUo/ 
abscesses which do not collapse may prove dangerous from deeoia|v. 
silioQ of blood aud pua in Uio iiuufGciuDÜy-«ivapflulat«l afaaoea 
The spontaneous pcrfumtian, cspeoially tbe snppiimüan of the : 
occasionany takes a good while, and, moreover, the (^leniflgt 
fonned are usually too small ; they must subsequently be 
If 3'ou introduce the finger through one of these artificial < 
you come directly on the bone, and in many case« find it deoode^l 
periosteiiiii. The extent to wliicb this denudation oceurt ilepeiidi| 
tbe extent of the perioslitls. It may extend tlic wbcde length of 1 
diapbysis, and in the<e worst MKS the s^-mptoms arc tbe mo«l sonn 
Probably, however, only a half or a third of Die periosleuiD bifi» 
rased, nor is the cnturc circumfcrcncc of tlic bone necessarily aflrtfsi 
but perhaps only tho anterior, Utcml, or posterior portion i» so, Tfe 
periostitis la particularly apt to atop at the points of origia at haa- 
ikiD of strong niusclcs. In those cases of slight extent all the 3)Uij> 
toms will be milder. 



^CCTE PBIUOSTITIS. 



308 




CrCD to (bis stage tlie dtscaM oiny tnkc one of two difTcrcni Jirco 

cJoiu : possibly, aft«r the eracustion of the pus, the soft ports iai«y 

«'luiddjr beootne adherent to the bone, as the wnlU of a.n acuIc kbscess 

io to e&di other. 1 hnve seen Uiia a few times in periostitiit of tbe 

fumur io ehildien two or tlireo year« old. After the opening, a 6%ht 

cjuaatity of pus oontinuect to dUoh«rge for only n shurt tiDip. The 

«openings soon closed entirely, the lumor reecdoJ, and perfect recovery 

look place. But, according to my experience, such a tcrrainatioa oiily 

oocun in eniull childn^n. Moru frutiUL'iitly, as a result of the suppu- 

vaiioo of the periosteum, the bone is mostly robbed of its nutrient 

"Vessels, and partly or vbolly dies, leaving the conditioa tenoed 

necrous, or gangrene of the bone. The extent of this necrosis viU 

■ rtw iiliiillj depend on tlic extent of the periostitiii. Tlie parttiilly or 

«ntirely destroyed diapbyftin of the lonj; boues must be delavhud a* a 

ibreigu body, as we have eeon to bo the en»e in gnnprene of tlie soft 

porta and tmumatio aecrosis. This rc<iuires n long time ; licace the 

process of nwiwsis, the detachment of the portion o£ dead bono op 

lueetnim, iiml cn-ry tiling coniiceted with it, Is alwayii a chrooic 

TVe shall hare to apeak of this hcreaft<r. Before the iuQammft* 

passes into this dirooic state, acute suppunitioh continues for a 

after the first (^uiug of the iibsu-se. Various ooiiiplieatioiia, 

even pytemin^iDay occur. Wlicnever these patienta are feveriji, they 

iSro to dan^r. 

P AVc; must again return to the tne<ltdla of the bone, whieh ve left 

In the first Ktngc of iuflauinintioii. Here, also, the inflamniiiUou msy 

,tcnntnate in suppuration. If the osteomyelitis be diffuse or total, the 

rhole tnedulb may suppumte. This suppuration may even assume a 

' putrid character, and induce B€p(ica>nm. If tliero bo extensive »up* 

purativc oeteomyelitis, with suppurative periostitis, death of the dis- 

pliysis of the bone is certain. Should there lie only pitrtial siippuru' 

Uoa of the medulla, or if there be none at all, the circulation of blood 

to the bone may be prencrved and the bono rcmaio viable. It may 

3i infrequently occur that, under such circumatanees, the bone will 

ivtt fur a time betvrei^n life and death, as the feeble circulation 

ncmrisbes the bone very iiKomptetcly. Acute suppurative osteomye- 

^^Utisp^rithout participation of tho periosteum, probably docs not occur; 

^Bh in not infrequently combined with 09leophl^UU, which may end in 

^■putre faction or suppuration of the thrombus, and ia prone to induce 

' nkctmatatic abscesses. Anollic-r not infrequent, though not constant, 

nccompaoiment of osteomyelitis \a suppuration of the epiphyseal car- 

tUsffCS Io pcTscins in whom lliey still exist, that 19, till about tlie 

iwcnty-iourtli year. The process is notdifficuH to explain. Thesup- 

pfir&ti<ni may extend to the epiphyseal cartilage partly from the 



io X 



304 ACLTJ: IXFLAMMATIOSS OF TlIE RUNES, PERIOSTECM, ETC. 



modullii of the bone, partlj £rom tJie periüstouin. If it twppvau, 
the cooUuuilr of ilie bone is dc&trojrcd, aiid st the ftcat of Uieq» 
{Ajsijs tbcrc ia motion, aa in fraolure ; dislocations may alflo be cuuel 
hj ouutmctiou of llic Diiucles. Usually there is only on« sucb «f» 
pliys4:al scpurntiua of tlic alTccted booe, above or below ; in rare cua 
it is double. I hATC oQcc scca this double separatioQ of the epip^ 
. BBS ia the tibia; Mroml limos Ibtro seen scputtioD of tlie lont 
epiphysis of the femur, oaix o( the u|^3cr cod of this booe, diceof 
tJie lower oad of tbc humerus, twic« of the upper cod. Ia one CM 
I finvr opij^yaeol Bofteaing, vith luxation of the luwcr cod of Ibc 
ieiniir, occur wllliout smpiniratioiL It liss &ln»dy been stated Üut 
iiißamiiiiLlJou of the iicigliburitig jotats are apt to accompany pedofr 
titia, Tlicso Articular inflnmiuatloDs usunJly bnvo a »tlier Bubaaüe 
couiseL The serous fluid collecting ia the joiut is usually reabsoiM 
as the acut« discBse of Uio bono suhides, but tbo joint often reitWB 
«wollen, and not in&cqucntly peimaQently stiff. Several limeB, aUa^ 
I have seen luiute perinslitis and osteomyelitLi of the femur Kucond 
Bculc articulur rheumatism of tbe knee. lastly, we must abo nx»- 
tion that this osteomyelitis may ocow in several bone« at once. 

Tlie diagnosis as to how far periosteum and bone are alfwitcd in 
the acuto JiaeaM oaunut be made with any oertoinfy, but can only ba 
decided by tb« extent of the consc<iuent necrosis ; aad wva Uiis is bo 
accurate measure for the perioxtitis may end in suppuration, while 
the inflanmution !n the bone nuy end in rcMdution, or only cauji^ 
vomo interstitial formation of bone. The prooofts may »turt .' L I^' 
the loose oclluliLT-tissuo hiyer of the periosteum; this «uppuraieg ^ 
If the euppumtion be ltin!tcil to this layer, after opening the abaoes-'^==^ 
wo Blay paaa the fiOffCr directly to tlic surQic« of the booe, wbkJi w^^"* 
find covered vrilli the gruimluliu^ tj>udiiiuus pnrt of the poriosteam ^ 
if tlic Iat4<:r Iiiycr also »uppiuBtcs, as it not infrequently does, ^^^^^ 
bono lies cxjKiecd, and the suppuration may continue into it. TliUK^-'S 
osteomyolida accompaniee piriostitis. If it be denied that Ü»c lomi»-^**^ 
cellular layer is perinstpum, but is t« be regarded a» part of the intew^^-'-'^ 
muscular cellular tissita (whiuli would not bo uatunil, because th^J'^^'^ 
vesael» csenpinf^ from the bone lie ohiefly in this layer), then tiMiv f 
no Buclt thing as acute periostitis; for the tendinous portion of thJ^^ 
periosteum is as little linbletopi-imMyiulluiiimatiunasÜic bedasuaK^iK ■>" 
tendons. 3, The inflammation begins in tbc bone, and tbenoe fTrfn<~a i ifJj 
to tlie pcnosicum ami cellular tissue; ottteomyclitis Is the prims" rm mJU 
periostitis the Bcoondarj-, disease. Hicu there is pus not only in *" ,«3 vm 
bon<^, but on its surbkee, olo»c under the t^ndinoos portion (4 '^ tii< 

periosteum. This is clc\'aled by the pus, as &r as its elasticity ^ — ^ 
miU; it is then perforated, and tho pus escapes into tbc oelluWÜa 



^-i 



AOTTE PEHI0STITI8. 



806 



Here it caasrs more Buj^iuiation, una thus the process «IrMioes to 
tbo surface. Jloetr asserts that la these cases Quid fat ia pr«ffictl, by 
the Btnmg arterial prntaurp, from the cnvHy of the bone through the 
Havenlan «uiula of the cortical substsnoe to the surfece of the bone, 
•0 that wc may diagnose Qstcomjelltis fixjni pus mixed with r»lH]m|)s 
jisiog from ander the periosteum. Moreover, in a few esses, JRoter 
foiniil a remartcnhle elongation of the bone, and a relnxation of tlie 
udgliboring joiats, after oat^omjrelitis. He refers this to too mpiü 
jrrovtb of the artiailiir li^mcnts and epipliyteol c<utUa(^9. 

fn Ihe proijnosi« of anile pitioslitis «nd osteomyelitis we have to 
dietinguLtli iHrtwL-cn tlie dangler to the existence of the bone uttd to 
life. If tbc <li8oa»o induces pnrtiid or total uccrosi« of tlio bone, the 
disease may be rcry protracted ; it may last ecvonil months, or even 
Tea«. Acute pcDoalitia and osteomj-olitis, especially in tbc femur, 
atid »till more when double, is always dangerous to life, because pye- 
mia is so apt to occur, and in childrcji, because of the profuse suppu- 
ration, it is the more ilaogeraus tlic longer the condition remains 
acute and the further it spreads. 

In tr««üng Ulis disease wc may neconip!i*h more if we are miled 
early; one of the most efficient remctlicsis pointing the whole tiitib 
wttb stcwg tincture of iodtoc This remedy should be continued till 
large vesicles form. Of oourw the patient is to be Itppt rpcumbont, 
vfateb la most eaaes does not neixl la be urged, as tlie pain keeps liiin 
quiet. Since oommencing this treatment I am so well satisfied with 
it, thnt I have almost pvcn up tlw other antiphlopstics ; cup», Iceehep, 
tneroiris] ointment, etc. When the i-esicles formed by the iodine 
dry up, you apply more. Dcriration to the intestinal cniiiil by saUne 
purgatircs aids the treatment, as it docs in all acute infliimniBtionft. 
Sooie Burgeons greatly praise the local application of ice at the com* 
moDoenimt of the disease. Should aiippuration ncTcrthclcns occur, 
iia4 distinct fluctuation be felt at the thinnest part of the sidn, vio 
tamr make Mnrral openings in EUcb a vay that iha pus shall escape 
iritbout being pressed out; then tlie swelling usually subsides quick- 
ly ; it is most favorable vbea the fever ceases early and the disetis« 
befomc* chronic If tbc fcrer continues, ttie suppuration reroaiits 
prnfuae, the pnbis do not cease. Wc muy try to rclici'e this condi- 
lido bjr continued applications of bladders of ice, with irhieh ire also 
try (o alleviate any uiflammalions of tbe joint tbul may occtir, I iuive 
also ijcrircd great advantage from the application of n fciicstnit«d 
plostcrvplinl) which should he supported with hoops on account of 
) the lai|^ openings thnt must bo made in it ; in cases where there U 
I'delachmeat of the epiphysis, it is abHolutely necessary that the limb 
kllovt<l be fixed, if otdy to render the daily dressing less painful 



306 AOCTE TSFLAMMäTIOSS OF THE DOXES, PERIOSTEUM, ETC. 



Uanjr surgeons do Dot foUov Üüa treatment, wlitdi is bsckcd hy a 
•eriea of faroreblo cases. Sonte rMommend maknig Urg^e, deep io- 
cisioos doini to the bone at tbe very itart, or at least as soon as 
suj>piimlton b«^ins. Such extensive wounds are bad in fererish pa» 
tients; I nm satisfied llinl, under tlie»ectroumstance8,th!a1ien]ia treatr 
mont renders the condition wors«, it increases tb« predisposition to 
p^ninia. The Ulea that id ncutc osteomyelitis exartieulatioa abould 
be mado at once, as othrrwi»; pjicmia is uuavoidablc, seems tone 
even more erroaeous. I'll!« belief is ocrtninly untroe, and und« 
sueb dreumstances amputatioo is nob indicated, 6ist, becatue at the 
on»ct tbc! diagnoüis of ostcomyditia is not sbM^Iutcly ccrt^n, as tbe 
cose ought possibly bo one of simple acute periostitis; secondly, be- 
cause tbe prognosis in esorticulatiun of largc Uinbs, if dcme far naitp 
difteosc of tbe lK)ne, Li always rery doubtful. In acntc periostitis and 
oatcomyclitisi, of tlie tibia for inataoce, I sltould only amputate at the 
tbigb If tbe eiippuratioii were Ycry exoeaaire, and acute suppuratiora 
of tbo kiiec-juint alioiild occur. Sliould tbe disease affect the rrmut 
and run on unfavorable eourse, I should searccly bop« to save the pa- 
tient by an operation eo dangerous as amputation at tbc Idp-joist 
liVo nuiy accomplish much by great care of the pulicuta, who are gei»- 
orally youtliful. A young girl vritli OEtcomycUtis and periostitis of 
the tibia had sixteen chills in twelve days, and norertbeless recovered, 
altliougb pa.rt of the ttbia I)ecame necrosed, and tbe foot was anchy- 
losetl 

I will bore add & few remarks about stippurativc periostitis of tbe 
third pbalanx of tbe finger, wbiclt is, perhaps, tbo plaoe wtiere it moat 
freciunntty nccuni. As this iuflamnutioD in tbo bimd and finfi:crs U 
usually called panaritium, this periostitja of tbe last phalanx is termed 
panaritium periostale. This, like any periostitis, is ^tny painful; 
It is « long wljile — äoinctiinea eight or ten days— bcfbro tbo pua per- 
forates outward. The temiiaation in partial or total necrosis of tbe 
pbabinx is common, and cannot be prerontod even by an early in- 
cision, although we often hitvc to mnkn one to rcUcvo tbe disogree- 
al^, tJirobbing, burning pain, partly by the loss of blood, partly by 
splitting tbe periosteum. .\tt the tr^rmination in suppur&tJon cuji 
scarcely ever bo nvoiilcd, we try to induce it by cataplasms, lund- 
balhs, etc., and thiu basten the course. 



t 



Thus far we have only spoken of acut« inflammatioa of tbe peri- 
osteum, an4 medulla of the long bones, but have not eoosklercd that 
of the «fiOfiffy bones. Nor have we cotisidered tbe r|ueetioa of in- 
flammation of the bonoBubetancc proper. Ts there sudi a thing ? I 
think this must be answered in the negati^'c, for I consider tliat dili»- 



ACTTB PEBIOSriTIS. 



SO? 



I 



Cation of Ü»e tcsscIb, ocU-iufiltmUoo, and seroi» iniliibillon of tbc Ü» 
tue, ia their TUtous conibinations^ coiutitutc the cöecnco of scute in 
AanRDstions. lu tbe compact bctii'-substADce (as iu tlie corlical layer 
of a loo; bone) nil these n^uircmctitä canoot occur. In maxty places 
at ]e«st, tbe capiQary vessels are »o dostAy embedded in the Harer- 
sian outals that tbfij caiiaot dilate much ; a certain »mount of serous 
■nCltnitioii of tbc bone is ima^oablc ; but the finn boDc-t^iibslance 
cannot pos^csa ntucb capubUitjr of swelling. If tbe tcnn iiillaintiui- 
tiixi be matle so generni as to include ererj (juantitative and qualita* 
ilive dbturbaooe of nutrition, it would be a very peculiar view, in 
which I do Dot participate. Every üfl»ue attacked by iuflunuaatiDii 
cfcai^^ Ua physical and cbctniral nature, and tn iLoitt«; iuflanmiatioa 
of the soft parts this takes place rapidly ; tlie oonnective tissue e»- 
pedally ia quiddy changed to a gvlatinous, albmniDoua aubstnacc ; tlie 
ÜMDB of the oomea and cartilage may also change very qnickly. For 
dMRlkal leaaons tbU Ü impoRsible in bone ; time is required for ibe 
dialkj salta of tbe booe to dissolve, and the bone-curtilng« left dell- 
qncaccs like other ttaiue. Hence, inHammatiou of compact bony tis- 
«ue, sovera thougb it b^, cannot run its course very tspidty ; it alway« 
lakes a long while, llic above refers only to oomgMict boac-subEloncc; ; 
tponyjf bones may readily become inflamed, that is, there may be ia- 
öammation of tlie medulla contained in the spongy bones wbteh ba« 
the nine peculiarities as tliat of the long bones, only it Is not collected 
together as it is ia them, but it is distributed in the tncBhes of 
the bancs; eacb space cuatains nutny capillaries, oonnoctivo tissue, 
btfxäb, and nerves ; acute inflammation of Uic spongy bancs flrst oc* 
curs io these intesspacee, and gradually extends tn tbe bone proper. 
AVhat is called aeuU oHUi» of a spongy bone is at first only acute os- 
tcomyditia. ^is «ben idiopnthia is rarrily acute, but is usually 
duoaiC) »omeliuies subacute. On the other band, there is a traumatic 
acute osteomyeUlis of spongy bones, about which we shall hero Bay 
something, although ne have di^ctisHed its more important fcnturt-« 
trbcn traatiug of aupjninitioa of boue. Imagiuc an ampufatiou 
wvaad cln«« below the knee: tlic tibia baa been eawcd Üirough its 
upper spongy part ; Iraumaltc inllamniation occur? iu the medulla of 
bone, in tbc mcabca of the bonc-substaocc, with proliferation ol 
lis, ocll-infiltnitioa, «to, ; this leads to development of gninuk- 
which grow out from Ibe medulla and soon form a granulating 
this dcatrizcs in tbe usual manner. But sulterquently, if 
ou have a chance to examine such a stump, you 6nd that, at the sawed 
!ace of tbe bone, the meshes are filled with bone^ultsl anre, and 
lO outer layer of the spongy bone is tnnsfonncd to compact l)ony, 
sttbstonoc ; that is, tbo dcatriv in the bone has ossified. Thi» is tin* 





SOS ACUTE ISyLAMMATIOKS OF THE BOXES, PEttlOSTEUK, ETa 

oonnal terminutton not oul/ of tisumatic but ot apaataonoaa ostitis 
tlic hoay dc&trix ohsUIc«. There may also bo BujipuraUon, pu' 
tion of Uio toedtiUR of spongy booefs *^ i« lo»? boocs ; 
and iu congequeooM may also ooour. In llie lecture on auppunUoti 
of bonu (p. 216) and healing of ojtRii fractures wo treated fully of Ihr 
obangvs which occur nfi<.-r tbo bone has lost ita perioslcmm, of lln 
derdopmctit of gruiiulHtiotis on the surface of cootpnct boa^«ub- 
staocc, and of ihc Bccoiupaoying superfidal oevroBis. 

Here I vill mcroly add thut we mDetimes tnoet multipl« inflm- 
matioDB of tbe bones as wo do tnultiple acute iuAaniuiatiaos of the 
aoft parta (acute poljarticular rheumatism); tbtsc may occur alnol- 
tuneoosly in tbe two oorrcsponding bones of the lover exlrrnnties 
or may follovr each other; e. g., osteomyelitis of the tibin, suppim- 
tivo inflomination of tbe knoe-}oint, oatcomyeliUs of tbo fi:iuux', putv 
lent inBammatioa of the bip-joint ; in one case there «as ahw OMO»' 
myelitis of the oilier femur am) purulent coiitis of tbc oxher 
Eren such cases may possil^y tcrmiuHtti favorably, but this ia 
rar«; tliey usually end fatally.'* 



MO»' 

I 



Wo now eonio to aeatt is\fiammationt of lAtJ^inlt, A* we Inn 
prenously spoken of traumatic articular inflammaUoDS, yott slmdr 
know some of the peculiarities of diseased joiuta. You also kno* 
tbat serous membranes have a Rreat t«nden<^ to cxcfcto fluid «xd- 
diitioa wlicn Irritated, but tlint tliis exudation may also cootato jhs, 
if tbc iuäaraiitatory irritation be very intense. As there is a plcmii^ 
with effusion of scro^brinoua fiuid (the ordinary form), and a TwMy 
with purulent eCTusion (so«alled emjtyciiui), so in Jotnl« wo sposknf 
serous synovitis, or hydrops, and of purulent syoontts, or cmpyou; 
both forms of the discaso may be citberacut« or chronic, and tbi-r is 
duce various duwasi« of tbe cartilage, bone, articular capsule, {W»- 
t^uni, and surraimdinfr muscles. You will st-c tlint it is aliraysanra 
complicated with thes« diwases tbe more oompUooted tbe alMd 
partis. Of late, great importance baa been attached (espedaO^by 
Frendt surgeons) to speaking', first, of diseases of tbo synoriai acBf 
brane, then of tliose of the cnrtilagc, articular oapRile, aitd boB«,ea>^ 
responding to the unutumiral coiiditiuos. Oorröct 88 tbis ^tkloB 
nould be, if it were only a question of representing Ibo 
anatomiobl ebangcs, it is of little ue« in praotiee. Tlio 
ways views inOammation of tbe joint as a «hole, and, altbough' 
choutd know which part of tiic joint euffera most, this is only a 
of what bo should know ; course, symptom«, end eonstrlulional 
«qually demand bis attention, and determine tbe treatment, 
the enlire clinical appearance will determine tbc diriöoos of 
of many other <*<»«■"■. 



mrLAMMATlOS OF THE JOIVIS. 



300 



At present vre tue speaking only of npparentlir spontaacoos Root« 
luflainmatiotkl of the joints. In many cases they arc evidently due to 
catehing- cold, \q tAher cases tbcir causes nre obsciirt^. Sumo of the mare 
subacute cases kic of mctutaUc iiuture anJ Bp[H<ur us pytcmia. But 
»t present vo sball spetk only of tho idtopatliic inllamiDatioQa, -which, 
iDOOotrwIisUnetionta the tnumalio, lira tprmcil rhettmatie^sa Htcytnt 
often doe to cold. Patir^t» n^uiring your uid for such acute taflain- 
tnutious of the joints, will present somuwhat different symptoma. If, 
ktt iUiMtration, we again take the kinN?-join1, yo« will hitve about the 
Ibtlowiiig picture: A strong, otliemise healthy man has taken to beiU 
Iweaase for a day or two hü knee has been sivollcn, hi>l, nnd puinful ; 
JOQ find tlüa on examining Ihe kue«, j-ou also find distinct iluctuntkin 
io Uu jwnt, aad that the piitclU is somewbat lifted up, and always 
HM agniu if preiiMJ down ; tlie skin over tlio joint is not red ; the 
patictit lie« with his leg strel^^'hed out in bed, hus no ferer, and, if you 
ask Mm, cun bend and extend the knee, thougli with somo difficulty. 
You bcre b&vc an aeute «frous «ynovi'f üt, or hy<irop9 ffmu acutae. llic 
anatomieal coiidiüon of the koee ts as follows: the synrmnl membrane 
la sliglitty »wollen and modenilely ranculsr; tlie arlieidnr oivity full 
of flerum, whicli bos mingled with the synoviii; tlicrc urea few flocculi 
nf filmne in the fluid, the rest of the joint is healthy. AnstomicAlly 
ibe stnte is just iiitu a sutmcute Imntttis Imdinum or a mojerule 
pleuriay. Thia dist-asc is generally cured without dilüculty ; quiet, ro 
peati^liy painting with tincture of iodine, or a few blisters, or com- 
prcvstoD wiih wet bandages, sofEce io remove the affeotion in a few 
■lays, or ab least to take ofT its acuteness ; all the ayniptoms of the 
•ftit« iaßammation may «ulwido, the pi»lient may |fO aboxit with 
■Qvody any difitcully, but there rrmsins too much fluid in the joJDti 
kh^rops dirontcus of the Joint Is left. 

Tott may be «died to another patiesfc with Inflornmntion at ih« 
nee-joint. A few days previously the young man hiis cnn^bt mid ; 
I aner tliia hi» knee hsa begim Io pain, lii^h fever bits come on, 
Friuji« a he-Avy cbill j the joint Tia» constsntly grown more painful. 
patient lies in bed, with (he knoo flexed so that tbo thif^h is 
aneiy ivtated outwurd and ubdix'ted ; he resists every attempt tv 
■ fixi leg, as it «mse« him terrible pnin. The knee-joint is greatly 
nroUen and feels hot, but there is no flueluation, the skin !« ecdcmatous 
apd ltd about the kneL% llic whole !e;r also is o^cmatoiis ; on account 
«f tti«p«ia it is impossible to extend the knee or to flex it more, 
Whataoonlmst to the former cosol Jf you have a ehance to examine 
Ae joint in tliis ntago, you find great swelling of the synorial mert»< 
ino<r; it is very red, puffy, aitd mierc8co}M<;ft11y appears infiltrated 

tter and serum, In tbe joint there Js usually a little 




310 ACUTE IKFLAHSIATIOKS OF THE II0KE8. rCitlOSTEm. ETC 

Rocculont pus miicd triUi Ihe «jnoria, tLcro maj olao bo pure pi& 
The surface of tlie cnrtUnge looks elmuly, and microsooplcallj [wrfaapi 
shows little cluDge bejond turhiilitjr of tbc bjKlinc substuiirc ; poca- 
bly fhccaTiilapt) cnvltieaarc sotncwbat ciilu]g^ ftod fiUed iriÜiuiui^ 
usual number of cells. The tinsoe of the articular capsule is cedeinatouL 
ITppe jou have M,punUent rwy aeutt »t/ncvitis^ in wbicb tbo cutitag«^ 
threal«ns to parUdpalc ; aboultl tbc diacuse continue, aoil tbe pus ta 
tbc joint increase, j*ou may oorrcctly call it empytma of thejoini. 

The differonco betuocn tb« ftnil nimI aecoad forms of acuta ijtock« 
t-itis is cstscntinlljr tbat, in tUc »ccood, tbe lisaiio of tba synor 
rocnibrane is deeply affo«toc)^ while in the first tbe increased eccreti 
it. the chief feature: Between tbesu two Curms are siibaculo caaita, 
wliicb tlie secretioR bcoomcfl purulent and coUocta iu great tiuaalhjr— 
witliowt there being any great destruction of the synovial mcmfanm^ 
H. Volkniann enlbi tliis "catarrlutl inflammatioa " of tbe joint; it 
somcvliat more paiuTuI tbnn ortliitaTy acute hydrops^ Chioi which th^ 
eatorrlud purulent farm may proceed, thou;;h this is mrely tlio caK^. 
I hare already said wimt nns necessary about lliu course and tnrn^ 
moot of acut« hj'dropa. The course nod results of tbe mora poieti. 
cbymatous syoovititf wbicb is predisposed to suppuration, depend 
fi^catly on wben tb« treatment is begun and n-bnt it is. Usonlly ^ 
few Iccchns arc applied and then the jränt is poullioed, from au ide% 
of tlie old sdiool, that riteumatic oHicuIar inflainnmtiMU «bould ba 
treated nitli warm applJcaüons. I cou»der leeche« almoai iiaeleM^ 
these afTections ; perhaps there may be a question about keepbiytts 
liiab warm, for this is often pleasant to the patient ; it allcriotes tJn 
]>aiii in tufl.-immnlioDS of tlioacrous membranes, often more so than otld 
does ; at least the latter must act for some time before having a bm« 
able cScct. I explain this as foUoira : Tlic warm applicAtiooailiARe 
fluxion to the resscEs of the sicin, and thus empty thnsc of tbe wpa- 
vial iikemlirane ; but tliia «Sect is ooi long couUmied ; flutioo lo tba 
inflamed deeper parts relunts again, ami ia stronger tiua to thevtiS' 
eially-wanned skin. On application of a large bladder of ieoio A* 
joint, the vesseU of the skin contract, and petb^i« drive tbe bkuxlu 
Uie ressels of the inflamed part more strongly Uinn bL-func, tiQ p»! 
ally the oold bas it« oSoct on these alao, and if tbe oold oontinud 
ciTect becomes permanent. It aeems more rational always to tae 
in these coffca; in very acute infiammalions of tbo juiot the ^m^\ 
mcnt of iee-blAdders has also pcoved very praotioaL Besides 
rahl, you may also Enduec active derivation to tbe skin by itnag 
tore of iodine, or by a lai^ blister. But bosidea these remedlesi 
most important to bring the joint into a proper poeitioa Bad 
there, for, if we do not obtain a perfect eure, and tbe joint 



IXFLAMMiTIO» OF TB& JOINTS. 



su 



Uiff, the flexed position of the knee, whidi is so frequent, is avcry un- 
rsriuut« gtddilion to tti« stifTncs«*, M it readers tlic Hmb ncariy if uot 
ealM; osoless. "^Ity tbc ncutdj-disoaaed joiut, espedallj* in inteose 
soppnnlire sjooritis, n]mo5t ulways mToluDtarily uasumcs a fiexcil 
[■oaiiioa, is a difficult qucttion, wlUch may bo oiuwerod in varioua 
«lys: it has bL^en said tliat tli^rc is a scirt of reSex a<4ian on ttic 
Ootor miuculnr nerve from tbc iiritatjon of the sensory nervcft of Uie 
'yxKyr'til mcmbr&ne, and that tbid is the cause of the miucular oon- 
IracdoDL Sonnet, a French jiurj^eon, ulio has done much for the 
Ireatmeot of diseases of the joint«, lliiiiks that iu tp^at dbteution of 
me jdiat villi pus, or evcu b^* svri.*Uiii{; uf tbu syiioviul tucmbrane, tbc 
'fixed pontion may be eaused mocbauitjtdlj, as tlie «jiaee in tbo joint 
^ giekter in tbc flexed than in the extended position ; be bas tried to 
pv^re tins bjr iajcctiag tbc joints in tbc cadaver, and by filbng tbeoi 
Coigpletdy be baa brought them into the ÖE'xed position. Against 
*l»is it may be said tbat in hydrops acutus, where tlicrc is usually more 
Quid ia tbe jmnt Üiiui there is in purulent synoviti», the llexion doea 
Qot oecur, and also tliat in acute inflammation!«, where I could satisfy 
Biyself of the noiKxistenre of fluid, there was flexion. It seems to 
■ ttc Uiat the acute, pufiy» painful »welling of the s^-noviut membrane 
^■btbe diief came of the Sexion, hence I should incline to theürrtcx- 
^H^Mtüm, according to which the pain is the trritation that induocB 
^^BHnctioa of ÜiemusrJcsflf the limb: oilier niuürlcs also, in parts 
luSering froin acut« pain, contract, as the cervical inuHcles in deep- 
seated «h»cess«s of the necic The malpoMlion should be relieved; 
Ihb oiiould be doue for eacb joint in such n way that in caiH> of com- 
^Bletc stiflncss ile poaition shall be most favorublc. Tlichip and kncc- 
^^oini should bo extended, the foot and elbow at riglit «ogles; tbc 
•wnA and shoulder do not get oat of position ; the formor usually re- 
OMias extended, the latter usually lakes such a position that the arm 
lies againet tlie tbunix. There is very great difTereiiec iti the frvijiiency 
of acute disease in the different jobts ; the knee is most frequently 
aäisct«d, then the elbow aod nrist; acute inflammation of Iho hip, 
■honlder, and ankle, is r«re. Acute articular iuäaiumalions arc more 
firequent in young persons than in old, but hnnlly cvrr orriir in rliil- 
dien. But, to return again to the iinpravcment of the position of the 
jcHDt; you will tell me this is impossible. Chloroform is here iweAil ; 
remeily has bccoitte most important in the treutment of inßomma- 
of the jointa. You narootixe tbe patient deeply, and can then 
tlu) hmb without Irouhio; the tnuscleit, which pretlously con- 
on tbc least touch, now yield without diflficulty. If wccoutinue 
witli our former bypotbclical case, you extend tlic knee, en\-elop it in 
■ thick layer of «-adding, aiKl apply a plaster-eplint from the foot to 





aiS ACTTE INFLAM UATI0S3 OP TUB DOSES, PEßlOtn'EIIX. ETC. 

(be middle of Ibo thigh. Whtsn fho patJeat vnkc*, ho win «t fint 
complain of sevpre piiin ; give liim qusrter of & grain of morpfakinj 
Rpply nnc or two libuldcrs of ice orcr the plostcr-splüit lo tho latcg; 
tbe coM «ots slowlj, but finally prorM effective, and in tirCQtjp^oir 
hou» ttie pRtient fi>els tolerablj conifortalile. Tbe sligfatoompranta 
miu]e by tlie well paddnd plastrrfiplint also hue a faronible Mtt^UiK 
gistiv Hction ; if iWre be fever, you may givo cooling nedioiBC» Ml 
giUine ptirgaüv4>5; but the patient needs no further lieatmrtit B(> 
lore applying ihe dressing, yon may have the limb rubbed vitli no» 
cuiitiloiDtnicot or painted ivitli tincture oEtodin«. Itubestlo*i>pi;f 
tbe dressing even in the most acute stage; of ooiirse it lauat be do» 
very caioEitlly, ai'oidiug any strangulating pressure. HcocQliy Hhi 
been shon-n that, cvca is very aoute inflammatioDS of t]io jointa, b» 
pming results may be obtained l^ extension witb vn^ghta. It ii 
very interesting to observe bow a continued motlerate tmctioalewB 
tbe puiu iu tb« joint and relates tLo musclea. But mucb dcptadia 
the applinatinn of tbe dressings, and I cosnot too strongly nrgeeo 
you to attend carefully to tiicae apparently itimple mecbnoical Himp, 
vbosc importance you will not correoUy estimate tilt tlirown oti mr 
own TOsourw« in prnoLioc, and obliged lo «tleiid to tlio ininutMldc 
tails yourself. 

If called to the case early, you may sometimes not only orreBttba 
acute stage of tbe disease, but may preserve to jrour patienlaaory 
able joint. But, even if called lute, Üie above treftliDent 
pursued. If the pain ia relieved and tbe fercr oeaaea^yoQ 
more the drcsüing in a few weeks, for tbe diMue h»t» wrenl nAs 
under nny Girouii»tan<>es ; perhaps three to five mootbs may d^ae 
before tlie {nflammation entirely disappears; gradually tbe twräid 
cwDditioQ and the former mobility return, titco tbo patieot aboiiMb* 
earnestly waned against taking cold or excesavo tnotioa, tot a 
■tiack might noi taro out so wclL 

Supposing the aoute process docs not subside under the trntatttfe 
instituted, but continues to prepress, it may paaa into a chraaio fiassy 
or remain «aite ; we ahall hcrcHAcr treat of the fnnner caac. Lti 
at present suppose that tbe pain, instead of tubaiding, becomes m 
sercro, and you are obliged to split tbe dressing along the frost; 
find the knee more swollen, distinctly 6actusting, and tbe 
very movable, while the patient has high fover. If tbe disesM 
tioues, the fluctuatioa may extend farther and brtbcr, npwsid 
thigh, for instance, and the subcutaneous cellular tinsue of tbe 
and leg may participate in the fiuppuralion. Formerly this 
was attributed to subcutaneous bursting, or partial aappuralioo of 
synovial sacs aroimd the joint, especially of tb« large oas nolsr 



■■Kt^n «f tbfi 



IKFLAXUAnOK OF THE JOINTS. 



818 




n of tbfi quadriceps fumoris, snd of tlie bursa pc^litea ; to pre- 

rrot this mi&Tortitac it was oonaidcrod advisable to tap tbc joint with 

» trocar, in tlk« above stuge of the dis«as«, to let out most of tli« pus, 

And then «rcfiiUy close the opening. From my own experience I shoulil 

Idor tliia openitiau as rarelj* iiidtcatcd, for I Imve ootirinoed my- 

hy careful cxaininatioa« of patients, &n<l occMlonnlly of the 

wr, tbat tbeee poriarticular nbswesses in tliu tx-llular tissu«, oc^ 

ing ia acute si-uoiHtis, and abw in 08lit.lt of tbc articular cxtrcim- 

t^CMy form separately, and break iulo tbe joiut late, if tlicy do so at 

^U. With the derelopiDcnt of tboKO nl)«ceHt«s tJio general condition 

I^C the patient is usually ini)Kiircd ; he has high fever, with intercut^ 

^^Bkt fihiUa, bis checks full in, he onmciat(^s, loses fais ajipctite, and 

treoonies sleeplc««. Quinine »nil opium tinally lose tbcir effect, and, 

tinlese yon amputate the thi^b early enough, the patient dies trota the 

fSibaastio^ au))pumtion and continued fever; peHmps, also, he may 

ItiLTO metastatic abeoeesca. If, by the ap]>lioAtions of i«e, by one or 

fBOn tncisioas for evacuating the pus, by quiniuc anri opitun^ you ruo 

oeed in breaking the acute stage of the disease, and inakiug it ohixuiic, 

ytm will Dot obtain a tnovabJe joint, but CTCn if it ia fioxcd at a right 

sngle, the leg will be useful ; tliis i:^ the IwAt n>»ult that we cau gain 

aAer days aud w<%ks of auxiety and cure, if the inllummatiaD reaches 

lb« abOTO gntdc. The anatomical cbnngca in a kocc-joint in this 

Hige of in&auiinatiou ar« as follows : The joint is filled villi thick 

f(Aow pus, mixed with fibrinous Jlocculi ; the s\'no^'ülI membrane ia 

a>ror«l with deuse punileut Kbrous riuds, urni^r which it is yory red 

■od puffy, partly ulcemted ; tlic cortilago is partly broken äowa into 

pufp, partly necrosed aud peeht off; the boiio under it is very red or 

:fililtrat«d (oäCoomyclitis ; usually in these cases a secondary, rarely a 

{ihmory disease). 

The jHogDoeis of this disease is not Tcry bad in yoin^^ irigoroua 
when Iho proper treatment ia resorted to eurly ; it is very 
almost absolutely fatal, in old, decrepit persons. 



In (be above I bare pictured to you typical oases of the two forma 
d' sjmovitis, tbc serous and parencliymatous (purulent), and atu sati» 
ibst io practice you will readily recognize these pictures again; 
you will hare no diJIiculty in applying what has been said of tbo 
to other joints. \ow I iiiii^t add that there is still anotlier 
or subacute lonu of articular iuflauiinaUon, \^Iiich offers some 
■ritiea; I refer to acut« arttcttiar rheumatitm. This Tety pty 
' disease, wliicb will be treated ;>f more fully in the lectures on 



314 ACTTTE INFLAM HA TIC N'3 OP TUE BO>'ES. rEKIOSTEUH. ETC. 

mternal meJioine, ts ctmnictrriz«! hy Hb aHncking scrcnl joioti at 
once, nod it« tendency to caitso ioflammations of other scroiu muf 
l)rancs, Euch aa tho pi?ricar(liuia niicl euclocanlium, iJic? p1(.>un, nad 
nkrcly tbo pcntona:um and anidinoid. Tbls sitnultaocous diacaw d 
Uieee merabtancs and of the joiuts marka the affcctaoa as ooe implt 
eating tliQ trliole body from (he start; indeed, from the isnportuoe 
of tbo organ offcctc*!, the iMricarditU and emlocardills are ditniK 
proouuent, and so much inlluciioc Üic treatRMMit, tbat the iur]gial 
treatment of tbc joiiitx ia a vor^ SGCondary matter; tliis i* tlie buk 
apt to be ttie ca&e, as tbia disease, altbough very painful, nrdj pnnei 
daageroua to lb<j limb or to life, llie uliief Hyiuptonta of the lool 
affeotjon, beyond which the disemte nurcly pirocceda, are, great paaih 
the joint oo everj motion or touch, a^ilama of the BiuToandtog idA 
paita, and rarely nxbiess of l]ic ekin. From the few autopsies tbl 
bare been made, it appears tbat the syaoria increa«» aome«fc«|,it 
Bometiiiies mixed vritb floocuU of pus, and iha synorial membnuwii 
anolleo and red ; tbc cartilage is seldom implicated ; tbo colleccioa 
of Quid is Dut often so great aa to cauae fluctuation. Acut« ibetn» 
tism ia TC17 frequent, but it ix rarely fatal, so tliat ttie pathologial 
anatomical appearances are liille known. From all Ihc ityuptomief 
this disease, it is cridcutly a speöGo, limited disease, of a p«ci^ 
character, but with a course so atypical, tind causes so obaoon, tbu 
ita iictiiul character baa not yet been determined. I have tny dnblt 
vrbetber, beeides tliis pott/ariiculart wo can speak of a motunliaiar 
aetO« r^t^umatiam, for it is just the multiplicity of tbo pointi {/ 
iudammatiou, and their slight tendency to auppurate, that chuao 
tcrizc tho disease ; at oil event», 1 should not consider an iDfiammsliin 
limited to one joint as a symptom of acute rheumatism, unlo» pK»- 
risy, poricarditis, or some other compUcatioa peculiar to rbewutiBi, 
also occurred; should none of tbcao come on, the disease is purely Itxal* 
a eioiple iuflammution of ttie joint, which is probably oaUed riieumitia 
simply because it is sappoeod to be due to cRtcbing oold. Id ai.iiL«> 
rheumatism, tbc rcsuluttoa of the articular hiflammation and tiic 
toiation of tlic joint to its functions are so oommom thatvo rardf 
any other temiinatiou. That the disease is tcdioun, auil 
lasts six or eight weeks, is nut so much due to the duratioa 
affcclioa in a single joint as to its attacking Gist ooe joint. Übet 
other, and exaourbnliona readily oocuning in joints that haij 
ered; thus the di»ense proves tedious, both for physician ami patica 
aad tho greatest watchfulness and car« are occeeeary to an«! 
sourocs of injury that may again aroiise the dlseaaa. It ia exceedingly 
rare for 00c of the affecied joint» to go on to Interne suppunuioa 
empyema; more frequently, in spite of tbc subetiiloooO of the 




ISFLAMMATIOS OF THE JOINTS. 



810 



«B 



* joint rcmauu BtifT and painful, and piuecs into a state of dirooic 
tonainmaLioo. You svc tbat the prognosis of this disoa«e, as far oe it 
caooems the juiut, may be called very fiivorablc ; without any inter- 
Jerence from the plnucino, the joint-inflammndoiut gcncrsUy nm a 
larorablo course. Heaoe «11 Uiat we do for the local disease ia to cd- 
Telop the jolut in waddin;^, tow, oakum, or woo), to protect it from 
cbaog«« of t«m|M!niture. Mild cutaneous irrilant« and piüntJn^ ffith 
tinofturc of iodiikC may also l>c U£«ful, For alleviating the pain ia tlie 
yAatm and hut«ain^ tho course of the disotue, Strome*^ and others 
recommend the employment of hladdera of ice, mid gcucnillj Itecpiug 
tbe joint oool, rather than irarm. But I think thia treatment wiU find 
fisw diaciple«, for it is quite troulilesome, and experience shows that 
ibe articular indammntionA get on well without auch applications. 
Internally, wc may give diuretic«, diaphoretics, or cooling salts; in 
beart-«ffcctions, local antiphlorätic«, digital», etc., are indicated, na 
will he taught you more particularly in 8i>e«ial pathologies, and in the 
medical clinic«. 

Next to acute rheumatism comes acute <trlÄritic inflammation of 
le jointa. The attack of podagra or ohiragra is also ^-cifio and 
Itelongs to true gout; here, alBO, tho articular inllainmation is an acute 
■u» 8i|-noi-ili9, but with \erj' little secretion of fluid in the joint. 
t ono thing peculiar to acute arthritio infla ruination Li the nevet^ 
Ig coincident iuflammalion of tJie surrounding parts : tlie peri- 
'bstcum, eheatlui of the («ndons, but e«pecta]ly of the skia; this 
always rt^deiis, Ijccomes glistening and tense, as in eryuipelas, and is 
wry j>aiiiful ; it even desquamates oi^casion-iJly after the attack. 
i^cutc BrtliriUo arliculnr iuilaiunrntion is far nioro painful than rheu- 
xnattf. We »liall hereaftcT apeak of the treatment of arthritis and the 
arthritic diath««i& 





Then Is still another variety of acute articular inflammatioD, the 

'tutaiiCt about which wc shall haro something more to aay when 

ting of py!Pmia. Acute or subuculc mctnetatic inflititimntJon of 

ke joint is uRually at first serous, but soon purely Buppuratlvo syno* 

vitls. Several forma may be distingTii»hcd : 

1. Gonorrftaal {fsfiammatüm of th« joint«. Thia occurs in men 
niirpnog from gooorrboBa ; oocaeioiially, also, it occurs aft«r tbc intru- 
ductioa of bougies into the lutrthru ; it attacks the kiicc-joint almost 
«Xclustvcly. Some authors assert that tt is «specially apt to develop 
wbeo the gt^inonfacea is arrested suddenly. This is not my own ci- 
peticnoe. In pfoportion to tho frc<iuency of gonorrhoea, it is very 
rare, but I have seen it quite frequently when a patient with active 




818 ACUTE IVFLAllllATIOSS OF TUE BOXES, FERIOSTEUU, ETC. 

gonorrlicEa has caught cold. The incomproltensEble cooncctioa b» 
twccn punilcnt catarrh of the urelliro and iuQainmuUoiis of Ibe koe» 
joint mig'ht be dcoicd, and tlio simultaneous occuircooo of iLc tut» 
diseases lie considered M ncddentn] ; but ihu cxpcriuic« of too uukav 
surgecB», sod also cases where EiifUaiiniitiuiis of llic knoc-joiot oecur 
after other irritationa of tlic urethm (ss h/ bougies), speak ia ua 
fsror. OoDorrliceal gODorthritU usually atlackft both side's, and ü i 
eulnoul« suroua synotHtis, which geucrally soon disappcws mtdcr 
pioper Kflt, nroida.ncc of new irr!la(ioa of lliQ u^eth^^ bliaten, lis^ 
hire of iodine, and Blight compression of the joint * and, aft«r retb- 
sorption of the Üiiid, it ends to p(n-fect cure But ■rrilubilitj* of l^m 
joint i& apt to ronudn, and not unirequeolly tlie same ponoo gotl^|H 
anolher gonorrhcea is again attatiked with inQimunatton of tbv joinU 
fn 8omc caAei rlironic articular rheiimiilism is said to follow goatt- 
th<£al {^oartUritis. 

2. Pyannie infiammtUion «Iso occurs rory frequently in oda katCi 
as well as in llie aiikle, shoulder, elbow, and wrist; rarely in tbo bip 
It ia a pure purulent eynoritis, subsequently aooompaniod by ni|if» 
tation of the periarticular cellular tissue, but usually witK 8id»nk 
OüuTse, and h<^nr<e we do not always find it Mly developed at the tins 
of outopay. Pmtnic palionts do not always die with Buppumtion of 
tba joint, and I havo witnessed rcabsorption in oases where the potiat 
lived through the pundent infection. The treatiiMut does not iKfcr 
from tlint alx>vo given ; if the collection of pus is czcc&sivc, punctum 
will relieve the pain. Suppurations of tho joint duo to iojixriea^ 
fauieratioDS of the urethm by careless catheterization, and 
BCcoinnAiiicd by cliills, itre of course pyicnü«^ not gononrluaal 
Berlin I trvatvd a youug mua who ba^ a rupture of tbe urethra 
by bougies, And ctiits«<]ucut1y an absoess of the left shoulder, vitk 
EuppuratioQ of the acrotniut joint of the cUvicIc, wfaicli induced tut>- 
tusation of that bone. Tbc patient recorded perfectly; and, 
the abscess was not largo, it was not c^wned. A. year lat«r 1 1 
the young man again. Tbe abflccfts had become Bomowhat saaDnr^ 
fluctuation was still distiaot ; but, u it Caused Do distuHbuM of 
function in- other dißiculty, and tbe potJent was blootning and 
healthy, 1 nvoidud opening the abscess, luid advise you to ilo tbe 
same nith cold abscci^Ms wliicli e^'iduntly couniuuicute with a joil^ 
as tbe opening doc« littlo good and may do much harm, liy po» 
Mbly inducing acute inflammalioa of the joint uk) my diugnv 
aUe reanlts. 

3. J*Mfperal inflammation of the jointt. Puerperal brer bb 
icon of pyemia tliat may ocxnu- after parturition. Hence, ibe supp» 
ntiro taflummalions of tbe joints occurring at that time oorao oaila 



lundu^k 



IN7LAU1UTI0N 09 TUE JOINTS. 



317 



Alt ilwvc cBtegorj of pycewic, Buppuratiro sjaövItK But not unlre- 
ipiCDtlv, tlic third or fourth week aft^r parturitinn, tlicrc Ü an acute 
Hippuntive inHammatioa of tlie koee and elbow joints, which has bo«n 
n'frntd to ritrioas causes. Some my it in n Kimpio form of acut« 
ittbiUr iiiflunmatioD due to catching coIJ, to which women are pei^ 
ticRilw})* liabl« after confiocmcct, bccaus« they pcnpiro so niucli. 
Ollicre aro of tho opiuion tliat tliosc Ulo inflaniinatJODS of Die joints 
ue tlso Bvtnptoois of pjaomia that liave been overlooked anil are 
iulatod, and h«ac« constdoi: tbcm an mctnstatte. Let this be as it 
oMj, il U at all crents certain that these cases have nothing specific. 
"Hier ran either an acute or Rubacuto course, and, under suitobic ircat- 
Bieat, may be so coatroUed that the joiat will renoain movable ; hut 
sometitiwa a more dironia courm begins later and terminates in 
•Dobjrlosis, The progoosig is notrciybad Tliejr rarely reach the 
higlictt grade of acuteneee. Tfao treatmont is the same as that 
alnodj ^rcn for acute suppunitive synoTitia. 

fel would ah» tnentioa (hat purulent articular inflammatiGDS oocur 
I tho pjiemia of the newly-born ; children arc even occasionaQj bom 
itli them, as has bcon witnessed by myself and others. Inflamma* 
CHM of the joints may derelop and even nm their course during fcetal 
"fo, as is sbowD by the cases where düldrco arc bom with ioints fully 
■lÄWlopod but anchylosed. 




f 



APPENDIX TO CHAITEKS I.-XL 

TROSPECT.—GJCXERAL nESfARKS ON^ ACUTE 
IXFLAMMA TIO.V. 



OExnjontM : 'Hiiu far I liave ^reii you a number of clintc&l 8iir> 
8^^*l pictures representing various fomia of acute inflammation. "Wo 
•**v« »(icn injuries and (heir results, iis well ns the acute surgieal dis- 
***»<* « occurring without injurj*, luid have atudicd iLe disturbed physi- 
'*'^*l?rfcal processes, the mean» of their removal, and the process of this 
'^«»soTal. It seemed as if tliis method would bo Btitnukling for you, 
*•*<! that it was permiiwibi'', as you were supposed to have some 
^'»^i^fslfldpe of general pathology and some starting-point for patho- 
*Ä*<5«l,phy5i(il(ijficjil, and hbtological iiivestigations. Still, it will 
^^ tw wperfluous, at the olose of this first nnd most extensive soc- 
'**•*■ of our work, to ^ve a brief rhtime of the present views of in- 
****«ii«lion, wliiuh have heco greatly advanood by recent labors of 
" ^*^ii^'M, Samutl, Arn<tidi awl others. 




918 



CENBRIL »EU&RES ON ACCTK tNPUÜlUATIOK. 



[ will begin by Mving that from our ignorance of llio 
tioa of iiervf« in inHaniniatioTi, vre inuiit Il-avc tliem out of the qtM 
tioa. VcmscIb, blooti, und tissue fona almost eiclusirel/ the objei 
of our study. 

OitataliuD of tbo blood-resKoLx is an importftnt factor Id ioAm 
mation ; Btill, neither the hypcntmia from hinHcrancc to the euira 
of blood ia the veins (congestive hypgro-mia) or diUinlio» of tl 
Arteriefl from pnrelytia of thrir «raJbi (aa in the rabbit*» ««r aflj 
division of thn <;*-rvical ürmpathflic), »or the 8udd<>n primary dibl 
tiou from mcchnuicul amJ ohcniitMil irrilatioiis, oecciMtarilr Icada 1 
triflauitimtioii. About ihc Inltrr form uf vascular dilatation T ha 
aomcthing to add to wlmt has already bcni niil. It is about tl 
follomng aymptoni : Vou rub the eye, and it booomcs red ; you ni 
the skin, and it Iwcomes red, as it also doos if you apply warm m 
ler ; you put mow on the akin, and it h^y^omea white, then red. Jl 
of these reddeniofifs soou paaa off if their cauaes only acted a lUi 
time ami ircr« soon rcmorrd. 'llic invmti^tionG montioned tn |«q 
tun^ V. ref(^rn.-d to tlic* uiodu of origin of these IiypotaitiiiiaK, hut tici 
arv now conBiderud unaatiafaotory. Tlic symptooi llaclf ia i-ooiplrbJJ 
estimated by Cohnkfim ; still, even under the acHoo of heat,«(U 
and chemical influpnce^ if we aupjiose a direct moiuentojy iwnl)ri 
of the vascular walls, from what we havi? thus fur st-cn, it t]i|Ml 
etraoj^c that u paralyzing influence should extend from a ciim 
eorihed pressure or tour U* an extensive portion of surrounding *H 
eular territory, uith a sort of wave-Hke motion. It aecni6 to me 
know no more about Ibis "aflluxua" tu the '^»tiaulu»" ttioo m; 
tnerly did. lint it ia important, as Coftttkeim ha« shown tliai «hi 
inflaiD mat ions occur after physical or chcmii'al influences, th^e 
mary fluxions may hare ps8w;d over long before thf nnw lii 
which leads to and continues with the intliimmation ; and tin*, 
mary fluxion« may entirely tail, but a regular InSauiinatton with u 
hypenemla nevertheless occurs. Tlene«» the fluxion immriliatcly Eq 
lowinpr the initalion is not an absolutely neceasarj factor <if d 
iiiflanimation. j 

A rabbit's oar whose vesaela have been paralyzed and dilated I 
section of the oympathetie does not inflame ; its tissue brcone« M 
tetise from oxjema, Init nothing more ; there is no further disHU 
ance of nutrition in the vessels and Uasoea. 

Entensiro eongcation, howc\-er, is more aerioaa. ]l bai all«» 
Ih-^h state<l in Leotnr« V. that slight inereaeo of itilmraiieQlar 
nre, such a» occurs after moderate injurie«, quieWy paaac 
has no efTect on the inflammation, Hut if the congeaüon bfiTi 
extensive and cannot be equalized, there is so copious an «xodsti 



CIBOUIAnON IN DiFiailBD TISSUE. 



stft 



itimo in tho \i»»tw (cetlomu) Ihat it cannot bo earnoil off by ibo 
\xtx» g>hatics ; sometimes llieru is free escape of red blond -corpusclM 
l^r-<L>a^ the walla of the capillarios into the tissues (diap€d<!si^), 
Ct^^inheiiit stated tt as probable [bat the diapedcmg resulted tfarouf^ 
rtnc^ KTJngs in the cnpÜlary wrIIs. ArnoM not only confirmed tliis, 
bufc- indicated tin «u-cullud sti^inal» (tbv ainnll opciiin^rft nhich bci- 
(.orv-k« viaibl« b«tween tiie dclU forming tlio rnpillaricfl, after staining 
wifcl^a iiilver) as the point of escape, antl alao showed that blood-serum 
f|a«.-^<i)oul tlirougli these slisTnnts. If the hindrmnoe to tlie rircu- 
bti«:>n be ofsuch u. autur<; that blood can «ontimie to flow, the only 
re»-«^ Its «ill bo ctnIrrui ami diiipedcsis ; if the drcutalian be entirely 
LHn-«??>trd, gantrrene n'sulls. 

^H Ouming at la^t to hypcncniia as U occurs in inflatninattmi, it b 
^^■IV^i^f the immediate result of temporary iitllammatiun, nor of paml- 
PVn^ of the va»o-mator nerve», nor of obstruction to the circulation, 
\M!t. of a peculiar alteration oE the Trails of the reasels, cs])eciaUy of 
tho capillaries and vfins. What nliemical or physiml eliangen occur 
it ^Iie same time in the umU» of tho vt^Mel« e-.»iinoI be stuled; but 
ve conclude thut the rc»cls in Lho iuflamcd part arc permanently 
!l!ii.t9d,and permit the fre* escape of white blood-corpuecles (not 
,' \' at llie stig-mata, but at any point in their waits), and that the 
- II .?»taüce ofthvau ve^tsols i» soflrnod und more yielding-. Why this 
' »u, certainly cannot be dc1ci-nuiic<d in all cases; it is considered as 
direct effect of the cause of (he iiifiammiitioo, though it does not 
UT for some hours. TIic inflamed borders and an-oln around 
ilj-bordered cuts or stabs arc ju6t as dUBcull to explain as the 
inufy fla^iions. Wo oiuat even involuntarily stippoHo that a di«- 
can Dover be accurately confined to the part supplied by a 
JD Tease], bat that it must spread somewhat, lcai>t ao in cuts, 
b«, or rapid bams, and most so after certain chemical aotions. 
11, this N no true pjiphioatiaa ; it is merely a limitation of ohser* 
ndoa. 

L^t U!> now cnn:<idcr the blood and its circulation in inlUracd 
titsuD. Primury fluxion '\» aocoiiipaniod by greatly increased ae- 
tirity of the movement of the blood, enpecially in the arteries, 
ikiefi again beoonies normal as the priinnry dilatatiou of the vessels 
medes. In the vesseJa which dilato pf-rmaTientJ}*, in the borders 
Ulli areola uf the inflamitintton, the rapidity of the eirctilation grad- 
■t-^''^ -'i-niuishes, especially in the veins; the blood may more by 
, or occasionally stop completely. This stasis, which ia not 
aooooipAnied by eoajfulalion of the blood, was formerly re- 
al a necessar)- part of Inic inflammation, and had many cxpla- 
ttttiom, which bnrdly interest lu now, as we know that many inflsm- 



890 



GENE&il. KEMAREft OX ACtJTK tSTLAXXXTlOS. 



m%t'im» nm tbeir course ^ithciut Ktads, as well as tbnt thu ttun 
nftcD dbappcHTs in spite ot ptogmssiiig ititluiniuatiun. It ii oootiv 
ties, the blood tin«ll y congtiUtcs in the ^0M^1 (thrombositt), tlie maili 
of vrliich vary wltli local conditions and thn extent; there may b« i 
return U> the normal state bj cnllateml diLatation, or gungrrae tur 
result. The ctrciilaiion in the inllBin«! p4tn i» nl Gr?t ilo«- aoil i^ 
ri'guliir, »nd aj^iii becomcfi iiormul. Meantime immunms «iiitv 
blood-cells collect along the walls of the smnll veina sod CDpilUria; 
then tbcy waodcr through tho walls of tbo yos»«ls ioto the ttMas^ 
whoso lutGrsticcfi boL-oinp tilled (cellalar, or, If exoessive, p ilHihu i 
infiltration) ; and fmalljr they reach tfacsurlocc (supcrftctal wppar» 
tion, puruknl catanli). 

We have now the compU't« picture of aonto inflammatiiHi ; I« 
tho proccMi may rcci-de at the time of dilntatioa of the vowdt mi 
arrest of the white blo<id-cclls, and even subsequcatly, when cellulir 
infiltration has ttdvaiice<l quite far, without leiiviug aoy c)ungr> pn- 
oeptible in the tiRsue that has been infiltrated or the veas^vhldi 
haTe been dilat«d. But at a certain lieij;lt( of tho imrulent üifik» 
tioa the tissue disappears cntiri>l_r, and is replaced b/ pD* (u iV 
scess forms), or by an interstitial neoplasia (grantilntioD timt), 
which, if it does nut die, boi-onics connective tissue (cicatrix), «itb 
vesacU and nerves. 

Tb4> question arise«, \Vliat causes this atrojiby of inflamed tim»i 
Is it the direct effect uf the oauao of tlie inflamnialion or of the kDu« 
lur infiltrstioii? Here we como to the tliird important puiolia in- 
flammation, namely, tho part taken by tho ttJisue itself. If uebvt 
oonsider the inflammations caused hy known chemical or phjrical 
causes, it is evitlcnt they cannot act on the vessels and blood will^- 
out at the sntn« timo affecting the tissae. Samuel starts fraiB tb 
Inflammalion induced by cbemtoal me»ns, and explain» it as a 
ant of the union of the eauao of tho inflamniution with the 
tho walls of the blood-vessels and the blood. The wanderii^ ef 
bIootl*cellB, their infiltration in the tivsue, and the 
changes, he n^giiriLi n.s .oeronditry processes. If the aodoD of 
tntted sulphuric Kctd on the tissue cauEcs such n mOtainoqfhoMi tldkl 
circulation of bluod and other fluids is do longer poasible, the tiSHBi^J 
is directly killed; but tbe most essential thing in the indammticrtiH 
is the change of tissue affected by dilute sulphoric acid (whvthcr *-*^ 
the borders <^ a part oaaterized by strong acid or where aniy dihtt-*' 
acid was used), where circulation still conlinuetL According to lltl«i 
if I havo riffhtly iimler^tood SiimiKVit ex|)lanntioD, the distuthan'' 
in the inflamed ti&üuc would vary in different ease«, aceoidinf^ M 1 1 - 
actiro cause was an octd, an alkali, ethereal OÜ (as oil of turptTO' 





DILlTATinS* OF VKISS AND CATILLARIES. 



3S1 



1, or ao mcrii oil (as croton-oil), etc. The cotKlitiou of the in- 
lUmed tU«u4 n-ould differ kUo with nction of cxtr«n)o oolJ, great 
hnt, cruxliiiijr, after stcaoi on expoiod »arf^eo« or serous meaibnuies, 
tic So we sbaulil hare to renounce entirely a uniforni ropresentatioii 
of the diomical processes iu the iiiflaa)<><i ti»«ue. I <Io oot know i( 
tiäa tiew trill »vur prore popular iu this form. Hitherto wr Imve 
diaswl tbos« ohaoges of tiüstic at the seat of iiinatuiimtiuii sU to- 
ivtbcr; jott as bj conoaaaioa of tb« bnio wc should muau not only 
th« itioiii«Dt of onncowüoii, but also its iinincdiatc effect ou tho brain 
aod its fimcliniift. If tho ooncussioo be followed by inQaminatioo of 
ibo bnin, the changes caused by Iho coDcus&ioa may influence tbe 
uatui« and. extent of the ioflstnmation ; but we do not say that a 
brain auffering from coiuniSMon !« already mflaine<l. The mrm ia 
(ruo of oontuaioiis: if tito uornutl fiinclioti of a tissue hus bfcu af- 
flMted by a concuasian, but its function oot eiittnvly destroy««!, th« 
strenUtioo will iltffer from normal, aiid thiu uiodiGcattun we call in- 
flammation, but do not so term the iimnedJatc result of the contu- 
•ion. The firoi^ou^s in tho tiesuos, after cbeiuical, physica.!, or me* 
ehanioat injuries, are essentially similar, differing only in extent aod 
intenaity ; they are what we tcmt ififlamniation, and in it the tisaae 
itsdf plays an important part, H-hich varies with tbu way tb« cause 
^baa directly affected (be tissue. 

^B A eooBtant perceptible result of aoate inflammation ia dilatation 

^^pf tlio Teina and capillaries, with escape of while blood-celU nitd ccr> 

j^Bpön disturbances of tbu phystnlugioal functions of the affected tissue. 

I'orall this to occur, oii« function of the vessels, espeeially that of 

tho celliiUr elemcata of keeping the blood in the channels formed bj 

tlwa, must be disturbed ; but irould such a disturbance bo coafiood 

to the walls of the reisels, and not extend to the adjaoent tissui]? 

This is not very pn^thahle. The granular doiidtooss ooourring in in- 

Baucd tnusolo, the todistJaotlioss of tbc filainenU in inflamed con- 

neotive tissue, the granular dtsintpf^ration in inflained nerve-ii laments, 

the rapid loss of color of red blood-cells in acutely intlanied tissue, 

ftU tiulicato that certain oonstont chanfifes go ou in the tissue alao, 

^_w|iieh nxually lead to gradual solution or death of tho tiasuea, unless 

^^nagrrae occurs from rapid increase of tho pirocees. I acknowledge 

' iberc is no proof that tbcsc chang^os bc^n aimtJiaitcouely «itb those 

ia tbe r«seU, and that they may be regarded a» an immediate fe> 

■uli of the Utter ; for if we End these alterations of tissue without 

dlliUatton of the vessels and celWmljrrution, or if we nrtiflcially cause 

thia state by obstructing the circulation Ui tbc injured part {Samu^^ 

there may be a doubt as to whetber it is to be tenneil inflammattua 

ibe ocdioaiy sense {C jhnh^im). But, on cbe other hand, at* 




32i 



QEVEiUL R£lURfiS OX ACDTE IXFLiH IIATIOJI. 



t«inpl6 have been mado Ui tlistioguiafa the cliang«»! oundilion of the 
VASseU wliich permiu llie extensive escape of white bloo(l-c«ib frm 
ioflammatiou. Whcu sluJyiiig vliruiiio inl]aniination, we shoU m 
that all of thcf« factors cuu oc<;ur ecparntvlr, and that it i* oa\y tlmr 
oombiuatiun which funus what wv caJl in6aminatiua. 

Viiv/tow located the inflammatory dlsturliancee chieflj id tW 
l)»3ue ; he wn» led to this partly by the miuroscopic changes jmt 
iiietitioucd, partly froin the obaervntioii that on iiritatJaD yoav 
cells appeared ctcd iu ngn-vascular tissues, like the corD<<a and en- 
tila^, just aa tbcy do in vascular tissuoa. These latter obaen«> 
ttotiB, which nere made at a time wbcD the cmi^rntion of miht 
blood-celbi was not undeitttood, can now )>e differently interpnttd 
(Ijäülure VI.}. We doubt now just as liLlle as formerly that earth 
lugc-celUnnd Komo other«, na certnin cndothflin nreoroucmanibntM 
{liifK^itch, Kundrat), youug epithelial cells (Remak, Buhl, Aü^ 
Jküc/i), etc., on being irrimled in a oertnin way, will form oevfn> 
topUsm and new cell» iu thoinsclirc«, will divide up, and may tkm 
lead to fornintioii of new tissue. It i» slill doubtful whether kl 
cells thus formed have independent movement», like piis-cclle; Ina 
very few obacrvcrs now bcliove liiat developed coiineclivc titow, 
corneal or bone eorpuscles, acquire this poeoUarity ; it is pntly |a> 
eratly reeogniited that rormatioii of pus does not reault frofn Ion] 
prulifcrut ion of fixed conocetivc-t issue cclla, oocordinfi: to FuvAot'i 
theory. Many re^Td it aa still undecided how much the waiiilfHag 
cells hare to do with inflammatory new formalioos ; from my obwr» 
vationn I can Itanlly doulit that the tissao which cauaes bealiaf liy 
first intention, »« wcU as gmnuUlioti tissue, may proceed froai hin- 
dering cellfi, alchuuf^h another mode is possible (by olFshoot«, ditecc 
outgrowth from the tiasae. Lecture VL). The tmnsfurniatioft o/t 
wandorin;; cells into oonnectiv« tissue eoonts to me quite plaosiUB^ 
fur, nccordin)^ to my invcsiif^iinna, tbcy probably originated (railB 
coonective-tijistie cells, oamely, from the irtellate cellii, GlamrDts of 
lymphatic inlands. Of late, attempts liavc been mad« to cxplato db3^ ! 
the aborc-mentionod tissue-colls, siieh ax enrtila^-oellfc, afu'r eMOxn ■ 
irritations, U-gin to enbir^, dtnde, and finally to produri- nen tis- 
sue, by the hy|)Otlieaia that every pfoloplaam, supplietl with prwp«?»; 
nourisbnietit, would grow nnd divide up if not hindered by ibp p w » » - 
ure of the tissue in whirb it develops ; tbe partial i-scapu of (ho o«>' 
dcus, as from injun' or inereased disteDsibilily of the tiseue, lb» 
nutritive conditions t>eing otherwise good, is aaid to b« «ttoogh to 
start the remains of tbe coll into ^^ntb. Tliis hypothesis, «cUA 
was advanced by Thterach for another object, and which has beO 
warmly taken up and generalized by Samueiy tcetoa very iogt^wi^ i 



FORMATION' Or FIBRIXE. 



S23 



Lad I tliiiik il nuj prove the fniilful basis of future obsterrations. 
3ut tissue- derelopn>ent independent on other iraporUnt Taotor« bo 
ddes tlio conditious of outrilioD ond pressure, ki oq inherited pecu- 
iarities of thi< protoplasm ; and tli« itbovo livpoüio»« docs not suit 
lU case» — for instanw, the t^odogcnou» cfll-dcvflopmtnt of tlic endo- 

Eiiun uflvr iuUaiiinialor^' trritstion of the peritoneum. 
[t is not Unown wlietlier there is a primary dimurbaDce of nutri- 
in ibe tissues ihemselres, itidcpend«nt nf the Wood-roascla and 
hoir TuuctiooB, that induces ttie apucific iitflamniutor}- oltenitioa iu 
be vessels. The deposit of urate« in the tissue of eertain parts of 
b« body in arthritis is usually regarded as of thin uatun- \ but the 
iepijsit requires ])itrlicipatioti of the rossoEs« and so tbcy and tlic 
Imtes arc siniullancously affected. An experimeat of CcAn^im 
bowa that continued exclu-sion of blood from a btood-TPiünl may so 
.Oect it« vralU that when the bluod sgnin entcni there will be a froc 
'BitgratioQ of white blood-.>eIls. It wiw mentioned shove that con- 
äntmd stasis of tlie blood did nut have Ibis effect on the walls of tho 
reascl where it was stagnated ; but from clinical grounds it is prob« 
kble that the pressure of extensively and ropidty diatendcd veasela 

Ellie p:kris around has somolhing to do witU the?ir intlnmmation. 
tt is very probable tlmt inflammations may be induced not only 
chemii'Al, physical, and mechanical causes., which act from with- 
eutdireotly on certnin parts of the body, but also b}' primary disturb- 
(BCM of nutrition in tJie tissupü and of the circulation, which develop 
intlie body williout perceptible cause. 

I tnust not forf^et to mention one «ymptom wliicli formerly played 

a great ruli? in tnäanimation, but is now hardly mentioned ; that is, 

Üte/ormntion o/ßhrint in some inflammations This occurs chiefly, 

inilpod almost exclusively, in iuflummation of the connective tiisue, 

gad sometimea on the aurfaoe of serous mcs, of fre^h and fifmniilnt- 

Pf wound*, and of mucous membranes (of pharynx, larynx, and 

bronchi) ; in other esses the nutrient fluid to the connective tissue 

SMUAes a fibrinous rigidity. It has been already mentioned that 

tbc formation of fibrioe is not from an excess of (ibrine in the blood, 

bat frota chemical alteration in 111» inflamed |>arl«. Fibrine forms 

n Che iiidamed tissue, but is not n constant result of inflammation. 

tin? great difference of the other symptoms occurring with dbrinoiw 

bHammations i» remarlcablo. While rapid formation of a moderate 

uootiol of fibrine favors healing by the first intention and purlial 

lilbesiott of the surfaces of serous membranes, when often soarcely a 

of inflammntion or fever ia perceptihie, in other cases, from 

n« eni^nalical cause, a very moderate fibrinous deposit in the 

I (■» fibrinous depont on the mucous mcmbrnno of tlin tlm^t, 




92i 



CEKEBAL REMARKS ON ACDTE INFLAMSHTIOS. 



dipbtbem) causes death. It 13 v&ry cvUIuut tbst libriDous hanlnv 
iog of the tisHUR llaicU ia one of the BCTOTVSt nltcratiuns of tbciril^- 
irilioD ; HD(I, as oxpf.<rivnce »bows, it often endt in necmgi». Stdl, 
the scTCTO general syuiptonu acd exteneire infUiniiiaiory mlaea tn 
tbese processes cannot be due sinply to the rormatioo of libriDfl^ b»t 
Mem referable to absorption of tlie products of deoompositioo in tb» 
discued tissue, vrbicb bos n rcry rapid poisonoua action. In dr 
acute in lUm ma lions with fonnatioa of ßbrinc tbero ecema to bti 
scflte of iimlignancy simitar to those without such formation, so ibt 
Ütis would seem to bo rather an accident due to the rartety of liw 
tissue ami its locality ; and vbile its signifioaaoe is wry imporlu^ 
it is not CMnntial to tho inflammation, nor does It mntcriallj- ehatg» 
ttie corns«. 

TIio ecrou» traneudaiion also, which accompanies anitc iiiOiiB- 
maCions, deserres a short notJco. tn many cases it c^^rtainlr in tb« 
result of change of prcmute in the veiisrls at the seat of inflamini- 
tiou; but- it is just as much due to impaired function of tlicwiU» 
of the vessels and of the lictsue; it is often % prominent symj^toioia 
inßammntiouK of the connective tissue, especially of serous niea* 
br&ncs. Tho walls of tho vessels cannot bold the serum of (be 
blood; the tissue does not prepare it ; veins and lymphatics do Ml 
carry it oway, espwially if they are oorercd ami stopped up bf 
fibrinc (in iiinuniniation of serous surfaces on which the lymphalif) 
open), Tbc scrum in acutely inSumcd tissue is essi^ntially diffenst 
from thnt wliicb, without inflammation, causes dropsy, for il art 
only (>oiilainfl Wandertag cells and disintegrated red b1ood-ee1lfi,biit 
also the aoluhlc product« of the ioSammation. Tbe removal of this 
lluid by the veins and lymphatic» releases the tissues from a oootid- 
erable pressure and carries off the injurious products, it is true; but 
part of it at Irast is carried into the blood, and probably caoaea the 
iullnmmalory (ever. This has already been fully treated of. 

Now we might spenk of the causes why circumscribed and often 
purely mechanical irritations, acting on small portions of the body, 
ooctisionaliy excite auch intense spreading InfU munitions, and of tbe 
way tbuso sprrad. But I will not now trouble you further with this 
subject. I hare already said something aliout it in Lecture XXL, 
and shall hereafter have occasion to say more. 

Palhnlogiea.1 anatomists have paid too little attention to Ibws 
questions ; surgeons see their importance too often, and s«ek la 
vain for a means to aneat these spreading inflammatiooa. Id Ütc 
clinic there will be many opportunities to call your attentioa to 
ibcae important points. 

It is in the nature of our times to undervalue Uio sig^nificance 



VALUE OF TOEORETICAL REFLECTIONS. 326 

id practical value of these so-called theoretical rcflectioDS with 
lici I have perhaps fatigued some of you. But hereafter, wheo 
>a liave been in practice for some years, you will haittly be able to 
bd and understand a medical work if, during your student-life, you 
.▼e Dot acquired a basis on which to build. After some years of 
'actice some of you, who are now sated with lectures, will long 
> hear a continuous scieatiSo exposition of important morbid pro- 
»ses. 



CHAPTER m 



LECTTRS XXriI. 

D17'. Hobt G»7nmo.— I<nni«'3 i>t« Oniai.— Prooau at Dattoknokt.— Tkrtttkagr (11 
fnmn «aeefälnr ta in« Bsmot* OtiwM,— I. Lmb «f Vlutlt^ of A« TIarai 
M«cliuiM«l or dioniod CauMw.— a. ConplaU html of tl>* j^iHui and BOmi 
Rlaad.—ln<iaTo«nÜ«n.— Conti noad Prcnarc.— Dombltw.—ürMt Tantkn of tli^» 
Tluao.— 3. Complato Arreat of tha fiofpl^af ArtarUl Itlo»d.— GaognrtiA 
Una«.— Can^aa Saailia.— Ktgotlaa. — L Kmi^ Oangrama ia TarlMi Bloftd — 
DlaaaaM.— Tsraatmotit. 






Wb have )tln.qutjr spoken Creqaently of gangrene aod raortiGaaUoc 
Von kiutw in general vhat they mean, nnd hare already encouat 
K acrica of cases where there was local death of a part ; but iher« 
niaoy other eircumslBncps, wilh whioh you are not yet ocqiiatntcc^*— ^d, 
whtcli favur gangrene ; all of whicli we shall include in tli» cluipter».^- 

You alieacly know the word ganyrvn« \o l>o perfectly iynonyB 
with itiurtificaliun. Originally it vaa only ttsoJ to expnsM the 
whnrc the dying \»art nan still hot aiiU pvinfiil ; thai is, Dot conif 
dead. This was called " hot morüficatioo," while the mobt ** toT- 
mortification " was called by the old autlwra aphae*la». Tho 
mummijication is also employed for dry j^angrenc From the 
tbo oirculatioa ceasea, moüt ganffrent ia perfectly aaalogous to or* ' ^m^ 
narypatrcfaction. Although itoannot always be ocrtainly stated w T '- ^fi p 
<&y gangrene ocotm in one case and molU in another, wo aar gen-, 
oily that wliun the cirouUtion cvoaes suddenly, cepeciklly if tJia 
hare boon previously inflamed or oedcnutoau, moist gnsgrene 
Dry giLDgren a— mummification or shrinking of the part»— Is toon 
qiiently due to gmduol death, wlioro the oirculatioa bos co«tin«.TC«j 
Äxbij in the deeper parts, and tbo serum baa been eanied off fro»s] 
t^te gradually-dying parts by the Iymphali<! re.<i5e1s and FPins. lUpT^^il 
evapontioit of tlie fluid also induces gnidual dryno». It is cectaiu/t 



CAÜS£$ OP OAXGRE.V&. 



337 



tint even in moist gangrene s supfirfidal <Irj-nesa of tlic skin nuij 
OeotuaoutHy be obtained hy rcmnring tlie bard layer of llie epUlenn», 
vlticli leodily peels off (row the decmnpo^ing limb; ire oibj hIso 
fgnsm-Hj fiiTor the (lr}-ing bj applicalion» of aubütanccs baring & strong 
•»ffiraitr for waLer, audi as alcoliol, »tilutious of corroftivo sublimatL', 
'^Ipliuric ucid, etc, j but vre cauuut obtoJa iwi complete n muminifica- 
^*oti u soanctimcB ooour« spoatoncouGlv. Hence, dry gaogrono is not 
* utnpl« pulrvfkction, but a rather compUcnled process, vriücb gradu- 

■^y leads to arrest of the drcalfttkm. 
Til« immediate cause of death of individual parts of Ibe body is 
«Ivays the complete oesiution of the supply of Dutriment oonscquont 
QD «irest of circulation in the oai>ilIiirifs ; uudcr some drouinstailccs 
t^e chief artcnes or reina of ad cxlicmity may he locally obatnictod, 
tad, iicvertlieleBS, the blood finds its wuy by neighlwring brandiea 
into tbcir lower or upper part«. Hence, obsbuction of an artery can 
only be the immediat« cau»e of gangrene wlieti oollat«ml circulation 
|i ii impossible?. Tliis may be due partly to anntomia.! oondittons, partly 
^Bo great ngidity of the walls of smull artrrica, partly to very exteu* 
^Küvc destruction of the wolU of the artery, as when the femoral ta 
y obelmcted from tlie bond of the leg to the foot, the nutrition only 
oaues vhen the caplhiry dioulation ia rendered impossible by these 
dnnmutancesi But it is not always necessary IWt cessation of clr- 
culntion in a nnnll capillary district, or in the parts supplied by one 
small irtoty^ should cause actual deconipoiilJOD ; under »wh ci[cun^ 
i tho disturbenco of nutrition may asaumo a tniUlcr furm, cspc* 
vben I1ÜS limited dbturbance of circulftUtai comes oa elowly 
l|{n4ually. In tJiis onse there is molecular disintegration of tissue«, 
^«bkii shrinks and dries to a yellow cheesy mass, in »horl, there i» a 
Bcrics of mctamtMphoecs which in the cadarer appmr as dry, yellow 
Solärctiofia ; this is eescntialiy merely a sort of dry gangrene limited 
to a small spoL If this disturbance of nutritioo and molecular disia- 
tegrstiOR of tissue taho place on a surface, we call it ulceration ; the 
^jfhole serlea of so-called atonic ulcers, to which we shall hereafter 
^K<stuni| are mostly due to such quantitative disliirbofices of nutrition. 
HSlan, intimate as Is the conneotioo between the causes of dry gan- 
B^p™* <^<^ ulceration, still, the Torious forma of gnogrene arc vol! 
marked and peculiar, as you will see from n-hnt follows, as there is 
.geBcmlly not only molecular disintegratiou of tissue, but death of 
fholo ftlipcds of tiasoc, or even of an entire limb, ApHcri^ it is cor- 
^toinly BuppoEsfale that oompleto closure of »11 tlie toiiis retaroiog 
from a limb, ahonld induce complete sto&is in tbe cajuIlaricB; 
ia pneiioe this is very nnlikely to occur, for the veins aro so rcty 
'intineKnts, aod in almost all parts of the body tbere are two ways Gor 






338 



GAUGREKBl 



.Üio return of blood, viz., tho do«p »nd mibratsDeoiia veiiu, xrhicli 
eonnDuniMte froely ; if one imy be closed, the other vUl be at kaut 
ptirllj opcii. Wlieik drjr gangrene occurs in tbe skiD aad deeper «oft 
purl«, Uiey uauallji- assume n gnyisb-black, tlicn a coul-blftck bu«. In 
cues wbere tbe part« vero prffviousJjr inflamed, the eIcid nppeus it 
first daric violet, then wbilisb jdlov, it only bcoonicK brcnmisb or 
grsjnsli MmIc tn oaae of jinrtial diying: ; dead toodoas aod bacm 
ehiuige their color little^ When, from disturbance of the (ÖKulatioo, a 
eonaideiable portion of tissue cmme» to be nourislied, tlie bordar be- 
tween dead and livin|; rc^arly becomes more dietinctljr nuulied ; 
around the dcud ekia there fonn» a bright-red line, the luxmlled Vm 
iff deifUtreation, This redness is caused by distentioa of the mpQlaiy 
TesAolfl, wliich ia partly due to collateral ciitnilatJon in tbomi partly to 
Buxtoo induced by the deoomp^Qg- lluiiU, and exactly teeenbles the 
mdne« around the edges of a woiiml with loMof Mibstanoe,«q>ecially 
of a coutuscd wound* ae we bare already explained. Along with tbos 
changes in the vessels tbcio ia an actire ct-ll-iDfiltratiott in tbe lias 
of demnrcatiun, by whit-h tho ttsEue, whstercr its naturo may be^ b 
partly softened and dUsolred. All over the borders of the liniig 
tissue young cells io the fonn of pus appear iu place of the firm tissoe^ 
and then the coht>rcnci> of the pnrta ceases. The dead beeomei d»- 
tavlied from tJic living, and on the bordcra of the latter tliere la akyer 
of tissue changed by inSltration of plastie matter and ectasia o£ (be 
vessels, granulations. To express this simply ia surgii:«] language «e 
say: Tbe dead tissue must be thrown ofT from the living by free sup» 
puratio», and thin detachment of tbe dead tis»ne i» (Villowod by actire 
grsnuUtions which cicatrise in tJic i|Biial manner. This pnwota mpeata 
itself in all tI»!U€s, in alt fonns of gangrene, sotnetimt« quickor, a 
times more alowly, m exactly tlie same way, cren in bones, at 
know from the necrosis of tho ends of the bono in open £ructur«L 
we shall not here treat of gangrene of bone«, as it into Intisnately 
connected wilh theirothercltronicdiseasps tbatwesliall baro to speak 
of it when tn-atiiig of tlivm. The timu rc«|uircd for the dotaobaieat 
of the dead t itjtiiy mny vary greatly. It depends : 1. On the siie of 
the (U-nd ]>or(ion; 'i. On the vaacularity and oonatsteaoQ of tlie tissue; 
3, On tho strength and vitality of the patient. 

As gangrene is usually the result of other diseases, it is not nlwayi 
easy to correctly group the symptoms wliich are to be referred to it. 
If the litio of demarcation fuLs formed, and (lie process of detnohment 
is going oa, an eSect on the general health is apparent vrben the 
gangrene aSects large extremities. Then there is a general maroeimis, 
a gradual It>sa of strength, depression of tbe bodily tempcratore, small 
pulse, dry tongue, a half-soporosc state in which the patient grows 



DECDBITÜSL 



8S» 



nod «roaker, and fiiiaDy iliea, witbout otir bring ahh todu- 
' ooTcr in the cadircr nay particular cauac of dcaUi, alUiough in oÜicr 
cas«6 potrid metastatic abecceses arc found in the lungs. Tbese oase« 
uro one form of dmniic septicaemia ; 2 have no doubt that tlie repcatod 
absorption of putrid inattera« during tlie development of gangieiu^ hy 
the blood and lymphatic circrulatioD which partly ccntimiea, maj be the 
cause of dvatli. I propose to return to this qucsüoa la the next 
acctioa. 

Aft«r tlic&Q gcocral rciDark8,we must study moie carcfuUy the 
diffcroQt Turietioa of gnugrvne, according tu tht^ir remoto and pioxi* 
tuate causcfl, and tlieir praciioU importance : 

L. Complete loss o£ vitality of the Hs&ue through tcecluinical or 
chemical aotioo, giich as crushing, contitxing, great hc&t or cold, cans- 
llo adds and alkaUoSf oootioued couUct M-ilh antmouiacal urine, with 
caitmiooloaa potaon, poisons firotn certain ccrpcnt«, putrid matten 
thai Bot as fonoents, ct<^, come under this head. "We bare already 

I^xikeo of some of tbHse varieties; we shall sbortly cotne to others of 
tbem. 
S, Complete aifOSt of tlic circulation, by circuhir compression oc 
Dihor mea^aoicat caufc, is in many cn»es the cause of capillary stasis 
and gangrenes For inAbtnce, If you eurmund a limb Crmly wiUi a 
bandage, you will hnre, Gnt, venous congostion, lhcn oxlcmn, and 
finally, gangrene. Let us take a practical example : if the prcpuee 
be too small and bo rorcn>Iy drawn back over the glaos so as to 
caoM a paiaphimoüa, Ike compr««Bod glanfi, or iu tliia case more 
ftwjtientJy ilie cotiipn'is&iiif* ring, becomes gangrenous. The roortifi- 
calion of strangulated lu<rnta depends on tlie B:in»c cxuac. 

Cootinoed pressura oIko, l>y aircEtlng the oiQux und cQlux of blood, 
may lead to gaopenc, espedally in persons in vrbom tbe hi-art's action 
Ss weakened hy long difease, or who by general septic intosicntioa 
^^■2« already disposed to gangrene. 

^B JXecuiitu», til« so-cnltod bed-«nre, a aoch a gangrene eatscd by 

Hf continued pressure, but uD sort« of bed«ores are not gangrenous front 

^p tbe first, for in sumo caeca they are lather to bo compered to 

». gradual maccmtion of the epidermis and cutis, as a result of coo- 

I (joually lying in a bod wet with sweat, urine, and other Ufjuids. De> 

rubitus is paxLicularly frequent oYcr the sacrum, and may there attain 

ful »izej all tlie toft ]>arls becoming gangrenous down to the 

it miiy also occur over the beol, tlie trochanters of the femur, 

head of the Rbula, scapula, or spinous processes of the vertebne, oo- 

oording to the [wsition of tbc patient. Ilic same thing muy bo caused 

by bsdlr-oppliocl dressingfi. This disease is the more unpleasant, as 

\it usually cornea during other exhausting aScctions. Although no 





880 



<;\NGItENE. 



iiMa»e iu which the paticot is ouudcmDcd to luog, nbsolutfi quiet, u 
rnlln>]y exempt from the diBngrceablc ncoompaniment of a decubitw, 
elill soitic [luculbrlv' iliH]K>ac to it, chief smon^ which is tvjthus; ia 
pulicat« with scptica-miu, decubitus occurs very carlj^, often cvea after 
threo to 6ve dajd of qiu«t ; it nsuaUjr begins with a very ctrciuaseribed 
conj^lioQ of the skin over tbc aacnim^ while, with proper care, oo» 
eumptivo patients koop their betb for mouths or yean, without baring 
bed-eores. 

Thbt disease Is pftrllcularljr troublesome for tho psUeat, becuusr, 
especially in cUronic maliicÜM, it nuy he accumpanicd bj* grcai pun; 
■a nciitc coses of typhus and scpticmmin, on tho oontnuy, the putinu 
sornL-UiiR>ü du not fool it at all when they bare a very large bod-nrc 
This form of fptngrcno ia parücnlarly dangiirous «hen Üie exdtlaj 
«aoKS canoot be entirely removed, and it bcoome» progressive; tk 
prognosis is worse the more exhausted the putient • not aafreqt>catt| 
bed-sore !a the cause of deatli, a5 it continues to ealar^ in ^Ittl 
alt trealmcat, or it uutj be tho origio of ft tital pyRmiA. 

Too grctit tsneion of tM ttMtte, causing groat dlsleatloa of tk 
Yi;s3<;ts, and compressing; sonic of tliem, induces, on the one hinil,i 
diminished amount of blooiJ, while the pathological BequitetDsiils it 
DUtriment are increased ; on the other, a cnogulstioa of blood !o ibe 
eapllUries fVum tlie increased Inction. IHiia ia the came of gangrae 
oocurrint^ in inflammation, and which we haro almdy moDliootä 
wh«n »peaking of phlegmon, but it m»»t not bo said that «rerj sta« 
of the bluud iu tlic capillaries that niair oocssionally occur in inflan- 
tnution ia to he referred to gront tension of the dasuns, as thcro arc 
also other causce. It would Icfid me too )*r to enter on tlienfea, 
espemally as you have already benrd them in tbc course on geoenl 
pathology. MoreoTOr, we shall return to this when treating of Omxsr 
bosis of the Tcin«. 

3. Comfilete arrest q^ tfu tupjUi^ of artertcd blood, which is particii- 
liirly due to diseases of the heart and artt^ries, must also sometioies 
lc«d to gai^grcno; io this class belong those cases of gangrene 
called gangnsna tpontanfay or oftenor ffanffnena $enUiM, from its 
more frcqiirnt occurrence in oM person»; this may come In variow 
ways and fonna. The causes inay vary Urns: Tlie coagulation of 
blood may begin in the capillaries (msnuunio tbrombosls as a roMill 
of debility of the heart, or iasitfficicut conduction tlirougb the smaUci 
arteries), or as an iodcpcDdent thrombus of tlic nitcty, or, lastly» a 
thrombtis from cmholism ; exo^-ssive, continued an»mia also, with 
great consecutire contraction of the arteries and deWlity of the heart, 
and, lastly, continued spasmodic oontractioo of tho arteriM, may b- 
duoo gangrene. Guogneoa senilis proper ia a disesso origioally o^ 



OANCa^S'A SSXiUS. 



831 



I 



» 



curriD^ in tbo toea, rarely in tlio finders, as Z once saw. Hefe nre 
two chief forros: in one of tlicm a brown spot forms on one toe ; it 
BOon becomes blaok, and gradually spreads till the whole too becomes 
complete!; dry. lu fnvoralJe cases a line of demarcation forms at 
the phahuigo-meUtars«) artiotilatJon, tho toe foils off, and tlie vt/tmA 
dcMiixra, But Lbe inuinniilicition may go higher and Uoait it«ßlf in 
üic middle uf the foot, above ILc nuiUvoli, in the middle of the leg, 
or just below the knoc. In another scriec of cmcs, tho discueo be- 
gins with symptoms of tnflarnmxtian, u*dematous swelling of tbe toes, 
ray great pain, and dark, blulsh-rcd color, n-bich subsequently be> 
coaves black; there are stages of the disease where, by the blui&b-red, 
mottled appearance of the skin, we may nee that in one place the cir> 
culstion i* carried on wltii the greatest difTicuIty, while clMwhcrc It 
has already ceased ; this etnigglc between life and death the French 
have not inaptlycomjiaivdtodoath by asphyxia, and termed tuphjfxia 
locale. In this fbcm of moiet, hot gangreor, the diftease usually attadts 
B^Tcral toes at once, and extends to the foot, till in the course of a 
few weeks the entire foot, pettmps also the 1^, bceoinei gnsgrcnous; 
at tbe same time Oeoomposltioa soon begins in the oedcmatous sab» 
outanoou» ocllular tissue, and the danger of ubsorptlon uf putrid mat- 
tM* tlvongfa the lymphatic vessels is much grrator than in the process 
of mummification. Tbe seat of the disease of tbe arteries that leads to 
qioDtancous gnngrene rarics ; m acute [uitLmsaiic) ffof^frcma senilis^ 
Uie primary coaguhitioo due to feeble circulation oocuis in the capiK 
latles and thence extends backward to t))C arteries. Tho feebleness 
of the arterial circulation may be due to fariorn causes : 1. To di- 
ndoiubtxl energy of the heart's action ; 2. To thickening of the walb 
of the arteries and contraction of their calibre; 3. To degeneration 
at Lite muscular coat of the smaller artericfi. In socno cases all of 
Ou^c causes miile, for, inutdpcrisoiis with ft^blchenrt-octiou, diseases 
of the arteries arc the most freqncnt ; besides, sfTectioos of the heart 
and arteries usunlly liave a oommon ooustitutional cause. Tliis is not 
tho place to discuss extensively how far rigidity and athrmsna of the 
coats of tbe artery aro to be referred to inflammation, or to be n> 
gsrdcd as a peculiar disease ; nor can I permit myself to diseiws 
further the distinctions ot tlio Gnnr histological [tnintn, of ^vlilcli wr 
thai! have something to aay when treating of nnoarism^, but w-ilt 
»imply mention that in old persons the coata of the arteries are oflcn 
thicken«], and deposits of chalk form in them to such an extent that 
the wixilc artery is calcified and tho calibre considerably diniinioisbecl 
b^ tbe thickening of the walls, and tlte inner surface becomes rough, 
so as to £spoac to the fixation of blDod*clols. llic original qualities 
of the arteries arc thus lost to soch an extent that they are tveither 



332 



OAXUKBNE. 



elastic nor oontzactilc, tiul b«DL*o, partly from the diininlsliol cnlibrc; 
partly from tho lank of contractility, tliu uuwnrd inorciaeut of the 
blood, already moved less forcibly o» uocouut of the feeble actioa of 
tlie beaut, is rciy mucU impeded, so tbat it is easy to UDclerstRDtl bow 
nnffulatjon oocure in sudi caees, especially in parts distant firam tba 
bcart. 

While Uie c*»e« just described are with some juitioe t*nned «eaile 
gangrene, and their cuiiuuc'tioiL vrith arterial diaeasea has been gen- 
cniUy rcoognuBcd sinoc tlic time of Dupuytroty there it aootber ft>m 
of spont&neaus gangrene, which occurs ia old pereona, but U disti» 
guisbed (mm the atioTc, because a large poitioa of an cxtretnity, u 
of thu K'K OS hi^h us tit« ciilf or thu knee, becomes gangreaooa at oaco 
This iiiVf^i place as follows : In tlte diicf artory, say the furoond, alon^ 
the thigh or iii tbc hollow of tbe kuee, a Gnu dot forma and adbem 
U> tho wall of the vcssi-1 by rough promincnoos on the internal ooa^ 
due to precedent atbi'Tvniulous disease, or else forms in sac-like dils- 
tatioos of the arteiy and gradually grows by appositioa of new fibrinev 
BO as iiot only to fill the calibre of the artery, but to plug uj) the wbol* 
periphersl end of the vessel, and even a portion of the central end, by 
tlMs fibrinous clot. Tlie consequence of tliis stoppage of tbe art«iy by 
a thrombus dcfuloping ou thu wall, which gradually omnls the cot- 
taUnU citcubtioQ also, is osuaUy gaagiene of the whole foot aod part 
of the leg, wbich is dry or moist according to the r»pidit<r with wbidi 
the clot has developed ; it ia occasionally pa<i9ible to trace tlie grovtli 
of th« Uiroinbus by llie spread of the gangrene. Not long siaoo I 
observed an old mnn, who whs taken into tlw hospitAl lor spontaaeoos 
gmngrene of the foot. He was so thin and the arteries were so rigid 
tliat the pulsations of the femoral could be dieiinctly foUowod into the 
hollo«' of thu kiiüe. SulMCjuontly the gangrene progresaed, and at 
tbe same time thn pulsation in the lower part c^ the artery oeosod. 
About- n fortnight later, shortly before death, when the gwigreno bad 
adiiinccd to Uie knee-joint, the puliation bad ceased at Poupart's liga- 
ment. Tlie autopsy oonfinned tlie diAgno§Is of oomplet« arterial 
thrombosis. Tbc giingrcnous lej; was so comptctely mummißod that I 
cut it from the body, and, io preserve it from ftirthcr destruction anil 
worms, \-iiruished it. It is slill in the surreal museum at Zurich. 

Another caaoof nrttrrial thrombosis is where the primary stoppa^ 
of the artery is caused by an embolus. A clot of fibrine, in cndooarcKtii 
or detnclicd fmm on aoeurismal no, may become wedged io an arterj 
of one of the cittremitiee; tlils Indticcs further deposit of Rbrine. OiF 
late, there is a tcndeooy to refer moat cases of softening and dcsiccatioi^ 
as of the brain, spleen, etc., to sucb emboli. In our clinic we saw a 
very intorcsting typical case of this variety. Six weeks after coafio» 



SSOOTfö». 



833 



lent, a youun n-oman Iiod great swcUing of Üic left leg, which vu 
m füllowod by » daric-bloc coIcm- of the »kin, and compictc putrcfao- 
>n of that part of tho body ; there was geueml E«ptic poisonhig 
nrliea tho patictit ontcrcd tho hospital. As there was no excessive 
ansetnis, and do <liscsse of the artexies coulJ be dJsooi'cxed, T nude the 
diaj^osisof endocardiüü nith fibrinous vng<>tatioii!4 on tlie mitml valre^ 
aud <let«d)ment of one of these regctatiifn.^, »illi iU lui1gin<^'iit at the 
bifurcation of the left {lofiliteul artcrj, I held to this diagnosis, al- 
Uioug^i no abnormal murmur eouhl be dtseoTcrcd, for it is well known 
that frome chsea of endocardiLis run their roorae iiln>oftt vritbout symp- 
toitta; the rapid pubrefitctioiiof the leg Tnuat have hmi u sudden eniisv. 
A» no line of demareation fAnucd, and the general (Tooditioa daily 
beoame worse, vra could bare no hopes of saving life by amputating; 
death took place about twelve days after the first Bymptuii» of gaii- 
grtn^i Hue autopsy fully ooufinucd the diagnoeiff. It seems rcuiark- 
ablo tbat no ooUateral circulation should develop in luoh cases, as it 
does after ligation of tlie femoiHl artery. I can only explain this on 
the supposition ttiat in eudocardiüa the heart's action 13 n-eakened, 
and oonaequeiiLly tbe pressure of the blood is inüufltricnt U* dilate the 
ttnmHcr collaterul arterica. 

Yay nrc arc the cases where &oia cxocssirc aainmia the artcriea 

are bo mufh contracted that but little Mood oirctihtca through the 

«naltcT ones, and the nervous excitation of the heart is 50 HÜght that 

Jta coatractions are incomplete. Otws of spontaneous gangrene from 

tbb cause are more frequent in slender chlorotic females than in men; 

ibe patients, who are geiiemlly young, often suffer from rigidity of tlio 

baods and foct, luoting>fits, and fatigue. Ilii» disease a[j[K.-ars to be 

iBOM frequent in France than in Germany or ICngUnd. Tbrrc is «ti 

excellent work on the subject by Raynaud^ entitled "De roKi^yxie 

locale et do la gangrene symfitriquc des cxträmitfe," 1863. As im- 

^c4ied by the title, the gangrene is usually symmetrical in tlte two 

^^bnlML t linve only seen one such case ; a young, rery ainBmi« mnn, 

^^nthout any apparent onuse, had first gangrene of tho tip of the noee, 

I llicn of both fccL After suffering for months, he died ; as on (be pft- 

^^bent, sD on the onduver, I could find nothing morbid beyond tlie ez> 

^^cssive, inexplicable oniemia. 

Tbe fbnn of gangrcao seen from eating spurred rye is referred to 

permanent spasmodic oontiact ion of the sinullor nrtcrie« ; cxperieiiee 

allows (hat this substance induces contraction of the organic mtuculiur 

fibres, eq>c<cially of those of tho uterus, and it is supposed of tho 

L^tter^oe arteries also, 

^f S^vmd rye^ ucaic eomutvm. Is a diseased grain growing in the 
cor of rye (scv'bIa coreate), in which is de\'eloped a peculiar material. 




334 



OAXQRENBL 



«^tia. If breed li« made £roin suoh grnin^ pc^raons eatlqy 
■ffeotcil with poGuliar s/mptoms, wbicfa arc compnaetl uudi;r tfao 
cgotUinu-a or raplmnia. As tbe aber« disease of tlio grain is usual 
limited U> ocrUia regions, il nin}' he tmvX'Ay undiTstood that tbo 
eaaa should occur epidemically io men and beutü. It hns been bao' 
fur a long time, but tbc first scourato descriptions are of an 
in France in 1630. Ttie diüeaBe seems to have occurred m 
Germany, England, or Italy. Of kte iL hanlly ever occurs, probat^ 
liccuuse the diseased grain is better Iciiown and is no longer used 
Food, and beoaiisc less of t*hc grain is gron-ti eincc potatoes hare oovd 
into comnion us«. From former dcscriptiüns, various (omis Bij, 
courees of tlio disease majr be distingni&lied, of which ttomeUmcs one 
«nd sometimes another prevailed in tbe different epidemica ; poaaiVr 
Lho poison is tiot always the same, or is at least of variabtc intensily. 
Ill the acute cases, the patients were soon attacked w-ilh svrere ge» 
eral cramps, and death resulted in from four to eight days ; etainn 
only occur oocaitionally j at tbe same timo, and prcnonsly in tlie two- 
driNiiul stage, tliere are great itching and crawling in the akin, but pKi> 
ticularly in the tiands ; tbcn is also a feeling of deafuj^ss, of wumUw- 
sia in the ends of the fingers, rarely moist gaogreae of the akin, then 
of wiiole extremities. In more chrouio cavos, the result is usually 
fnvorable, allhotigh eevcnd Siigers or toes may be lost. 

4. We bare sini to speak of eercral forms of gangreue 
causes are not exactly Liionn, in which probably sererat inB 
unite. Among these is SQ-cuIlcd watcr-eaiiVcr, noma, a ^x>n 
gangrene ef the cbeeka, especially common in children, which 
fircqucnt in dlica along the Baltic, and DKire r%ro inbnd. Very puny 
children, living in cold, damp dwelling», are particularly prone lo ihia 
(li&osse, in vliicb, without any known cause, a gangTonous nochde 
fonnt in the middle of the cheek or lip and spreads rapidly t31 iW 
child Snally dies of ezlmustion. It is doubtfitl wbetlier this is due to 
anseniis with feobloncna of tbo heart, to miasmatic iiiflucoce, or tosotav 
peculiar disease of the blood. In occasional remarks about septa- 
ciemifl, we have already slated that certain morbid states of the hiöed 
predittposc to gangrene. Under tliia cauM wc must chas the cam 
occurring after tyj^ux, intermittent and exantbctnatoua forcn, in. 
diabetes mellitus, morbus Brigtitii, etc. After and during these 
eases, gaagretio of the tip of the Doee, of the car, cliei^i!, hands, atuT 
feet, occuia ; and in rare cases an cxaalhcma of ibc skin nmj pass (oica 
gniigrcno. In fiueh cases we may consider that tbo mlasiiut which 
induced the con^titittioiiA) dlseaso also inflticnces tbo oncutrence 
the gangrene ; and, on the other side, there seems reason tor ths^iloea 
that these caaes are motilly Ibc resnlt of feeble aettoo of tbe 



e wtgjk 



TBEATUBXT OP GANOUBXE. 



335 



bduocd by the long illness, which proves insufficient to canj the 
blood to the remote pnrU of the bo<ly with aufficient enerj^y ; accord- 
hg to this view, this gungreiie would be due to nurMtnio capillaiy 
thnrntbosÜB. DoubtIc«4 rnrious cirrutnütances act mora or less promi- 
nently iu iudii-idual oaa«0| so that qo ilefiiJle cliolo^ can be given 
for tii«sä rare fonns of gangrene fmm int«nuil muses. I may also 
mootioD that stomititis, from exccsaive use of mercury, also has a 
fTOftt tendency to ganpvnc. Wc EhalL Lereafler spoak t^ a peculiar 
ft»tm of gangrene of wounds, the so-called hoapUat gangrene,'^ 



llicro ue certain important prophylactic rules for the pravention 
^^f gu^reoc, especially of decubitus and other forms due to pressure; 



I gBiigrcnc from infiammation may sometimrii be prevented, by r»< 

g^^ag-wing the great tcosioa of the tissue and the tcdous congestion by 

^x^ incision made at the proper time. Be ooostantly on ynur guard 

y I ^tniit bed-«ores !n all discaM?« at all disposed to de<cul^tU5 ; turn 

»^y«jr attcntioa to this point cnrly : a wcU-stuffcd hor^c-hair mattress is 

IJh, ^^ h(«t siL'k-bcd ; the sheola plarcd over it should always bfl kept 

: «toih, so that the patient shall not lie on wrinkW As iKion as any 

Ixcsft appears over ihc sacrum, you ahould ha doubly curcful about 

tlk «9 |)usagc« of urine and ftocc^, so that tlie bed may not bo iret. I«t 

II X-flSKM» be cut and (he reddened spot Tubbcdduily with the fresh jittee 

fti ^— ^ Mi the cut mrface. If there be excoriation over the Karrum, ptacn 

IIk.^9 patient ou a ring cufihiou, or, if ]x<5sible, on n cuoutciiouc, air, or 

w^».4n cushion. The exooriatioa may be painted with nitmtc of silver, 

PC cxnrcrcd with leather spread with lead-pIaaU-r, If (he decubitus be 

' woa-vspuious from tho firat> and this beginn to extend, wo should resort 

to *h* ordinary treatment of gangrene, of which we shall speak pre»- 

The fcco/*iwi/ni(»i/ of gangrene lina two chief objoct« J 1. To pro- 

dO' ' ' ixMit of the gimgrenous parte by exciting aetirn suppura- 

äo>i I ■ acvompiiiied by arrest of the gangrtnc ; 2, To prevent 

iho jciLQgreoous |mrls deoouiposing, und thus acting injuriously on thr 

patient, and infecting the diambcr too miieli. 

For the linit indication, inoi«L warmtli iu the ßirm of calaplasms 

«■a (ijnncrlv emjiloyefl. Birt T cannot find that they arc pccnliarlr 

eficacvnis in thv9c cascfl. If tlic gangrene be moist and the gangre- 

uoo» parts «re much inclined to decompose, this would only be favored 

hy tlic nppliciitton ofL-ulagtlnsms; for llie dolarhmcnt of o dry eschar, 

whiL-h does not smrll baillr, and when the line of domarL-atioo is ftl- 

rsarlv formed, it is hnrdly worth whilo to hapten the process a little 

^T '•rannth. Hence T prefcr covering the gangrcnou* parts ami ihc 



336 



QXSGRSati 



Lordora of tlie bcolUiy ti«suö willi compresses or charpic, sookoJ is 
cUorioowater, and tbua in muint gangn-im I al&o ditititiish the lad 
Btocll of Uie decomposing substances. For tlie same purpose, we aaj 
vsc cTeo6ot«-wftt«r or cAcboUo Acld, or dilute purified pyroltgncoDi 
«cid, very slroiig* aloahol, spirit« of cmmpltor, or oil of tutpmUiiic 
Charcoal-iKiwder ubaurbs tlu: gases Cn>m tltc dcvoinpoWDg »nbrtaiKieib 
but, u it 6oiU the part« rcry mucli, it is pcrlinp« too little used. Otlwr 
powerful aotiseptics are svetAte of alumina (alum 3 v, plumbum Becti- 
cum, I j, aqua, lb I), and oool-tar with plaster ; both remedies are 
Tery scn-iccable, but, like sU similar one», must ha Croshly R[^)lied 
sevenü times daily to remov« entirely the smell of the deooatposiog 
parts, or late, permanganate of ))oUs1i (gr. z to ? i water) lias been 
ipvatly prui^tl aa a local aotJAcptic and disinfiKtunl; I baTO made 
several trials of it, but bav« fotmd it far inferior to the remedies pr» 
TJDusly mentJoQcd. Couceutnited sülutiaus of curbolic acid In oUvfr 
uL (say S ij to lb 1} cause Symptoms of poisonlug (olirc-groon urine), 
hence tbcy sliould be usod carefully. As soon as the gangreDtxu 
muss baa become somewhat detached, the shreds should bo lemored 
«■itli tlie scissors, nitliout cutting into tbe healtby parts ; tfiis is ps(> 
ticularly imiXM-tant in gangreae of tl>c subcutaneous cellular tissue^ 
M-liich ii often cxtensire, as after infiltnitioD of urine ; at the KUIM 
tiiiu; the local antiseptics should be eoutiuucd till hcallliy granulatioDa 
arise. Led hy the anatomical conditions In spontaneous gangrotto, it 
has been advised to break up tbo ooagulation of blood, by strokiog 
and rubbing tbe limb; from the poin and swelling of the parts, this is 
rarely prauticablc ; m cases where I have had it done, it has bad no 
effect on the progress of tho gangrooo. 

If the gangreue affect a limb, as in tbo various fi>nus of spoDts- 
neoufl and senile gangrene, I strongly ui^ you not to do any opeiv 
iio» till tlie line of deniareation is distiucL If titer« bo merely gna- 
grene of single toes, leave their dctaobinent to Nature ; if the wbols 
foot or leg b« aflEeeted, do tlie amputation so that it amy be monly 
an aid to the nurmal process of delucbmcat, i. o., ou the borders of 
the healtby parts you try to dissect up only cnoi^gfa skin to cover the 
stump, and saw the bone as near as pructieablo to the Una of demsr» 
cation. Thus you will oooaaranally succeed in aroidioj; a new out- 
break of the gangrene, and in BSviog your patient's life. If tbe patient 
dies before a distinct line of demarcation lia<i formed (ns is frequently 
Ihe case), you need not reproach youraelf for having nc^loated am- 
putaüOD, for you may rcat ai&ur«d that the patient vould have died 
oven sooner if amputation luid boon performed. Tlie prognosis in 
gangrene from internal causes (as the older surgeons termed H) is 
generally bad. 



i 



TREATMENT OF GANGRENE. 337 

Tlie w^emaZ treatment should be strengthening, in some cases 
even sümulant. Nourishing food, quinine, acids, and occasionally a 
few doses of camphor, are proper. The severe pain in senile gaa- 
j^rene often calls for large doses of opium, or subcutaneous injection 
of moTphine. For gangrene in stomatitis, after poisoning by mercury, 
we 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, provided with clean 
body «nd bedclothes, and have a gargle with 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- 
(HnmeDded. We oould only pat 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. 



chaiter xni. 

ACCIDENTAL TJiAUMATIC AND IXFLAMMATO^ 
J)IS£ASIiS, AND POIHONED WOUNDS, 



LECTURE XXIV. 



T. Loenl Diseucs vkldi nay Koiinpaiii Wound» nnd otlici Pobtk of lalunnukii 
1. FroKrcMivo Punileub uiil I'uruteui Putrid DiiniM ItdUnutnion of CclliaXj 
TlMur.— 9. BoaplUlOangTCD«, I'benulve Mncout-Mlirkiy UlplillMiia, ITImtmUi 






GEiTTLEiiEN: M'bcu BpcftkiDjf of Iraumntic iDflftmnution, I t<r>I[|. 
you tlmt it did not oxtond beyond Üio bound» of the injury, ivm! ilxnC 
Ibis WBs only npiuirciitly tliv r<0« when wc couM not accurately e>ji 
ftiniiKi the iDJurcd p&rU I stUl mnintain the truth of tttts. Bat ^nre ^ 
have already added that, from vurious accidcnls, cither ioilDedlateljr H 
after llie injury, a» in contused wounds, thcie may bo very seTE*m ~ 
progrctwirc inÜammution, with putrefaction, or that, latcr^ iieooDda.ry 
inflltmmktiotis niAy develop around th« alroady granaUtin|[ wound 
from causes whirh wn moDlioned ot tbe time (L(.>otun> Xlll.). I must 
now tell you that slid nnothcr eeries of pei-iiliar, partly infljiminiilor;T, 
partly gangrenous processes occur in the wound, which cause «Tom, 
UBually feverish, constitutional discoBcs. Some of the latter may k1*o 
occur without any tiling peculiar bving ofaaervuble in the wonnd. 
Lastly, Bubstanci*» may enter a wound already existing, or at »V 
lime of itit ooeurf^noc (as from the bite of a poisonous or dicca^wd 
ouimal), whicli may Itiduo« both severe local infbinmatkxi and ec**** 
eral blnml-poisoning. In this clinptcr I i-hnlt fpeak of all t^^d* 
things; I will try to give you a general view of tlicin. \\> kImIA 
speak first of the local .tymptouia whictt aocidentally acconipA 
wound, or a» infiammation due to other cause». 



^j-w't 




nORPlTAL U.U'GRr.N'K. 



»99 



BlVC? 



^l^CAL DISEASES WmCH MAT ACOOStPANY WOUNDS ASD f<THKK 
POINTS OF INFLAMMATION. 

_ For the *al<e of completeness, wc hrrc mention agnin pmgre«« 

suppuretirc aud SAiuo-purulcnt difTuec iafiamoiittion of Itic- celluliir 

^^^,^«. Putrid iMttcn which form on freeh wound» from gangxcno 

P ,t3-me mifaccs of the wounil, »nd may diffiwe rapidljr in the rocshes 

I" ^'■-m «! oelltiUr tissue, occasonally cause, on the «word, IIiird,or fourlli 

j^y^ ibrwc forms of inllftinmitioQ of t!»o iN*lliitar tissue lIiatsTt cbor- 

^t^ijer*-*^^ ''T «piJ deoorapnsition of the intlflinmatory product atwl by 

f^pifX. extension. If the patient nnrvivcs the deomrkatton of such a 

phlcT^^ninn, the process always ends with necrosis of ihc inRltralci] 

ccW* *1ar tissue and pcnnioiiltis ndiposuo. 'i'hc «anic thiu^ occurs iii 

Cbrin^ous (diphthprilic) phlegmon. Both prucesscw am usually ao> 

rom ^tuiir-d by sovcre const itutianat symptoms. If suppuration has 

i1r^«a.aly Wffun, as long as the wound ia open, phlcf^monous infiani- 

ntstioo may spread around Die wourHl from itk*ehanii-^il irriialiua, 

{on-'i^ii liodies, great ooiigeslion, ret^ntinn and decotn posit ion of 

yuM in lb« rccesKS of tbe wound, or iorcction of the wound witli 

{»blojEZOgcnouH Bulistancet! of various tiorls (Lecture XXI.). 

Ä. J/ogpital Gangrene^ Gan<^nma A^otocomialis/ Pourntvre dea 
ITvj* itnux. — I will fir^t describe the di&ease, then add a few rcmarka 
about the 6Uo)opy> -^t a eertain lime we notice, especially iu hos- 
pitals, tliAt a number of wounds, as well those from recetit operations 
X» l-Hosc that wc^rc jcranulatin^ and cicittriKini;, M*ithout knoiru cnusc, 
Ixicome discA«cd in n peculiar manner. In some cn«C8 the granulat- 
ing surface changes partially or entirely to a yellow snuwiy ptdp, 
wUIc-tfa »my he wimhcd olF from the surface, but more deeply it is 
änrily adLcreiiU 'Hiis metamorphofi» e-\tends not only to the granu- 
lating »urfiicc, biit to the surrounding;; skin which was previously 
beaJtliy, which becomes n»y-rcd ; thia also uoMmies a smeury yel- 
lowiah'gray color, and in from three to eis days the »urfiicc of the 
original nound almost doublps. Tlie iticresfie in depth is less in the 
■o>caI!ed/nj//>ouj form fif lio^pilal gnngrcne. In other cases a frtsb 
ound, or a gramilating- 6urf»c(>, rapidly assumes a crater shape, 
.exeretea a sf>ro-putrid fluitl, nftrr the remorni of which the tiasuca lie 
xpoaed. The surrounding Kkin is ».lightly reddened. Tlie progret» 
Ihia aioleeular disintegration to thin ichor is usually in shnrplycut 
ircl«», so lluit tho wound may acquire a horseshoe or trcffiil shape. 
la H^iMrou« form of hospital gangrene progresses more rapidly than 
the puIiKnis, and extends with especial mpi<lity in t/r/jM. Although 
both of Uie alxn'e forms occaeionnlly occur »cparatcly, thfy are 
•l»o feen In comUnatioD. I have seen t!io pulpouR form oflener 
t^n the uleerous, but acknowledge that my indindual experi- 
PPOC of diphtheria of -wounds is based oo a small number of ob> 



uo 



TRACMATIO AND INFLAMUaTORT DISEAftRS, ETC. 



serrationa. Ilospital gangrene does Qot attack chiefly large wo: 
but nth er insignificant injuries, Huch as ]civi>h~bit«A, nip-cutt, cvrrr-^ 
llie ponioiis of iJiin denuded by a liliKter, wliilc it never ix-<;ursoti4-^ 
uniiijiireil part of ibu akiu. The resemblance to diphttivritic iaDnv— 
■nation of tlic Diucoiuiacmbratics is montionod hy «ome autltots, ht-t 
aftvr suL-in)^ a wuitnd infedod from a dipbtheritic niucous mt'Dibmc, 
lam cuni-iucod that diphtheria and hospital gangrene arc two ilifrr- 
ent proocescs. A wound attacked by diphtheria in covered wiilt 
thick fibrinoua rinda ; the entire wound becomes inKltratnd and is 
MirrotiiKliiijr I>art.-4 iiiti-UM-ly cryaipeUlouB-, thvii a large part of i 
inlilltntL-d tisauc becomes necrosed und breaks down or.fiüla off i 
shrod». Uui we do not see the daily progress of pulpous degeaen- 
tion, forming round Bgurrs on lb« margins of the wound, whtcliut 
pulTy, very Ecneitire, and inclined to bleed, us Is so common in 1m» 
pital gon^rcnii. It is well known that after diplitlimii vt tnnous 
meinbnuie« paralysis ia not unfruquent ; but tbiK has out been oV 
•erred after buepilal gangrene. In the latter diacaso there are i^ 
the tame time constitutional symptoms : qI first the fever b ni>* 
erally sevrre, but tlie«' is more or li*»» gastric aSt'ction ; the ton] 
is coated, there is inclination to Tomit, and general dep: 
llic dlaeaac may prove dangerous to old or dclnlitated 
[tmally if i( cJit» an-ay nnnll arteries and onuses «rteriul ha-morrl 
Tlie Itirgv urLaries often rcsisl bospitst gatigrvne u'oricWfully, 
once saw a :nnn, for nhom an inguinal abscess bad been opcoed, a 
tacked by the pulpoaa form of the disease; the sktn of the groia t 
about the size of the hand was destroyed; tlie dinoaee had ai 
vanced .so de<-p Ittal alKiut an inch and a half of the femoral arte 
lay exposed in the wound, and ouuld be diatinetly seen pulutiog«« 
1 detailed a nur«; to May with tlia jyitient constantly, and tu mak0 
instant comprt-isMOii if bki-iling ahould occur, as it might »t any mo^ 
ment. 'riie pulp was thrown off, the wound granulated rapidly, am) 
after a long time complete recovery took plaiMi without bfcmorrbagc. 
Tlie eryeiptilatous redni-as acfompaiiying diphtheritic phlegmon and 
hospil«! gangrene is occasionally as aharply bounded an<l dcaqua- 
matca as much aa in erysipelas about wouml« otherwise beollby ^ but 
it hax not the same tendenny to spread. Tlie const itulional wptio 
poisoning is wonv^ in di|>h(hcria than in hospital gangrene 

Views as to tlic CBUB«) of hoapital gangrene vary ; Ibis is eJdeflj 
becauaemimy living surgeons hare had the good or bad rortunf neror 
to have seen the disease ; thus in Ztlrieb it haa nercr been aeen. la 
liis maxima on military surgery Ä(roHiey«r states, as a young physician 
in the Berlin Charite, he had only seen onocaHOofhoitpiial gnngrer»«. 
burgeons who have not seen this diacase, or have only iwen sponuUc 



J 



UOSI'ITAL GANCRENK. 



S41 



s,tfaiak it 18 duo logroBS nrgloct, dirly r]rv»mi)j^,cte., »nil regard 
as little marc thnn an ulcer of tbc Ipg that ha» supcrficiuiljr become 
Jigrenou» ttoai dirt and neplrct. Other eurgeoas suppose that hos- 
fl^iUI gangrene U, as the iiRme would tndirate, a disoaee pDciilinr to 
Vwe lioaptlaU, ami tluii its ocnirrrnce in only prnmote<l hj neglect 
of tfaedrc&aings. (jisUy, a third vi«w U that this fonn »t guat^rvnc is 
tla« to epidemic iofluoncos, mtd that it^ name io in »o far incom^^ a« 
it neenrs outfiidp. and ijistdu of hospiiaU at the sumo time. lu tlie 
tmpitab it probahl^ spreads by ittomdalion, for I do not doubt thnt 
atlor eaa be carried from gangrenous to healthy «routida by foK*ps, 
Febarpic, spoiigi^s, otc, and there I'xcite the di!i4>ase. Von Pitha and 
J^ock hav« «ipresscd the belief that it is an epidemic^nnasmatic dis- 
CAM. In the surgical cllato at Burlia with I-vci: I obst-rvcd an epi- 
demic, while the disease waa aeon uot only in other hospitals in Ber- 
lin, but in the city, in patJenta who could not he proved to have had 
any lliitig to dn with a hospital. The disoaa« upiK-»n-il very äuddooty, 
iml eotiroly di<appcarcd in a few months, »llhoiigh tho treatment of 
«rounds bad not been at all changed, nor could any cbangea b« 
Iknaile in tin; hospital itself. Tliis stems tn show that the cauaea da 
Lnot lie in tbc hospital itscIC Epidemie hospital gjingrenc might nc- 
lear from certain small organiam», whieh are rarely dcveltiped, which, 
Jk« a ferment, induce decomposition in the wound and grannlating 
Itbsue ; hence I sboolii preferably compare this disease of wounds 
writh blue suppuration, whidi cause» no injury to the wonnds, but, 
scounliug lo Lttckf, like blue milk, is caused by auiall organisms mmI 
can Infect other wounds. The requlrcmcDts for the growth of these 
small belie» are probably particularly favoi-cd by certain atmospheric 
Idfluenoca; benoe the disea-se spreads rpidi-niically. Tliero is no 
doubt that in the pulp of erery hoi^pital gangrene microcucei and 
Irvptooncct ar« jiu( as frequent M iu the secretion of simple dipb- 
kberitle wouiidfi. But it has not been proved that they were in the 
liftsue before it was destroyed, that they grew in it, or broke it 
luwo into pulp ; uor has it been shown that thix id a peculiar va- 
firty of microoooeus. Bot it ia certain that the transfer of hospital 
rpingri*ne pulp or putrid mailer to bi-althy wounds usually (alway», 
[U'cmling lo f^ifi'/icr] induces hnepital gangreno, and ihia ia very 
Important in praetiee. From my recent experience in the Vienna 
' General Hospilnl, I am more and more convinced that tbi« disease 
rraulla from specific cJiuses, cntin-ly independent of pyiemia, 8ei)ti- 
'Csemia, eryeipidaa, and lymphangitis, althougb it may bo followed 
bjr either of t1ie«e di»Mi»e8. 

The ßrst point in the treatment ia strict isolation of the paticnta, 
wIk> «bould hare special aur^es, dressinga, and inätrumeDts. If thia 



949 



TIUCVATIC JLND INFUIIIMATORY DISEASES, ETC 



docs not entirely prevent tlic spr^jid of the dtacaac, n» Oie conlayion 
may posail)!; bo carricd by tlie air Uom a dUoiuc-d to « hedlli; 
wound, still experience sliows tliaC it [iitwferes with tbe spread. In 
BOme vpidroiKS in niiUtary hospitals it kaa necessary ontirvly to n- 
oate oert&ia looBlities. Locally we eliouid apply strooff cliiurit«- 
water, or spirits of ciimphnr or lurpeiitiru?, to tbetw tvouncU, Scqd^ 
tiroes pHinliug lliu pun every twu Iiuiire vrilli tiiicttire of iodine uu 
well, or solution o{ aootato uf alumina applied uo a compress till ll« 
wound beooiDOs clean ; but tlic solution should not bo too eaoi 
traied, and its »pplicatioa should be stopped when tbe proc^i 
to eprcoil. If tbis also prove ineiTectuul, it b«s be«Q recomincidtd 
to burn the wound down to Ih« heallliy ti&su<}, so tbat lb« tloajtfc 
shall reiDain attacliod six or oigbt days, as in a bcaltby wuoad. 1 
find it just as cff'cclual to cautrrizn the wound with fuming time 
acid or carbolic acid, but tb«se ca uterina tious also should extend (« 
the healthy borders of the wound, and be repented till the floogh 
remains adliereat. Tli« ^iicnil treatment »hould bo strengtbefilogi 
or even Htimulani. The forcr occnrrinK in hospital ^aDgrcoc isdte 
to reabsorplion of putrid matt«r, and does not differ from other 
forma of putrid fever. 

Tbc pulpous pluiffeduniu fn>'>K'^'"^ above di»cribcd is C4i)eclAltI 
apt to occur in wounds of the muuth or urinary bladder, even mi^*^' 
out any external soume of infeetion. I mention this here becaLi^ 
these diaeaaes are doubtless allied to phagedenic diphtheria, ^ 
though, from their limitation lo ccrtsiu parta uf the bffdy, tbcy m(7'^ 
properly belong to spceial surgery and the clinic. After extirpatiC' 
of large portions of the tongue and reseetion of tbe lower jaw. 
have sometimcit »ecu a rapid pulpy breaking down of the wound fv'' 
lowiiij; hard and extensive inßltratiou of the cellular tissue ; bcr«' 
tbere is a combination of diphUierilio phlc^rniuu willi phagMlcni«-' 
ulceration. Mo»t of theso cases ended fatally from ficplictemia ; 
oLbe» recovered afier the whole cellular tissue had become liccroeod 
and been throivn off by free suppuration. Aithnugb mucus and 
saliva coming in contact with these wotimla may have no pbktgo^ 
ROUS or septic cjualities of their own, putrid ferments may be miacd 
with thorn, euch as are ocoasioually found in the conting on tbe f^ois 
and between ihn teeth of patients who do not clean their mouths ha- 
bitually) or neglect this on account of painful ulcer? iu the mouili. 
So this ferment will be carried to wounds in the mouth by rbe am- 
CU8 and saliva, thus justifying the name mucous »oliKUty dtfththeria, 
Thifl diacuäo mily threaten» the patient during tbo Itrst five days 
after operation; only recent wounds in the tnoutb are infected by 
tbe ferment in queatiori \ if good granuUtions bave ouoe develop««!, 



BOSriTAL GANGRENE. S4S 

tliEs dipUtbeiia does not occur, unless tliore be infection frum iritli- 
oat, or th« vround be mcchftnLc&ll; injured and the granulations 
partly destroyeil. lu tlii« dis«a)iu tlio cüiLstiluLiuiml sytitplumB may 
bo »cry sercrc, and tbo patients are parlicularly subject lo sudden 
coQapcte, wbicfa is tbc more daogoroua as, from the ioipainucot of 
sutritio.i which has often gone before^ the patients are usually much 
iebilitnti-d. 

».After oporatioD« fur stouc, urcllirotoniy, Tosico-voginal fisttUa, 
ectopia vesicif, pulpotu; breaking down of the pdgca of tho mound, 
»ith fibrinous coating of the walls of tho bladder or of thy vsgina, 
a not rar«, especially when tbo urine i:^ ulkalinc. As this dist^ase ia 
iSaociatcd v,-ith deoompoaition of the urtn<>, tt is called urinary diph- 
Atria. This form of diphtheria i« die mildest of those above rwd- 
ionod, from liavin^ little tvndcDcy to spread, and running its course 
■rithout confititulioual symptoms, if tbc wound i» kopt clean. Itarcly 
ifie mucous membranes break doivn, but more freqiioiitly tho prooeas 
-iCComts a purulent retropcritoniti», which becomes a peritonitu 
^^id cause» deatli. Diphtheritic iaÜammution of the vaginii also 
^ftjr^prrad aa su|>orfieial suppuration to tlic tnn<7 surfnoe of tho 
\tjem, and thence through the oriducui to th« pcrlioiieum ; Ulis 
^oH'iu^^^b peritonitis also is usually JätaL Under such circum- 
«kJincc-a I hac« never soon fibrinous inflammations. In the latter 
Q^ss, which unfurtunattily aru not rare after cotifinement, but do not 
ofioa occur after operations for vpsieo-vaginul tistutii, screrc oonsÜ- 
(utio»sl symptoms are «arly manifested. 

In the pulp from mucous-salivary and from urinary diphtheria 
ntcrococci and atreptococci am constjintly found ; they aru just ua 
Tcj^ularly found in th« coating of the gums and tongue, aud tn uriuo 
which has booome alkalio«, but w»om to develop with particular ra- 
pidity tn this pulp, llic cuulugious principle of this pulp has not 
Tct been separated from tho micrococcus; so we may suppose the 
Utt«r has in or on it the oontagions material. Inhere is no proof 
that miorooocoi from any MUroe oan excite tin« prUL-ess ; but many 
obawmlions Icud to show that tboao regotMions take up conlAgious 
fcbütances ver^ readily, nnd to bceomo vehicles of contagions and 
^prments. If we inoculate thu conica of a rabbit witli a 6uid eon- 
Uiuiug Riicrocorei, the interesting experiments of W(isitiV<>I?^ fCberlA, 
i-t^tTf Stromeyer, Doltchvnkotr, Ort/i, JfrigcA, nnd others show tbut 
US ooeruH grows to s ourtain point, and in some camih (when unao- 
Wmpanied by ajiy peculiarly injurious substances] causes irritation, 
Briefly tueehanically, by separating the corneal lamella;, so Uiat tbc 
''noctis colony gradually becomes enveloped in pus, and tlien is 
^coMrn off wiLh tbe pus ; but in other cases (if tho inoculated mat- 




344 



TR-itTMATIO AXD WFLAMMATORY DISEASES, ETC. 



ter bas t-ery dclulcrioua properties) the whole come« luay 
guigronous in twenty-four hours, and the ffrawth of tb« 
tiarOly be as grent .is in the iirat iiistnnc««. I^JUtly, coap» orriir wtiiM 
the coccus growth induces no [Yuction in thr cornea, but disnppoa 
without lexrinf^ a traoe; this i$ orta tbo rule ia ioooulntiug lU 
oortKa of the <^. 

riD.Mi. 




a, Ptin«u> tram Ikr camn of ft raliUI ; «xcaa pnlUVtMlnn WIwwb tt* limrto «f A* Mn^ I 
diunlbrliiaculiiUiii: «HgrÜl/nHcailM. t. Oiw iiolat uT A iMCBlBpi ttt Altor/^tofc 

From litis it follows thnt Iho intcns'tir RnJ nxtiir» of inflii 
tiona induced hy euch conta^on» do not depend on tbv coccus { 
liferatlou ilsclf, hut on tbo injurious tiuaJities of the matter coovit^c 
with the COOCIIÜ. 

1 thought you »liould he told these ihin^ so tbki ^-o« troul^*- ^ 
have some hnowlrdg^ about processes whicli are now »o uracil ii^^B»- 
(■tiRSod. I ropommend for your Epecial study Iho exocllent tnnncr "M- 
Ifrapb on ho«piln1 gitngrene by C. ITtine. 

3, Enfstprlat tr<ium<Uicuirt. Ervsipela», as prt-vJouiJy nreiHiooir- ^—«1 
(page S81), 18 classed among the iicutr> OÄanlhfmata, und i« eliarK^^«?- 
teri/jM) by a diffuai* BWelling, ro^ rvdn«w of tbe skin, and pain, i^^a* 
wrll an by (lie accompanying fever, which ta usually sorerc. Eryj p^a »- 
«las ha» a peculiar nlation to tbo other exanthcmatn ; on the <in^*>« 

hand, bocausG it often ncconipaniea wound«, although it may appa. r- 

cnlly contc npontsncously ; on the other hand. becauM« it does «:-—*>* 
ICcawrally spread by »iich an intenm coDl«gion aa measlr«, Kulatio^ 
etc.; lastly, also because, when on« hrw had thix diS4>SBf>, be u oc 
only not Kife from anoth^riittnck uf it.hut insoaiocBsrKie n'fnj» 
Itarly prvdisposi-d to it. A» 1 dare hardly nssuiDe that you hare < 
ready xtudiod 5kin-<l)i;ca«cs carofulty, wc will h«« briefly r«^ew 
syniptoins of this disenae. 

Its coDimonconicDt may vary by the fever preceding tb« e;xaDrhe 





ERmPBLAS TRAtrUATIOUK. 



84S 



fir1>7tl)dr einiultanooiis appeamnoo. Suppose jou hare a patient 
nith a suppurating wouDt) of the bead, attd attPT he bus beon prei-i- 
ousl^ well, and the wouod n-as hcalioff uiccly, you find him with higb 
'H'er, wliii'ii may have been preceded by u cliül ; you cxuiiiiii« llio pa- 
[luTul, sikI can (iad uotliiiig biit some gustrio doraugnment, as cviiicvKl 
fv Meoated toiigi»*, Wd tiwti: in lUc mouth, nuusex, and lota of appo- 
*t<^ Tbis state 15 prvMHit at tbu ousct o£ so maoy acute difrcascA 
">4tTou cannot at ontw mukv a diagnosis. Besides the possibility of 
"'* tj<ri.h>nt!d romplicaiion with any acute int«raal disease, you would 
"*» tjk urpblfgiuoii, ly tiiphaiigitiH, aoii c-ry»ip<^lafl. Perhaps tweiityfoiu 
V^Mrt later you find the wouimI dry, düchnrging a little serous Kocre- 
^Ki; for some Oislaiu.'w aruuud there are swelling, redness, and pain, 
°^ tiegranulationsaro large, swollen, anduroapouB; tberedncanofthe 
^P^»u i> of a rosy hue and evefywhere aharpty bounded ; the fever is 
^'^ifJ tolorably intense; now tho dingnosisof erysipelas cannot be mis- 
^keo, and wc are well content tliat we hare to drat with a diaeaae 
^liich, although not frc« from danger, is one of thu tvaa dungcrous nf 
t&e traumatic diseases. In a 8e<.-iun<l series of cases the i'rj':)ipeliiH ap- 
pears nith the fever. We may for a brief period Joubt whether the 
cue be one of lymphangitis, inflammation of the subcutaDCOus oeUular 
liisae, or of erysipelas, but the rouiso of the disease will soon show 
tids; the eiteiit that tho erysipelatous inflammation of the skin has 
the 6rst day rarely remains the luimo, but it usually spreads farther 
and farther, in such a n-ay that the rounded, tooguc-shapod, projcet- 
ing borüerü of tlio tnnamed ükin are nlfraya sharply bounded, niid vre 
caa aocaratoly follow it» removal from one side tu tho other; in many 
oaaea Uia redness advances like fluid in hihuloua paper. Thus the 
process may extend from the head to (he n4>eh, Ihcnee lo the nhoul- 
cler»,or (he anterior jMrt of the trunk, or even pass down the ami, and 
finally may oven re^ch the lower extremities. I^gtr bus obacrved 
that lb« mode of extension of wandering er^Mpelntt is almost always 
the same, and iis probably due to (he iluw of certain fluiils (Uinph), 
which again dopemls on the arrangement of the filaments of ihe cutis. 
As long aatlieerysipelassprcadsinthia way, the fever usually remains 
at the tamo height, and thus old or debilitated persons are readily 
^BxhaoslMl. Most ejisca last from two iu ten days ; it is rare for one to 
^Hantinue over a fortnight ; the most protracted case I have seen wna 
^Boe lasting thirty-two dnys and recovoniig. In this«r^M/)t'//u<irri/'u/an4 
^^r »trjiai* j-ou will notice that the same grade of inflammation of tho 
akin only continues a certain length of lime in one place, so that wheu 
^Bttie erysi^telns ndranoc», the whole surfuee in not inflainod at onoe, 
^4at only a part at a time is »t the acme of lhi> local inllainmation. 

After the inflammation has remained at the same point about 




34a 



TRAUILITIC AND L<IKLi.MVjlTOKy DISEASES, ETC. 



three dajTK, tbe redot-ss g^ws Ic&c, Uie skin duKiuamatcs, partly ' 
brmn-lilcc powJc-r, or in «calos *nd tags of epidermis. I» sotnc 
eren al Uip comiiwnoeiiK'iit of the erysipelas, the vpidtfrmia rises 
vosiclrs, which arc filled with acruta {trytiptlas bttttosum). Bat tl 
crvsipclaa is not a peculiarformof tbe diaease; it »nlf indicates ni| 
exudation. ^V'e nnt unfri>c|uenlly see reaicles appenron tlip fan 
t-ry»ip<.-l»s while on the rest of the body th« dü«a«c hnii the no 
fonn. If crysipvlaa attacks the softlp, tbo huir oft«» falls, but grc-^^ 
agaiii quicltly. A(.-cordinf; to my «>zporieii(N.>, the disease is most 
qucnt on the lower limbs, then on the face, upper Mtrcroitics, br 
and back, head, neck, and belly, Tliis arjile of frcqnciicy pratial 
depends on tbe proportionate numbers of injuries in the dilfi>nrrvi 
part« of the body. 

Erysipelais üko other exanthemata, may be accompanied by vsr— S- 
ous intornal diseases, as pleurisy, and erysipelas capil is by mcninj^ite 
but, OQ the whole, these compUestions arc mre, and when theyi 
aiü usually a result of the disease adi-arvcing to the deeper parts. 

The course of erysii>cln9 is usually farorublc, (If otte hundrrduL 
thirty-M'Von eiiaes of the iincomp^eated disease, which 1 ohserv«) L 
Zurieh, ten died; ohildrco, t^d persons, and paticnis ()ebilitat«IU_ 
)»revious disease are most endangered, and, aceordJriK to my eipdr S- 
ener, they u*iuilly die of exhanstton from the continued ferer ; o 
autopsy, u-e find no remarkable change of any organ that can ben 
garded aa the cause of death. Cloudy swelling and partial gianili 
ÜCf^taeratioaof tbo liver, kidneya, and epith«Iium, and softncMoftb^« 
spleen, are found in caM>sor fntnl erysijiehiü, ns of lor all intense Uoom^cI- J 
diseases. The nature of crysipvlas is mtt fully undervlood, as its i 
and tbo mode of its progress arc not quite clear. Dilatatioe of I 
eapillarieg of the eutis, serous esudslioa in the tissue itself, sad 
active drtvelopmeiil of the cells of the rcte )I«lpighii are all we ( 
Hod iinatomicalii/. Tlie dti^ense nirely extends to tlw subcul 
oclluUr tissue ; it ix tnte, this swells enormously in some place«^ 
in the eyelids and scrotum, being greatly saturated with Bt^rusi ; h^ 
in most cases thin trdrma recedes without any seiiuclir. In rare i 
this oedema attains such a grade thai, as a result of the great diste 
of tissue, the circulation of blood is arrested, and tbe parts (as thor,?- 
lid») mny become wholly or partly gangrenous. Biiould all tlie ak. 
of an upper or lower cychd bo lost in this way, it would caum; (itT?- 
deformity ; Ijut usually only sinall portiwis niortjfy,sn«lT in the upf 
lid particularly, the skin is so plenty in moil pcnoii» that the dvh 
is subsequently but little noticed. In other cases, after the siitf- 
denc« of the cr}-sipelatDu<t inflammation, there remains a swelling 
the subcutaneous tissue, in which we may distinctly feel lluctuatHi 




BHT^IPELAS THAnMATICÜU. 



3i7 



,ad by incüdon may c\'ncimtc piu. Microscopic examination of skin 
.rflectwl witli cr]r»poUs shows only more or less inGllrution of the 
^xitJ* '">'J iubcutaoiious tissue. 

The causes of erysipelas evidently vary ; that occnrriiig without » 

^^of n<l, »poiitaneouser^-sipeUsi^npitifi, is said to come mont frequently 

f^cT catching ool<). S>nic old pernnits am siid to hsv-o this dise^M 

^rvyear, in spring or autumn; psychical influeaoen are ahio blamod 

. ^ ■(, especially tcrrnr, particularly in womni duHn;; thoir inettses. 

r oxs*!'^*^'^ voQoh for the lailor, but think it may belonff to «nodical 

jition<i. Disturbances of digptttion arc also regarded as causes. 

. ^_tg* ^"^ skuptiral of all the views which arc not bused on accurate 

l^^c-rvation, hut rest on tradition; indeed, I consider it doubtful 

Ij^-tlier erysipt'lfls cvur ocwurs without hiiving stnrmd from a wound 

©<."! me point of inflammation already csiatinjf, 

^rom what I hare seen of erysipelas traumaticum, uy idea coo* 

P,^itig it is »ft fnllnns : I consider the loonl afTeciitinaa an inllaTnma- 

doo "^ ^^^ cutis, in whitTli the iitflniiuimtiiry imtslion gradually 

§pre*»«l* through the lymphatic net-works ; the way in nhich the io- 

^^^j^txutory redness »preads nnrl ig sharply hounded shows positively 

^Kjit 'the pnxesA is limited to the vuHCulur districts ; by close ohserra- 

uort ■*»" "">y i*«^' that very often, dose to tho horvler of the redness, 

[TfO forms a r^d, round spot, at first circ«m«eribed, whioli soon 

gitc^s with the preirlously-retldened portions of skin; these newly- 

Eiip red spnta evidently represent VASciilar districts ; we see 

bhJiig similar when we injooi the »kin throu^^h an nrterv ; thcQ, 

too, tbo color from tho injection finit nppc>nrs in «pots, and only unites 

i«)iFn heavy pressure is made on the sy ring's; now, as the Tenons luid 

jltnipliatii? districts in tho skin arc to some extent analo^ua In the 

dUrial, the irritating^ potion causinp^ the dilatation of the blond- 

, TOKeU niglit circulate in one of these tracts. The arterial and 

maus 1nu?ts in the cutis have few connecting- hranchcs pamllel to the 

narfa<5c, whit'? the lyinphatie vesRels have very many, and but fcW 

tmnclics going down into l lifi soljc ntaneons tissue ; thus the exciting 

IKÖsoD may readily spread superficially in the cutis, like liquid in btbn- 

k"u paper, but it aJ&o enters the subeutaneoiis lymphatics, and often 

autORianammAtioi) there, as well as in the neighboring lymph-itie 

d«niti, iiiriated reiliicss of the sliin, and Hwi^lling of the adjacent 

'ytnjibatic ^«ods. When I here speak of a septic or other similar 

' }*o>»oii as a cause of erysipelag, I refer only to traumatic erysipelas, 

J'*>r I ihink I hove sntiati<?d myself by obser\*alion that t his is always 

P**" toxic origin. Conoeming the nature of this poison, I may say; 

'• It is nhiefly blood mixed with deoompo&iog secretion from the 

**>tn(l that indnccs cr^-sipela», which then appears the second or 



Ud 



TEACIUTIC ASV LNFLA1UIAT0&7 DISEASBS. KTÜ. 



third day »ftcr Ihe injurv or opcr&tioD. ti. Thrre i« proh«b1y ■ ijn', 
diul-liktf aulMtaiive, nliicli, ooming od th« wounJ^ wlicilivr liwi m 
giBntUnliof;, cause» erysipelas ; tbis substaDcu clings esiKcUDj tn 
Bpoogcs srvd drcuings. 1 have often obfterred tlist patieats opcntrd 
■lu after cat^h otltor, under tbe same rircumstauces, in tlic euu 
opentting-roont, all bad i^ry-MpeUi) on tlif fresb wounds nfevboin 
after tho opvratiou, witbout tvtculioa of »i-cretion Irutn tbe ynmä, 
ahbou^h llicy Ujr tti purfnclly s^^parutc wnnls of tbo bospitol. Eiy- 
aipeUs llms bccumcadomcsticaicd in I be bospiul^ the infecting «ulk 
Bloooe imtjr be tmie|>ortt>d on tbt^ clollics of tbe Mirgeous luikinj Üie 
dressini^ ; it may adhere to inatrunient», bed», or ercn to the wilk 
Tlw inoro iicctiniU*ljr I eiamiitetl Uie oases of erysi[K-1at( in tbe Zoricb 
buepital, and in mj cKnic in Vivana, ihc more c'vidvot was ila occur 
rence in group» — an ocfurrvncc entirely independent of «LI otbtt 
morbid influences outside of tbe bospitu). From Ktmiitiics duriif 
two years, supfMiricd by contributions from tbe phvstciniu at Uw 
Canton ZUricb, I hare found that during tliat time vry»ipctas bad d«( 
oeourrvd opideinically in thu country- or city, but that, like otWr 
scute diseases, it was particularly frequent in autumn and iqiniig; 
benoe erysipelaa epiüeniicH in lit»pital must dcp<<nd on circumstuM 
that are to be sought in liie hospital itself, and which I have alit«jjr 
indicated. Hero arises tbe question nhetborlhe jxiisou wbicb exölta 
erysipelas is always the same, -whether it is speci6cL Tbts cannot be 
nocurately answered : in its favor is tlte fact that the form of th«Ct- 
taiMOus ioflammation induced is always thi^ nam«, ailiiougb varying 
in totoDsity and extent ; againtt it vre may mj that rrysipelas U 
probably caused by «arious kinds of putrefaction, by miasma, per 
baps also by aome soitnal poisoiiB. Possibly in all of these pcdsoo- 
ous substances there might tic one certain material wbicb tnducf^ 
erysipfls», particularly n variety of mateml, uhicb had a speoiSc affin- 
ity for the lymphatic vessels of the skin ; it must be acknowledged 
that, under certain circumstances, existing at Kmie parlieulsr Umk, 
such a material may dcFclop tnorc readily and extensively ibsnst 
other times. It has often been asserted, and of lute more particu- 
larly by Orth, that erysipelas extends by inirroonceus wgotatjaa 
fmm ihe noiiiid to the »bin. AUbough tlif spreai! and n'|iroductioo 
of thi.- ery»ipi.'li(a contagion much rcaerobl« tbu»« of a fcnnent, there 
is as yet no proof tliat in erysipelas tbe mtcroooccus is the bearer fli 
such a ferment, still lets that it is only micrüCf>ocii5. 1 do not Ofh 
bold tbo oorreetness of this view, I have sometimes found oocca* 
and Streptococcus in tbe serum of ery6i|ieUs vesicle«, but ifaeysfO 
also found in bli^te-rs from burns nr sweating, in stnall-pox pustlJe*, 
etc. ; and this is do proof that these diseases ar« due lu niicrocaft- 



J 



KRVSIFBLAS TBAITUATICtru. 



349 



no 



^^g. tt is (loit1}tru1 vrhetlier the suppuralions inducoil in rabbita by 

-^ ^3t3«l«t4on witb lb« Bcruni fi-om «rysipclas blülurs i» idcnttcftl witb 

- ^ orj'sipclas of msn, Tho most recent work on crvsipcUs, b^ 

^TTf^JS^omsly, shows lite near relation of micrococcus to erysipeUs ; 

• ^^n ooiirinn hia obsorrations from others made at my clinic by 

j^yi fiifK ; but intercBting as these are, thi>y cannot settle the vexed 

^^^tiou as to tho etiology of erysipelas. 'Die dumuie always begin« 

T.£j.Ja a «pidly-iucreaaing fcTcr, which contioues as long as tbe 

^,rt-tioQ lasts; it may be «ithcr remittent or contimic<1, »ometinaM 

^jj^jinateB with critical symptoms, Konioliines grnduully. I bare 

e3Ctenstve expericnro of the so-called idiopathic erysiprlos capiliA 

£»cici ; from what- I have seen, it seems to me very probable 

.|^^^ tbia alio starts from slight wnunds (exooriations on the hend or 

t^t^i^'y or inflamiuiitioiLf (njual catarrh, aii^iia), and is also chiefly of 

tosio origin. 

The treatment of erysipelas is ehiefly oxpKtant. Wo may try 

pP4^pIivIftxi.H by carefully cleansing the wound, and thus keeping oft 

csrc-Ty thins that can favor the owrurrenoe of orj-sipolas; and when 

several cases occur in bospila!, n-i> should earefully guard against too 

mm»y of them bebig in one ward, and oooasionaliy some of tho wards 

■Ssot^d be enlirely rxcAtcd and rcntilatcd for a time, to prevent the 

de velopoieot of a more intense erysipelas contagion (little as we oei^ 

tAtnly knoiv of it). 

Ab to the local treatment, a series of remedira has been tried to 
prevent the advance of ihr crysi])elatouB inflammation and arrest the 
Ai bCHO at its commencement. For this purpose wc circumscribe the 
bordirrs u iih a stick of moist nitrate of silver or with strung tincture 
of ioiUoo. Aoconiing to my expi-riencc, this does little go<id, so that 
of hlc I bare entirely left oft this treatment. Older ptij-sioisQS 
thoiKfhL that cold might force the eutaneous inflammntion back, and 
(b ui jpreaily favor inflammation of the ititcrual orjpins. Allbuugh 
tbis caiiuut be regtinJed as provctl, a series of facts renders llio uee of 
DOld apparently unadvisnhle. We have already mentioned that the 
ACQutonally great oMlema may indace gangrene, which of course would 
l*e greatly bvored by intctkae cold ; and the applicatton of bladders 
of* ice to a hirge surface, u to the back or the whole fftco, is ecdKely 
pnuticalite ; lastly, tho Ic« does no goed, as in spite of it the dis- 
I'AAcntRs its typical course, for hero almost more thnn in any other 
mmamuilion the local process and general infection ko hand in 
^nd. In tbe affected skin tbe patient ba-i a disagreeable tt-iision, 
k aligtit btimtng, as well as great sensitiveness to draughts or other 
"Huyes ol tcmpcnture. Hence it is advisable to corer the diseased 
*Vin uid protect it froai the air, This may be done in rarioiiä ways : 



950 



TRAUUATIC ASÜ lüELXiinXTORV DISBASES, BTC 



tlio simplottt, vhtch I usually emploj, is to smear tlw sur&oe villi i<i 
and apj>ty waililiii^; tUo paUenls aro generali/ satiafiad vilb thk 
Others t>|>.nnUe Üie iuHaincd sUn witb Qour or powder, or tCftUO 
nnulv-ruhbeil cnmpkor ia the waddlag that is to bo applied, thinks^ 
tliua to act spLTtttlly on the local process. If vesicles Conn, tliej AcaU 
be opcacd with fino needle-punctures, and the looaened epidcrmi* V 
I«rt lu ilry. If gangrene doTclop anj-where, moiit vrarmth m die 
brm of fetntmlations or poultices should be applied lUl tbe cac^rl« 
<lel«cbcd and ItealtLj suppuration begun, which is ihoa iavond bf 
dfcssinga of chorpio dipped in chlorinc-vriitcr. If, after etjsipeluv 
absccsLsea fonn In llie subcutaiteous lluue, tbi>j should be opened ew)/ 
■tkd tmlcU like unj suppuxatia); Hvund, 

Amoi^ t-lie intcmnl Tcmcdics, wo have oa« wliich may pctliapi 
arrest Ibt- di'vclopmenl of some cus(>s of the disease. If inslmig, 
otherwise bcalthy persons, in whom the gastric syinptoma are nry 
proraiuent, we give an emetic, the advance of tlte erysipehis is often 
chucked. Tlits is not absolutely reliable, but you may try it maiät 
able case». Subeequcntly jou employ only tlie onünaiycoolingnsD» 
die«, If symptoms of debility show themselves and the diseaseibif 
on, you should begin with tunics nnd stimulants ; you may doily pn 
a few gruins of camphor or quinine, or some wiuc 

The ioflstntnatioDS of iDtcnial organs occaaoDoUy compli(«t)Bg 
erysipelas aro to be treated Uffe artt'g, and in tneningitis you must dH 
be afraid to keep a bladder of ice constantly oo tbc head, ercn if the 
scalp is atlccted by the erysipelatous InflamiDatlon. 

4. Ji^ammation of the Ijpuphatic vesaeU [lymp/tanffiiis), ncliul 
inflammation of the lyniphatio Teasebt oocasloiially occurs in tlieei- 
Lrcmities under various cirouinttances, which will be mcatkiucd im- 
mediately. The symptoms, Id tht; arm for instance, are as fuller»'. 
There is a wound of llic hand ; the whulc arm becomes painful, cvgf 
ciaily ou motion ; tlic uxlllaty glands swcU and are scBSttirc, erea on 
the sligfatosi touch. If we iuspoottho anncarefully^we find red slhai, 
espccLilly on the flexor side, runmng longitudinslly from the womnl 
toxTaid tho glands ; these reddened portions of «kin are very Beiu> 
Live. At the same time thci'o is fever, often a eoatcd tongue, nausea, 
loss of appetite, and general depression. The lermination may be in 
one of two directions: undi-r proper care and treatment, Iberc is gtv- 
etally resolution of the inflntnmnti^vn ; the striie gradtmlly di^ppcsr, 
as do aUo the swelling and ]>ain uf tliu axillary gliiitds ; the frrtr 
cease« at ttie same time In other cases there is suppuration [ the 
sWn of the «rm reddens gradually and cxtensivcly In a few days uwl 
heeomfs cedeinatous. The swelling of the axillury gbinds increases, 
the fcTcr become« greater, and there may even be cliilla. In a few 



ERrSirELAS TEAUM ATICDU. 



8^1 



^jrs fluctuation Acciir!} most frequently iu Ü>c axillu, ticcaüonsUf cUo- 
.^■r^cre in tbft arm, tlie absans opens Bpootancounl^ or is incised, and 
— yijii, such as ii* uitunlly f^nUincd in n cimiinsrribct) abscess. Is eracu- 
^te*i- Tlitfii the fever ftulMidps, aa do also the pnin and swelling; 
r^^^cJ tJic patient speedily rccorcrs from bis diseaae, which !s oAeo very 
■>2a'(^^"' und troublosonM. Tbo terniinatioa is not alwn^itofitrorablc; 
I^^C:^ in Irmptiai^tis from poisoned wotimlx, pj-iprniiL ia occasionally 
i^^^«:loped, in tlie subacute form most frequently; of this mure bcro 
|-^_^^r. In one oaso with l^rmphnngitis of the leg, -where the pntioat 
l^a^^ chronic iofliunniation of Uio kldiic^-s at ihouimp time,Isaw thein- 
^^j i «:sal g^nis with the »uperjuccnt akin bccooio gangrcnoos, after tiicy 
l,0,«3. been coonnously swollen. This termioittioa is rery laie, alUiougb 
th«? r*" ^ tJieso iuOammations of the lymphnlio vesaela, especsatly 
(^ft«9K- poiaoniog with csdareric matter, iti occa.iion.'Uly putrid in chnr* 
^crt-«^'* Acute inflammutioa uf the lynipbutio ylaf^d^^, tcniilniklJng m 
fx;A>olutio« or euppuntioD, ooeun as an idiopulhie discaiio ; in mich 
tjewt^^fB we cannot see tlie connection, by red Lines akmg the lymphatics, 
zt. ■«''veen a vouod, or anotlicr pdnt of inflammation, and the lymphat- 
io £f lands ; Uiix nay be bo^auae only the superficial vessels appear na 
r«5d OOfds in tlie skin, while the deeper ones, even when inllantud, arc 
nofc Etcopiiiable to the aight or touch. Henux in the patient we only 
IcnO'^r sitpetficial lymphangitis. One of the peculiarities of this dia- 
cann b, that when it occun iu the cictreiiiitiex it rarely extends hi*- 
jroiad the uxillsry or inguinal ghmtis. Once in acoso of lympliangitis 
uf 41ae am and adenitis of the axilla I saw picumy occur on the 
nuna side, which pos»ibly may have reoulted fruui extension of tho iu- 
Oaxnmation through tlie lymphatic vcsacls, 

"Wo know very Uttlc ef the puthologicsl anatomy of lymphangitis 

of "the BuboutanoooB Ümuio, Hoaroi'Iy more than we can see with the 

tutlcod eye on the patient, for this disease is scarcely ever &tal when 

it only atladis tJie lymphatic vessels, and in animals it can only be 

wr y impcffectly induoed by experiment. The oellular tissue ioinity 

dlat«1y ntounrl the l^Tnphatic vessels is decidedly implicaleil, tlio 

capiUUrica dilated and distended M'ith blood, "Wc cannot decide 

wluatlicr the lymphatio vossct ifl obstniotod in the Inter stngc« by 

poagulating lymph, or whetlier ooagula form in the lymph at the start 

mmI irritate the walls of the vcascU. If wo may transfer the obsei^ 

Tatioos on uterine lympbangitis, which so often occurs in puerperal 

Wer, to the skin, in eertain stages tJiere is pure pas in the dilated 

lympliatio reaaets; tlio vicinity of these Tcseels is infiltrated witli 

*en»a and plastic matter; the plastic iofiltratioa of the oellular tissad 

iaotease« to suppimtivc iiifdiratloii, or even to fonuatioa of abscMs, 

"n w\icb the thin-walled lymphatic vessels tliemselvcs disappear ; the 



3^2 



TIUCUATIC A\Ü INFLimiATORy DISEASES, ETCL 



finer the net-work of Ijmpliatic tmsgIs, Uie more difGeuIt it is U du- 
tin^i.Oi l^-mjilmn^tis Ironi iriflammBÜon nf thn onlliiUr Ussii^. Vom 
tho illuatrationa of QrttveUhicr (Atlas, livre 13, PI. 2 aod 8), wcmj 
derire an idea of pu<>rperiil Irmphan^Cis, and carr^ thU to tbe nno 
«Bt-'ctioiui ID other parts. Tlic red strife lliat 11*6 tea ia the sldii cu 
only >>t^ cauMdbjrdilatotioQ of the blood-vcSMls around thcl^phttiok 
not hy blood forcing its way into tlie latter; liance ia patientswe 
n>ally see tbo symptoms of perilympluingitis indinccd by eoDtad witk 
ill« )iDi«>ii »trcaniiiig in iltc lymphutic tchi'Ih. We know tfaecbanglt 
ill tho lymphiitic glands rnthor better. In them the veHeb ve 
much ilUlendcd, and tliu wtiolc ti&su« greatly iufillnted witli serm; 
quaotitics of cells fill tbo alvooU tcuscly, wbich prulmbly nt first in- 
pedes and finally arrests alto^lbor tlio movement of Uio lymph in the 
gland; this blooking up of tbegland will to socne extent prevent llw 
extension of tlie morbid prooeas, 

Lymphiuigitis may oceur in nny wtjtind or point tS iRflanm- 
tion ; but in my opinion il is alurnys tfa« result of inritation fron a 
poison im^<iiDg tlirou^h the lymphstic ixsscls. The OBtnrc of tbii 
poison iiuy vary; it m*y bo dccompoeed secretion from s \tomA, 
pdtrkl matten of all sorts (especially that from the cadaver), er 
matters whidi from exceMii'e irritation form an inflamed point. W« 
havo alroitdy staled that Ihc frictiun Crom a boot-nnil may czdt« • 
simple excoriation into a difTus« inDammation, in vhioh a (pliloglctin) 
pcHson may and often docs form, and excite« l^-mpbangitis ; tbe sane 
tliin^oo(»is in point» nf inflamniatioo from otbor eauscs ; by inciraad 
irritation a material is form«! in tho inflammatoiy focus itself wbidi 
proves vary irritant to the lymphatic veswls and their surroniMfiogi; 
even a paisoii encapsulated in an inflamed part may by ]ocmM<l 
pressure of tlio blood be driven into the lympttatic rosscls, and 
thence into the blood, although without this ouitse it Diight bsT« 
remaned quiet, aud been graduaJly throirn off or eliminated by ta^ 
pumtioD. Tlie following case mny tfervo as an illustntion : One cf 
my colleagues had a sliglit inflammation on tho finger, from a db- 
sccting wound ; thin inflnmmatJon wtis pnrely local, acarcoly obsenr» 
able; on a short trip in the Alps bo became heated, in tbc CTcntng 
he had a lymphangitis of tlie arm and high forer ; the aetivo move- 
ment awl ooDsequenily inereaBed action of the heart had rlrivf>a the 
poiaoii, previoiialy lying t\u\f-i in tho circumscribed point of inflamina- 
tion, throi^h the Irmpbatio Teasels into the blood. Why, in tb< 
different casc5i, we hare sometimes dilTuHe phl^^onous inflammation^ 
lomciimed erysipelas or lymphangitis, cannot he certainly etated, 
thougli it may be due to purely local eatisea, and to tbo cliaract«! 
of tb« poison. From our prosont knowledge of tli« passage of cells 



THLSBITia 



803 



tat tlie VfMeU we may imagiuo Ihat pus«>]U dt.>%-GlöpeiI in the 
thenoe pass into tlie lymplmlic vcs-sels, waDder through the 
vtsIIh of Lbcsc ves&cls, antl as hc&rcrs of an irritating suhstanco excite 
pcritjmpbaogiti«, while the c«Ub, fion-ing mure rapidlj in the centre 
of tbe vessel, cDler the blood, and thus perhaps incliice fever before 
be local disease has sttaineil anj- conflidexable extent. 

Tbe object of treatment in rcooiit. cncea of lymphangitis is to ot»- 
reaolutioD if ponuiUe, and to prevent suppuratiou. Ilie patient 
lid keep the alFected limb as qnirt as possible ; should titcro be 
»trio dcrang'eaicDt. ao emetic is vciy bcaeficial. TUo disease not 
itJj subsides after the purgaäoa and sweating induced by 
etoctic Among the local rcmedicf^, rubbing the whole limb witb 
mcrcurisJ oiatiacnt is purtici^ily cfHcoeious^ tlioa the arm should 
be covered warmly so as to maittl»in an cleimted, regular tempera» 
tare For this purpose vc mny employ »itddiug or moist wmnntlu 
Sbouhl the iufUmmation increase iii SfHto of Hiis treatment^ and dit 
fuse reduess aud swelling uecur, su|)punitk>n \rtll lake plaoo ut eome 
This diS^isc inftammntiou is do lon^T limited to the l^-mphutao 
I bot the catifo subcutaoeoua tissue participslcs ia it more or 
As soon OS fluctuatioQ is distinctly perceived, an opening 
be made, and the pus evacuated. Should healing be retarded, 
may bo hastened by daily irann baths ; these are particuliu-ly ustr- 
wberu thoro is a great teodeney for tiic disease to n-turn to s 
ODCe attacked. A septic p(^soa encapsulated in the lympfaslie 
if forced into the circulatiOD by flusioa to the gliiods, mny lo- 
netr lymphangitia and phlegmonous periadenitis ; thii expluina 
repeated relapses, and the latency of the disease after infectioQ, 
Ily in djssooting vounds. 



LECTURE XXV. 

; fUtbMli ; ThnaibeiAf; EmHotinn— Cbium of Vmaui Threoibötis ; Tarinu* H»t^ 
BMpboMS «f th« TbrMnlnu.^Eiii'balUtn. — Rod luTarctiua, £!ulii>Ua UutsataUo 
AbMMiM ^l>«atnaat. 



b. JftMifi»; Thromboaia ; RnhtAtam ; Kmht^ie Mda^tUie Ab- 
I. — Besides the aboro foniis i>f intlamniation, there is often 
bCT phlebitis and thromhosi», irhioh, starting from a wound or 
nt of iaflammation, Is at first kx»), but afterward etprcmls in a pe- 
^oliar laaancr to flc:vL-niJ organs. lu persons dying froiu this disease 
«e find pus, or frialile, purulent, or putrid clots, in tlie thickened or 
rt]y«uppurating veins Dcnr Ibe injured purt. Often, also, tber« 




35t 



TRAUUATIC AND IKFLAUliXTORV DISUSBg^ ETO. 



arc ubecCäHcs in Üic lutigs, more rarcljr in tbc Uvcr, spieen, and Iddnejt 
OvpflWAio* proved tliat tlieso metastatto ibeoes&ea were oonoeci«! 
wltb tke pus in Üie veins; but tbo mode of this conoectioo wat va 
cxpluncd till 9iit)isn)iieiitl^'. 

WLkt I eliall iiiU jou to^Iti; oa tliis subject i» tJie result of aamcr 
ous investigations and experimenti^ for nliioti wo are indebted to 
FVrcAoto, aod wbich liavc been ho often repeated and confixtDad hj 
difieront persons that there can bn no doubt of ihcir correctncH; I 
have myself studied th*- subject a go«I deal, and shall at tbe prepcf 
pkrvg »lute wliore 1 bave arrived at different results. It vouldlead ne 
too far Ui fullotr this great work of VircÄOK hisloricallvt and to gtrQ 
jou an epitome of it ; 1 must leav« it to jour own industry to ttaäy 
ilivw worka, and oootent nijaelf with gpvUig jou a short rigmni of tin 
positive results. 

The £rst important queetioo is, Wliat is the relation of tbo oo- 
agulation of the bloml to the iiiRammation of the vessel? The frnnu* 
view, tluil the coagulation i&due to ihe indamnintion of the wall cf 
Uie vcftscl, ia purely hypoUieticciI, and not tuiocptihle c^ prooC On 
(he <-oiitniry, \rc tciww frotn t))c inTcstI|*at{on8 as to tke ffmintitui 
of tiironiljus after ligation of arteries, and of tbc prooca« of heating 
of injured vcius, tliat there is immediate coagulation of blood in the 
BJured vessel, before there can be any inflamninliun of the walls nf 
Se vessel. The bk)od-cIot forming in veins after their injoij", and 
'ooosUtuting tJieir tliroiubus, is usuallr bhoH, it i» true, but wc may 
readily imagine that it should increiLSi! in size from e-ontinned d^ 
posits of fibrine. Voii know, from your studies in physiology, thai 
we cause coagulation of the fibrine by whipping the blood. During 
the motion of tbo blood the ebagulating fibiine dcp^iMts tike eryatak 
oo a rough body, and you ran readily satisfy yonrsolves pxperiment- 
ally tliAt Bticb a 1>ody, as a ootton-tbrrad, introduced into the nin 
of a livinfc aniiiiat, soon becomes covered wilb fibrine. Thus nn^^ 
nes»R8 of vanous kinds in tJio vfiiwcls may giro rifto to more or 
less esleuuve oougiJaliuiiH of the blood. These roughnesses may rrr- 
taiuty form on the inner 'wnll of the van as a result of inflatnaiatioo, 
and coagulation nf tbe bkxid may tlius be induced. Projeetiuns into 
the calibre of the veini may be caused by small abscesses in the 
walls; formerly, it was supposed that there was a fibrinous ooaguls' 
tion on the inner surface of llio inflamed vein, as on an inflamed 
pleura; it can scarcely bo decided whether this mJly occurs; what 
was fomierly considered as such baa been found to be a discolur^d pe- 
ripband hiyer of the blood-clot. At all events, inßammatioB of tho 
walla of tbe vessel very rarely causes the coagulation ; mi' ' 
((Uently the clot forming in a reosel after Inju.'y, lau 



TaBOXBOei£. 



au 






ntely^lcnowncircumBtaooeSj&niistbe startong-poiDt forfuruierooagn- 

latioo, and finally Jor inflamniäticiQ of the vail of the resftel. Besides 

DJuriec, tbere is n boooimI foctoc trom nhicli coaguliitioss m»/ result, 

Fri^ from r«tardBtion of the current of the blomi from friction, ns in 

oontnictioD of the ressel ; this variety may bo called t/iropilms from 

eompntsion. It also is independent of infismniation of the wall of 

tbe rein, but may result from infiatumatioo of the pcrirenous tieeu« ; 

kit ID severe iaflamnmliou a Uftiio, e^MicIally when it is uudcr tl:« 

prcsaare of n fiiacia, may swell »o much, partly from serous, peutly 

from pUstia iufiltmtioD, that tfao Tce«cls will be compressed, uud stasia 

^bul ooaguliitiiHi uf th<* bltxxl ho thus indui^d. T1ie«o thrombi, from 

^BBOinprMatoo in rtrry acute ioäummution, and especially in acute acct 

Bdcntal inBamntttion of ocUutar tissue around irounds, are toare frequent 

.than ptimsrr tnunuitio thrombi; it is the most dangerous variety 

nf thrombu-t, a» it \% moot liable to piirifonn dcliciuescciice." In rapid 

(«lilalaliou uf a, vessel, alao, aooordtitf to phyitjcal law», the vurreat of 
blood is much retarded ; then ooa^ulation takes place ut Üie point of 
dilatation, aa wo sball hereafter see iu aneuiisuis aod raricca ; these are 
railed t/trombi from ^Uatation. Fiirtht-nnorc, the oiirmit i>f blood 
■nay be rclnrded from iiisufRcjcnt eontni^'lioii of tho heart und arte- 
ries; as this occurs diiefly iu penoiu debilitated by age or serere ex- 
hausting diseases, it is called maratmic throm&ud. This, alwi, is evi- 
dcDtly independcot of inflammation of the reins, ami occurs moat fre- 
(juctitly in parts distant from the benrt. 

Vou must remember tliat in all Uieitc cases (he tfaroinhi arc at Gift 
«null, and f^radually grow from depo&it of more fibrioe. It has not 
Ktteeo ptorcd that, in ca»«s where the thrombus attains a considorable 
Kextent« tbcr» is unyabuormni inerease of fibrinc in the blood, although 
11)15 night be suppo«ed, H'Ay traumatic thrombi should extend so 
&r la some cases of injtiries of the veins, we can otdy understand in 
cases wfacro extensive ruptures of the reins are eauscd by eitenuve 
coQtusionJi, and extensive distiirbaocc of the circulation is thus ioduoed. 
ilut, in coses where a widely-branched thrombus results from a punc- 
or inobed wound of a vein (as from venesection), It 1^ often 
alt to explain the cause without resorting to disputed hypotheses. 
il>i (nmi injury itnd compression, and their sequuls^, particulariy 
ittn our attention, while those &om dilatation and marasmus we rarely 
imrt in surfpod Cases. It has been observed that venous tlirombi 
in supimiution are Gir more frequent in hospitals than in 
pmrticR, and this tendency to coagulation of tlie blood has 
xl in t])0 liospltal atmospliero nud the minsnia it contain!), 
miasm (itself a very indefinite and very variable tfain;^) 
uce ooogidation of the blood, can »either be proved 



350 



TRACMATIC AXD IKFLAMIfATOnY DISEASES^ ETC. 



nor dmimL Actxirding to mj idea, Üie connectioD is protslilf oolf 
inflin-ct : toiio-miasnutilo infecUoo of a wotinH, wbctbcr induood ht 
instnimciits, dressings, or otlicrwUe,M previously atntcd, ezdl«« inb 
siippurativc iniliiiiiniatlaits around tlie wound, somoÜinM as ordbut 
ot-IIuUr iiiHanimatian, sometimes aa diffuse lympban^tis, ric. ; ifcndU 
trom con)p[<j«ioa aro cauaod bjr Ihcso iofUmniatioQS, ju9t as htffta 
in »avto ■pkiegmoaoxiB inflammation outside nf the hoepttal ; bcDce lb 
Infiucnoe of miasmatic [MMSoning is iuducing venous tlinnoboils b not 
direct, iHit indirect, at-tin^ tlirou^b the iniiftminsüoD. 

The next qiict^^t iou is, Wlial beoonMS of ibc Uood co«gu]at«d in il» 
I'cMels, and what is its relation to the vail of the vessel ? From ik 
Injuries of arieriea and veins, vre are only acquainted vrith one iDcti> 
morphoaia of the thrombus, namelr, its orgnnimtioo to eoanectin 
tiuue. Id oxiensivc vetwus tlironibi this is ikj^roaL ntritj,aDd kadi 
of oounte to complete oltlitcniUun of tbo vciu. Let us lake a my 
simple case, a venesection thmmhus. After a bleeding, say from llit 
uiedluQ rein, from an acute tuAammatioti of the cellular lisbue tbnc b 
a coagiilation of blood in this vein, and ako in ihc cr-phntic* and basQie 
veiua, down to the ntiai and up to the axilla. From the diatnrbsMO 
of the cireulalion tliusoauaed, there is great ledema of the vbole atn; 
when Ulis sulieiiles, we may distinctly feel the subcutaneous reins u 
biu\l conla. Tho coune may vary : Gret, the affcctioa may pocsibl; 
end in roanluLion — rundcr timely treatment this it usual ; the patial 
should be kqit in bod, as he is uftiially fcwrish; tlie an» sfcoold be 
kept absolutely quiet, luid cori-rrd uilh a compresa thickly ooatcd 
n-ilh mercurial oiulmciit. At the same time wo give a pttrgs tiro, and, 
if the tongue be coalL'd, an cmeliv. Uiidpr this treatment, the swcU» 
iag of the arm usually decreases, and tlie fcrcr subsides. Tbcn tke 
firm venous cordd can bn plainly felt ; in six Of eight days they bcoOCM 
Boftff, and anally ceaJie to be p«rceplibl«. \Vu very raroty have the 
chance to examine such cases auutumkally in the early stages. Heooe, 
w« cannot decide to wint extent, if at all, the vrall* of llie rein parti- 
cipate bi this coHgulntion of the blood ; but, fmm the symptoms sod 
the rxaminaÜnn of I lie piilJent, it would ajjpcar that tlic ßbriue txiagn- 
lated in tlie vC8»cla is gradually reubaorbud nod niinglva with the 
blood without injury,like otlier blood that hiui been diffusely extiara* 
sated in the tissue, "nic second termination of inflammatioa of the 
arm after rcncsection, complicating thrombosis, is tho formation of 
ab»00M. Tlio first aymptoms are tlioeo above described ; bat then, 
eitJier in tlie bend of tbo elbow, tho arm, or the foieann, a more 
drcumecribcd inflammatory tumor foruis ; tJiia increases gradually, 
and finally fluutimlos distinctly. On iDcisJon, pus is evacual«d from a 
kigcr ur smaller earity, the swelling of the arm then gnduallr de> 



THBrtUßOSlS. 



ser 



nraees, the absce» hculs, anil complete cure nny i««iüt. Anatomical 
cskmioation of tlws« cascii shovrs that tturro lias been suppurative 
itiiUmmalioa in the oonaectiTe tissue uound tbe vein. M'c> aleo fiud 
tfaat tlic coats of Uie Ihrombosed reins are gietiÜy tliickencd ; this ia 
to be regarded as a result, cot as n cause of the thrombcais. I will 
ht^re add that (ho diogiiosis of a vi-noua tbronitiiis cnnnot alirajs be 
made, from the vein frcling like a liantl coin!; for occaaionalty inflam- 
niAtioQ in tbe cellular ti«5uo around the tciq may oxtctid, and cause 
ooodeosalioQ and tube-like tbickviiiog of the sLfalh of tlie vessel, 
which may rcadilj* cause it to be mistakcQ for tlimmbus, though it 
docs not occc«BarUj lead to it, I linvi} twice seen this nü»tAkeof 
pcripUebitie cellular itiduration for tlirombiis of tlie saphenous vein, 
and I oaasider it impossible to make a certain diagnosis in all cases. 
The fuct that euch a poriphlcbitis, which is perfectly analojufous to 
porilvmpliAn^tis, and in which lUe walls of the veins certainly pnrtU 
dpate, can exist trilhout thrombosis, proves beyond a doubt thai the 
latter is not neoessarily tlie cause of inHaniniatioa of the veins, as was 
toraierly supposed. Another possible metamorpliosis of tltrombos is 
^^L friable disiutpgratina In iIiin, softening of the clot usually begins at 
^^B the point where llie thrombus bcgnn, that is,at the oldest pnrt. The 
^^1 Gbriiie breaks donni into a pulp, vrbiob is yellowish or brownish, and 
^F soesry in proportion to the number of red bloot}-corpiisclcs oontamed 
H in Ihe ooB^um. This disintegration spreads more and more ; evca 
|W tbc tunica intiioa of the vein does not escape, it liceomos wrinkled 
j^L slid thickened. The thrombus olianfres to pus, which mingles with 
^^B tlK detritus of tite Hbrioe, wlitle the wuUs of tlwjvein» and siintniiKling 
'^ coAnlar tigsue are greatly thickened; oocusiouiilly, allhoii^h rnrcly, 
^imJI abaooescs form in Uie walls of llio vein. Hence, hern the itiOani 
itiMtiaa of the wall of the vein is to be rc^nlcd as the result of sofU 
aoi^ of the thrombus, and the pus which we then Gnd in tbo rein 
does not come from the wound (the old idrni), but fonns in the veto 
from the blood-clol. Often, also, tUo puriform fluid la only fluid 
SbrJoooa detritus, while in many «oscs good thick pus, with fully-de- 
rt^loped corpuscles, may be found in these veins. If the wound be 
putrid, the iibrinouB detritus in the vein may also assume u putrid 
cluLi*ttc(«r, putrid Uuid boiug taken up by capillary action of the throm- 
l>ua from tlie wound and acting as a feirDcnt on the disiutograted 
fibrioe. Tliis capillar)* action of tlie thrombus might also be supposed 
to c%uiie an action of the dooon][K>scd secretion on the blood. Of course 
tbere can be tio extensive flow of pus or other secretion &om the 
vtmod into the vein, as the opening in the vessel is plugged by the 
"UOmbus. Should there be a rapid disintegration of the venous throm- 
btu tnm the peripheral to the central ends, which is rare, there would 



3S8 



TRiinUTIC AXD INrLAHUATOBY DISKASBS, ETC. 



fttoncc be TCnous hicmorrlia^, and the {onnation of n new tUrouilKu, 
■u llittt eveo tliea tbera coiüd bo uo c-otraac« of Ute pus from the 
wound into tbo vein, or of that fi-om the vein into th« blnod ; moreover, 
the pus forming Htid coIWctvd iu the vein Is so tliut olT hy tbc ccntnj 
adoftbe tltrotobuSfthat it i^annot mingle with the blood; atleast tbä 

Jd only bnppen if the central end of tbe tlirombtu should be entirely 
brokca down, but this probably happens very exoeptiooalljr, for hi 
moat coaes tJicro arc constantly ncv drposita of Gbrine, -wbila dtüat» 
gntion goes on from tbc oliiost pnrt« of tbv Ibrombiu. Vou vrUl Itiui 
und«;nituii(l ilint tliu ontrauoe of pus into tho Injured Tds amnoC read- 
ily occur, but tbnt, as vnll be soon ftUtcd, tlie circumntanccs must be 
voty peculi»r to r«odvr tbts posbiblo. I niu&t here brivilj' inlrrmpt 
tlic description, to xtute tbnt VinJtow doe» not dLiiiticUy u-JuKtwlMlg« 
tbß trnosfonnKtion of tbe tlirombus to pus; I luive no doubt on tbi» 
point : if tbc bluod-ci-lls in tltc Utroinbus bare the |>owcr of iuctcasiaff 
nod changing to ti^u«, as socnis most probable, Ütoro is no veuon 
fix not referring to them the fomialion of pua in tho thnnnbos, just *m 
wo do to the white i-vli» vnndering out of tho vessels, for tlto cfWftu- 
lation of the blood is not firm enough to entirely prevent M?U-DKnc- 
ment. Hint the thrombus may change to true pus by dirisinn of tho 
wbiic blood-ci-lls docs not appear to mc di3]>ruved ; vc bare already 
mentioned that this pus, which is ususUy cocnpstilated, docs not enter 
tbe circulalion, or does so very rarely, snd heoee has no direct eon- 

tion uilli p^'iriiiin. To i^Mime my expericnocs of renoua Ihramlii, 
tlio history of tliroiiiUus, tbey are to tlic efivct that tooet venow 
thrombi are the result of Tciy seute inflammation of cellular tiBne, 
(especially uudcr fiutciar, or tvniM] skia, niid in bone), and iKal tke 
coagulum undergoes the eunc mctamorphoac« as ibo inflantnatoty 
new roniuitioii. If the latlor lead to fonnslion of tiuue, the throott 
arc also organized to connective tissue ; if tbci iuQammation goes on 
to suppurntion or putrefaction, the tluombi also EUppwatc or jnjtrcfy 
and break dovm. This Is tho enxier to understand, aa we know, fata« 
Von IUt3cltntf}icniteiCs and Svbtxftff^» investigntkins, that tbc cdla from 
th>] Uesuc may {uv>9 tbruiigli tlie walls of Ute reiD into tbe lliroblbllfc 
T)>e ivaIIs of the vein h»ro the same fiito as the tbrambui and 
rounding tissue: tbcy are iiililtrated Mitli plastic matlrr, and boouMi 
thicker, or they suppurnte. 

Tlirombus, with phlebitis, may also run its com-i« aa a 
loeiU di^csKe, as not uofrequently bappeoa after vmeaeeUon, an) 
{n some otlitT crises. Then there can only be furtbcr danger when 
tho Ihrombuit is friublo, or when there is purulent or putrid d<>«truo- 
tloD of the eoaj^Ium. The central etid of the thrombus (as vs 
stated when speaking of arterial thrombus) usuoUp extends to tW 



% 



i 



_jg_ 




TnitOUBOSlS, EUBOLISIL 



850 



point where the next Ijranch join», nnd has « «miciil cikI, irliicli 
projects a little (Fig. 67,<'), hihI, if iho eoiigulum loses ifs firainoss, 
a porttOD of Uic ooaj^uni msj be torn off bv the cummt of btami, 
ukI pass into Ibo circiiUtion ; this p>t«ftcs into the hirgcr veins, thcno« 
bto the right huart, tlipace to the pulmonary arlcrj-, in tvfaoee 
branches it is fiaoll^' BiTCst<*d at some point of bifurcation, as ita aiu 
•iocs not allow it to paee brther. Thia branch of tlie pulmoDary 
artAT is nonr clo««d by a dot of fibrine, as by n cork, a 8i>cal]Gd 
vnMtu ; tbc iromodiato oonscqucoco is a lock of blood in thu part» 
of tbo lung previously supplied by the pltig^rl 
artenr. This locol lack of blood (ischiemla of ^'°- *l- 

Virchoie) does not usuaily limt long, but blood 
itcn the empty artery from anuU collateral 
irteries; it i« true, blood nin.y tbiis sgiiia enter 
lie reitt, but it coniua froia tbc small collateral 
raavlics, and flows vory slowly, and may at last 
np altogethtv, and congulntiun ext4*nd bunk- 
Li through tlie capillanea even inLo lh« tlirom» 
■rturial branch. Thus, us a result of em* 
!ui in tlto artery, Üie wimie coiTcajx>nding' 
ular territorj- is thrombosed ; there may also 
lie ruptures of Ute vesaeis, haemorrhages ; as tho 
art«Hes of the lungs, «plccn, and kidneyü, con- 
;itly divide intx) smaller branches, and thus 
ixscuW territory constantly enlarges toward 
tho pcripboiT, »nd roecmblc« a cone with tbo 
apex in the organ, so tho part iu widuh tlie M 
above coagulation occun must bo shaped like a nunn : a. »mimi n>d of 
«rndgc oroon«^ Iu pathologioul aoatomy thes« V'™!"* l»»"* l*™" 
ooag^ulationa due to embolism havo been cnll«(l 
gj **i«d or biemorrhagic wedgoabapud iufaretions." 
iHBVncpicatly as Uiumj wcdgc-sbapcd iufarctions 
^^^Mwur, tboy aro not a necessary result of embo- 
lism ; fi]r, when the arterial collateral circulation is strmig enough 
in the ischemic part to driro (ha blood through the capiUaiiaai 
aa is the case in otherwise h^^althy persons and in animals, aa well 
as la emboli causing little mechanical or chomioal irritation of tlie 
tiaavr, there is uo infarction, at all events no oonsUlenüjIo dia- 
toibaoce of circulntion, but we havo simply to consider ilie lo(?al 
prooes8«B around the embolus, as foreign bodies in the branrh 
of the artery. Ilicsc local pnx-esses depend on Die character of 
tbo embolus ; if the latter bo a pure fibrinous dot, there is a slight 
thickening of the wall of the ressel at the point where the embolus la 



^btaii: 
^ihei 



Irani: ; ^ i Imnch «IcFi- 
iiulthroDibna; iboUood 
fSowIng tbfiinch It inaj 
(]rCad>aiiiloiFT7 Inlo tb« 

cInruUiliiD UiB end at 

IÜO tbn>mbu« ^, 





SSO TRAUMAnc AMD IKFLAinUTOET DISKASBS. ETC. 



located (usually where tbe artery divides into sniaOer brancbe»), i;: 
tb« latter may have nev clots depoüt«d around it, and be oi^gui^ 
to Qomieetaro tissue, or be reabsorbed. Should the enibolui oonsUi < i 
a fibiinoua clot iminrcgiiat<Ml witb pus or putrid nuitU-T, itexdtesiii' 
purative or putrefactive iafluntnation, not only in tbe wtül of tho v» 
sel,lnitalso in tbo parts around. ThsnwUTnorphoftisof tbi}r«diiilan> 
tton in part depends on its sixo, partly on ibe gmdo of tbe circnlatia 
«till coatiauing in parts of it, and portly on the embolus cauäof tie 
trouble If the latter be iiinocuoua and the infarction b« ainaU, or if 
it be still nourisbcHl by some vessels not tbiombosed, the ooagntom 
lummig the iu&ur.-tion may again lie diaaolved, or else beoome otg»» 
bed to a ccnncciire-tiaiiiie cieatrix. If tbe embolus be ionocuous, bot 
the thronibiw exientling oompletely through tbe trliole tufarcdoa, the 
tissue Bud oooffuluin alowly disiDtcgmto to a yellow, gmnular, 1I17 
pulp, Vfbicb becomes encapsulated, and may calcify ; this is j/flht 
dry ittj'arvtio». If tlto embolus bo impregnated with putrid matlcrv 
pus, it exritea putrid or suppurative inflamiu&tion all about it; ibt ^ 
fofction also becomes putrid or purulent, and abscesses forau A» m 
were jusl sponking of the hings, we may bnrc mention that these tlh 
Messes, nliirb ore tisuslly peripheral, often excite pleurisy; that die* 
are moat Iri.-L|tiu[itly multiple in botii lungs, and may even iuduM top- 
punitioo of the pulmonary pleura over tlw abeccss, and may th« 
oocanonally cause purumotboras. 

Vou can hardly imagine, gentlemen, what labor it oosta to denwa- 
Btiate tliis oonneotion between venous tbrombi and nbscecs of (be 
lung, flo tlint I eiu) here onnounce it to you as a simple fact. To« 
will rend tbe classical works of Vircfiov, J^tnuin, 0. Wcitr, ui) 
other«, on this subji^ct, with astooishmpnt; it woulfl take too long fur 
tue to enter into tbe subject more fiiUy ; we tdiall here aamitne ihi 
right of only tuking tbn fads from these works. Wo now understanj 
lung infAn;tiöas and «bsoossoa; but bow is it with those that oonr 
under like circumstanoes, aHhoiigh much more mndy, in the Mitif 
spleen, kidneys, and mitscles; are these also alwars dependcnl on 
emboli ? A few years since w« could not bnvc answered this qput' 
tinn \dtb certainty; now we may aGSnn it From oxporimental i» 
vesttgutions, especially those of 0. W^er, it is established that etf 
lata forms of emboli, especially flooculi of pus, pass tbe pulmooai; 
cnpniarlea witbout difGciilty, may enter tbe left heart, and thence the 
syvtomio circulation, mid be arrcstorl in ihe S]ilc<>ii, liver, kidneys, or 
elsewhere, and catisc abscesses. This eapluiod the rare oases wbert^ 
with venous tbramba«, Uipre are no absoosses in the lungs, -while they 
exist in other organs. If, with abscesses in tbe lun^ (here are cm- 
bolic iiiljirctioiis or abscesses in pari supplied by the syBtemio eifOuU* 
tion, tlicy nuy be atlribuccd to tlio formation of venous tliroaU 



IHROKBOStS, £UBOUf^M. 



801 



agb Ihc pulmooaiy abaccss; poriioQS from these tliroinbi past into 
■ left heart, and thence farther. As rcgArds liv«T>nb«oi-ss(^a, Btaeh bfia 
that retrograde movemt'ots of tLc blood from tl:c riglit heart 
la place io the vena cavs, and io this \my hepatic emboli maj occur. 
Tlie embolie origin of tnetattatie abseisee$ is now bo undoubted 
tittt, from th« existence of ono of thc$e, we decide certainljr oo a 
rcDooa thrombus undei^^ing putrid or suppuratire litiucfaction. The 
dtseoTciT of the connection may bo «wy in somo oases, very difficult 
in others: verv easy in case« of thrombus of large venous trunks, and 
embolism of branches of ihc pulmonary art<:rytfaat miiy be readily 
itkobed with the si^issors ; very «üfficult where there is simply coagu- 
l^laikia in some small venous net-work (as in phlegmonous inflamniation 
^Br ilecubitits) and emboliftui of capillaries of the lung», spleen, kUloe)'», 
Hsrer, muscles, etc. ; still, these htttcr case« are alpaost innuiacmÜc. 
Bvn CavoraUe object« (as in ocrebral capLIlarics) it has been prored, 
beyond n doubt., that eapilhiry emboli exist In some eases ; it b also 
«erlntn that sinall veins become thrombosed in all suppurative inflam- 
roatioiut ; it m very difficult, often impossible, to dcmunstntte tliia 
anatomii-nlly in eveiy case. From what »yraptoms we conchxle 
^wbctlivr a coaguliirn is old or recent, wiU be taught yciu in the Ico- 
I on patholngtcnl anatomy." Here we are only speakinj^ of mcta^ 
tic cifDumsGribed inflammations, of iufarctioos, and absceüses ; theso 
are ootniected with venous thrombi and emboIL For diOTuäe 
metostatio inflammations another ex|>1anatioa must- be sought; wo 
«hall treat of this tnonj under scpticiemia and pyremia. Nor shall wo 
hefe duKusa the queslioa of fever in phlebitis and in the fonnatiou of 
iMlaatatic abaoesscs. Ax plilehitts, ^^-ith its results, so Tcrr oPtoTi 
ae an addition to ulrc;tily-exi]i.tin^ acute tiiflamniatioui;, it ia dif- 
ult to judge how fiu* it of itself excites fever ; metastatic ab6Ce.ise<i, 
to aJl other points of iuflammation, undoubtedly induce fever; we 
Id scarcely expect fever from a simple thrarolMu or the tcshcIr. 
In dogs, by Inducing numerous small emboli in the hings bv in* 
ing'flouror powdered coal into the jugular rciii, we may, it is 
lie, excite fever, aa was shown by Jierffmann^ Strieker, and Albert • 
: this does not always occur iu embolism in other vascular tiaets, 
bfeod possibly depends on incrcaiTod action of the respiratory muscles. 
TIm irtatment of phlebitis and thrombus is the same as that of 
lymphangitis and other similar neut<_> inflammations. Careful frictions 
«rith mcrc«rial ointment, or, if wc fear detachment of the enagnlum, 
DOrering the part with compresses smeared with mercurial otittment, 
DTwitb bladders of ice, and absolute rest of the affected part, are indi- 
cated. Under p\iemiB wcsluUl spnak of the diagnosis and ln?ntment 
of iDotastatio abscMsea. If phlt-bitia and thrombosis cause local sup 
■ ptirsllon, the absc«8MS should be opened as soon as recognized. 






SM TRAUMATIC AND [NIXAlOUTOftV DISEASES, ETC 



LECTURE XXVI. 

n.— OMienl jlMldenUl DImmm wfclah nu; t6t«n^nj Woiu4a ui4 LMftI Ii 

tiiHi«. 1. Tniinwila and InllMftmktorjr F*r4t; S. Septle FftTu uul 8«fltMnt: 
V. SupfHtrmlii« FvvcT «04 Pjrwiui*. 

n-GBNEBAi. Accn>e:iT.a i>ii«i:Afii:3 mucii mat accompaxv woosvsud 

orilKR LOCAL tNrLAlfllAnoKi». 

Trb local ucciilt'iilitl Irauinntio diseascit whicli we hare ao far dr 
Bcribed MC nlwaj's nooomi^intwl hj ronntittitionnl disuvw, «Itidi i» 
diieflj' tbough not alwajs fert^riali in ilä luiture, Kervr is mch a ooi^ 
plicotioD of sj-mptoms that it maj seem very different nccoidb^ lo 
tJte ftdilittoo of one or oUier ayraptotn ; now it is generally dotcfmbcd 
onlj to say that tbera is fever when the tenipcreture of the hlood ii 
rlerstcd, and to measure the intcn»itj of the forer by the lidgU a( 
tb« temperature. I do aot tJiink it advisat>lo to oombat this poätiot, 
for by alxindoning it \ra «hould loso th« common ido* of what we nil 
ferer, aiHl throw it back into the old chaos. Rut I miut tell yoa tbt 
there uro many and very dangeroua ^ncral diseases in paticaU «itb 
wounds or olher local inäammatioos, in which no rhaogv of terapa» 
tUR! of tlie hlood can be illacoi-ered ; hcoo« th« latter ia ooly'condi- 
liooally a tueasure of tho patient's danger. BeaJdca tho dcvatioa of 
temperature, in fever we haro the following chief Symptome ; Incnaud 
rapidity of cardiac action and reparation, loss of appetite, fTvqoentlf 
nausea, feeling of weakncas, gnat sweating, not unfrcquently tim- 
bUng of ccrlsin groups of mudclcs (in chills), more or less mental 
exdtement anri blunting of the senses. Fevi?r is a gen4>ral discsK, 
whidi may result from many causes ; In other wonb, the OTBnber tt 
pyragenous, liWe that of phlogogcnous substances, is inROiMiifalc^ 
Aeocading to llio quantity and quiiHty of those subetaneoB («hkjiwv 
ierro pcösons) that Imve entered the bluod, one cr other set of sjrnij» 
toirts Is more promincat: thus ihoro is fevor with very high tcupen- 
turo, while all other s^'mptoms are slight; fever with gn>at tiluniing 
of ilic Bcnsrs, and hut Ultle elevation nf bodily t«mperatttre; fcri'r 
vboee prominent aymptoin is acvere sliivcriug, so-called ohilU ; fem 
vitli disturhanoe of the gnstrio functionfi, fatigue, ete., for the efaiuf 
symptoms. Why, then, »liould we not have f^ver (a stale of into»* 
cation caused by nuteriula absorlwd From wounds or points of inflaiO' 
mntion) with all the ^■mptoms, except elevation of the temperatttro 
of the blood ? From some cause or other tliis particular aymptoia 
migtit in some cases Imj concealed or prerented from appearing. Bill; 
«8 already stated, we shall accept the present view offerer, sad onir 



TUAUaATlC AND IKrLlHKATOBT FEVER. 



8B3 



;)pOiSe it to exist wliero we find elevatioa of tcinperature of Uie bloody 
but must then add tbut there itrc cases of acTorc gcRcntl, aocidcDtal 
iMufnalic and inOAmmator^ diseases which run their «ourso witliout 
forer. 

But tlicre is oiiotbcr cxininioa footor of tlicse general diseases tlut 
w« ifaoul^ bear in mind, riz., that tlicy are nil due to rctibsoqition of 
mattet« t)at fonn in the wounds or the pai-t« nruuod thcni, or (what is 
«bout (be umc tiling) in a poLit of inllsniiiuition. On tliia ptMiit ve 
ftgrec vitb tbe present Tiovrs, as &r u ooooema traumatic fvver, iii- 
Aumnatory ieveTy pjwmia, and septiaeinia, less so perhnpH ts regartl« 
U^Cnnus, delirium potatorum, dcliriiiin ncrvo»uin, and acut« roaniiu 
But uuiujir tinportaut rcaAOos Siror the view of tlic Inttcr diseases be- 
iu^ aUo of humoral origin ; heneo I shall make no fiirthcr divisions 
vaoag tbe above diseases. 

L TVaamatic and Ii\flamnuUory Fever. — It ba« been ab«adjr 
explained (p«^ 93) that tho fer(!T appearing in voimdod patients is 
pxrtJjr due to the blood taking up materials resulting from dceompo- 
«ition of innrlificd ti&sue on the »ubstanoe of the wound, partlj lo the 
absorptiaa of matcriali formed hy the trnumatio or aeci^lcntal inRnm- 
matkiii; ben«'-, in tlie laltcr cue, the nature of tlic traumatic and 
inflammatorj fever is |icrfectlir obscure. On this supposition, which 
»e prcrioufily tried briefly to prove, it will depend partly ou Uic looal 
advnntagoB for rcabt^orption, portly on tbe quality ami qunnlity of 
pyrogenous material in question, bow great tlie poisoning will prove. 
There arc oases where the rcssels opened by the injury- close do rap- 
idly, and the whole tniuiuatio iniluinmation tenniiiates so cpilL'kly, that 
thcru is nu gt.iienil iufecliou or fever at (ir»t> and tliey may not occur 
at all ; Bucb cases arc rare iu extensive injuries, tbcy ore tlio ideal 
of tho nonnal coufse \ in tbem the plastic infiltration on the edges of 
tha wonnd leads quickly and tbrcnigliout tbe wound to solid organized 
•ew tiunnationa, growing firmly in tlie edges of tlm wound, and pa«»- 
i»g oo to cicatrizatioa immodiately or after precedent granaUtion. 
If we aasune this case as a nonnal type, every tmumntie fever is a 
pathological AOcideTit. We must utknuwli^^u this in theory, but in 
I He great majority of «wc«, in wounds of any «iw, fever occurs sooner 
cir later; hence wo considered it advisable to treatof trainnatio fever io 
llie previous description of tite general oondiiion of the wounded pa* 
lit-iit. "We have still, however, to add something lo what was llicii 
ttid, which at tlint time U would hnve hoen ditTicnIt for you to under» 
stand. Ijet ua firsb spcnkof tlie i<eriod at which traumatic fever 
usually appears, and of \\A course. Iu many cases, especially where 
tbe injury bus afleoted tissues )>rt>viousIy healthy, tho fever does not 
begin till tbe SAXtiid day, increases mpidly, and, with evening rerai»* 




304 



TRACMATIC ASD KW-AlOIATOIlT DIS&ASXS, ETC. 



■Ions, remains for some daj-s at n certain licight, &nd tlien otam 
gjsdually (mrcly wilhiQ Iweoty-four houn). Accor<Ung to niT vt^ 
Domerous obscrc&tious, ju Ikr tliv greater majoritj of cu»e« tlio tnu- 
matic fever begins vitbin two da^s after the injui^. lliis fcrcr a 
luual]}- reptesented gnpliically as IbUovrs : 



Fn. «L 



f «1/ v/ the Itificagc. 



M. 



mi 



^^ 



3£_ 



2. i <. 



:^ 



G. 



Tii«r-tnirn' «RrtBinpauilon r/tS« inn. tUearoTj. TU« «nd Ilia fVillmrlni rrTiT^vm* art 
arr*iiff">l en Ih« enla uf Cclilna'« thoroigfiwlvr. Batb ivvnv \* dlTMvd talo !<■ f«rt», 
til* hnrloiiiiiil iliTidmt» liirXrato Ui» ilijr atilifiUmM i th» rarr* I* tn>a*M»i(fUiaiallH 
BiAmlnir >nil rvimtiiK niaunnuimtn ; (Iia lir» W«vf Itoca ladlMU IM — »'"■^ M 
nilitliiium uufiiikl tsiii|ivniiu mufft bMltbif |>eraiiii. 

The cun'e slinws tlint, arti>r an smputation of tJic ann, rcodnml 
necessary by an injury (nicaaurement wa« accideolully neglected the 
finit dny), tlio fercr did not begin till Üie tliird day, then oonttaoed 
from ilie fourlh to the seventli day; aflvr iLe eigiith day the patieat 
remained free itom fever. In otbcr cose», bovrerer, acOOodary few 
often oceura Iminodiately alter amputntion. Siicli an oocurrenceol 
traumatic fever is quite frequent. I cxpluin it as follows: Immedi- 
Ately after the injury tlie tissue of tlio edges of tlic wound was dofted 
by inlillration of plastic matter; the third day this comme 
breakdown into pus, and to mingle with decomposed sbredaoTl 
on tlie BurCtce of tlio wound, thus iudtidng a moderately extawTC 
inflammation of tlie amputation rtump, witb rcab«oqitioo of pus aad 
otliiT products of decomposition and inflammation; tbis rcahaorptilii 
goes on till chocked by some mcdiooical cause (diminished prcssisv. 



TRACIUTIO AND INTLAUHATOßV FEVBR. 



38 B 



ing an<I partial dosnrc of tb« vessels, etc.). la other oases, 
rer bfgiits the very day of the injuij ; we see tliU when blocx] 
I iKsea enclosed between Ibe flaps of Llie iiuited w-oitii J uud it, liaa 
npidly decomposed; fmiiicnlly, nlso, tphcn opcniliuns haro bona 
>ne in tissues iniUlTatfid wilh the product« of ehroiiio iiiGltrstioa. 
le following case (Fi^. GO] majr scn'o us an iUu»tnttoa of this 
ccoad cliuti : 

P.O. Ik 



Hay of tiir D»w«jir. 



/. I 2. 3. 4. S. e. 7. $. 



m 



J3 



zis 



3$ 



J7J 



37 



KT 



3t 



iTrvtr-cont ilt-i rvMciiog «f & oiiicia« vrt>t. wltb ffivftl ludltralioa of Iha aull (uta 

In infiltrBtina of tlie tissue from ohrouic iafUunmutiuii, (be finer 
Ijniphatic capillanrs may Iw contntctccl and to some cxtcut dosci), 
and bene«, for some time, may not hare curried off suffidont serum 
fioRi tba tissue, but tite mcdium-Mz^il IjrmphAtio TesselR, like tlie oor' 
respODfltoi; veins, wbkli in «bronio iiifltunrDntion bave lon^ b&en ex« 
to high pressure, are undoubtedly distended, perhaps «rcn 
png-, from rigidity of theEr wulU ; lieiico, if not quictdy filled nitli 
Grm plaati« iafiltmtäoo from tlic otort, they take up b good deal of Üic^ 
secretion from the wound ; moreorer, on the edges of wounda ia taof 
bidly-iii&ltrated tissuo, mortification is particularly apt to oceur. Thifl 
explanation of the lal<i and early oociinenoe of traumatic fever is 
purely bypotbelicul ; but it is tnken from und biui been induced by 
muDerous obsernttions. It migiit abo be assumed tliut in ono oiM 





TOAUltAnC AND 



INFLIMKATORY D1SB4EES, ETC 



tlM fennODl absorbed mlo ibe blood acted vety elowly, is anoüier 
rtnj quickly ; nothing definite can be said od tiiu poiat. As Z toi* 
merly bolicvcd llial tlic Fever wn« alwajs caufted b^ nerrtnjs imUtion, 
it was necessary Ui ■iiippoHc Üiat tbis irritability was varied, sod benee 
the febrile effect niigbt occur at veiy difTerent periods, but I liave ei>* 
tircljr abandoned thU Ibecr^-, witbout uudcrvululag tlie iiuporUnl 
part played bjr tlie nervous «ystem in tho origin and »ymptoms of fevcK 

TVaumatio fever usually last« a week; it is rarely longer, without 
some miblo local complication. 

WliCD tlicre is an «i-cidenlal inBuamatioQ of (lie cvHalar Uhm>, 
lymphatic ressclfi, or vein«, al>out a wovmd, fever occurs »imultaneoualy 
with this inflaminalion, or apparently precedes it (coining «a an In» 
fiummatory eccondary fcrcr, cither iiumediately after the txaunatk 
fever or when several or even many days bare parsed without ferer). 
I »ay it apjurt^ntly prorcdea, becnute the firat t^igns of tbe local afieo 
liou may Uure eacaped ue, as (hey may posaiUy have jmsented do 
ncnsihle symptom», or because the poi«onoii« mntrrini may have la- 
fccted the blood sooner tlian il did the parts immediately around; 
probability of the latter Idea, h I>3&cd on the fafit that poison, t^vi^k^ 
into (be lymphatic vessels or veins with tho lymph or blcxxl, flows mon g.». 
rapidly in tbe centre of the vessel than along its n-alls, and thus qnidd j ^ 
readies tbe large blood-vessels, while the fluid, moving more slowly — 
along the valU of the vessels, only gradiially passes into tbo perirna^'^ 
ciliar li&Eue, and there induces iuflumniatioQ by tbe phlogogcoous potc — hS 
eon it contjiins; thus fever (the hlood-iofcctioo) mny appear bcfon^c?™ 
erysipelas, lymphangitis, or phlebitis (from tlie local iuEcction), is fo^r^^ 
reived. Tbe course of tliis secondary fever entirely depends on lli 
of ttic local inflammation; as the latter begins, tbe Icmprralure rw^^^ 
rapidly, often vnth an initial cbilL Tbe longer these secoodary fevBM. a 
oontinue, that ig, the longer the poison in kept up, the more dsngi^ 
ous the couditiun becomes; mpid emacialion, great sweating, si--«'- -j-» 
IcBsnoa, and eoDlinufd Id?» of appetite, are bad symptoms ; usually ma 
these secondary fevers there is absorption of pus or infection fro«a 
without Pronounced erysipelas or inflammation of the h'mpfasCäe 
ftsisels or {glands arc the relatively most favorable forms of tbe socj* 
dental i n tin mniiit ions, as sooner or later they geneniUy lead to a certiaiii 
usually favorable termination, and thus are somewhat tyjiical in th 
course, although tho duration of au eryai])elafl may vary from tbrrc 
days to three weeks or more, and prove very debilitating ; at fiwt tic 
feveremre rises rapidly, then remains for a time at n «•rtain beigbt, 
usually with mnming remissions ; not unfrequenÜy Üic tempcratuns 
blls rapidly ; the same is true of h-mpbangitis. Fortunately, it is nw 
for lymphangitis and erysipelas to extend deep into the cellular 
sue and under the Cucise ; in sucli a case the disease would Im 



§1 




■niATniillC AND ISTLAMMATORY FETEK. 



tbe severer iDlIaiiinutions im^ would lo«c ita aomowliat t^'pk'al 
character. 

In diffuse, deep UiltAinmation of l1ii> ceilnUr tL<wiie, witli or witliont 
TCoouA throiutxMis, Uie fever tiova not bc^i ao sudduuly, but, from thu 
£i»t, aIwaj-9 bu a dceidcdiy remittent type, and, like tlie local aOoc- 
tioaS| U incompubiblo in its further courae; lli« loss of strcnglli, tli« 




I In <iyi|pelM tnamHlnai «nbaliH ftcM, captlli n cam, Si]lo>rlnK waitpMl« 
•r«Mna«rtflb«lp. HMwroir. 



itiou, ftweaLiiig, «enaitivenes», aiid exdtabiUly of the patJeot, 
tbe highest gndtx lulcnuitteut fever and metastatio inflam- 
tbc dticf Bjrmptonia of those malifpiuuit tiBunmtio fever« 

. wo call ** pytemia," arc grvstly to bo fuftrod in such ciweti. 

I all tbcse fcrcrs the qiiantitj of urea is incrcusi-d and exceeds 
3UOt of nitrogenous food ooiuumcd ; at tho satao time, oocoid- 
receot iDveetigations, tJie weight of tbe body diminUht» oon- 

looff aa tbe oonsUtutioiial syinplonw, eapeoLnlljr these dua to 
i-rcr, do not extend bejoml Üie aborc, and especially if th« dia- 
not prove Jatal^ we are geaerolljr aatisBed with tho ternia 
itte, luppunUivr, or acoondary ferer.** But^ if otliersymptoinai 
[and death rcwilU, thue severer infections liar« two othisr 
' strplit-iviiiia " and " pyemLa." We follow this common claisi* 



MB 



TIUnUTJC AND INTLAMSATORT DISEASES. BTC. 



3. Sepiic Fever (Septiccania), — By seplitacmia, vo undersUnd ■ 
constitiitionn), ^[«ni^rally acute disease, which u due to the ftbeorpiior 
of vnrious puLri'l eulKiftim'C» into the blocxl, nml it b thought tlut 
t}ioae act a» fcrniciitg in tliu blood, aiid spoil it so that it cannot fgliil 
its phjr«ologi«ftl fuDc-tiona. This diseine« may be iodcMod in ui)> 
mal» by iujoctiug' putjid miUler iiito thi^ir blood or subcutaneous tiau 
Btic, and it boA been fouiid ttmt largo nnimals {1>rgo do^ hones, Dto) 
naj, under certain oircumstanccfl, live through the putrefactive blc 
poisoning, nlttiougli it makes them very sick. Certain circut 
are neccsxary for putrid inattd- to be taltco into lb« bkml of man ;] 
euch sub»l«ucC9 ar« only takca through the L«a]Uijr skia and m\ 
mcnibnitiC'S vhon the putrid substances hare a dc«tructive or caule»-! 
ant action, or an active pon-er of pcnctrvting^, like fimgi and inTuaoriB. 
DiscDEcd akin or wound Biiriacc-a luko up auch putrid matten loon 
readily, but even they only do so under certain cinnunstaiiees ; fbr 
Instance, they do not readily pass througb wcll-orgnnizod, uninjun-J 
grunulatinns. If we drctis a nicely-^ranulaHn;; iround on a do^ kiU 
«Iiarpie dipped in the fdthiest putrid matter, if Ibe Istter eontain nc 
i^ulornnt substance ihat may destroy tlie granulation xur&c**, tlie ani— j. 
mal will Dot siokcn, nothing will be nbsorbfHl. Hence I conclude tiia^K t 
thc> poison must in some vriky be presented from entering tbo blooal 
vessels in the surface of tlie gnuitilations. If the sepiic poieoD be is 
tToduoed Inio the fresh tissue, it not only esclles severe local *"*■"— n^ 
mation, but qiuckly iuduces gcocrat fever. From thciw peculiar 
ditiuus uudcr which infection from putrid substances usually tmk r^ ^ 
place, it swms lo ine evident that the poison is absorbed chiefly l^^j 
the lymphatic vessels, as 1 have abcady mcntioDcd. BcMWRibrr, ab -^i 
that, iu contused wounds, decompusiug shreds of firm conneclir« tS^^ 
sue, espoöally of tendons awl fasds, often lie for a long time ^"m 
gninuUting wounds, without any septic poison passing from ihcT^Q 
through the superficial vessels of the gmnulnlions into thp lilo-xi ; Xtti* 
observation veriße-i the experiments made on dogs. But, If the potftc« 
be not takeu up by the blood-vessels, or be taken only under 
drcumstances, it w veiy probable that its absorption in chiefly tlifOU| 
the l^-mphatlc vessels. I will not deny that posaibly in certain 
lim states of the walls of tlic blood-vessels, as well as from capillairl 
otlraclion, and also through tlte thrombi of the vessels, infectious naff* 
rials fncrjr reach tho blood, nor tliat cells tako ap septic BKilemlv 
Hubstancea and may wander with them into the blood-veasde ; Uit, en 
(he whole, I consider this mod« of infection the exception, «spe(til|f 
if the infectious substance lie not dissolved, but «xiat as vn^r Rw 
molecules ; if, for instance, ü be token up in tlte form of dast. (M tin 
healthy parts of the body exposed to the air, it has only bocn provH 



a^^ 



nvtM 



SEPTICtUIA. 



369 



^ lliat dust-Uko bodies (ns coakluet) enter the lungs, aud may thenee 
Breach the bnmcbial glands (thence also the blood), w1i3e a similar 
BktieoiptioQ from tbc walls of thß intostiii«^ Itiin not j«t hceii observed 
t or erperimentalljr proved. Slioulii the niiasniata reidly b<? small fungi, 
that is, molecular bodies, from vital bas been said, it would seem vei^ 

r probable that the infecüon may take place tfarouj^i Ihorespirauoa; ijf 
Ihi« aliou