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L 



itf 



OF 

Cooper Medical College 

Date 
No. '' « / Shelf '''- 'i 

<;ii--r ill-- 

, ' , ; y, / V - i 



Ib^S&BKSt 




FstssjmiracBi} to 
. LIBRARY OF 
COOPER RIEDICAl COLLEGE, 






..k^ 



f 



Entered according to the Act of Congress, in the year 1859, bj 

BLANCHARD AND LEA, 

in the Office of the Clerk of the District Coart of the United States in and for the Eastern 

District of the State of Pennsylvania. 



PniLAPRLPHTA ! 
COLLINS, PBINTEB. 






A3\ 



TO 

THE NUMEROUS PUPILS 

WHO, DURING THE LAST QUARTER OF A CENTURT, 

HAVE ATTENDED HIS LECTURES, 

AND WHO ARE NOW SETTLED IN EVERT SECTION OF THE UNITED STATES 

IVTBK 

HONORABLE PURSUIT OF THEIR PROFESSION. 



f^tst ]?0lsints, 



DESIGNED TO ILLUSTRATE ONE OF TUE MOST IMPORTANT AND VALUABLE BRANCHES OF 

THE HEALING ART, 

ARE RESPECTFULLY AND AFFECTIONATELY INSCRIBEi:^ 

BT THEIR FRIEND, 

TEE AUTHOR. 



A certis potius et exploratis petendum esse pmsidiam ; id est, his qu89 experientia in ipsis cura- 
tioDibus docuerit ; sicut in cseteris omnibas artibas : nam ne agrioolam qnidem aut gabernatureui 
dispatatione, sed usa fieri. Cklsus. 



We may not only rank Chimrgery among the Sciences ; bat look on it as one of the noblest, most 
certain, and most necessary of them all. Di05is. 



The nobility and dignity of Chirurgery are too well known to want the help of an oratour to f>et 
them forth. If a panegyrick were necessary, it were best made by running through the particulars 
of the art, and the history of the diseases oared thereby. Wiseman. 



IV 



LIBRARY OF 
COOPER MEDrCAL COLLEGE, 



PREFACE 



TO THE THIRD EDITION. 



The rapid exhaustion of two large editions of this work, its translation 
into the Dutch language, and the favor bestowed upon it by the peri- 
odical press, both at home and abroad, are a pleasing evidence of the 
manner in which it has been received by the medical profession. This 
evidence, so gratifying to my feelings as an author, instead of abating my 
ardor, has only served to stimulate me to increased exertion to render the 
work still more useful as a faithful exponent of the existing state of the 
art and science of surgery. 

Upon the edition now issued upwards of two years and a half of arduous 
labor have been expended. Every chapter has been thoroughly revised ; 
the text has been augmented by an amount of matter nearly equal to two 
hundred pages ; and a considerable number of new woodcuts, nearly all 
expressly prepared for the purpose, have been introduced. Many portions 
have been entirely rewritten, and every effort has been made to condense 
the language ; while an enlargement in the form of the work has prevented 
an increase in the number of pages. The general arrangement is the same 
as in the previous imprints ; and the additions, for the most part widely 
scattered through the text, are essentially of a practical character. 

To Dr. Richard J. Dunglison my acknowledgments are due for the kind 
assistance which he has afforded me in preparing the new index and table 
of contents. 

S. D. GROSS. 

JEFFER5I05 Medical Collehb, 

PuiLADBLPHiA, October 1st, 1864. 



PREFACE TO THE FIRST EDlTlOlf. 



The object of this work is to furnish a systematic and comprehensive 
treatise on the art and science of surgery, considered in the broadest sense ; 
one that shall serve the practitioner as a faithful and available guide in 
his daily routine of duty. It has been too much the custom of modern 
writers on this department of the healing art to omit certain topics alto- 
gether, and to speak of others at undue length, evidently assuming that 
their readers could readily supply the deficiencies from other sources, or 
that what has been thus slighted is of no particular practical value. My 
aim has been to embrace the whole domdin of surgery, and to allot to 
every subject its legitimate claim to notice in the great family of external 
diseases and accidents. How far this object has been accomplished, it is 
not for me to determine. It may safely be affirmed, however, that there is 
no topic, properly appertaining to surgery, that is not discussed, to a greater 
or less extent, in these volumes. If a larger space than is customary has 
been devoted to the consideration of inflammation and its results, or the 
great principles of surgery, it is because of the conviction, grounded upon 
long and close observation, that there are no subjects so little understood 
by the general practitioner. Special attention has also been bestowed 
upon the discrimination of diseases ; and an elaborate chapter has been 
introduced on general diagnosis. 

The work, although presented, as its title indicates, as a formal and 
systematic treatise, is founded upon the courses of lectures which it has 
devolved upon me to deliver during the last twenty years ; first in the 
University of Louisville, for a long time the most flourishing medical 
school in the Southwest, and more recently in the Jefferson Medical College 
of this city, in which I had the honor, in 1828, to receive my degree. 
During all that period, I have been unceasingly devoted to the duties of 

an arduous practice, both private and public ; to the study of the great 

• • 
vii 



Viii PRKFAOB TO THE FIBST BDITION. 

masters of the art and science of medicine and surgery ; and to the com- 
position of various monographs having a direct bearing upon a number 
of the subjects discussed in these volumes. The work should, therefore, 
be regarded as embodying the results of a large personal, if not of a ripe 
experience, of extensive ifeading, and much reflection ; in a word, as ex- 
hibiting surgery as I myself understand it, and as I have, for so many 
years, conscientiously taught it. If, upon certain points of doctrine, I have 
been obliged to diflfer fipom colaborers of acknowledged authority and of 
the highest professional eminence, it is because I have found it impossible 
to do otherwise. As Luther said at the diet of Worms, " hier stehe ich, 
ich kann nicht anders," so I may declare that what I have here written, I 
have written under a solemn conviction of its truth, though certainly not 
without a strong sense of my fallibility and shortcomings. 

In the composition of a work so extensive as this, comprising so many 
and such diversified topics, no man, however great his opportunities for 
observation, could possibly rely entirely upon his own resources ; for there 
are certain diseases, and also certain accidents, so infrequent in their occur- 
rence as hardly to come under notice even once in a long lifetime ; and it 
is, therefore, only by availing himself of the recorded experience of the 
profession that an author can hope to be able to communicate full and satis- 
factory information respecting them. I have, accordingly, made free use, 
wherever this was deemed necessary, of the labors of my contemporaries, 
both among systematic writers and the contributors to the periodical press 
of this and other countries. To the excellent works of Erichsen, Miller, 
and Fergusson, so well known on this side of the Atlantic, I have fre- 
quently referred as embodying the latest r&umd of the art and science of 
surgery among our British brethren ; while I have not neglected to consult 
some of the more recent treatises in the French and German languages, as 
well as numerous monographs. 

Of the engravings which adorn the volumes, upwards of five hundred 
are original, the remainder having been selected from different writers, as 
Ashton, Barwell, Bennett, Bird, Cooper, Curling, Druitt, Erichsen, Fergus- 
son, Jones, Jones & Sieveking, Marcet, Mackenzie, Liston, Pirrie, Skey, 
TampHn, Toynbee, and Walton. To Mr. Gemrig, the eminent cutler, I 
am indebted for numerous illustrations, many of them specially prepared 
for the work, of the latest and most approved styles of instruments. Mr. 
Kolbe, another excellent manufacturer, and Messrs. Tiemann & Co., of New 
York, have also placed me under obligations for several similar favors. 

To Professor Wright, of Montreal, Dr. E. Williams, of Cincinnati, Dr. 



PBSFA^S TO THE FIBST EDITION. IX 

Lente, of New York, and Dr. Packard, Dr. James Darrach, and Dr. Walter 
F. Atlee, of this citj, my acknowledgments are due for various favors 
received during the progress of the work. To Dr. Bozeman, of Alabama, 
a valaed friend and former pupil, I am indebted for a complete series of 
drawings illustrative of his peculiar mode of operating for the cure of 
vesico- vaginal fistule. The index, which will be found to be unusually 
elaborate, was prepared, with great care, by my son. Dr. S. W. Gross. 

The mechanical execution of the work will, I doubt not, meet with 
general approval The publishers have spared neither pains nor expense 
to render it as perfect, in this respect, as possible. To Messrs. Baxter and 
Harley, engravers, and Mr. Collins, printer, my be«t thanks are due for the 
able manner in which they have executed their respective tasks. 

S. D. GROSS. 

Juljr S, 1S59. 



CONTENTS OF VOL I. 



PART FIRST. 



GENERAL SURGERY 



PSEUMI5A£T ObSEBTATIOXS 



FAQB 

35 



CHAPTER I. 



IRRITATION, SYMPATHY, AND IDIOSYNCRASY. 



37 



CHAPTER II. 



C0N0E9TI0N. 



49 



CHAPTER III. 



INFLAMMATION. 

Sect. I. General CoDsiderations 

1. Causes of iuflammAtion . 

2. Extension of inflammation 

3. Varieties of inflammation 

4. Ttrnuinations or events of inflammation 

II. Acate Inflammation 

1. Local sjmptoDEis • 

2. Constitutional symptoms 

3. Changes of the blood in inflammation 

4. Intimate nature of Inflammation 

5. Treatment of inflammation 

I. Constitutional treatment 
II. Local treatment 

[II. Chronic Inflammation . 



52 
53 
67 
59 
60 

61 
61 
69 
73 
76 
83 

83 
99 

109 



CHAPTER IV. 



TERMINATIONS AND RESULTS OP INFLAMMATION. 



Sect. I. Delitescence and Resolution • 

II. Ivpo^itioti of Serum . 

III. Lymphization or Fibrinous Exudation 
1. Uses of plastic matter 
;^ Injurious effects of plastic matter 
Treatment 



113 

114 

117 
121 
123 
124 



XI 



Xll 



CONTENTS OP VOL. I. 



Sect. IV. Suppuration and Abscess 

Abscesses . . . • 

1. Phlegmonous abscess . 

2. Diffuse abscess or purulent infiltration 

3. Scrofulous abscess 

4. Multiple abscess or pyemia 

5. Hectic fever 

V. Hemorrhage .... 

VI. Mortification . . • • 

1. Acute mortification 

2. Chronic mortification 

VII. Hospital Gangrene . 

VIII. Ulceration and Ulcers 

Ulcers .... 

1. Acute ulcers • 

2. Chronic ulcers . 

IX. Granulation .... 
X. Cicatrization .... 



PAOK 

125 
130 
131 
139 
141 
145 
152 

155 

156 
157 
165 

170 

176 
179 
180 
184 

190 

192 



CHAPTER V 



TEXTURAL CHANGES. 



Sect. I. Softening ...••, 








. 195 


II. Induration ...••• 








. 196 


III. Transformations . • . • . 








. 197 


IV. Hypertrophy .....< 








> 200 


V. Atrophy ...... 


> ' < 






. 202 


VI. Contraction and Obliteration . . • . 








. 2(U 


VII. Fistule ....... 








. 205 



CHAPTER YI. 



CONGENITAL MALFORMATIONS. 



208 



CHAPTER VII. 



TUMORS OR MORBID GROWTHS 



Sect. I. General Observations . 

II. Benign Tumors . 

1. Hypertrophic tumors 

2. Vascular tumors . 

3. Fatty tumors 

4. Homy tumors 

5. Fibrous tumors 

6. Cartilaginous tumors 

7. Osseous tumors 

8. Calcareous tumors 

9. Neuromatous tumors 



211 

214 
214 
215 
216 
220 
222 
224 
226 
226 
226 



CONTENTS OP VOL. I. 



Xlll 



10. Enojsted tamors . 

11. Hydatio tamora 

12. Poljrpoid tomors • 

13. Myeloid tamora 
Excision of benign tamora 

Sect. IIL Malignant Tamora 

1. Scirrhos . 

2. Encephaloid 

3. Epithelioma 

4. Colloid . 

5. Melanosis 
Treatment 



PAOI 

229 
231 
232 
234 
235 

236 
239 
243 
248 
250 
252 
257 



CHAPTER VIII. 



SCROFULA. 



Serofala and Taberole 
Treatment • 



264 
269 



CHAPTER IX. 



SYPHILIS. 



Sect. I. General Considerations 

XL Primary STphilia 

1. Chancre . 

2. Babo 

IIL Secondary Syphilis 

1. General considerations 

2. Affections of the skin 

3. Alopecia 

4. Cervical adenitis 

5. Affections of the mncoos 



membranes 



IV. Tertiary Syphilis 

1. General considerations 

2. Syphilis of the brain and spinal cord 
8. Syphilis of the throat, month, teeth, and bowels 

4. Syphilis of the nose 

5. Syphilis of the larynx and longs 

6. Syphilis of the eye 

7. Syphilis of the ear 

8. Syphilis of the skin 

9. Syphilis of the cellalar tissne, masoles, and tendons 

10. Syphilis of the osseons system . 

11. Syphilitic synovitis . • 

12. Syphilis of the nrinary apparatns 

13. Syphilitic orchitis 

14. Condylomatons growths 
Treatment 

Syphilis in the infant . 
Syphilixation . 



274 

276 
276 
293 

297 
297 
300 
304 
305 
305 

308 
308 
310 
311 
312 
312 
313 
314 
314 
316 
316 
319 
320 
320 
322 
323 

d3i 

336 



XIV 



CONTENTS OF VOL. I. 



CHAPTER X. 



WOUNDS. 

8bct. I. General ConsideratioDS 

1. Mode of dressing wounds 

Maggots in wounds 

2. Mode of healing wounds 

II. Incised Wounds 

III. Lacerated Wounds 

IV. Contused Wounds 
V. Punctured Wounds 

VL Tooth Wounds 

VII. Gunshot Wounds 

Question of amputation in wounds 
Secondary effects of wounds and contusions 

VIII. Poisoned Wounds 

1. Wounds inflicted by poisonous insects 

2. Wounds inflicted by Tenomous serpents 

3. Wounds inflicted by rabid animals 

4. Glanders, farcy, or equinia 

5. Wounds inoculated with a peculiar septic poison 

mal bodies .... 

a. Dissection wounds . 
* b. Malignant pustule . 

CHAPTER XI. 



generated in dead ani 



PAOI 

337 
339 
347 
348 

351 

353 
355 

358 

361 

363 
380 
383 

385 
385 
386 
391 
396 

400 
400 
404 



EFFECTS OF INJURIES UPON THE NERVOUS SYSTEM. 

8bct. I. Prostration, Collapse, or Shock .... 

II. Traumatic Delirium ...... 



407 
412 



CHAPTER XII. 



GENERAL DIAGNOSIS. 



Sect. I. Examination of the Patient 

Examination of the different organs 

II. Mensuration 

III. Attitude of the Patient 

IV. External Characters 

V. Instrumental Explorations 
VI. Examination of the Discharges 
VII. Microscopical Exatuination * • 



416 
418 

422 

423 

424 

426 

431 

433 



« •■ 



CONTENTS OP VOL. I. 



XV 



CHAPTER XIII 



MINOR 8URGERT. 



BCT. L Instniments 


• • • • • 






PAGE 

4;59 


IL IncisioDfl 


• . • . « 






443 


III. Avalsion, EDiicleatioii, Ligation, and Crashing 






446 


IV. Abstraction of Blood . 








. 448 


V. Transfaiiion of Blood 








. 457 


VI. Vaccination 








. 458 


VIL Counter- Irritation 








. 459 


Vin. Escharotics 








4G4 


rX. Dressing 








. 466 


X, Bandaging 








. 468 



CHAPTER XIV 



OPERATIVE SURGERY. 



Qnaliftcationa of a surgeon 

Preparation of a patient 

A:i:tiAtants . • 

pQtv of the surgeon 

Position of the patient and surgeon 

Operation 

Accidents dnrini; the operation 
rHw»«ines and after-treatment 
Source of danger after operation 



472 
474 
477 

478 
47« 
470 
479 
480 
482 



CHAPTER XT 



PLASTIC SURGERY 



487 



CHAPTER XYI 



SUBCUTANEOUS SURGERY 



491 



CHAPTER XT II. 

AMPUTATIONS IN GENERAL. 
Pbtt. I. Introductory Considerations 

II. Circumstances Demanding Amputation «• 

III. Methods of Amputation 

IV. Operation and After-treatment 

Synchronous Amputation 
Re-ampntation 

V. Affections of the Stump 

1. Primary affections 

2. Secondary affections 



495 

406 

502 

5(»7 
512 
513 

513 
414 
516 






i 



XVI 



CONTENTS OP VOL. I. 



Sect. VI. CoDStitntional Effeots of Amputations 
VII. Artificial Limbs 
VIII. Mortality after Amputations 



General considerations 

Instruments 

Position of the patient 

Incisions 

Removal of the bone 

Dressing 

Statistics 



CHAPTER XVIII. 



EXCISION OF BONES AND JOINTS. 



General considerations . 
Chloroform 

Mode of administration 

Effeots 
Inhalation of ether 
Local anesthesia 



CHAPTER XIX. 

ANJSSTHETICS. 



518 

521 

'523 



528 
530 
531 
531 
532 
532 
533 



534 
53G 
536 
538 
549 
541 



PART SECOND. 

SPECIAL SURGERY ; OR, DISEASES AND INJURIES OF PAR- 
TICULAR ORGANS, TEXTURES, AND REGIONS. 



CHAPTER I. 

DISEASES AND INJURIES OP THE SKIN AND CELLULO-ADIPOSE TISSUE. 

Sect. I. Erysipelas 

II. Furuncle or Boil 

III. Anthrax or Carbuncle 

IV. Gangrene and Bedsores 
V. Bums and Scalds 

VI. Frost-bite and Chilblain 

VII. Morbid Growths 

1 . Warts, or verrucous growths 

2. Sebaceous tumors 

3. Molluscous tumors 

4. Moles 

6. Hypertrophy of the skin . 
6. Blephantiasis, or hypertrophy of the skin and cellular tissue 



545 

558 

559 

562 

564 

571 

575 
575 
576 
578 
579 
580 
580 



CONTENTS OF VOL. I. 



XVll 



7. Keloid tamors 

8. Pibroos tumors 

9. Eiloid 

10. Lepoid 

11. Lupus 

12. Melanosis 

13. Soirrhas 

Sbct. VIII. Insects in the Skin and Cellnlar Tissne 



PAOB 

583 
5SG 
587 
687 
588 
591 
591 

592 



CHAPTER II. 

DISEASES AND INJURIES OF THE MUSCLES, TENDONS, BURSES. AND APONEUROSES. 



. I. Muscles 
IL Tendons 

III. SjnoTlal Burses 

IV. Aponeuroses 



593 
598 
602 
605 



CHAPTER III. 



DISEASES AND INJURIES OF THE NERVES. 



Swct. I. Wounds and Contusions 
II. TeUnus 
III. Neuralgia 

rV. Paraljtic Affections 

1. Wasting palsy 

2. Infantile palsy 

3. Partial palsy 



607 
608 
617 

623 

623 
626 
627 



CHAPTER IV. 



DISEASES OF THE LYMPHATIC VESSELS AND GANGLIONS. 



Sect. I. Lymphatic Vessels 

IL Lymphatic Ganglions . 



. 628 
. 630 



CHAPTER y. 



DISEASES AND INJURIES OF THE ARTERIEa 

'. I. Wounds and Hemorrhage 

II. Subcutaneous Hemorrhage 

IIL Collateral Circulation . 

IV. Hemorrhagic Diathesis 

V. Diseases of the Arteries 

1. Acute inflammation 

2. Chronic affections 

3. Intra-parietal separation, or dissecting aneurism 

4. Varicose enlargement . . • 
VOL. I. — 2 



635 
654 
655 

658 

661 

661 
663 
665 
666 



XVill CONTENTS OF VOL. I. 

Sbct. VI. Anearism ..... 

1. Locality, prevaleoce, age, sex, and oaasea 

2. Varieties .... 

3. Symptoms .... 

4. Diagnosis .... 

5. Effects and termination 

6. Spontaneous cure . • 

Treatment ..... 

a. Deligation of the artery at the cardiac side of the tumor 
6. Deligation of the artery at the distal side of the tumor 

c. Instrumental compression . . 

d. Digital compression .... 

e. Forced flexion ..... 
/. Galvano-puncture . . ... 
g. Injection ..... 
h. Manipulation • . . . » 
1. Valsalva's treatment of internal aneurism 
I; General medical treatment . . • 

False aneurism ..... 

VII. Aneurism of Particular Arteries • • • 

of the thoracic aorta 
of the innominate artery . . • 

of the common carotid artery 
of the external carotid . • • 

of the temporal artery . . • 

of the supra-orbital artery . • 

of the middle meningeal artery • 
of the ophthalmic artery . • • 

of the internal carotid 
intracranial aneurism • . • 

of the vertebral artery 
of the subclavian .... 
of the axillary artery 

of the subclavian artery on its tracheal aspects 
of the brachial artery and its branches . 
of the abdominal aorta 
of the hepatic, gastro-epiploic, and mesenteric arteries 
of the common iliac artery 
of the internal iliac 
of the external iliac 
of the femoral artery 
of the popliteal artery 
of the arteries of the leg and foot 

VIII. Operations on the Arteries .... 
Ligation of the innominate or brachio-cephalic . 
of the common carotid . 
of the external carotid and its branches 
of the subclavian and its branches 
of the vertebral artery . 
of the internal mammary 
of the inferior thyroid . 
of the axillary . 
of the brachial . 
of the radial and ulnar . 



CONTENTS or VOL. I. 



XIX 



Ligation of the abdominal aorta . 








PAOB 

. 760 


of the common iliao 








. 761 


of the internal iliac 








. 763 


of the gluteal . . . . 
of the Bciatic 


B • 






. 764 
764 


of the external iliac . . 








764 


of the epigastric and circumflex iliac . 
of the femoral . 








. 766 
. 766 


of the deep femoral 

of the popliteal . . . , 

of the anterior tibial 








768 

. 769 

770 


of the posterior tibial . 

of the peroneal . . . . 








770 
772 



CHAPTER YI. 



INJURIES AND DISEASES OF THE VEINS. 



Sbct. I. Wounds 

II. Diseases of the Veins . 

1. Acute phlebitis 

2. Chronic atfections . 

III. Varix . . • 

IV. Introduction of Air 





. 772 




. 773 




773 




774 




775 


• • • • • 


778 



CHAPTER YII. 



Sbct. I. Arterial Tumors 
II. Venous Tumors 



AFFECTIONS OF THE CAPILLARIES. 



782 
789 



CHAPTER Till. 



DISEASES AND INJURIES OF TUE BONES AND THEIR APPENDAGES. 

Sect. I. Periostitis 

Acute periostitis 
Chronic periostitis 

II. Endosteitis or Osteomyelitis 

III. Oateitis . 

IV. Suppuration and Abscess 
V. Caries or Ulceration 

VI. Necrosis or Mortification 
VII. Softening • 

VIIL Rachitis 
IX. Fnurilitj 



791 

791 
793 

793 

795 

798 

800 

808 

818 

821 

825 



XX 



COXTEJfTS OF VOL. I. 



X. Axivphy • 

XL H jpcftfopb J' . 
XIL Oiteophjtes . 

XIIL TmDora 

InsooeDt fonnaticms 

1. EzobUttes or bonj tumors 

2. Fibro-cartilagiDoiu tomon 

3. An«iirisiiial tamon 

4. Hemaioid tamon 

5. Sefo-cjstie tnmoim 

6. Hjdatic tomore 

7. lijeloid tamon 
lUlignant IbnnjUions 

XIV. TabertolAT disease . 

XV. Keormlfia 

XVL Fraetarcs 

1. Gcnenl eonsiderations 

2. Simple fmctoru 

3. CompticAted fractares 

4. Incomplete fiactores or bending of tbe bones 
f>. Diastasis or separation of tbe bones at tbeir epipbrseB 

6. Cnonited fractares 

7. Vicioas onioD of fractures 

5. Diseases of tbe eal las . 

XV IL Fractures of Particalar Bones 

1. Head and trunk 

Fractures of tbe nasal bones 

of the nasal cartilages 
of tbe upper jaw 
of tbe malar bone 
of tbe lower jaw 
of the hvoTd bone 
of tbe larjnx 
of tbe clavicle . 
of the scapula 
of tbe ribs 

of tbe costal cartilages 
of tbe sternum . 
of tbe rertebne . 
of tbe pelvic bones 

2. Superior extremity 

Fractures of tbe bones of tbe band 

of tbe shafts of the radius and ulna 
of tbe ulna 
of tbe radius 
of tbe humerus 

3. Inferior extremity 

Fractures of tbe foot 
of the tibia 
of the fibula 
of both tbe tibia and fibula 

Complicated fractures of the leg . 



and fingera 



CONTENTS OF VOL. I. 



XXI 



Fractures of the patella . • • . . 

of the femur ..... 

1^ of the shaft .... 

2. of the inferior extremity 

3. of the superior extremity of the femur 
Intra-capsular fractures 
Extra-capsular fractures 

Impacted fractures of the neck of the femur 
Fractures of the great trochanter 
of the thigh in children 



PAGE 

949 
949 
9t>l 
963 
9G5 
974 
977 
9S1 
983 



CHAPTER IX. 



DISEASES AND INJURIES OF THE JOINTS. 



Sect. I. 


Wounds 


• • • • 4 








. 984 


II. 


Sprains ....... 








, 987 


III. 


SjnoTitis ...... 








. 990 


IV. 


Dropsy of the Joints . . . • . 








994 


V. 


Morable Bodies within the Joints 








997 


VI. 


Tuberculosis of the Joints • . . . 

General Observations • . . . 
Tuberculosis of particular joints 

1. Temporo-maxillary joint 

2. Clavicular joints 

3. Occipito-atloid and atlo-axoid joints 

4. Sacro-iliac joint 

5. Wrist-joint . . . . . 








1002 

. 1002 
. 1013 
. 1013 
. 1014 
. 1014 
. lOlG 
. 1018 




6. Elbow-joint 


1 • • • i 








. 1019 




7. Shoulder-joint 










. 1020 




8. Ankle-joint 


» • • • 4 








. 1020 




9. Knee-joint 










. 1021 




10. Hip-joint 


> • • • < 








. 1022 


VII. 


Chronic Rheumatic Arthritis • . . , 

of partic ulan j oints 








. 1034 
. 1037 


VIII. 


Anchylosis ..... 








. 1041 


IX. 


Neuralgia and Hysteric; 


Ell Aflfections 








. 1047 



LIST OF ILLUSTRATIONS TO YOL. I. 



na. 

1. 

2. 

3. 

4. 

5. 

6. 

I. 

8. 

9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 
30. 
31. 
32. 
33. 
34. 
35. 
36. 
37. 
3S. 
39. 
40. 
41. 



Retionlated arrangemeut of the corpuscles in inflammatory blood 

Baffj and cupped blood .... 

Natural ear of a rabbit .... 

loflamed ear of a rabbit .... 

Eztravasated blood in an inflamed serous membrane 

Changes in the capillary circulation in inflammation 

Plastic corpuscles and filaments in recent lymph exuded on the pleura 

Recent lymph, forming false membrane . 

> Nuclei and cells developing themselves into fibres 

Perfect fibrous tissue .... 

Newly-formed vessels in plastic lymph . 

Vessels in false membrane of the pleura . 

Fibrinous exudation in process of absorption 

Lymph of pleuritis, with fatty deposit 

Natural appearance of pus corpuscles and after the application of acetic 

Abscess opening into the external carotid 

Bistoury for opening abscesses 

Pus from a scrofulous abscess 

Acute mortification .... 

Mortification, with an appearance of the sloughing process 

Chronic gangrene ..... 

Chronic ulcer ..... 

Granulating ulcer, beginning to cicatrizes 

Strapping of an indolent ulcer 

Arranj^ement of bloodvessels in a granulation 

Structure of a cicatrice of the skin • 

Vascular tumor of the scalp 

Fatty tumor . . • • • 

Minute structure of a fatty tumor 

Homy excrescence of the scalp • • • 

Section of horn ..... 

Micro^opical characters of a fibrous tumor 

Enchondromatous tumor .... 

Minute structure of enchondroma . • 

Section of a neuromatous tumor . 

Microticopic structure of a neuromatous tumor 

Painful subcutaneous tubercle 

Microscopic structure of the subcutaneous tubercle 

Hydatids inclosed in a common cyst 

Cysta of echinocoocl • . • • 



acid 



PAOB 

75 
75 
78 
78 
78 
79 
119 
119 

120 

120 
120 
120 
121 
121 
128 
136 
137 
143 
158 
161 
165 
185 
188 
189 
191 
193 
216 
217 
218 
220 
221 
223 
225 
225 
227 
228 
228 
228 
231 
232 



XXIU 



XXIV 



LIST OF ILLL'STBATIONS TO VOL. I. 



42. 
43. 
44. 
45. 
46. 
47. 
48. 
49. 



51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
6(;. 
67. 

cs. 

69. 
70. 
71. 
72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 
86. 
87. 
8«. 
89. 
90. 
91. 
92. 
93. 
94. 
95. 
96. 
97. 



Echinooooci 

Serrefine • • 

Small forceps for temporarilj checking hemorrhage 

Canoer-cellfl in the earlier stages • 

Cancer-cells farther developed 

Cancer-oells in their fibroos stroma 

Stroma of scirrhos 

Scirrhos cells 

Stroma of encephaloid 

Encephaloid cells . 

Taberoid form of encephaloid 

Epithelial cancer in a state of ulceration 

Cells of epithelioma 

Papilla from epithelioma . 

Colloid tumor, external appearance 

Colloid tamor, internal stmoture 

Microscopic stmctnre of a melanotic tomor 

Tubercle corpuscles • 

Tubercles in the mesenteric glands 

Indurated chancre 

Sloughing chancre 

Acute phagedena . 

Chronic phagedena 

Syphilitic ulceration of the larynx 

Syphilitic rupia 

Syphilitic caries of the skull 

Syphilitic hypertrophy of the femur, internal structure 

Syphilitic hypertrophy of the femur, external characters 

Condylomata 

Syphilitic temporary teeth 

Syphilitic permanent teeth 

Interrupted suture 

Silver needle for twisted suture 

Twisted suture, elliptical . 

Twisted suture, figure of 8 

Pin pliers . 

India rubber suture 

Glover's suture 

Quilled suture 

Price's needle for wire suture 

Murray's needle 

Lister's needle 

> Invaginated bandage for longitudinal wounds 

Diagram representing effects of gunshot wounds 
\ Gunshot probe • 

Bullet forceps • 
Thomassin's forceps 
Gemrig's forceps • 
Gross's forceps 
Kolbe's bullet extmctor 
Thomassin's extractor 
Head of rattlesnake 
Poison fang, magnified 
Probe 



PAAI 

232 

236 

236 

238 

238 

23S 

211 

241 

245 

245 

246 

249 

249 

219 

251 

251 

253 

266 

266 

278 

281 

282 

282 

313 

315 

318 

319 

319 

323 

335 

335 

341 

S42 

S42 

842 

342 

342 

343 

343 

344 

344 

844 

345 

866 
374^ 375 

375 
375 
376 
376 
876 
876 
887 
887 
427 



LIST OF ILLUSTRATIONS TO VOL. I. 



XXV 



99. 

mo. 

101. 
liiS. 
103. 
lOi. 
105. 
106. 
107. 
108. 
li*9. 
110. 
111. 
112. 
113. 
114. 
115. 
116. 
117. 
118. 
119. 
120. 
121. 
122. 
123. 
124. 
125. 
126. 
127. 
12s. 
129. 
130. 
131. 
132. 
133. 
1^4. 
135. 
136. 
137. 
138. 
139. 
14u. 
141. 
142. 
143. 
144. 
145. 
146. 
147. 
14??. 
149. 
15»». 
151. 
152. 
153. 



Specalum . ..... 

EzploriDg needle ..... 

Smith and Beck's large compound microscope 
Arrangement of microscope for transparent objects 






Scalpels 



Bistoory . . 

Sharp-pointed bistoury 
Probe-pointed bistoary 



[ Forceps 



V Scissors ...... 

Moseax's forceps . . • . . 

Pronged instrument for pulling and holding tumors 
Forceps for uterine polyps 
GrooTed director ..... 

Trocar ...... 

^eecLies ...... 

Suture needle ..... 

First position in holding scalpel . 

Second position in holding scalpel 

Third position in holding scalpel . 

Fourth position in holding scalpel • • 



Diiferent forms of incisions 



Double canula • . • • • 

Ecraseur ....•• 

Scarificator • . . • • 

Cupping apparatus .... 

Cupping glass with India-rubber top 

Veins of arms ..... 

Mode of holding the lancet in venesection 

Bleeding at the jugular vein 

Compress applied to the temporal artery after arteriotomy 

Grosses transfixing apparatus 

Corrigan's button cautery .... 

Seton needle armed . . . . 

Eye probe as a substitute for the above . 

I'orte-moxa ..... 



I Acupuncture needles 

Marshairs galvanic cautery 
Different forms of cauteries 



PAOB 

428 
429 
434 
434 



440 



440 
440 
440 

441 

441 

442 
442 
442 
442 
442 
443 
443 
443 
444 
444 
444 



446 



447 
447 
451 

451 
451 
453 
453 
457 
457 
458 
460 
4«)1 
4«)1 
463 

463 

464 
465 



XXVI 



LIST OP ILLUSTRATIONS TO VOL. I. 



FIG. 

154. 
155. 
156. 
157. 
158. 
159. 
160. 
161. 
162. 
163. 
164. 
165. 
166. 
167. 
168. 
169. 
170. 
171. 
172. 
173. 
174. 
175. 
176. 
177. 
178. 
179. 
180. 
181. 
182. 
183. 
184. 
185. 
186. 
187. 
188. 
189. 
190. 
191. 
192. 
193. 
194. 
195. 
196. 
197. 
198. 
199. 
200. 
201. 
202. 
203. 
204. 
205. 
206. 
207. 
208. 
209. 



DreasiDg forceps ..... 

Bandage of Scultetus - . . . . 

Mode of applying tbe bandage 
Appearance of the bandage after its application . 
Gangrene from strangulation by anequal compression of 
Tenotome ...... 

Circular ampatation, illastrated in the leg 
Circular operation, shown in the thigh 
Corresponding stump .... 

Flap amputation, illustrated in the thigh . 

Corresponding stump .... 

Amputation by the rectangular flap in Teale's process 

Api)earance of parts when brought together in the same 

Tourniquet of Petit 

Tiemanu*s improved tourniquet 

(iross'fl arterial compressor 

Amputating knife . 

Catlin 

Amputating saw . . 

Small amputating saw 

Bone nippers . . 

Detached sequester 

Neuromata of the stump, after amputation of the arm 

Appearance of bony stump after amputation 

Palmer*s artificial leg 

Ordinary form of wooden leg . 

Palmer's artificial arm . . . 

Butcher's saw . . .^ . 

Hey's saw ..... 

Narrow concave saw for division of bones 
Chain saw .... 



a bandage 



} 



Bone forceps 



Carbuncle in its forming stage 

Ulcerated carbuncle . . . 

Cicatrice after a bum 

Sebaceous tumor of the scalp 

Cyst of a sebaceous tumor containing hair 

Elephantiasis of the foot and leg . . 

Keloid tumors .... 

Microscopical characters of keloid . 

Nodule of black cancer in the skin 

Globular hydatid .... 

Fibroid bodies of a ganglion 

Fibroid bodies of a synovial burse 

Opisthotonos .... 

Syringe for endermic application of morphia 

Scrofulous pus from a lymphatic gland . 

Hypertrophied lymphatic glands . 

Melanosis of a lymphatic gland . 

Cretaceous degeneration of lymphatic glands 

Plan of wounded arteries 

Contraction of a divided artery 

Plan of natural heniohtatics in a cut artery 

Change in artery after ligation 



PAcn 
466 
469 
470 
470 
471 
493 
503 
504 
504 
506 
506 
506 
507 
608 
509 
509 
509 
510 
510 
510 
510 
616 
617 
521 
522 
623 
523 
530 
530 
530 
531 

531 

560 
560 
566 
576 
576 
580 
584 
586 
591 
597 
601 
605 
611 
621 
631 
632 
634 
634 
636 
637 
637 
638 



LIST OF ILLUSTRATIONS TO VOL. I. 



XXVll 



210. 
211. 
212. 
213. 
214. 
215. 
21C. 
217. 
218. 
219. 
220. 
221. 



224. 
225. 
226. 
2n. 



229. 
230. 
231. 



233. 



235. 
236. 
237. 
238. 
239. 
240. 
^1. 
212. 
243. 
214. 
245. 
216. 
247. 
248. 
249. 
250. 
251. 
252. 
253. 
254. 
255. 
256. 
257. 
258. 
259. 
260. 
261. 
262. 
263. 



2i65. 



Diagram of the ooU&iend cironlation 

Spring artery forceps 

Teoaoalam .... 

Sliding foreeiM .... 

Mode of isolating an artery 

Effects of ligation on the inner coats 

Exterior of an artery after ligation 

Reef-knot ..... 

Sargeon's knot .... 

Tenacalam-needle, armed with ligature . 

Phyaick's artery forcepe . 

Anenrism-needle, armed with ligature 

Carotid of a dog forty-eight hours after deligation 

Carotid of a dog ninety-sijE hours after deligation 

Carotid of a dog twelfth day after deligation 

Acupressure ; the pin seen through the skin 

Position of the artery and pin in acupressure 

Tourniquet applied to the thigh . 

Field tourniquet ; handkerchief and stick 

Field tourniquet ; handkerchief and sword 

Compression of the fingers, arresting the circulation in the upper extremity 

Compression of the fingers, arresting the circulation in the lower extremity 

Plan of a graduated compress 

Torsion-forceps .... 

Partial absorption of the clot 

Collateral circulation shown in the thigh 

Plastic deposit in the aorta 

Plastic plugs occluding the axillary artery 

Deposition of calcareous matter in an artery 

Atheromatous deposits in the aorta 

Minute appearances of atheromatous deposits 

Dissecting aneurism 

Varicose enlargement of the arteries 



Arrangement of arterial tunics in spontaneous aneurism 



Sacculated aneurism .... 

Aneurism of aorta .... 

Sacciform aneurism of aorta ready to give way . 

Tubular aneurism of aorta 

Aneurism by dilatation .... 

Erosion of vertebrs from aneurism 

Aneurism obliterated by deposition and organization of fibrin 

Aneurism of descending aorta ; burst 

Illustration of Hunter's operation 

Illnstrmtion of Brasdor's operation 

lllostration of Wardrop*s operation 

Gibbons*s modification of Charridre*s compressor 

Carte*s compressor .... 

Hoey's clamp ..... 

Cartels circular compressor 

Prarax*s syringe for injection in aneurism 

Varicose aneurism ; external view 

Varicose aneurism ; internal view 

Aueurismal varix • • • • . 



PAQB 

638 
640 
640 
640 
641 
641 
642 
642 
642 
643 
643 
643 
645 
645 
645 
647 
647 
647 
648 
648 
649 
649 
649 
652 
653 
667 
662 
662 
664 
6«;4 
665 
606 
666 

668 

672 

672 

674 

675 

676 

681 

682 

684 

692 

692 

692 

694 

694 

694 

695 

698 

703 

703 

704 



XXVlll 



LIST OF ILLUSTRATIONS TO VOL. I. 



PIO. PAAI 

2G6. Aneurism of arch of aorta bursting into the trachea • . • • 706 

267. Aneurism of arch of aorta nearly filled with laminated clots . . • 708 

268. Aneurism of innominate artery bursting into the trachea . . • 700 

269. Traumatic aneurism of the brachial artery . . . • • 734 

270. Aneurism of aorta producing caries of vertebrie ..... 736 

271. Spontaneous cure of aneurism of femoral artery by sac filling with ooagulum . 741 

272. Aneurism of posterior tibial artery, undergoing spontaneous cure . • 745 

273. Ligation of the common carotid ....... 748 

274. of the lingual artery ...•••• 751 

275. of the facial artery .••.... 752 

276. of the occipital artery ....... 752 

277. of the temporal artery ....... 752 

278. of the subclavian artery ...... 753 

279. of the axillary artery .....•• 758 

280. of the brachial, radial, and ulnar arteries .... 759 

281. Double brachial artery ...••••. 760 

282. Ligation of the common iliac . . ' • . • . • 772 

283. of the femoral .....••• 767 

284. of the popliteal ........ 769 

285. of the anterior tibial ....... 770 

286. of the posterior tibial ....... 771 

287. Phlebitis 774 

288. Varix of the leg . . . . . . . . . 776 

289. Structure of an arterial tumor or anastomotic aneurism . . . 783 

290. Ligation of an erectile tumor .••.... 786 

291. > 

292 S ^^^^^^'^ mode of ligating vascular tumors . • . • • 787 

293. Hypertrophy of the tibia from inflammation ..... 796 

294. Abscess in head of tibia ........ 799 

295. Large chronic abscess of the tibia ...... 799 

296. Trephine ....••.... 800 

297. Caries with softening of the cartilage ...... 802 

298. Caries of bone consequent upon tertiary syphilis .... 803 

299. Caries of the head of the humerus ...... 803 

300. Caries of the tibia, showing an ulcer in the skin .... 803 

301. 302, 303. Bone-drill, gouge, and scraper . • . • . .806 

304. Structure of a granulation in a bone ...... 807 

305. Necrosis of the tibia . . . . . • • .811 

306. Necrosed tibia, the dead bone lying loose within the new • . • 812 

307. Cloacae in a necrosed tibia ....... 812 

308. 309, 310, 311, 312. Instruments for removal of dead bone . . .817 

313. Madame Supiot — a case of osteomalacia ...... 818 

314. Section of a softened femur ....... 819 

315. Rickets .......... 822 

316. Eccentric atrophy of bone ....... 828 

317. Atrophy of the cellular tissue of the thigh-bone .... 828 

318. Senile atrophy of thigh-bone, in its advanced stage . • • . 828 

319. General hypertrophy of bone — internal structure .... 829 

320. General hypertrophy of bone— external characters .... 829 

321. Hypertrophy Involving both the thickness and length of bono . . . 830 

322. Osteophytes of inferior extremity of femur ..... 831 

323. Exostosis of the thigh-bone ....... 831 

324. Remarkable form of exostosis of the thigh-bone ..... 833 

325. Ivory-like exostosis, showing its internal structure .... 834 

326. Spongy exostosis of femur ....... 834 

327. Enchoudroma of hand ........ 836 



LIST OP ILLUSTRATIONS TO VOL. I. . 



XXIX 



328. Enchondromatoiis tumor undergoing ossification 

329. Enchondromatons tnmor of the ribs 

330. Anastomotic aneurism of bone 

331. Cjstic disease of the femur 

332. Bncephaloid disease of the tibia . 

333. Enoephaloid disease of the thigh-bone 

334. Colloid tumor of bon« 

335. Tubercular infiltration of bone 
836. Tubercular excavation of the cuneiform bone 

337. Oblique fracture of bones of forearm 

338. Longitudinal and oblique fracture 

339. Appearance of the ends of the fragments 
MO. Impacted fracture of the neck of femar . 

341. Eooephaloid of the thigh, followed hy fracture 

342. Fracture of the end of the radius . 

343. Bisected fhustured tibia, showing the formation of new bone 

344. Union of fracture, showing the condition of the medullary canal 

345. Appearance of ends of fragments in ununited fracture . 

346. Fracture of the arm-bone of a chicken 

347. Wire-rack for fractures of the lower extremity . 

348. Seutin^s scissors ...... 

349. Arrangement of the starch bandage for fractures of the thigh 

350. Dressing in compound fracture of the leg 

351. Fracture of the leg, complicated with wound and comminution of 

352. 353. Incomplete fracture of the bones of the forearm 

354. Diastasis of the femur, reunited .... 

355. False joint in ununited fracture .... 

356. Absorption of the humerus .... 

357. Gimlet for piercing bone ..... 

358. Brainard's perforator ..... 

359. Smith's apparatus for ununited fracture . 

360. Vicious union of fractures .... 

361. Exuberant callus after fracture of the thigh 

362. Fracture of the lower jaw . 

363. Gibson's jaw bandage ..... 

364. Barton's jaw bandage ..... 

365. Pasteboard compress ..... 

366. Hamilton's apparatus ..... 

367. Fracture of the clavicle ..... 
36S. Complete oblique fracture of the clavicle . 
369, 370. Levis's apparatus for fractured clavicle 

371. Figure of 8 bandage for fractured clavicle 

372. Beyer's apparatus for fractured clavicle . 

373. Hunton's joke-splint for fractured clavicle 

374. Fracture of the acromion process .... 

375. Fracture of the neck of the scapula 

376. Fracture of the glenoid cavity .... 

377. Fracture of the coracoid process .... 
37$. The ordinary situation of fracture of the body of the scapula 
379, S.'^O. Fractures of the ribs, showing direction of displacement 
3^1. Fracture of the ribs, united by osseous matter 
3S2. Fracture of the spinous process of a vertebra 
883. Fracture of the vertebral arches . 
3^ Fracture of the vertebne . 
885. Fracture of the odontoid process of the axis 



the bone 



PAOK 

837 
837 
838 
840 
845 
845 
845 
848 
849 
852 
853 
853 
853 
855 
860 
862 
8G3 
864 
864 
869 
872 
872 
872 
874 
878 
880 
881 
883 
884 
885 
886 
887 
889 
893 
894 
894 
895 
895 
898 
898 
900 
901 
901 
901 
902 
903 
904 
904 
904 
906, 907 
908 
911 
911 
912 
913 



xxx 



LIST OF 1LLCSTKATI0N3 TO VOL. I. 



pio. piei 

386. Fractare of the acetabulum ••••••• 913 

387. Fracture of the pubic and ischiatic bones . . . • • 914 

388. Fracture of the shafts of the radius and ulna . . • • .916 

389. Vicious union after fracture of the shaft of the radius . • • . 916 

390. Fracture of the shaft of the ulna ....••• 917 

391. 392. Fracture of the olecranon process . . . . • 917, 918 

393. Fracture of the olecranon process, united by fibrous matter* . • . 918 

394. Apparatus for the same ..... 

395. Fracture of the coronoid process .... 

396. Apparatus for the same ..... 

397. Fracture of the shaft of the radius 

398. Fracture of the head of the radius 

399. Multiple fracture of the lower extremity of th^ radius 

400. Fracture of the lower extremity of the radius 

401. Fracture of the lower end of the radius, complicated with luxation of the nlna . 

402. Bond's splint — the part for the back of the forearm 

403. The same, for the front of the forearm and hand . 

404. Apparatus for fracture of the lower end of the radius 

405. 406, 407. Dr. Swinburne's apparatus for fracture of the radius 

408. Fracture of the condyles of the humerus 

409. Fracture of the internal condyle of the humerus . 

410. Fracture of the outer condyle of the humerus 

411. Fracture of the inferior extremity of the humerus 

412. Complicated fracture of the elbow ... 

413. Fracture with detachment of the head of the humerus . 

414. Fracture of the anatomical neck of the humerus . 

415. Fracture of the surgical neck of the humerus 
616. Welch's shoulder splint ..... 

417. Oblique fracture of the tibia 

418. Tin case for fracture of the tibia .... 

419. Welch's splints for fracture of the tibia . 

420. Bauer's wire splints for fracture of the tibia 

421. Vertical fracture of the fibula .... 

422. Dupuytren's apparatus for fracture of the lower exlremity of the fibula 

423. Fracture of the tibia and fibula at the ankle-joint 

424. Fracture of the extremity and malleolus of the tibia and the lower end of 

425. Appearance of the broken articulating surface of the tibia 

426. Fracture of the lower end of the tibia and fibula . 

427. Neill's fracture box ..... 

428. Extension in fractures of the leg by the gaiter 

429. Extension in fractures of the leg by the handkerchief 

430. Extension in fractures of the leg by adhesive strips 

431. Swinburne's method of treating fractures of the leg 

432. Salter's apparatus for suspending the leg 

433. Smith's suspending apparatus .... 

434. Complicated fracture of the leg .... 

435. Fracture box for the leg . .... 

436. M'liityre's screw splint for compound fracture of the leg 

437. 438, 439. Fracture of the patella .... 

440. Separation of the fragments in fracture of the patella . 

441. Hamilton's apparatus for the same 
442, 443, 444. Fracture of the upper portion of the shaft of the femur 

445. Fracture of the inferior fourth of the shaft of the femur 

446. Jenks's fracture-bed ..... 

447. Physick's long splint ..... 

448. Gross's fracture-box • • . • . 



918 
919 
920 
920 
921 
922 
923 
923 
924 
924 
925 
925 
926 
927 
927 
928 
929 
930 
930 
931 
931 
935 
936 
936 
936 
937 
938 
940 
thefibuU 940 
940 
941 
941 
942 
942 
942 
942 
943 
943 
944 
945 
945 
946 
947 
948 
951 
952 
953 
954 
964 



LIST OP ILLUSTRATIONS TO VOL. I. 



XXXI 



no. 

449. Gilbert's apparatus for compound fractures of the thigh-bone . 

450, 451. Hodge's mode of coanter-extensiou in fracture of the femur 

452. Smith's anterior splint ..... 

453. Mode of application of the same .... 

454. Buck's fracture apparatus .... 

455. Swinburne's treatment of fractured thigh, without splints 

456. Double inclined plane. of Sir Charles Bell 

457. M'Intjre's splint, simplified and improved by Listen 
45S. The same applied to the limb .... 
459. Fracture of the external condyle of the thigh-bone 
4*H). Comminuted vertical fracture of the condyles of the femur 
461. Normal appearances of the head and neck of the thigh-bone 
4(>2. Changes in the head and neck of the thigh-bone from old age 
463. Capsular ligament of the thigh-bone 
464, 465, 466. Intra-capsular fracture of the neck of the thigh-bone 

467. Vertical fracture of the neck of the femur 

468. Senile atrophy of the neck of the femur . 

469. Atrophy which might be mistaken for united fracture 

470. Fibro-ligamentous union of the neck of the thigh-bone 

471. Daniers fracture-bed .... 

472. 473. Extra-capsular fracture of the neck of the thigh-bone 

474. Impacted fracture of the neck of the femur 

475. Impacted fracture through the trochanters 

476. Fracture of the great trochanter . 

477. Sir Astley Cooper's mode of treating fractures of the great trochanter 

478. Acute synovitis 
4TJ. Laced-cap for dropsical joints 
4h). Loose articular concretions 
4-^1. Attached articular concretions • 
Ai'l, Fimbriated synovial membrane 
4?3. Fibroid bodies in the knee-joint . 

454. Section of a strumous ulcer of a cartilage 

455. Section of a strumous tibia 
486. Tuberculosis of the wrist joint 
4^7. Tuberculosis of the elbow 

488. Tuberculosis of the ankle 

489. Tuberculo.<iA of the kuee . 
41^X Appearance of parts in earlier stages of hip-joint di.'^ease 

491. Appearance of parts in advanced stage of hip-joint disease 

492. Changes in acetabulum and head of femur in coxalgia . 

493. 494. Davis's apparatus for extension in coxalgia 

495. Sayre's apparatus for coxalgia .... 

496. Head of the femur in chronic rheumatic arthritis 

497. Changes of the acetabulum in chronic rheumatic arthritis 
49S. Bony anchylosis of the knee .... 
499. Kolbe's apparatus for straightening the knee 
5<••^ Stromeyer's apparatus for straightening the elbow 
.HU. Barton's operation for anchylosis of the knee 



PAOB 

. 955 
955, 956 
956 
957 
957 
958 
960 
960 
960 
962 
962 
964 
964 
964 
965, 966 
966 
970 
970 
971 
973 
974 
977 
977 
981 
982 
990 
997 
999 
999 
1002 
1002 
1003 
1004 
1018 
1019 
1021 
1021 
1025 
1026 
1031 
1032 
1033 
1040 
1040 
1042 
1044 
1044 
1045 



PART FIRST. 



GENERAL SURGERY. 



VOL. I. — 3 



f 



SYSTEM OF SURGERY 



PRELIMINARY OBSERVATIONS. 

UvDER the diTision of General Surgery, I shall consider, at some length, 
the leading facts illustrative of the great principles of surgical diseases and 
injuries, and of the operations necessary for their relief, removal, or cure. Be- 
jBrinning with the subjects of irritation, sympathy, and congestion, as intimately 
concerned in the production and maintenance of many of the most common and 
interesting morbid phenomena, I shall pass successively in review all that relates, 
^nerally speaking, to inflammation and its effects, textural changes, new forma- 
tions, whether benign or malignant, wounds, and poisons ; as all these affections 
are liable to occur in every organ, tissue, and region of the body. To this divi- 
sion of the work, also, naturally appertain the subjects of general diagnosis, 
surgical instruments, and other appliances ; and, lastly, anaesthetics, or the means 
of averting pain during the performance of surgical operations, and in the reduc- 
tion of hernia, fractures, and dislocations. Such an arrangement is suggested 
not less by common sense than by sound experience ; for it is just as necessary 
in surgery to pass from the known to the unknown, or from the more simple to 
the more complex portion of the various topics which fall within its province, as 
it 1.-5 in the study of mathematics, or any other abstruse science. 

The above subjects being disposed of, I shall pass to the consideration of 
Special Surgery, embracing an account of the various surgical diseases, injuries, 
and malformations of particular organs, tissues, and regions of the body. The 
pt^neral principles or great doctrines of surgery being understood, a knowledge 
of the various topics discussed in this part of the work will be a comparatively 
ea>y task. 

The word surgery is a corruption of chirurgery, derived from a Greek com- 
pound, literally signifying manual procedure. Hence, surgery was for a long 
time regard<»d merely as a kind of handicraft, fit to be exercised only by men of 
inf^'rior attainment, ability, and skill. For many ages, in fact, the chirurgeon 
was nothing but the servant of the physician, without whose advice and direc- 
tion he was never permitted to perform any operation, however simple. He had 
no acrency whatever in preparing the system for the approaching ordeal, nor any 
hand in the after-treatment of the case. His task was completed when he had 
made his incisions, spilt a certain quantity of blood, and relieved the suffering 
organ from impending danger, by restoring it to its natural position, or ridding 
it of foreign substances. His occupation was a mere mechanical one ; and, 
although there can be no doubt that he often possessed great manual dexterity, 
yet it is obvious that his very education unfitted him for the exercise of the more 
lofty duties of his profession. The contrast between the surgery of former times 
and that of the present dav, forms one of the brightest pages in the historv of 

35 



86 PBELIMINARY OBSERVATIONS. 

human progress and human achievement. Redeemed and purified by the genius 
of uioderu discovery, it is no longer a handicraft, but a science and an art, reduced, 
if not to perfection, to principles as accurate as any that have been introduced 
into the study of the natural pciences in general, of which, in fact, it forms one 
of the most interesting and useful branches. 

Surgery, thus improved and perfected, can no longer bo separated from medi- 
cine ; any attempt to produce such a severance must prove abortive. They are, 
in point of fact, one and the same science, and therefore indivisible. No surgeon 
can practise his profession with credit to himself, or benefit to his fellow-creatures, 
if he is not an enlightened physician, or deeply grounded in a knowledge of the 
great doctrines of disease. He may, it is true, be an excellent operator, a good 
mechanic ; but unless he is an able pathologist and therapeutist, he is unworthy 
to be intrusted with the health and life of the humblest citizen. 

Surgery has occasionally been separated into two distinct branches, medical 
and operative ; the fonner treating, as the name implies, of the principles of the 
science, or of the nature of disease, and of its management by drugs ; the latter, 
of the various manual, instrumental, and mechanical procedures considered 
necessary for the cure of external affections, and the repair of mutilated struc- 
tures. Upon this plan have been constructed several very excellent modern 
works, as those of Liston, Miller, Fergusson, Sedillot, Blasius, Yelpeau, Pan- 
coast, and Giinther ; but it is questionable whether such a manner of treating the 
subject is altogether judicious, as it is certainly calculated to invest the operative 
part of surgery with a degree of importance that does not legitimately belong to 
it, and which may lead, especially on the part of the young practitioner, to errone- 
ous conceptions of the true province and dignity of surger}^ considered as a 
science and an art. A work on surgery, or, indeed, on any subject, without 
principles, may be compared to a vessel at sea without helm or rudder to guide 
it to its place of destination. If, therefore, there is any one part of the present 
treatise upon the study of which I would insist more than upon that of any 
other, it is that which relates to the great principles of surgery, as comprised 
under the head of inflammation, wounds, morbid deposits, new growths, and 
morbid poisons. Let the student make himself fully acquainted with these 
details, and he can hardly fail to become an enlightened and judicions practitioner. 
Let him learn principles, and he will be able to form a more just appreciation of 
what is merely operative. 



CBAF. !• 



IBBITATION. 87 



CHAPTEK I. 

IRRITATION, SYMPATHY, AND IDIOSYNCRASY. 

It is perhaps impossible, in the present state of the science, to offer any satis- 
factory definition of irritation, or to assign to this expression its true pathological 
and practical import, without an intimate knowledge of sympathy, or of those 
various and mysterious relations, anatomical and functional, which exist among 
the different organs and tissues of the body, and which thus serve to bind them 
til up into one harmonious, uniform, and connected system. Irritation and sym- 
pathy are not only closely associated together, in all the great operations of the 
economy, but they so constantly run into each other, as to render it impossible 
always to draw a precise line of distinction between them, or to determine what 
part they respectively play in the production, propagation, and effect of disease. 
Much of what has been written upon these topics has necessarily been exceed- 
ingrly obscure, de}>cnding not merely upon the intrinsic difficulties of the subject — 
great and perplexing as they certainly are — but upon the unphilosophical man- 
ner in which they have, for the most part, been discussed by surgeons, whose 
authority has not only never been disputed, but regarded with a blind devotion 
as 8uq>rising as it has generally been unaccountable. To arrive at any other 
conclusion from an attentive perusal of their writings, is impossible. Every page, 
nay, almost every paragraph, bears testimony to the fact that they have con- 
stantly confounded together affections of a very different, and even of an o[)po8ite 
nature ; that they have, in numberless instances, violated their own definitions of 
disease ; and that they have attempted to establish systems of treatment based 
uiM>n principles of the most erroneous and unfounded character. 

What is irritation ? Is it an entity, or a mere myth, a certain undofinable 
something, which no one can see, but which every one may recognize by its 
effects ? Perhaps the best definition we can give of it is that it is a disordered 
state of the nerves of the affected part, attended with more or less pain and func- 
tional disturbance, but not with inflammation, although it may lead to that result, 
if not timeously arrested ; in other words, irritation is a disease whose predomi- 
nant symptom is nervous derangement. Viewed in this light, it may be con- 
Fid»T«Kl as l>earing the same relation to the nervous system that inflammation bears 
to the vascular; the one consists essentially in disordered sensation, the other in 
dis<»rdered circulation ; in the one there is pain, but it is the pain of perverted 
s<*nsation ; in the other there is pain also, but it is the pain of inflammation, as is 
evinced by the concomitant vascular injection, discoloration, and tumefaction, 
which are wanting in the former. The differences between irritation and inflam- 
mation have sometimes been defined by stating that the former terminates where 
the latter begins ; just as congestion may be said not to be inflammation, but the 
pn'lude to that affection. Both may be merged in the latter disease, and may, 
cons<»quently, serve to augment and perpetuate it. 

Irritation may be of limited extent, as when it is confined to one particular 
organ, or part of the Iwdy, and is then said to be local ; on the other han<l, it is 
sometimes widely diffused, manifesting itself at numerous points, and constituting 
what is termed general irritation, of which one of the most familiar illustrations 
occurs in nervous shock, consequent upon severe injury. It is also divided into 
din»ct and indirect ; in the former case, the irritation displays itself at the ])lace 
of the morbific impression ; in the latter, on the Contrary, it occurs at a situation 



38 IKRITATION AND SYMPATHY. chap. i. 

more or less remote, sympathy and reflex action being the agents of its transmis- 
sion. An example of direct irritation is afforded in the intolerance of light which 
results from over-fatigue of the eye, and of the indirect, in the convulsions which 
supervene upon the presence of worms in the alimentary canal, the irritation being 
communicated here from the nerves of the bowels to the spinal cord, or the 
cerebro-spinal axis, and from thence to the nerves of the voluntary muscles, the 
seat of the spasmodic action. 

Local irritation may manifest itself in a great variety of ways and circumstances. 
It is generally excited by the contact of some extraneous substance, or agent, 
foreign to the part, and, therefore, a source of offence to it. Thus, a drop of 
alcohol, falling upon the eye, instantly produces pain, and injection of the con- 
junctiva, with an abundant flow of tears ; the organ resents the aggression, and 
the consequence is a marked perversion both of sensation and circulation, which, 
the exciting cause ceasing to operate, soon passes off, the parts regaining their 
comfort and accustomed action ; or, the cause continuing in play, violent and even 
destructive inflammation may succeed, the minor evil being merged into the major. 
A pinch of snuff will excite sneezing by the irritation which its presence induces 
in the pituitary membrane ; on the same principle, some emetics cause vomiting, 
some cathartics purging, and some diuretics an increased secretion of urine. 
When the hand is held near a hot stove, or rubbed with spirits of ammonia, the 
skin presently shows signs of irritation ; its sensibility is perverted, it burns and 
stings, and becomes intensely red. All these, and numerous analogous cases 
that might easily be adduced, if it were necessary, are examples of local irritation, 
or of perverted nervous action, accompanied by vascular determination, but not by 
inflammation, although such an event is certain to occur, if the exciting cause of 
the irritation be not promptly removed. 

Indirect, or reflex irritation, like the direct, also displays itself in different ways, 
and not unfrequently in a manner not less singular than perplexing, defying all 
effort at explanation. The subject offers a wide field for contemplation and study. 
Time and space will permit me to glance only at a few of the more prominent 
facts which naturally connect themselves with such a discussion. To do anything 
even like partial justice to the subject, it will be proper to consider it in relation 
to the principal organs of the body, a procedure which will necessarily bring up 
the question of sympathy, as a knowledge of the latter is indispensable to a cor- 
rect appreciation of the former, and conversely. 

It would be out of place in a work of this kind to inquire into the nature of 
sympathy. All that we know respecting it is that there exists, both in health 
and in disease, an intimate relationship between certain organs and tissues, the 
restilt either of a continuity of structure, similarity of tissue, or of ties, of which 
anatomy and physiology have failed to point out the true character. In health, 
this action is carried' on so imperceptibly as to escape attention ; but, whenever 
there is any serious disorder of the system, it manifests itself at every point, serv- 
ing at once, at least in many cases, to indicate the nature of the lesion, and the 
particular tissues, or set of textures, which it implicates. It is not difficult to 
account for the sympathy that exists between parts that are united together by 
continuity of structure, as, for instance, the eye and nose, or the bladder and ure- 
thra ; or by similarity of structure, as the fibrous membranes, whose diseases, as 
gout and rheumatism, are sometimes suddenly transferred from one to another ; 
but, in other cases — and these constitute some of the most interesting and import- 
ant exceptions — no connection of any kind can be traced, and we are therefore left 
in doubt in respect to its real character. It is only, then, by studying these effects, 
as they exhibit themselves in different parts of the body, and under different cir- 
cumstances, that our knowledge of them can be made practically available at the 
bedside. 

1. Brain. — The brain, from its elevated position in the scale of organs, and 
its importance to health and life, is subject, in a remarkable degree, to the causes 
which develop and influence irritation. Connected, either directly or indirectly, 
with every other organ and tissue of the body, its functions are liable to be dis- 



CHAP. I. BRAIX — SPINAL CORD. 39 

turbed in every variety of way, and in every possible degree, from the inost 
siiuplc and almost imperceptible departure from the normal standard to the most 
complete and thorough perversion, amounting, at times, to total annihilation of 
sensation. Hence, it is not surprising that while the brain is itself a source of 
irritation to other parts, it should, in its turn, be more or less seriously affected 
by irritation having its seat in remote structures operating upon it through 
sympathy, or reflex action. It is in this manner that are developed many of 
the most distressing diseases of the cerebrum and cerebellum, and, also, as a 
natural consequence, of the mind ; and, what is remarkable is, some of the most 
disastrous lesions often have their origin in apparently the most trivial cerebral 
irritation, which, but for neglect or ignorance, might usually be relieved by the 
most simple treatment. The arachnitis of infancy generally begins in reflex irri- 
tation, which has its seat in the bowels, stomach, liver, skin, or gums, fretted, 
perhaps, by the pressure of an advancing tooth. Such cases are of constant 
occurrence in this country, during our hot summer months, and there are none 
which are more justly dreaded by the practitioner. The influence of this kind of 
irritation is often forcibly exhibited in traumatic delirium, or that excited state 
of the brain consequent upon accidents and operations, especially in subjects of 
intemperate habits and of a nervous temperament ; the brain appears to be in a 
state of the utmost tension from pent-up irritability, which nothing but the most 
liberal use of anodynes can generally control ; all the symptoms are such as to 
preclude the idea of the existence of inflammation in the cerebral substance, nor 
is it by any means certain that there is always gastritis, although usually there 
is marked derangement of the stomach. In disorder of the uterus, the brain is 
often affected by reflex irritation, as is plainly evinced by the eccentric pheno- 
mena which so generally attend hysterical diseases. 

On the other hand, disease of the brain is often productive of serious irritation, 
or disease in other parts. Thus, after concussion of this organ, it is by no means 
uhcommon, after the main symptoms of the accident have subsided, to meet with 
paralysis of one side of the face, occasional vomiting, constipation of the bowels, 
irritability of the bladder, or disease of the sphincters, causing involuntary dis- 
charges of urine and feces. 

The sympathetic relations between the cerebellum and testes have always 
been a matter of observation, and afford a ready explanation of the occurrence 
of certain diseases, which, but for a knowledge of this fact, would be impossible. 
Military surgeons long ago noticed that wounds of the occiput, even when they 
do not involve the substance of this portion of the brain, are often followed, at 
varial>le p<*riods after recovery, by atrophy of the testicles. Injuries of the 
cerebellum have been known to be succeeded within a short time after their 
infliction by the most violent sexual excitement. In a case of gunshot wound, 
the particulars of which have been related to me by Dr. Donne, of Kentucky, 
this »c»xual irritation existed in a most remarkable degree. The man was twenty- 
five years of age, and the ball, discharged from a common rifle, penetrated the 
gkull near the lambdoidal suture, whence it passed obliquely downwards and 
liackwards, lodging, there was every reason to believe, in the cerebellum. The 
reaction, which was verj' slow, was attended with excessive excitement of the 
genital organs. Intense priapism supervened on the fifth day, attended with the 
mf>st extraordinary salacity, which formed the all-absorbing topic of his remarks 
during his semilucid intervals up to the time of his death, nine days after the 
receipt of the injury. Nocturnal pollutions and the habit of onanism, in their 
most degrading fonns, are often excited and kept up by a diseased state of the 
brain operating prejudicially upon the testes and seminal vesicles. The effect 
may be produced simply by inflammation of the cerebral tissues, or by the pres- 
sure occasioned by some morbid growth, as a fibrous, scrofulous, or encephaloid 
tumor. 

2. Spinal Cord.— The study of the sympathies and irritations of the spinal 
cord naturally follows that of the brain. Connected as this cord is, on the one 
hand, by the nerves which are detached from its substance, with the organs of 



40 IRRITATION AND SYMPATHY. chap. t. 

volition and of special sensation, and, on the other, bj the acastomoses of these 
same nerves with those of the great trisplanchnie system, its sympathies and 
relations are as universal as they are close and intricate. Hence whatever has 
a tendency to derange these consentaneous movements, must necessarily be a 
source of disease, often of a wide-spread, if not of an all-absorbing character. 
Concussion, for example, of the spinal cord, when not immediately followed by 
death, is generally productive of excessive prostration of the vital j>ower8, hardly 
less extensive and fatal than that of the brain itself. Life often hangs literally 
for hours upon a mere thread ; the face is ghastly pale, the pulse weak and flat- 
tering, the breathing hardly perceptible. In the milder forms, the mind is fre- 
quently disordered for days, the bladder is excessively irritable, the bowels are 
costive, the eye sees objects confusedly, and the ear is incapable of accurately 
noting sound. There are many diseases which may induce spinal irritation ; I 
shall allude only to inflanmiation, ulceration, and displacement of the uterus, the 
practice of self-pollution, constipation of the bowels, and chronic gastric disorder. 
On the other hand, spinal irritation is capable of sending its baneful influence 
through every portion of the system, deranging the functions of every organ, 
and causing a train of phenomena frequently as distressing as they are enigma- 
tical, or difficult of interpretation. Nervous headache, hemicrania, partial para- 
lysis, imperfect sight, partial aphonia, embarrassed respiration, palpitation of the 
heart, gastric irritation, vitiated appetite, costiveness, and disorder of the men- 
strual secretion are often directly traceable to disease of the spinal cord and its 
envelops ; and no practitioner can make much progress towards a cure in these 
affections without bearing in mind the sources whence they spring. The renal 
secretion is often greatly deranged by disease and injury of the spinal cord, and 
a very common effect of such lesions is a tendency to various deposits, especially 
the lit hie and phosphatic. The bladder is also apt to suffer under such circum- 
stances ; becoming irritable, inflamed, and the seat of calculus, especially when 
the spinal cord has l>een severely concussed, wounded, or compressed. Many 
cases of neuralgia, gout, and rheumatism owe their origin, there is reason to 
believe, to disorder of the spinal cord, or the spinal cord and brain. 

3. Nerves. — The ner\^es, those agents which convey to and from the brain and 
spinal cord the impressions made upon the various organs of the body, are them- 
selves not unfrequently the scats of serious diseases and injuries, serving to 
modify and pervert their functions. A spiculum of bone, a ball, or the point of 
a needle, pressing upon a nerve, or partially iml)edded in its substance, has often 
been i)roductive of epilepsy, partial paralysis, loss of sensation, and other 
unpleasant symptoms, which promptly vanished upon the removal of the foreign 
bodv. 

4. Heart. — As the heart is sympathetically connected with every portion of 
the body, so there are few diseases which are not capable of exerting a prejudicial 
influence upon its action, exalting it at one time and depressing it at another. 
It raay be irritated and fretted in a thousand different ways ; now by this thing 
and now by that ; at one time by the solids, and at another by the blood, its 
natural and proper stimulus. Both the surgeon and physician daily witness 
examples of these disturbing agencies, and prepare to meet them by the judicious 
exercise of their clinical knowledge, often sadly tried by the perplexing and dan- 
gerous features of the case. There is no organ, the brain hardly excepted, whose 
action varies so much as that of the heart within the limits of health, and none 
which suffers more frequently and profoundly in disease and accident. The blood 
which, on the one hand, serves to animate and rouse it, and which, on the other, 
it is obliged at every moment to propel to every portion of the body, is itself one 
of the greatest sources of irritation to which it is so constantly exposed. At 
one time the cause of the irritation perhaps is plethora, at another anemia; in 
one case it may be due to an undue proportion of saline matter, in another to 
the presence of some extraneous substance. Among the more prolific sources of 
cardiac irritation are disorder of the digestive apparatus, mechanical obBtraction 



CHAF. I. LUNGS — STOMACH. 41 

to the circalation, howeyer indaced, mental emotion, and derangement of the 
liver, uterus, and kidnejs. 

In injaries, derangement of the sympathetic relations of the heart is of constant 
occurrence, exhibiting itself in yarious forms and degrees, from the slightest dis- 
order of its functions to almost complete annihilation of its muscular powers. 
In shock, the pulsations of the heart are weak and flattering ; in compression of 
the brain, slow and laboring ; in hemorrhage, thrilling and yibratory ; in plethora, 
^rong and foil; in anemia, quick, jerking, and accompanied with a peculiar 
i^ystolic marmur. 

Irritation of the heart is often aroused by compression of the cardiac noryes 
by TarioQS kinds of tumors, by aneurism of the great yessels, and by diseases 
resident in its own tissues, causing them to act in an irregular and imperfect 
manner. 

As the heart's action may be disordered by yarious diseased states of the body, 
so may this organ, in its turn, occasion derangement and irritation in other struc> 
tared, leading not nnfrequently to yiolent inflammations which no remedial 
measures, however judiciously applied, can always arrest and subdue. These 
disordered states form a wide field of study, which it would be out of place to 
parsoe in a work of this kind. The intelligent reader will not fail to appreciate 
their pathological and practical import. 

5. Lungs. — The action and reaction which are so incessantly going on between 
the longs and the rest of the system cannot fail to strike the most superficial 
obseryer. From the importance of their functions, and their extensiye sympa- 
thetic relations, these organs are subject to numerous and diversified changes, 
the influence of which, upon the general health, can only be duly estimated by a 
profound study of the subject. Whatever seriously affects the functions of the 
more important structures is sure, sooner or later, to exert an unfavorable impres- 
sion upon the lungs, disordering the respiratory movements, and untowardly 
interfering with the aeration of the blood, or the introduction of oxygen, and the 
elimination of carbonic acid. Hence, a perfectly healthy state of these organs 
is a matter of paramount importance in the treatment of every case of injury 
and disease. Among the more common objects of attention, with this view, 
should be a pure state of the atmosphere, the use of wholesome food, and the 
correction and improvement of the secretions, without which our best directed 
efforts will often fail to avert irritation and disease, or to combat them success- 
folly when their development has been unavoidable. 

6. Stomach. — The stomach, possessing a wide range of sympathy, is oft(»n' 
the seat, not less than the cause, of severe irritation. Food and drink are the 
natural stimulants of this organ, and, rationally employed, seldom fail to ])rove 
wholesome. But when the laws of digestion are contravened by dietetic debauch 
and indiscretion ; or, in other words, when the stomach is overloaded with indi- 
ge:$tible articles, nausea and vomiting, with more or less cerebral and other dis- 
turlMince, are the necessary and inevitable consequences. In children and delicate 
nervous females, such abuse often manifests its effects in the most violent con- 
vulsions, from the irritation it produces in the cerebro-spinal axis and the nerves 
which are distributed to the voluntary muscles. An overloaded stomach fre- 
qoently brings on a severe attack of asthma, palpitation of the heart, indistinct- 
ness of vision, and distressing noises in the ears. 

Affections of the oesophagus often create excessive irritation of the stomach, 
manifesting itself in nausea and vomiting. Examples of this morbid sympathy 
occur in scirrhus of the cesophagus, as well as in ulceration and ordinary stricture 
of that tul>e. I have seen a foreign body, as a common cent, lodged in the 
cesophagus of a child, keep up nausea and vomiting until it was extracted. The 
irritation of the stomach, produced by tickling the fauces, is well known to every 
one. On the other hand, the oesophagus is liable to suffer very seriously from 
disease of other parts of the IxkIv. Thus, spasmodic stricture of this tube, 
sometimes of an exceedingly severe and intractable character, may be produced 



42 IRRITATION AND SYMPATHY. chap. i. 

by disorder of the stomach, bowels, uterus, or spinal cord, which can only be 
relieved by addressing our remedies to the seat of the primary affection. 

T. Bowels. — Disorder of the bowels is a prolific source of irritation, exhibiting 
itself in different viscera and tissues ; for there are few organs whose sympa- 
thetic relations are of a more varied and extensive character. We have already 
alluded to the effects occasioned by the presence of worms in the alimentary 
canal ; the retention of irritating matter often produces similar impressions upon 
the great nervous centres, followed, in many cases, especially in infants and 
delicate nervous persons, by violent convulsions, disease of the arachnoid mem- 
brane, and palpitation of the heart. Itching of the nose, and various affections 
of the lips, tongue, and fauces, are frequently directly chargeable to dyspepsia, 
constipation and other gastro-enteric derangement. What is called sick head- 
ache affords a familiar illustration of cerebral irritation dependent upon disorder 
of the stomach and bowels, or of these organs and of the liver. Costiveness 
never fails, when long continued, to oppress the brain, and produce a sense of 
general nialaise, 

8. Bectum. — There is an intimate sympathetic connection between the bladder 
and the rectum ; also between the urethra and the lower bowel. In dysentery, 
hemorrhoids and fissure of the anus, strangury and spasmodic retention of urine 
are by no means uncommon, and sometimes constitute a source of real suffering. 
The ligation of a pile not unfrequently compels the surgeon to use the catheter 
for drawing off the urine ; and I have known the vesical irritation in such a case 
to continue for several days. The same affections not unfrequently produce 
spasmodic stricture of the urethra. 

9. Teeth. — A very lively sympathy exists between the teeth and some of the 
other parts of the body ; more intimate and extensive than would at first sight 
seem possible. Children, from the pressure of the teeth upon the gwais, are 
extremely liable, especially during our hot summer months, to vomiting, diarrhoea, 
fever, and convulsions. Arachnitis occasionally supervenes upon difficult denti- 
tion ; and certain affections of the skin, as eczema and porrigo, are frequently 
directly traceable to its effects, and rendered obstinate, if not temporarily incur- 
able, by its persistence. A heated and tumid state of the gums, with thirst and 
redness of the skin, should be promptly met by the free division of these struc- 
tures ; otherwise, \vhat is originally a mere irritation of the brain, stomach, or 
bowels, may soon be transfonned into a fatal infiammation. 

A decayed tooth, even when it does not itself ache, will often cause severe pain 
in the face, temple, neck, throat, or car ; generally, but by no means always, on 
the corresponding side, doubtless because all these parts are supplied by nerves 
derived from the same sources. When the ear is involved, the pain is propagated 
along the nervous cord of the tympanum, a filament of the second branch of the 
fifth pair of cerebral nerves. A carious tooth occasionally creates violent pain in 
a sound one, though at a distance from it ; and the suffering ceases the moment 
the offending tooth is extracted. I have known a severe attack of pleurodynia 
kept up by a diseased tooth ; the patient was bled and purged, but relief came 
only with the removal of the affected stump. Enlargement of the lymphatic 
ganglions of the neck, ulcers of the chin, epilepsy, hysteria, dyspepsia, and vari- 
ous other affections, sometimes of a very obstinate and distressing character, may 
be produced by carious teeth. It is difficult to conceive how a diseased tooth 
could keep up an attack of rheumatism of the hip, and yet the possibility of such 
an occurrence is established by some^well-authenticated cases. Dysmenorrhoea 
has been cured by the extraction of several of the large grinders ; and writers 
refer to instances of intermittent fever which were relieved in a similar manner, 
after the fruitless employment, for several months, of bark and other remedies. 
A decayed tooth has been known to produce neuralgia of the arm, which promptly 
vanished upon its removal. 



CUAF. I. LIVER — KIDNEYS — BLADDER — UTERUS. 43 

10. Liver. — The sympathetic relations of the liver are at once numerous and 
diversified, and any disturbance in them is generally productive of irritation in a 
namber of the more important organs, especially the stomach, bowels, brain, 
heart, and lungs. The skin also frequently suffers in consequence of hepatic 
derangement, and, conversely, the liver from disorder of the cutaneous surface. 
Various medicines, as well as different kinds of food, are capable of seriously 
disturbing the functions of this organ; and it is well known that its secretions 
are often materially disordered by the direct influence of anxiety or strong mental 
emotion. An attack of jaundice is sometimes instantaneously produced by severe 
fright. The timid duellist and the affrighted soldier often suffer from this kind 
of irritation. Hepatic abscesses not unfrequently follow upon injury of the skull 
or brain ; and, on the other hand, disease of the liver occasionally provokes serious 
cerebral irritation. Dyspnoea, palpitation of the heart, nausea, flatulence, and 
vomiting, are conmion effects of disease of this viscus. Pain in the top of the 
right e^honlder has long been recogniized by physicians as a symptom of hepatitis. 
Violent shock is occasionally followed by total suppression of bile; and the 
pasM^age of a gallstone always causes intense gastric irritation. 

11. Kidneys. — The kidneys have important sympathetic relations with different 
parts of the body, manifesting themselves in various forms of irritation, some of 
which are easily explicable, while others are involved in impenetrable obscurity. 
Thus, it is easy to understand why a renal calculus should excite pain in the 
urethra, and a desire to urinate, simply by remembering that there is here a direct 
continuity of structure, the mucous membrane of the kidney being prolonged as 
Cm* as the head of the penis ; but it is very difficult, if not impossible, to compre- 
hend why a foreign body of this kind, as it descends along the ureter, should 
occasion retraction of the testicles, and excessive irritability of the stomach. 
Severe injuries, involving great shock of the system, are often followed by total 
sioppression of urine ; and, on the other hand, there are various affections in which 
this fluid is poured out in enormous quantity. 

12. Bladder. — The bladder also is variously affected by disturbance of its 
sympathetic relations. After injuries, as compound fractures and severe opera- 
tions, the organ is often incapable of contracting upon its contents, thus necessi- 
tating the employment of the catheter ; its perceptive faculties are suspended, and 
a few days usually elapse before they are reinstated, so as to enable the patient 
to i*a.*s his water without assistance. Stone in the bladder causes pain and 
burning in the head of the penis, and retraction of the testicle. Sometimes the 
pain is felt in the knee, heel, and foot; and a curious case has been reported where 
it waii* i»eated in the arm. For a long time the professional attendants were un- 
able to dijicover the cause of the suffering; but at length, the man complaining 
of vesical trouble, a sound was introduced, when he was found to have stone, the 
removal <if which put at once a stop to the unpleasant symptom. A very com- 
mon effect of stone in the bladder is spasm of the sphincter muscle of the anus, 
which is often so great as to interfere with the passage of the finger. The intro- 
duction of a bougie into the urethra occasionally induces swooning, followed by 
violent rigors and high fever; and cases occur, although they are not common, 
of severe pain being excited in the extremity of the coccyx by such an operation. 
In the female, a warty tumor at the orifice of the urethra will occasionally cause 
intense pain in the region of the bladder and kidney, with a frequent desire to 
urinate, and excessive scalding in passing water ; in short, a train of phenomena 
Homely resembling that produced by vesical calculus. A tight and elongated 
prepuce has been known to produce amblyopia and incontinence of urine. 

13. Uterus. — There is perhaps no class of sympathies of greater interest, in a 
pathological and practical point of view, than those which subsist between the 
uterus aii'l the general system. It was a knowledge of this circumstance which 
induced Aristotle to say that the womb was an animal within an animal. The 
moTDing sickness of early pregnancy, the hysterical convfilsions, the depraved 



44 IRRITATIOX AND SYMPATHY. chap. i. 

appetite, the rigors which usher in labor, and the contraction of the uterus when 
the cold hand is suddenly applied to the alxlomen, are all examples of the mys- 
terious relations by which this organ is bound to the rest of the Jwdy. Nowhere 
do these effects display themselves more strikingly than between the uterus and 
the mammary gland. During pregnancy, the breasts begin to sympathize at an 
early period, as is evinced by their tender and tumid condition ; and the effect 
which the application of the child to these organs has, soon after delivery, in 
causing after-pains, is familiar to every one. A knowledge of this fact has in- 
duced obstetric practitioners to take advantage of this means as a remedy for 
inducing contraction of the uterus in case of tardy expulsion of the placenta, or 
tendency to hemorrhage of this organ. The derangement of the stomach which 
accompanies prolapse of the uterus, the pain and swelling of the mammary 
gland from menstrual irritation, the suppression of the lacteal secretion in puer- 
peral fever, and the occurrence of carcinomatous disease of the breast at the 
decline of life, may be cited as additional illustrations of the intimate connection 
between the womb and the rest of the system. 

14. Testicle. — An intimate sympathy exists between the testicle and the parotid 
gland. In mumps, or inflammation of the latter organ, it is by no means uncommon 
for the testicle, after the lapse of some days, to take on inflammation also, and 
generally to such an extent as to bear nearly the whole brunt of the disease. 
The translation of the morbid action is usually quite sudden, and the suffering 
of the testicle is often much greater than that of the parotid, being not only 
attended with severe pain and swelling, but occasionally terminating in complete 
atrophy of the seminiferous tubes. In what manner, or in accordance with what 
law of the animal economy, this occurrence takes place, it is impossible to deter- 
mine, as there is no similarity of texture between these parts, or any direct nerv- 
ous connection. The parotid is supplied with filaments from the ascending cervical 
nerves, and with branches from the fifth cranial ; the testicle, with filaments from 
the spermatic plexus, formed by the sympathetic. 

15. Skin. — Remarkable sympathies exist between the skin and the mucous 
membrane of the alimentary canal, as well as between the cutaneous tissues and 
other parts of the body. Irritations, the result of a disturbance of these rela- 
tionships, are of frequent occurrence, and serve to explain many morbid pheno- 
mena which, but for our knowledge of this circumstance, would be a complete 
mystery to us. The sympathy between the skin and mucous membrane is 
particularly close and intimate, arising from their great similarity of structure, 
it being well known that these tissues are convertible the one into the other, 
although there is no direct connection between them, except at the various 
mucous outlets ; here, however, it is inseparable, and this is perhaps one reason, 
if not the princii>al, why disease of the one is apt to cause disorder of the other. 
The fact that various substances taken into the stomach as food and medicine 
often produce the most singular cutaneous affections, within a short time after 
their introduction, is of daily occurrence. Every one's experience informs him 
of certain articles which he cannot use with impunity. There is no doubt that 
many diseases of the skin, generally of a very simple character, are often greatly 
aggravated and rendered obstinate, by inattention to the diet and neglect of the 
bowels and secretions ; and it will be readily conceded that the practitioner who 
is aware of all this possesses a great advantage in the cure of these maladies 
over one who is ignorant of the circumstance, or wilfully disregards it. It is 
generally supposed that the skin suffers more frequently from disorder of the 
mucous membranes than the latter do from derangement of the former ; but this 
is probably a mistake. It must not be forgotten that there is a marked difference 
in respect to the relative frequency of the affections of these two classes of 
structures in different climates, and at different seasons of the year. In tropical 
regions the prejudicial effects of a disordered state of the skin show themselves 
in a great variety of ways in the mucous membranes, especially those of the 
stomach and bowels, as in different forms of gastric irritation, diarrhosa, and 



cuAP. I. KTES. 45 

drsentery. Errsipelas, carbuncle, and farnncle are generally supposed, and very 
correctly, to be essentially connected with disease of the chylopoietic viscera ; 
indeed the more common varieties of these affections usually owe their origin to 
derangement of the stomach and bowels, and hence the practitioner rarely makes 
much progress towards a cure if he loses sight of this pathological relation. An 
unhealthy state of the skin often produces serious disease of the eye, brain, lungs, 
and liver, which is promptly relieved by attention to the cutaneous surface. 
Observation has shown that in bad cases of burns and scalds life is not uufre- 
qoently destroyed by ulceration of the duodenum, or the U])per portion of the 
bowel, and yet it would puzzle the most profound physiologist to account for 
such an occurrence by a reference to any of the known laws of health and disease. 

16. Eyes, — It is notorious that the eyes, like all symmetrical organs, have an 
important sympathy, not only w^ith each other, but also with many other portions 
of the body, which di^^plays itself both in health and disease, and not unfre- 
qoently becomes a cause of irritation and inflammation. A familiar example of 
this intemnncial action occurs in cataract. When one eve suffers from this 
diiteai^^, the other, at no distant period, is very apt to become affected also. 
Even in ordinary ophthalmia a similar liability to the extension of the morbid 
action is exceedingly common. The sound eye either soon takes on inflammation, 
or, if it be so fortunate as to escape this disease, it is sure to become the seat of 
foch an amount of morbid sensibility as to rendei: it utterly unfit, for the time 
being, for the purposes of useful vision. A percussion cap, or other foreign 
body, lodged in one eye, has not unfrequently been the cause of destructive in- 
flammation in the other ; and this disposition to the involvement of both organs, 
where one is originally exclusively affected, is nowhere more forcibly and pain- 
fully exhibited than in amaurosis. It is true it is not always easy, under the?te 
circumstances, to determine, in any given case, what share of the disease in the 
eve s**condarilv affected is due to the influence of consentaneous imtation, or to 
the operation of the same morbific agency which provoked the original malady ; 
but it may reasonably be assumed, in the absence of positive information, that 
much, in the majority of instances, is the direct result of deranged 8ymi)athy. 
This liability of the eyes to participate in each other's diseases seems to be due 
to the intimat4^^ connection which exists between the optic nerves ; and the same 
cimimstance serves to explain the reason why the eyes are so frequently affected 
in or^ranic disonlers of the brain. 

The eyes and nose are intimately related with each other, first through the 
dii>tribution of the ophthalmic branch of the fifth pair of nerves, and secondly 
through the pituitar}' membrane, which is prolonged upwards through the lach- 
rymal pasiJag*»s to form the conjunctiva. Hence it is easy to see how catarrhal 
affV'ctions should induce pain and redness in this membrane as it is reflected over 
the eyes ; how snuff should excite a flow of tears ; and how sudden ex])osure 
of the eyes to a strong light should cause sneezing. The connections which the 
frontal, infra-orbitary, and other nerves form with the filaments of the ophthalmic 
ganglion enable us to explain the occurrence of amaurosis in consequence of 
blrtw«, wtHinds, and neuralgia of the face, eyebrows, forehead, and temples. 

The eyes are connected with the alnlomiual viscera, particularly the stomach 
and Ixiwels, through the medium of the branches of the sixth pair with the 
grvat sympathetic. The partial blindness, consequent upon gastro-enteric irri- 
tation, is readilv accounted for in this wav; and the same circumstance serves 
to i-xplain the dilated state of the pupil which occasionally attends the presence 
of w«>nns in the alimentary canal of children. It is probable that the pneumo- 
gastric nerves also play an important part in these sympathetic relations, 
oihiTwise it woul^l be difficult to assign a reason for the excessive nausea and 
vnndlting which now and then supervene upon injuries and operations of the 
ey4\ as n-vere blf>ws and the deprt^ssion of the cataract. 

The eyes and teeth sometimes actively sympathize with each other, caries of 
the latter occasionally keeping up violent inflammation of the former, which 
prvMoptly disappears upon the removal of the offending organ. I have several 



46 IRRITATION AND SYMPATHY. chap. i. 

times seen the photophobia attendant upon strumous ophthalmia, speedily 3rield 
in this way, after the failure of numerous other remedies. 

IT. Ears, — A curious sympathy, noticed by all aural practitioners, exists be- 
tween the ears and the respiratory apparatus, and also between the ears and the 
stomach. Thus, pruritus of the auditory tube sometimes provokes coughing and 
vomiting ; and the former of these effects, it is well known, is not unfrequently 
caused simply by probing or sponging this passage in the removal of wax, or 
the extraction of a foreign body. Mr. Wilde, in referring to this phenomenon, 
says that it is by no means unusual, although it cannot be produced in all cases. 
*'l never witnessed it," he continues, "in children or very young persons; it is 
most common in males of about middle life, and is in nowise connected with any 
previous disease existing in the respiratory apparatus. In some persons the 
slightest touch of the floor of the external auditory passage, about midway be- 
tween its external outlet and the inferior attachment of the membrana tympani, 
will bring on violent irritation and spasmodic action in the larynx. In this case 
also the patient will generally tell us, upon inquiry, that he does not experience 
pain ; but the moment we touch this very sensitive spot he feels a tickling sen- 
sation in his throat, which immediately increases to the feeling one has when * a 
bit is gone astray.' What the nervous connection is which induces this has not 
been fully determined, but the fact is worthy of note." 

Arnold has reported a case of chronic vomiting in a child, which long resisted 
a groat variety of remedies, but was promptly cured by the extraction of a bean 
from each ear, the foreign substances having been introduced during play. Mr. 
Toynbee states that he had had under his charge a patient who suffered under 
a cough which no treatment subdued, but which permanently disappeared upon 
the removal of a fragment of dead bone from the auditory canal. 

18. Age and Effects, — All persons are liable to suffer from irritation; but 
there is, as might be supposed, great diversity in this respect, in different indi- 
viduals. Thus, it is well known that persons of a nervous, irritable temperament 
arc more prone to be affected with it than such as are of a sanguine or leuco- 
phlegmatic disposition, owang no doubt to the fact that they possess a more 
highly-wrought nervous system. Women suffer more frequently than men, both 
from local and general irritation ; and some of the worst forms of reflex irritation 
that the practitioner meets with, occur in hysterical females. Infants and chil- 
dren are extremely liable to the disease, the slightest cause often serving to light 
up the most distressing suffering. Loss of sleep, anxiety, grief, hard study, 
intemperance, inordinate sexual indulgence, impoverished diet, and the ener- 
vating effects of a hot climate, are circumstances which all powerfully predispose 
to the occurrence of irritation. The inhalation of the foul air of the dissecting- 
room is another well-known cause operating injuriously upon the system. If a 
young man who is nightly engaged, until a late hour, in the study of practical 
anatomy, pricks his finger, he will be much more likely to suffer severely than 
one from a similar wound who enters the dissecting-room only occasionally. In 
the one case the constitution is deteriorated by exposure, and is therefore inca- 
pable of resisting the effects of disease ; in the other, on the contrary, it is healthy, 
and indisposed to take on morbid action. 

An irritable state of the system often sadly interferes with the reparative 
process. Thus, the healing of a wound is sometimes suddenly arrested by an 
unhealthy state of the system, manifesting itself in a general exaltation of the 
nervous sensibility, altogether incompatible with the development of healthy 
blastema. An aneurism of the aorta, attended with constitutional irritability, 
has been known to prevent the consolidation of a fracture of the femur. These, 
and other similar facts, are of deep practical interest, as they are suggestive of 
valuable therapeutic measures. 

Another very common effect of irritation, especially when extensive or seated 
in an important organ, is derangement of the secretions, not only of the parts 
more immediately aflected, but of the rest of the system. Thus, irritatiou of 



citAF. I. IDI03YXCRASY. 47 

the brain, however induced, is very certain to disorder the functions of the 
stomach, liver, and kidneys, as evinced by indigestion, a bilious appearance of 
the skin, and a high-colored and scanty state of the urine. The salivary glands, 
too, soffer, the month becoming dry and viscid ; the head aches, the pulse is ex- 
cited, and the extremities are cold. 

In conclading this rapid survey of irritation and sympathy, a few remarks may 
be offered on the subject of idiosyncrasy, as it closely connects itself with the 
discQssion of these two topics. 

Idiosyncrasy literally signifies a peculiarity of constitution, or a state of the 
genera] system in which certain articles, whether taken as food, drink, or medicine, 
prodoce an >effect altogether different from what they are accustomed to under 
ordinary circumstances. Thus, lobster and other varieties of shell-fish, although 
they may be used with perfect impunity by most ])ersons, are extremely prone in 
some individaals to induce urticaria, vomiting and purging. A young lady, a 
patient of mine, married, robust, and of a florid complexion, cannot eat eggs, no 
matter how prepared, without being almost immediately seized with vomiting. 
Some persons are overpowered by a particular odor or by the sight of blood. I 
know a lady who has not been able, for many years, to eat watermelon without 
being very speedily attacked with hoarseness, and soreness of the throat and 
mouth, attended with a burning, pricking sensation, nausea, and colicky pains. 
The use of watermelon-seed tea invariably produces a similar effect. Another 
Itdy, formerly a patient of mine, can never take an ordinary dose of laudanum 
without being copiously purged ; opium affects her in a similar manner, but 
morphia does not. Laudanum, administered by the rectum, vomits freely and 
nauseates for many hours. These articles, however, always afford relief to her 
suffering. I am acquainted with several persons, among others a physician, in 
wliom the inhalation or smell of ipecacuanha invariably excites a violent attack 
of asthma, generally lasting for two or three days. In the case of the medical 
practitioner, the perception of the presence of this substance is so keen that, if 
he be in the third story of a house on the first floor of which an ordinary dose 
of the article is compounded, he is instantly seized with spasmodic cough and 
▼he<*zing. A gentleman, for many years my patient, cannot drink a cup of 
green tea without being promptly and copiously purged ; it usually operates 
on the bowels in from fifteen to twenty minutes after it is taken, bringing away 
thin, watery evacuations, accompanied with more or less griping ; black tea pro- 
duces no such effect, which he has experienced from the green from his earliest 
recollection. In two other cases, the use of green tea, even if taken only in small 
quantity, invariably acts ns a powerful diuretic, causing an abundant secretion 
of urine, with a frequent desire to void it, for a number of hours. 

I reniemlier the case of a ]>aticnt, an habitual asthmatic, thirty-five years of 
ajre, a trailesman by occupation, who cannot enter a room where feathers are 
without instantly experiencing an aggravation of his pulmonary affection. To 
provoke this effect, it is not necessary that he should see or smell the feathers ; it 
l* only necessary that they shall be near him. Ijcd blindfold into an apartment 
thus furnished, he will at once be conscious of their presence, and be immedi- 
atf-ly compelled to retreat. 

Idiosyncra.sy not unfrequently displays itself in the operation of various 
m**dicine3, affording thus useful hints to the practitioner in the selection of his 
remedies. There are many persons who cannot take opium in any form without 
being kept awake by it for hours and even days, besides suffering greatly from 
nau«ea, excessive itching, delirium, and other distressing symptoms. The most 
minute quantity of mercury will, in some persons, cause profuse ptyalism, while 
in others the article may be given in large doses and for a long time without the 
filightest effect of this kind, the system being absolutely proof against the action 
of the medicine in any of its forms and modes of exhibition. Most individuals 
are freely purged by a drop of croton oil, and yet we occasionally meet with an 
instance in which hardly any operation upon the bowels is produced by twenty 
times that quantity. , , 

ooom mDmu i., . 

SAN fRA//0WO3 ftAi 



48 IRRITATION AND SYMPATHY. chap. i. 

The above instances, which might be multiplied to an almost indefinite extent 
from my own experience, will serve to illustrate a class of the most singular 
affections, whose influence in modifying, if not in inducing disease, is eminently 
worthy of the attention of the practitioner. 



TREATMENT OP IRRITATION. 

In the treatment of irritation there are several leading indications which claim 
special attention. The first is to remove the exciting cause ; the second, to 
correct the secretions ; and the third, to palliate the disease, both primary and 
consecutive. ^ 

To remove the exciting cause of irritation is not always an easy task. In 
many cases, indeed, it is either wholly inappreciable, or can only be guessed at. 
The duty of the surgeon of course plainly is to get rid of it if he can ; the ball, 
the calculus, the splinter of wood, the dead piece of bone, and the carious tooth, 
are promptly extracted. Irritating ingesta are dislodged by emetics ; offending 
feces by purgatives ; worms by anthelmintics. The mortified toe is amputated ; 
the compressed gum lanced ; the suppurating felon freely laid open. Light is 
excluded from the inflamed eye ; noise from the suffering ear ; cold from the 
shivering surface. In all such cases the indication is evident, and in general easily 
fulfilled. But it is otherwise when the cause is occult. Here the disease must 
be met on general principles ; and the judicious practitioner will do well to look 
into the condition of his patient's secretions, his bowels, and his diet, which are 
among the most common sources of the disease. 

The correction of the secretions is a matter of primary importance in every 
case of irritation, whether local or constitutional. The manner of doing this 
will necessarily depend upon the character of the suffering organ ; but no practi- 
tioner will fully discharge his duty if he neglect attention to this point. The 
viscera whose derangements are most liable to provoke reflex irritation are the 
stomach, bowels, liver, and uterus, and they should, therefore, always be objects 
of special consideration. Not unfrequcntly the cause of the trouble will be 
found to exist in irritation of the spine, or of some particular portion of the brain, 
demanding local depletion and counter-irritation, with perfect tranquillity of mind 
and body. Whatever the cause of the disturbance may be, it will be found that 
purgatives can rarely be dispensed with, while in not a few cases they constitute 
the chief anchor of our hopes. The diet, as a general rule, should be mild and 
unirritant, the proportions of its nutritive principles varying with the exigencies 
of each particular case. 

The last indication is to cure the disease, or to palliate it if it be irremediable. 
To point out the methods of doing this in a class of affections of so protean a 
character as this, would be absurd. Every case must necessarily suggest its 
own treatment. In ordinary instances antiphlogistics, properly so called, may 
usually be dispensed with, and large draughts made upon the narcotic class of 
remedial agents, as their direct influence is to allay pain and spasm, and induce 
tranquillity of the system. The choice of the particular articles must be regu- 
lated by the circumstances of the case, and will often require no little judgment 
and experience for its successful exercise. 



C«AF. II. COXGESTIOX. 49 



CHAPTER II. 

CONGESTION. 

It is practically a matter of no little importance that the surgeon should be 
able to discriminate accurately between inflammation and congestion ; or, in other 
and more comprehensive terms, that he should possess clear and definite ideas 
respecting the more essential differences between these two morbid states ; for 
open their correct appreciation must often depend the result of his treatment. 
The snbjcH^t, it must be confessed, is one of no ordinary difficulty, and a careful 
examination of what has been written upon it will serve to convince any unpre- 
judiced mind that there are no two points in pathology concerning which there 
still prevails a greater amount of confusion ; for what one author considers as 
congestion, another with equal confidence calls inflammation, and conversely; 
leaving thus the young and inexperienced practitioner in painful doubt not only 
in respect to the nature of the disease, but, what is far worse, in regard to its 
proper mode of management. As the subject of inflammation will be fully dis- 
cussed in the ensuing chapter, I shall limit myself here to a plain and simple 
exposition of some of the more important facts relative to congestion, preceded 
by an attempt to assign to this expression its legitimate import. 

Congestion signifies an accumulation of blood in a part, the result either of 
some mechanical obstruction, or of some vital defect in the circulation, interfering 
with the onward movement of the sanguineous fluid. The word is synonymous 
with hyperemia, which Andral has proposed, without any just reason, as a sub- 
stitute for it. It simply denotes the existence of an abnormal quantity of blood 
in a part, without any of the ordinary phenomena and effects of inflammation, 
which, however, it generally accompanies if indeed it does not form a necessary 
consequence of the increased quantity of blood sent into the suffering structures 
ID that disease. Pathologists usually divide congestion into two varieties, de- 
nominated, respectively, the active and the passive. The first, as the name 
implies, is characterized by inordinate activity of the part, as is evinced by its 
scarlet complexion, its augmented temperature, and its functional disturbance ; 
and soon leads, if allowed to progress, to various kinds of deposits, particularly 
the serous and plastic. Passive congestion, on the other hand, is distinguished 
by the dark color of the parf, the enlarged and sluggish condition of the vessels, 
and the chronic march of the disease. Owing to these differences in the action 
and aspect of the affected structures, these two varieties of congestion are often 
denominated arterial and venous ; terms which are ill chosen, as they have a 
tendency to create erroneous impressions respecting the true nature of the two 
lesions, for it is impossible to conceive of any case of congestion, however slight 
or severe, in which the disease is exclusively confined to one set of vessels. 

It will thus be perceived that active congestion is closely allied to inflammation, 
althoujrh it does not, properly speaking, constitute inflammation, except in the 
opinion of certain pathologists, who, as it seems to me, are not very felicitous in 
tb«-ir attempts at separating the two affections from each other, although it is 
evident that they strive very hard to do so. They treat of congestion as a distinct 
entity, and yet they do not hesitate to ascribe to it phenomena and effects which 
belong exclusively to inflammation, and which congestion, considered in the proper 
§ense of that term, is utterly incapable of producing. Whenever a part, how- 
ever situated in relation to the amount of blood it contains, is the seat of morbid 

VOL. I.- 



50 CONGESTION. 



CHAP. IX. 



deposits, it has passed the stage of congestion, and gone over into that of inflam- 
mation. If tliis be not so, then it necessarily follows that active congestion and 
inflammation arc essentially one and the same disease, and that, consequently, it 
would be absurd to attempt to describe them separately. 

In all acute inflammations, whatever their cause or situation, active congestion 
is a necessary antecedent of the morbid action ; one of the first links in the chain 
of the malady. Hence it would not be improper to say that it is part and parcel 
of the inflammatory process, ushering in the disease, and continuing up to the 
very point of effusion ; or, in other words, ceasing only where effusion commences. 
But this is strictly true only to a certain extent ; for there is in every case of 
inflammation a circle beyond the process of the morbid action, where the blood, 
playing about in eddies, has accumulated in large quantity, distending the capil- 
laries, and destined soon to part with some of its constituents, if the disease be 
merged in the inflammation. A real fire is lighted up here ; the part is hot, pre- 
ternaturally red, and perhaps somewhat painful ; nay, it may be, even a little 
tumid, from the dilated state of the vessels; the blood moves with unwonted 
force and velocity; the functional disturbance augments more and more; and 
presently congestion ceasing, inflammation takes its place, and goes through its 
allotted course. Another sign of distinction is that, in active congestion, the 
capillaries, although greatly crowded with blood, are more easily emptied than 
in inflammation : during life by pressure, and after death by injecting matter. 

But active congestion is not always necessarily followed by inflammation, al- 
though prone to pass into that state if it continue even for a short time. The 
cause which induced it having been removed, the vessels cease to attract blood in 
undue quantity, and getting rid of what is redundant, speedily regain their normal 
caliber and function. A familiar illustration of this occurrence is afforded by the 
conjunctiva, when, from any transient cause, a sudden and violent rush of blood 
takes place to the affected part ; in an instant hundreds of vessels, previously 
invisible, become apparent, being crowded with red blood, so as to give the sur- 
face almost a scarlet hue. Now, if we analyze these phenomena, it will be found 
that they depend simply upon a dilated state of the vessels of the eye and the 
presence of an unusual quantity of blood, containing a large number of red glo- 
bules, which, in the healthy state, are either withheld from these vessels, or which 
are propelled along them in such small numbers as not to permit their coloring 
matter to become visible through their delicate walls. 

Another familiar example of active congestion is furnished by what occurs in 
the hand when plunged into cold water, or exposed to a very low temperature. 
The skin soon becomes remarkably red from an unnatural afflux of blood, the parts 
are the seat of an unpleasant tingling sensation, and the capillaries, both arterial 
and venous, are exceedingly dilated ; still, there is no inflammation, or any ten- 
dency to morbid deposit ; the suffering structures are only irritated and preter- 
naturally injected. Cautiously treated, the hand soon regains its natural con- 
dition ; the skin recovers its former hue and sensibility, the blood ceases to 
accumulate, and the vessels resume their normal caliber. But it is otherwise, 
when the case is improperly managed ; the congestion then will not only continue 
but it will steadily increase, and be soon merged in inflammation, or perverted 
action and effusion. 

Now what occurs in the external parts of the body, immediately under the eye 
of the observer, may be supposed to happen, under similar circumstances, in the 
internal viscera. Thus, we know that when there is a sudden repulsion of the 
cutaneous perspiration, the blood is extremely apt to collect in the lungs, causing 
active congestion of the pulmonary tissues, so often the precursor of pneumonia. 
Poison introduced into the stomach almost instantly induces active congestion 
of the mucous membrane of that organ, frequently followed, in a few hours, by 
the most intense and destructive inflammation. A ligature bound tightly round 
a limb affords a good illustration of the manner in which active congestion may 
be supposed to be induced in strangulation of the bowel in hernia and in intus- 
susception. 

A distinction should be made between active congestion in a part, and a de- 



CHAP. II. COXGESTIOX. 51 

termination of blood to a part. Tlie former is always tlie effect of some morbific 
influence ; the latter, on the contrary, may be the result simply of a natural cause. 
Thus, when the infant is applied to the breast there is an instantaneous determina- 
tion of blood to the organ, so as to enable the vessels to furnish the necessary 
supply of milk ; during menstruation, there is a marked determination of blood 
to the uterus, probably accompanied with more or less active congestion. In 
blushing there is a rush of blood to the cheek ; in erection, to the peuis ; in anger, 
joy, and other emotions, to the brain. Excessive, sudden, and overwhelming 
determination of blood to the internal organs sometimes takes place during the 
cold stage of intermittent fever, especially in that variety of it to which Alibert and 
others have applied the term malignant. In the congestive fever, as it is termed, 
of the Southern States, death not unfrequently results within a few hours after 
the commencement of the attack, the system never reacting from the effects of the 
chill. Scarlet fever occasionally proves fatal in a similar manner ; the surface is 
pale, or slightly livid, the extremities are deadly cold, and the internal organs are 
literally inundated with blood, determination and congestion co-existing in their 
worst forms. 

Id passive congestion, the morbid action is distinguished by its peculiarly 
sluggish character ; the vessels are not only dilated, but frequently varicose, tor- 
tuous, elongated, and incapable of contracting upon their crowding contents ; the 
discoloration is dark, venous, or purple, the circulation is tardy and languid, and 
there is often marked evidence of morbid deposits, especially of serum and lymph, 
occupying the cells of the areolar tissue. 

Various causes may give rise to passive congestion. The most common are the 
following : 1st, inflammation ; 2dly, mechanical obstruction ; 3dly, debility ; and 
4thly, dependent position. 

1st. Inflammation, in whatever form occurring, is almost always followed by a 
certain degree of passive congestion ; the affected parts, exhausted by severe 
suffering, are reduced in strength and life-power ; the vessels, dilated to their 
utmost capacity, and perhaps partially ruptured, are too feeble to contract upon 
their contents ; the crippled structures are unusually vascular ; and the slightest 
cause is generally sufficient to rekindle the disease. Indeed, as will be stated by 
and by, an organ that has been once severely inflamed is ever after extremely 
liable to become inflamed again ; passive congestion often lasting for mouths and 
oven vears. 

2dly. Mechanical obstruction is a prolific source of passive congestion. Ex- 
amples occur almost without numlM?r, both in medical and surgical practice. I 
shall allude only to a few, as they will be suflScient fur my purpose. 

A good illustration of the effects of mechanical obstruction in producing passive 
congestion is seen in organic disease of the valves of the aorta, impeding the 
passage of the blood through the lungs. Compelled to remain here habitually in 
undue quantity, the pulmonary vessels soon fall into a state of passive congestion, 
which thus acts as a predisposing cause not only of inflammation, to which indi- 
vidnalt) so affected are extremely prone, but also of pulmonary apoplexy. Ob- 
struction of the larger veins, as the femoral and iliac, is always followed by passive 
congestion in the parts below. In varicose enlargement of the veins of the leg, 
atti'nded with disease of their valves, the blood has great difficulty in finding its 
way to the heart, and the consequence is that the distal portion of the limb is 
always in a state of passive congestion, with a strong tendency to inflammation, 
and different deposits, especially the serous and plastic. Obstruction of the artery 
uf the leg. by fibrinous concretions, is always followed by congestion and inflam- 
mati<»n, if not gangrene of the foot. 

The structures in the neighborhood of morbid growths are generally habitually 
o>ngeste<i ; hence the profuse hemorrhage which so often attends their extirpa- 
ti«>u. Their vessels being compressed by the overlapping tumor, the passage of 
their contents is seriously interfered with, and hence they frequently undergo a 
remarkabV dilatation, almost amounting to a real varicosity. 

3dly. Debility of a part, however induced, is a frequent source of passive con- 
gestion. Examples of this form of the affection are seen in the retina and choroid 



52 INFLAMMATION. chap. in. 

coat of the eye from over-exertion of that organ ; and in various parts of the 
body from loss of innervation, profuse hemorrhage, or other discharges, and from 
the natural wear and tear of the frame. If, under these circumstances, any par- 
ticular organ is more feeble or exhausted than the rest, it can scarcely fail to 
become the seat of passive congestion, or congestion and inflammation. 

4thly. That dependent position may give rise to passive congestion is a matter 
of daily observation. It is in this way that inflammation of the luDgs is so often 
induced during the progress of lingering diseases and accidents, as typhoid fever, 
erysipelas, and compound fractures ; the disease usually begiuDing in the poste- 
rior portions of these organs, in the form of passive congestion, and proceeding 
gradually but steadily from bad to worse, until it proves fatal, a result so much 
the more to be dreaded on account of its insidious character. In the so-called 
bedsores, consequent upon long confinement in one posture, during which the 
pressure of the body is concentrated with peculiar force upon the sacrum, the 
iliac crest, and the great trochanter, similar effects are produced. There is, both 
in these and similar instances, in the first place a determination of blood to the 
most dependent portions of the body, then passive congestion, and, finally, as a 
natural consequence, inflammation ; oft^n followed, in the latter case, by morti- 
fication. 

Passive congestion, however induced, is a frequent cause of inflammation ; 
often of a very destructive character, the more so, because the symptoms which 
attend it are so indistinct, if not so completely disguised, as to prevent the early 
recognition of their real import. It is for these reasons that the practitioner 
should constantly be on the alert whenever he has anything to do with diseases 
and injuries involving long confinement to one particular posture, and an unusual 
amount of expenditure of the vital forces. 

Inasmuch as congestion may be induced by such a variety of causes, it would 
be folly to attempt to lay down anything like a regular systematic plan of treat- 
ment ; to do so, would be to encroach upon every department of pathology and 
practice, both medical and surgical, of which we have any knowledge. The 
judicious surgeon, knowing how likely the continuance of such a condition is to 
be followed by inflammation, or to aggravate inflammation when these two states 
coexist, will do all in his power to avert the evil, or to combat it when he finds 
that it has already taken place. The leading indication of cure, in every case of 
congestion, is to equalize the circulation ; but to accomplish this object often 
demands great judgment and an amount of pathological and therapeutic know- 
ledge such as comparatively few men possess. 



CHAPTER III. 

INFLAMMATION. 

SECT. I. — GENERAL CONSIDERATIONS. 

A THOROUGH knowledge of inflammation is indispensable to every practitioner 
of surgery. It should form the principal subject of his studies during his pupil- 
age, and the main object of his professional contemplation in after-life. When 
it is recollected that there is hardly any disease which comes within the province 
of this department of science that does not originate in inflammation, or that is 
not more or less affected by it during its progress, the truth and force of these 
remarks will appear sufficiently obvious. The smallest pimple upon the nose is, 
in point of fact, as much an inflammation as an erysipelas that covers the face 



CHAP. III. CAUSES OF INFLAMMATION. 53 

and bead. An ulcer of one of the mucous follicles of the mouth does not differ, 
in principle, from an ulcer of one of the glands of Peyer, which are the seat of 
8o much disease and danger in typhoid fever. Many of the maladies, vaguely 
called nervous, are nothing but forms of inflammation, the nature and seat of 
which it is often difficult, if not impossible, to determine. Their predominant 
symptoms are of a nervous character, and hence the diseases which they accom- 
pany are usually considered as nervous, while in reality the reverse is too fre- 
quently the case. 

All accidents, whatever may be their nature or degree, are necessarily followed, 
if the patient survive their immediate effects, by inflammation. The little wound 
made in venesection, the incision left in cupping, and the bite inflicted in leeching, 
woold never heal without the aid of this process ; the parts would remain open, 
and be the seat of incessant bleeding, or they would become festering and putrid 
sores. In a word, there would be no reparation after injuries of any kind, how- 
ever simple, and operative surgery, instead of bearing healing on its wings, and 
being a blessing to our race, would be the merest cold-blooded butchery. Thus, 
it will be perceived that inflammation is capable of playing, as it were, a double 
game in the animal economy, being at one time a cause of death, and at another a 
soarce of life. It is for this reason that it is often designated by the terms healthy 
and unhealthy, according as the one or the other of these states predominates. 

Inflammation may be defined to be a perverted action of the capillary vessels 
of a part, attended with discoloration, pain, heat, swelling, and disordered func- 
tion, with a tendency to effusion, deposits, or new products. In addition to these 
changes, there is also an altered condition of the blood and nervous fluid as an 
important element of the morbid process. In what inflammation essentially con- 
sists, it would be idle to inquire, since it would be just as impossible to unravel 
its true nature as it would be to explain the intimate character of attraction, 
repalsion, gravitation, or cohesion. Hence, in studying its history, all that we 
can do is to examine its causes, symptoms, and effects, or, more properly speak- 
ing, to institute a rigid analysis of its appreciable phenomena. If we endeavor 
to step beyond this, we shall, like our predecessors, lose ourselves in the mazes 
of conjecture and hypothesis, those quicksands upon which so many of the noblest 
minds of the profession have, in all ages since the origin of medicine and surgery, 
been wrecked and stranded, as if to warn us of their folly and the impossibility 
of further progress. 

1. CAUSES OP INFLAMMATION. 

The causes of inflammation are almost as numerous as the circumstances which 
surround us. Whatever has a tendency to affect injuriously our mental or physi- 
cal organization, whether directly or indirectly, is capable of inducing disease, or, 
at all events, of laying a foundation for it. The division of the causes of morbid 
action into predisposing and exciting has long been recognized by pathologists, 
and cannot be dispensed with at the present day. By predisposing causes are 
under^tcxid those which produce in the system, or in a particular part of the 
economy, certain changes, states, or conditions favorable to the development of 
inflammation, without actually provoking it. They are usually tardy in their 
ojieration, and are either natural or acquired, according as they are inherent in 
the constitution of the individual or dependent upon accidental circumstances. 
The exciting causes, on the contrary, are such as are directly concerned in awaken- 
insr the disease, or fanning it, as it were, into existence. It is not always, how- 
ever, in the power of the practitioner to ascertain either the predisposing or ex- 
citing causes of the morbid action, and hence such cases, which are by no means 
unfreqnent, are usually known as occult cases. 

The natural preditfpfmng causes of disease have reference to peculiarities of 
constitution, and to a tainted state of the economy, in consequence of hereditary 
transmission. To the former class belong plethora, debility, and nervous suscep- 
tibility, which prepare the system for disease, by the changes which they produce 
both in the fluids and solids. Persons who have naturally an undue quantity of 



64 INFLAMMATION. chap. hi. 

blood, as indicated by their ruddy complexion, and the extraordinary functional 
activity of their organs, are peculiarly prone to inflammation ; their bodies may 
be compared to a mass of tinder, which the slightest spark is capable of kindling 
into a devouring flame. Those, on the other hand, who are naturally feeble, are 
remarkably prone to local congestions, which, especially when they become habi- 
tual, are sure to lead to inflammation, often lof a very unmanageable character, 
l)ecause it cannot be met by the ordinary remedies. Persons of nervous tempera- 
ment are predisposed to maladies of the brain, spinal cord, and sympathetic nerves, 
as exhibited in derangement of the respiratory, digestive, and genito-urinary ap- 
paratus ; maladies which are generally tardy in their progress, and which are 
often so obscurely marked as to be difficult of recognition. 

The fact that some diseases are transmissible from the parent to the offspring 
has long been known to practitioners. There are family diseases, just as there 
are family likenesses, manners, and peculiarities ; and, what is remarkable, they 
are more liable to be communicated by the mother than the father, as if it were 
her special prerogative to impress her vices, as well as her virtues, upon her de- 
scendants. Another law is that some of these diseases may skip one generation 
to reappear in another, and that it is not necessary that the parents should be 
actually laboring under an attack of them at the period of conception. The 
affections which may be transmitted in this way are gout and rheumatism, pul- 
monary phthisis, asthma, scrofula, carcinoma, and constitutional syphilis, to- 
gether with several others which it is unnecessary here to specify. It is in .this 
wise apparently that God visits the sins of the parents to the third and fourth 
generation of their offspring. In what element of the economy the germ of the 
morbid action is locked up, neither reason nor experience has been able to deter- 
mine ; for a time it would seem to be latent in the blood, and then to explode, 
either suddenly or gradually, with zymotic violence. 

Among the acquired predisposing causes of inflammation are, the effects of 
previous disease, plethora, and debility, however induced. When an organ has 
once labored under inflammation, it is extremely apt to suffer from it again from 
the most trifling causes. The part, enfeebled by the attack, does not recover com- 
pletely from its effects for a long time, if ever. Hence, influences which, in the 
natural state, would not disturb its physiological relations, are, under such circum- 
stances, peculiarly prone to e.xcite disease. A good illustration of this fact is 
afforded in the tonsillitis of children, in whom a reproduction of the malady is 
almost sure to be awakened upon the slightest exposure to cold. It is not neces- 
sary here to enlarge upon plethora and debility as predisposing causes of inflam- 
mation. If these states of the system are capable of preparing it for the devel- 
opment of diseases when they are a natural result of the organization, it may 
readily be supposed that they would be much more likely to produce such an 
effect when they are acquired, in consequence of the mode of life of the indivi- 
dual, or of the influence of structural lesion. 

Age, sex, temperament, occupation, food, dress, exercise, climate, and season, 
are all so many predisposing causes of inflammation. Infancy is particularly ob- 
noxious to enteritis, croup, and arachnitis ; childhood, to affections of the skin, 
struma, parotitis, and tonsillitis ; manhood, to pneumonitis, carditis, and diseases 
of the genito-urinary organs ; and the decline of life, to gout and rheumatism, 
asthma, arteritis, and the various forms of malignant maladies. 

The differences in regard to the liability of inflammation in the two seses arises 
mainly from their anatomical peculiarities, and are much less common than is gen- 
erally imagined. The function of parturition renders the female particularly liable 
to peritonitis, phlebitis, arachnitis, and carcinoma ; while the male, from his occu- 
pation and mode of life, is more prone to cystitis, urethritis, gout, rheumatism, 
arteritis, hepatitis, pneumonitis, and pleuritis. 

Of the influence of temperament as a predisposing cause of disease, too little 
is known to enable us to speak with any degree of certainty. The sanguine tem- 
perament, characterized by plethora with inordinate capillary activity, disposes 
to inflammation of the internal organs ; while the lymphatic is apt to be attended 



CMAT. III. CAUSES OF INFLAMMATION. 55 

with affections of the skin, joints, serous membranes, stomach, bowels, and lym> 
phatic granglions. 

Occupation is a powerful predisposing cause of inflammation. Persons who 
work much in the open air, and who are much subjected to the influence of cold 
and wet, are extremely liable to suffer from pneumonia, arthritis, tonsillitis, and 
enteritis. A sedentary life leads to chronic disorder of the alimentary canal ; 
and, if conjoined with constant mental exertion, is liable to be followed by dis- 
eases of the brain and arachnoid membrane. Excessive exercise of an organ, as 
of the larynx in singing and speaking, is always a predisposing cause of inflam- 
mation. 

The influence of food in disposing to inflammation is well known. The habi- 
tual use of stimulating articles of diet, especially when conjoined with a want of 
due exercise, is among the most powerful of the causes under notice. On the 
other hand, an impoverished diet, or a privation of nitrogenous food, by inducing 
a defective blood, leads to scur\'y, chlorosis, typhoid fever, scrofula, and inflam- 
mation of the serous structures, terminating in dropsical effusions. Certain 
articles, as ergot, if employed for any length of time, or in any considerable 
quantity, dispose to arteritis and gangrene of the extremities. The habitual in- 
dulgence in alcoholic drinks leads to gastro-enteritis, hepatitis, and attacks of 
epidemic diseases, whenever such diseases are prevalent. 

Dresfi may be an indirect cause of inflammation. It may keep the body too 
warm or too cold, or exert injurious compression ; in either event, local congestion 
will be apt to be induced, which the slightest circumstances may fan into disease. 

A change of climate, whether from hot to cold, or cold to hot, powerfully pre- 
di.sposes to inflammation. Hence the period of acclimation is always peculiarly 
trying, and few persons escape without suffering. Season, too, exerts a predis- 
posing influence. Thus, in summer, inflammation is most apt to assail the 
stomach and bowels ; in winter, the lungs, pleura, joints, and throat. 

Menial excitement is a prolific source of inflammation. Fear, grief, anxiety, 
hard study, and loss of sleep, by deranging the secretions, and interfering with 
the digestive process, all dispose to this disease. In short, whatever has a ten- 
dency to interrupt, disorder, or arrest healthy action, is apt to exert a pernicious 
influence. This is often the only way in which we can account for the occurrence 
of erysipelas, carbuncle, rheumatism, cerebritis, scrofula, and carcinoma. 

The exciting causes of inflammation are extremely numerous, and of the most 
diversified nature ; they act in two ways, either directly upon the parts, or indi- 
n*ctly through the system. Hence they are said to be local and constitutional ; 
and the former are either of a chemical or mechanical character. 

Among the chemical causes are, first, high degrees of heat, as hot water and 
iron ; secondly, partial application of cold ; thirdly, caustic substances, as the 
alkalies and acids ; fourthly, acrid vapors, hartshorn, and gases ; fifthly, certain 
secretions, as urine and bile ; sixthly, blisters, embrocations, and rubefacients ; 
and, lastly, various septic agents, as those of smallpox, syphilis, glanders, 
and malignant pustule. All these agents act directly upon the parts to which 
they are applied, either destroying them by their immediate effects, or combining 
with them in such a manner as to change completely their structure and function. 
Their operation is always rapid, and the resulting inflammation is usually marked 
by severe symptoms, both local and constitutional. 

' The mechanical causes comprise, first, punctures, incisions, contusions, and 
lacerations ; secondly, fractures, and dislocations ; thirdly, sudden and forcible 
distensions, as from the accumulation of pus, serum, blood, or gas ; fourthly, 
compression, as by bandage, ligature, posture, or effused fluids ; and, fifthly, the 
presence of foreign bodies, as a stone in the bladder, a bean in the air-passages, 
a bullet in the flesh, a tubercle in the Inng, or a fibrinous concretion in the brain. 
Embolism, or the formation of clots in the bloodvessels, leading to obstruction in 
the circulation, frequently occasions inflammation. The manner in which these 
rarioos causes act in producing disease is too evident to require explanation. 

The constitutional causes of inflammation make their impression either directly 
upon the part, or indirectly through some remote structure. Logically speaking. 



56 INFLAMMATION. chap. hi. 

it would perhaps be more proper to say that they all act in the latter way, and 
not in any case immediately upon the part, as is usually asserted they do. Thus, 
a morbific impression primarily made upon the respiratory passages, as the inha- 
lation of some noxious gas, or the contact of malaria, instead of causing disease 
in the lungs, or some of its constituents, often, if not generally, explodes upon 
some other organ, perhaps very distantly, if at all, associated with the lungs by 
sympathy, or similarity of structure and function. A septic poison, for example, 
as the virus of smallpox, introduced into the system, acts not merely upon the 
blood into which it has been conveyed by the absorbent vessels, but also, and 
mainly, upon the cutaneous tissues, for which it evidently has a greater elective 
aflSnity than for any other part of the economy ; if it produces any action at all 
upon other structures, it is altogether of an indirect character. In the transmis- 
sion of secondary syphilis from the parent to the offspring, the force of the disease 
is spent, in the first instance, upon the skin and mucous membrane of the throat 
and mouth ; there is no inflammation, so far as we are able to determine, in the 
cellular, fibrous, and serous tissues, or in the internal organs, properly so called. 
In tertiary syphilis the bones, periosteum, and cartilages are particularly prone 
to suffer, although the disorder has a more general tendency, as there is more 
profound contamination of the system. 

Whatever doubt, however, there may still be respecting the mode of action of 
the above agents, there can be none about the operation of heat and cold, which 
are such prolific causes of inflammation. The influence of a tropical sun, acting 
upon an impressible nervous system, in producing hepatitis, is well known to 
the practitioYiers of our Southern States, and to those of Africa, Asia, and the 
West Indies. Gastritis and enteritis, in their worst forms, are often developed 
in the same manner. The effect of cold feet in producing tonsillitis, croup, 
pleurisy, pneumonia, enteritis, cystitis, and rheumatism, is familiar to every one. 
In all these instances the primary impression is made through the medium of the 
skin, by suppressing the perspiration, and throwing the onus of the functional 
disorder upon some internal and remote organ, between which and the cutaneous 
surface there is not the least direct connection. 

Excessive shock, whether induced by direct nervous exhaustion, or by loss of 
blood, is a prolific cause of inflammation, often followed by the worst conse- 
quences. The inflammation which succeeds to gunshot, railway, and other severe 
injuries, is generally extremely violent, and is prone, when the patient survives 
their more immediate effects, to give rise to secondary lesions, often more fatal 
than the primary. The system thus affected does not seem to have sufficient 
vitality to keep the morbid action within proper limits. Hence its disposition 
to spread not only over the parts originally implicated, but to other structures, 
more or less remotely situated. 

The blood itself is a frequent source of inflammation ; sometimes, because it is 
overloaded with earthy salts or other irritating materials, as the poison of erysi- 
pelas, carbuncle, and various eruptive diseases ; at other times, because of its 
impoverished condition, rendering it unfit as a supporter of life and nutrition. 
There is reason to believe that the latter cause lies at the foundation of many of 
those low and unhealthy forms of inflammation which so often eventuate in 
destructive ulceration of the mucous and cutaneous tissues, as well as of some of 
the worst forms of morbid deposits, as imperfectly vitalized lymph, albumen, and 
tubercle. Deficient secretion, especially of the liver, kidneys, and skin, is a fre- 
quent cause of disease, various substances being thus retained in the circulation, 
much to the detriment of the general economy, as well as of particular organs, 
perhaps already predisposed to morbid action. 

From the foregoing considerations it will be perceived that inflammation may 
be traumatic or idiopaihic^ that is, produced by external injury or by constitu- 
tional causes, the latter of which are often wholly inappreciable by our senses. 

Inflammation is sometimes caused by sympathy. Thus, the eye occasionally 
suffers in consequence of disorder of the stomach, the brain of derangement of the 
intestines, the mamma of disease of the uterus, and the testicle of lesion of the 
urethra. A man who has for years habitually overtaxed his digestive powers, 



CDAF. III. EXTEXSIOX OP INFLAMMATION. 57 

and in the meanwhile taken hardly any exercise, will be extremely apt, in time, 
to perish from carbuncle or erysipelas ; or, at all events, to have disease, in some 
form or other, of the skin, simply because these parts are intimately related to 
each other by similarity of structure and function. For the same reason disease 
of the skin is very liable to be followed by disorder of the alimentary canal. 

Finally, inflammation may be caused by metastctsis. The event is character- 
ized by a transfer, for the most part gradual, but occasionally quite sudden, of 
irritation from the part originally affected to another, perhaps at a considerable 
distance from it, and in nowise related to it by structure or function. In inflam- 
mation of the parotid gland the testis is often involved in this way, but why it 
shoold be, neither our anatomical nor physiological knowledge enables us to 
explain, as there is no traceable connection of any kind whatever between them. 
In rheomatism of the joints the heart often suffers ; and in erysipelas of the skin 
the morbid action frequently leaves one part of the surface and breaks out upon 
another. Such occurrences, which are sometimes greatly promoted by our local 
applications, should always be sedulously watched, as they are generally fraught 
with danger, especially when they show themselves in important internal struc- 
tures. 

2. EXTENSION OP INLAMMATION 

All inflammations, of whatever character, are, in the first instance, strictly 
local, that is, they begin in, and are confined to a particular tissue, spot, or point, 
from which, as from a conunon focus, the morbid action radiates in different direc- 
tions, until it becomes, so to speak, general. To illustrate my meaning, let it be 
supposed that the malady commences at a certain part of the mucous coat of the 
small bowel, as, for example, in one of the glands of Peyer. After having 
remained here for a short time, it gradually spreads to the fibro-cellular lamella, 
then to the muscular fibres, and finally to the peritoneal investment, thus involving 
the whole in one mass of disease. In erysipelas the same law is observed. Here 
the morbid action, beginning at a little point of skin, gradually extends to the 
deeper structures, until, as in the case of a limb, it invades cellular substance, 
aponeurosis, muscle, vessels, nerves, periosteum, and occasionally even bone. A 
pneumonia, in its progress, usually involves the pulmonary pleura and the bronchial 
nincons membrane. These instances will suffice to prove the position here 
assumed, which is the more important because it presents the characters of a 
general principile. 

The rapidity with which inflammation extends from one texture to another is 
too variable to admit of any precise statement ; in some instances the time is 
very short, perhaps not exceeding a few hours, and such cases are, it may be 
remarked, generally very prone to be characterized by more than usual violence. 
It must not, however, be inferred from this statement that the morbid action 
always spreads from the point originally attacked ; for, although there is unques- 
tionably a very strong tendency to this, yet there are numerous exceptions to it. 
In some cases this limitation is due to the nature of the disease itself; in others, 
it depends upon the deposit of plastic matter ; while in a third series of cases it 
is owing to the structure of the overlying tissue, as, for example, in the periosteum, 
which often serves to protect the bone which it surrounds from the encroachment 
of disease of the soft parts. 

One of the most common modes in which inflammation propagates itself is by 
r-r^ntinuity of structure. The morbid action, once begun, finds it easy to pass 
along the tissues in which it originated, and hence it often spreads rapidly over 
a large extent of surface, similarity of structure and function favoring the process. 
By continuity of surface an erysipelas of the skin, perhaps not larger at its com- 
mencement than half a dime, spreads in a few hours over an entire limb, or even 
over tbe greater portion of the body. In the same manner inflammation is liable 
to be propagated along the mucous canals, as is exemplified in tonsillitis, croup, 
and other affections of the throat and air-passages, and in the various di^:eases 
of the stomach, bowels, and genito-urinary apparatus. In duodenitis the morbid 
action oiay readily extend along the choledoch and hepatic ducts to the liver; 



58 INFLAMMATION. chap. hi. 

and in gonorrhoea nothing is more common than for the disease to spread along 
the seminal passages to the epididymis and testis. 

Secondly, iutiammation may propagate itself by contiguity of structure. A 
phlegmonous er}'sipelas of the skin has a tendency not merely to spread oyer the 
ncigii boring surface, in consequence of its similarity of structure and function, 
but also to extend in depth, thereby involving cellular tissue, aponeurosis, muscle, 
nnd, in short, every other texture within its reach. The tissues mainly concerned 
in the enteri)rise are the vascular and connective, the peculiar structure of which 
renders them highly favorable for the propagation of the morbid action. An 
inflammation, beginning in the conjunctiva, often in its progress involves the 
entire eye, simply from the intimate manner in which its different tunics are 
superimposed upon each other. In the bowel and other mucous canals the same 
effect is frequently witnessed. In pneumonia, especially in the more violent 
forms, the disease is rarely confined to the parenchymatous substance, but is 
almost sure, in time, to spread to the pleura and bronchia. In orchitis, although 
the inflammation is primarily seated in the tubular structure of the epididymis 
and testicle, it is by no means uncommon for it to extend to the albugineous coat, 
and occasionally even to the vaginal. An inflammation of the synovial membrane 
of a joint often spreads, by virtue of the same law, to the articular cartilage and 
the hciad of the bone beneath, contiguity and intimate connection favoring here, 
as elsewhere, the propagation of morbid action. 

Thirdly, the extension may be effected through the agency of the veins and 
b/mphatics. Of the former a good example is afforded by what occasionally 
happens in venesection, where, apparently from the use of a foul lancet, the 
infianimation sometimes spreads from the little wound in the vessel, at the bend 
of the arm, as high up as the right auricle of the heart ; and of the latter by 
what occurs in chancre, where the poison, taken up by the absorbent vessels of 
the penis, is conveyed by them to the glands of the groin, where it causes a 
hard and painful swelling, constituting what is termed a bubo. In dissection 
wounds the absorbent vessels always serve as vehicles for the transmission of the 
peculiar poison which gives to these lesions their characteristic features. For a 
short period after the inoculation the poison is apparently latent, when its effects 
show themselves by one or more red lines extending up the limb as far as the 
axillary glands, whence, as from a common centre, its injurious consequences are 
radiated over the whole system. 

Of the extension of inflammation by nervous agency , or sympathy, a familiar 
example is afforded in parotitis. In this disease, which attacks chiefly young 
subjects, the inflammation often suddenly leaves the organ originally involved, 
and fastens itself upon the testicle, which is then compelled to bear the whole 
onus of the morbid action. Of the precise manner in which this transfer is effected 
we are ignorant. That it is not through any direct nervous connection is suffi- 
ciently obvious, for everybody knows that no such connection exists ; hence, as 
the only plausible explanation left us, we must conclude that it is brought about 
by the operation of sympathy, although of the nature of this operation it is 
impossible, in the present state of the science, to form any just idea. . A similar 
relationship exists between the mamma and uterus, the stomach and lungs, and 
between the stomach and brain, or, rather, between the former organ and the 
arachnoid membrane. 

Finally, inflammation may be propagated by the blood. This fluid, as will 
afterward appear, undergoes various changes in this disease, of which the most 
important is an increase of fibrin and colorless globules, with a strong tendency 
of these substances to adhere to the sides of the vessels as they are propelled 
along with the general circulating mass. The blood, thus altered in its properties, 
leads to obstruction of the capillaries in different parts of the body, thereby 
establishing foci of morbid action. It is not improbable that metastatic abscess, 
or what is now called pyemia, is generally produced in this way ; at all events, 
this is a more rational mode of accounting for that occurrence than the one which 
attributes it to the absorption of pus, or the admission of this fluid into the blood, 
through the agency of open-mouthed veins. 



Clip. III. VARIETIES OF INFLAMMATION. 59 

3. VARIETIES OF INFLAMMATION. 

With the exception, perhaps, of the epidermis, the hair, and nails, there is no 
part of the human economy which is not susceptible of inflammation and its con- 
e^qoences. The reason whj these structures are usually considered as incapable 
of this process is, that we are not able to demonstrate in them any bloodvessels, 
nenres, and lymphatics, which are the great and essential elements of organization 
in the more thoroughly elaborated and complex tissues. Notwithstanding this, 
it is extremely difficult to unite in so sweeping a conclusion, when we reflect upon 
the fact, of which daily observation furnishes examples, that these external covcr- 
ings undergo various lesions, of form, size, color, and consistence, which can only 
be explain^ on the assumption that they are the product of inflammation, modi- 
fied by the nature of the affected parts. There are other structures, as the 
arachnoid membrane, the cornea, and some of the cartilages, in which it is impos- 
sible to detect vessels, and yet no one would doubt for a moment, on this account, 
that they are incapable of disease. We should, therefore, I think, not make any 
exception, as it respects the possibility of the occurrence of inflammation, even in 
regard to the scarf-skin, the hair, and nails. 

The susceptibility of a part to inflammation may be stated to be, as a general 
rule, in direct proportion to the amount of its vascular and nervous endowments, 
the importance of its functions, and the nature of its exposure. Hence it is found 
to be most common in the skin, cellular tissue, the mucous and serous membranes, 
the joints, lungs, liver, kidneys, bladder, urethra, ovaries, and uterus. The only 
exceptions to this law are the brain and heart, which, notwithstanding their inces- 
sant labor, the excessive delicacy of their organization, and their universal sympa- 
thetic relations, are comparatively rarely the subjects of inflammation. In the 
thyroid body, the salivary glands, the pancreas, the prostate, and the spleen, to- 
gether with the voluntary muscles and their tendons, the nerves, vessels, fibrous 
membranes, and even the bones, the disease is also quite uncommon, although 
several of these structures are sufficiently prone to suffer from inflammation as it 
manifests itself in certain forms of syphilis, scrofula, and rheumatism. It is easy 
to know why the skin should be so frequently diseased when we reflect u])on its 
vast extent, its wonderful vascularity and nervous endowments, its sympathy with 
the brain, lungs, stomach, and, in fact, almost every organ in the economy, and its 
constant exposure to all kinds of injurious impressions. For the same reason it 
is not difficult to account for the frequent occurrence of pneumonia, hepatitis, 
nephritis, and inflammation of some of the other viscera. The cellular tissue, 
although less highly organized than the skin, is yet a frequent subject of disease, 
growing out of the circumstance that it is the great connecting link by which the 
various tissues of the frame are c(^mented together, and also that it serves as a 
means of transmission of the vessels and nerves from one part to another. The 
functional activity alone of some of the organs affords a ready key to their lia- 
bility to inflammation. Thus, the genital organs are almost exempt from disease 
until the age of puberty ; but from that time on, when their slumbering season is 
over, and their fretful life begins, they are extremely prone to morbid action, both 
common and specific. 

The progress of inflammation exhibits much diversity, being at one time rapid, 
at another slow ; hence the distinction into acute and chronic. An acute attack 
ia one which runs its course swiftly, and which is characterized by well-marked 
symptoms, as is seen, for example, in tonsillitis consequent upon a severe cold, 
where, in the space of a few days, the affected gland acquires a large bulk from 
vascular engorgement and interstitial deposits, attended with great local and 
constitutional disturbance. Force and rapidity of action are its distinguishing 
features. Chronic inflammation, on the contrary, is marked by comparative 
slowness and feebleness of action ; the attendant phenomena are also less bold, 
although there is generally a decided tendency to effusion. It may be the sequel 
of an acute attack, or it may show itself as a primitive affection : that is, it may 
exist for a considerable period without being discovered, owing to the absence of 
the nsojil diagnostic signs. Once in this condition, it may last almost for an 



60 INFLAMMATION. OHAP. hi. 

indefinite time, as is exemplified in certain cases of gleet, leacorrhcea, tonsillitis, 
osteitis, arthritis, otorrhoea, and ophthalmia. 

Inflammation may be healthy or unhealthy, according as it manifests a tendency 
to restoration or to mischief. It would be wrong to regard inflammation always 
in the light of a disease, since it is the means which nature must necessarily em- 
ploy whenever she wishes to repair the injury which has given rise to it. It is 
only when the process proceeds blindly, so to speak, that it is likely to be pro* 
ductive of harm by overpowering the part and system. An incised wound, 
occurring in a sound constitution, will, if properly managed, heal promptly by 
union by the first intention ; but if the reverse be the case, there will not only be 
no immediate union, but its edges will separate, and suppuration taking place, a 
long time may elapse before consolidation will be completed. In the one case, 
the action is said to be healthy, in the other unhealthy ; and it will generally be 
found that the nature of the action is a true index of the condition of the part and 
system ; as the latter is, so will be the former. There are of course exceptions to 
this law, but they are infrequent and unimportant. 

There is a form of inflammation to which pathologists have applied the term 
irritable, but which in reality does not differ materially from unhealthy inflam- 
mation. The best illustrations of it occur in strumous ophthalmia, in ulcers of 
the extremities, in rupia, and in chronic tonsillitis, bronchitis, dysentery, cystitis, 
urethritis, and orchitis. It seems to depend upon an exaltation of the natural 
sensibility of the affected structures, aggravated by an unsound state of the 
nervous system. 

Inflammation may be common or specific; common, when it proceeds from 
ordinary causes ; specific, when it is produced by some peculiar poison, as that 
of gonorrhoea, syphilis, or smallpox. A more important distinction is that cer- 
tain inflammations are capable of appearing only in certain tissues. Thus, 
erysipelas is generally a disease of the skin ; in rare instances it involves the mucous 
membrane of the mouth and throat, and, perhaps, also the peritoneum and pelvic 
veins, as in lying-in females ; but it never fastens itself, as a primary affection, 
upon the muscles, aponeuroses, nerves, arteries, bones, cartilages, or internal 
viscera. Gout and rheumatism have a special fancy for the joints and fibro-serous 
textures ; secondary syphilis, for the skin and fauces ; tertiary syphilis, for the 
bones and periosteum ; scrofula, for the lymphatic ganglions ; and carcinoma, for 
the glandular structures, as the mamma, uterus, and liver. 

Finally, inflammation may be latent. This expression is curious, and yet full 
of meaning ; it simply implies that the morbid action does not reveal itself by the 
ordinary phenomena. Such an inflammation is always to be dreaded, because, 
being of a peculiarly insidious character, it is extremely apt to be overlooked, 
One of the best examples of this form of disease is afforded by the glands of 
Peyer in typhoid fever, the inflammation and ulceration of which constitute the 
anatomical lesions of that singular malady. Patients thus affected seldom com- 
plain of pain, or, indeed, of any other suffering directly referable to these bodies, 
even when the morbid action is so extensive as to lead to perforation of the bowel. 
Latent pneumonia is a sufilciently common disease, and abscesses of the spine 
and other parts of the body often make great progress before their true nature is 
even suspected. 

4. TERMINATIONS OR EVENTS OF INFLAMMATION. 

Inflammation has various modes of termination ; upon strict inquiry, however, 
it will be found that these amount only to two, and that all the rest are merely 
so many states, conditions, or events of the process. This distinction is real, 
not imaginary, and therefore of no little practical value. Philosophically speak- 
ing, there are but two terminations of the morbid action, the one being in health, 
the other in the death of the part The former may occur by delitescence and 
resolution ; the latter, by ulceration and gangrene. All deposits, whether serous, 
plastic, purulent, or sanguineous ; and all changes of structure, whether in the form 
of softening, induration, contraction, or thickening, are to be viewed simply as 80 



CHAF. III. LOCAL SYMPTOMS. 61 

mmnj prodocts, effects, or results of inflammation, without necessarily involving a 
sospeasioD of the process itself. This indeed may still go on, sometimes even for 
an indefinite period, and thus produce additional changes, more serious, perhaps, 
in their oonseqnences than those which attended the act in its earlier stages. In 
nippuration, for example, the inflammation does not generally end the moment 
matter forms, or as soon as the pyogenic crisis has been fairly attained ; instead 
of this it proceeds in a modified state, accompanied by ulceration, or still further 
deposits. The same remarks are applicable to lymphization and even to the 
prodnction of serum, the latter of which may be regarded as one of the processes 
employed by nature to deplete the inflamed tissues ; in this, however, she gene- 
rally sncoeeds only by degrees, as is shown by the fact that the disease often 
continiies for a considerable length of time after the drainage has commenced. 
Blood, either perfectly pure, or variously combined with the secretions of the 
affected surface, may be poured out quite freely, and yet the morbid action con- 
tinoe as Tigoronsly as before, as is exemplified in dysentery and other hemorrhagic 
forms of inflammation. Hence there is really no such thing as a termination of 
inflammation in effusion of serum, deposit of fibrin, or the formation of pus. 
These events occurring, the morbid action may still go on, being merely modified 
in its ebaracter by the influence exerted upon it by the attendant secretion or the 
nature of the morbid product 

The ncmenclaiure of inflammation has been much simplified within the last 
quarter of a century. As it now stands it is based essentially upon the anatomy 
of the affected tissue, structure or organ, the term itis being merely added to the 
name by which the part is generally known, as sclerotitis, cystitis, laryngitis. 
Sometimes, however, the old expressions are retained, as quinsy for inflammation 
of the tonsils, ophthalmia for inflammation of the eye, and gonorrhoea for inflam- 
mation of the urethra. 

SECT n. — ACUTE INPLAMMATIOX. 

The symptoms of inflammation naturally divide themselves into local and 
constitutional ; or those furnished by the part and those afforded by the general 
svsteuL 

1. LOCAL SYMPTOMS. 

The most prominent external symptoms of inflammation have long been known 
to practitioners. They are tersely stated by Celsus to be ** rubor, calor cum 
tumore et dolore." This writer flourished in the first century of Christianity, 
and was a contemporary of Virgil, Horace, and Ovid. His knowledge of inflam- 
mation, however, was extremely imperfect, and it was not until some time after 
the commencement of the present century that the subject began to be studied in 
its relations with the different organs and tissues of the body. Bordeu, Car- 
michael Smith, and Bichat, by laying the foundation ^f general anatomy, paved 
the way to a more comprehensive acquaintance with the nature and seat of morbid 
action, and were thus instrumental in revealing an amount of light, the beneficial 
effects of which can even yet be hardly foreseen. They have shown us, what 
might, a priori, have been anticipated, that the phenomena enumerated by the 
Roman author, as characteristic of inflammation, are liable to great and constant 
variations, according to the nature of the affected structure, and that the most 
violent morbid action may often be present, and yet nearly all of these phenomena 
be absent. Hence, at the present day, too much stress cannot be laid upon dis- 
ordered function, inasmuch as this is frequently the only symptom that is at all 
appreciable, especially in inflammation of the internal organs. Modem research 
has shed important light upon the condition of the capillary vessels and their 
contents in inflammation, and has enabled us to explain much of what was before 
obscure and mysterious in regard to the more intimate nature of the process. 

1. Ducoiaration. — The discoloration of an inflamed part varies from the 
slightest increase of the natural hue to the deepest purple, according to the 



62 INFLAMMATION. chap. hi. 

character of the affected tissues and the intensity of the morbid action. It is 
always, other things being equal, most distinctly marked in those structures which 
are very vascular, while in such as have comparatively few vessels it is either 
entirely wanting, or present only in a faint degree. It is a prominent phenon?e- 
non in inflammation of the skin and mucous membranes, the cellular tissue, lungs, 
pleura, spleen, kidneys, and peritoneum ; structures which are distinguished by 
their great vascularity, and by the large amount of blood which they are capable 
of admitting in disease. On the other hand, there is but little discoloration in 
inflammation, however intense, of the tendons, cartilages, bones, and fibrous enve- 
lops, the brain, nerves, heart, and voluntary muscles. In inflammation of the 
arachnoid membrane the only evidence of disease observable after death is effusion 
of serum or of serum and fibrin ; all trace of vascularity is wanting, and yet the 
morbid action has been sufficient to destroy life. 

The discoloration of inflammation often acquires a high grade in a very short 
time, depending upon the activity of the circulation of the affected structures. 
In general, however, it proceeds rather slowly, keeping steady pace with the 
gravescent action ; advancing from rose to red, from red to purple, or from purple 
to black, as when the part is about to mortify. It is always most distinct at the 
focus of the inflammation, from which it gradually recedes until, in most cases, it 
is insensibly lost in the natural hue of the surrounding healthy structures. Occa- 
sionally, however, as in erysipelas of the skin, as well as in some affections of the 
mucous membranes, the line of demarcation is very abrupt, the diseased surface 
exhibiting a red and well-defined circle. 

The discoloration varies not merely in degree, but also in its character, thereby 
throwing, not unfrequently, important light upon the diagnosis of the case. Thus, 
it may be scarlet, as in the skin, throat, and bowels ; lilac or bluish, as in the 
sclerotica and the fibrous envelops of the muscles ; brick-colored, grayish, or 
brownish, as in iritis ; yellowish, as in erysipelas, especially when associated with 
derangement of the biliary secretion ; of a copper hue, as in the eruptions of 
secondary syphilis ; purple, as in the edges of a scrofulous ulcer ; livid, as in 
violent tonsillitis ; and black, as in mortification. These varieties of color, in 
these and other structures, are dependent, partly upon the organization of the 
affected tissues, partly upon the nature of the inflammation itself, and partly upon 
the amount, degree, or intensity of the morbid action. 

The discoloration varies in extent, from the smallest speck, perhaps not larger 
than a pin's head, to a surface occupying many inches, if not several feet in 
diameter, as in erysipelas, where the disease sometimes involves the greater por- 
tion of the body. When this is the case, the discoloration is said to be diffuse ; 
it is arborescent, when the vessels upon which it depends are spread out in den- 
dritic lines ; punctiform, when it occurs in the form of little dots, or points, as 
in some of the inflammations of the serous and mucous membranes ; linear, when 
it presents itself in a distinct streak, as in phlebitis and angeioleucitis ; and macu- 
liform, when it assumes the appearance of a blotch or ecchymosis. In the latter 
case, as well as in the punctiform variety of discoloration, the morbid hue is due 
to an actual extravasation of blood, consequent upon a rupture of some of the 
capillary vessels of the part. 

To be of value as a diagnostic sign of inflammation, the discoloration must be 
permanent, not transient ; advancing and receding with the morbid action ; dis- 
appearing under pressure, but reappearing the moment the pressure is taken off. 
The blush of shame vanishes in an instant, with the excitement that produced it; 
and the hectic flush upon the check of the consumptive merely denotes the 
existence of the fever which succeeds the afternoon's rigor ; they are very different 
from the discoloration which marks the rise, progress, and termination of inflam- 
mation. Besides, the latter is usually associated with other symptoms, as heat, 
pain, swelling and disordered function ; phenomena sufficiently distinctive, in every 
case, to prevent error of diagnosis. 

The immediate cause of the change of color in inflammation is a preternatural 
afflux of blood. It was formerly supposed that it depended upon the formation 
of new vessels, but the fallacy of this opinion was long ago disproved by minute 



CHAF. III. LOCAL SYMPTOMS. 63 

injection and microscopical observation. It is now well known that there is a 
class of capillaries too delicate to admit a sufficiency of red blood to render them 
visible iu the natural state, but which, the moment they become involved in irri- 
tation or inflammation, are distended to such a degree as to show themselves in 
every direction, hundreds and even thousands appearing, and that frequently in 
an instant, where hardly any could be discerned before. We see this fact exem- 
plified in the vessels of the conjunctiva, when a particle of foreign matter lodges 
upon the cornea ; and what occurs here may be supposed to take place, under 
similar circnmstances, in other structures. It is only in reparative infiaramatiou, 
or in the inflammation which is necessary to rebuild parts that have been lost or 
destroyed, that vessels are ever formed. The process is entirely incompatible 
with ordinary inflammation. 

2. Pain. — Pain, like discoloration, is one of the most constant symptoms of 
inflammation, usually setting in early in the disease, going on steadily increasing 
until the morbid action has attained its maximum, and then gradually abating, as 
the disease recedes, until it is insensibly lost. The subject of pi^in presents several 
points of interest, which, as they have a practical importance, should be well 
understood by the surgeon. 

Pain varies in degree from the slightest change in the normal sensibility of the 
part to the most excruciating agony, according to the nature of the affected 
structure, and the intensity of the morbid action. Doubtless idiosyncrasy also 
exerts an important influence, for it is well known that what causes pain in one 
individual occasions little, if any, in another. Most persons bear the application 
of a blister well, but I have seen some iu whom the remedy, although retained 
only for a few hours, was productive of the most exquisite torment. Such a 
result can only be explained on the assumption of an idiosyncrasy, or a difference 
in the nervous organization of our patients. The same remark is true in regard 
to the effects of injury. As a general rule, the pain is greatest at the focus of the 
inflammation ; it is usually flxed in its situation, but sometimes it darts al>out in 
different directions ; is increased by pressure, motion, and posture ; and rarely 
intermits, although it often remits, especially iu the morning and the early part 
of the forenoon. 

Much diversity obtains in regard to the character of the pain, so much so, 
indeed, that we may often, from this circumstance alone, form a tolerably correct 
idea of the seat, and even of the nature, of the inflammation. Thus, in the 
pleura it is sharp and lancinating; in the cellular tissue, acute and throbbing, as 
is exemplified in boil and carbuncle ; in the liver and lungs, obtuse and heavy ; 
in the testis, sickening ; in the skin, prurient, itching, or burning ; in the bones, 
dull and gnawing, as if insects were feeding upon the part; in the urethra, 
scalding or burning; in the conjunctiva, gritty and itching; in the teeth, throb- 
bing, beating, or pulsatile. When inflammation is about to terminate iu morti- 
fication, the pain generally becomes hot and burning. 

Pain is sometimes felt at a point more or less remote from the seat of the 
morbid action; hence, it does not always serve to denote its existence. In 
coxalgia, the earliest and most prominent symptom usually is severe pain in the 
knee, and it has often happened, especially in the hands of the ignorant and 
inexperienced practitioner, that the latter has been leeched, cupped, and blistered, 
when all this care should have been bestowed upon the former. In inflammation 
of the bladder, ureters, and kidneys, a prominent symptom is uneasiness in the 
bead of the penis ; and in hepatitis, considerable suffering is often felt in the 
right shoulder. It is not always easy to explain these occurrences ; but, in 
g^-nerai. they are dependent either upon continuity of structure, as in the case of 
the arinary passages, or upon reflex action, as in coxalgia and hepatitis. 

It is worthy of note that the pain is generally much more severe when the 
inflammation is seated in the covering of an organ than when it occupies its 
proper ^abstance. A pleuritis is always attended with severe local distress, 
whereas few persons ever experience any pain in pneumonitis. In inflammation 
of iht parenchymatous structure of the liver, great disorganization may take place, 



64 INFLAMMATION. chap. hi. 

aud yet the patient be entirely ignorant of the fact, as far as pain is concerned ; 
but should the fibro-serous envelop of the organ be mainly implicated, violent 
suffering will be a prominent symptom. The same law obtains even in inflamnuh 
tion of the brain and its membranes. 

It is important that the practitioner should be aware of the distinction between 
the pain of inflammation and the pain of spasm, since it must exert an important 
influence upon his therapeutic measures. It has already been seen that the former 
is gradual, not sudden in its attack ; persistent, not intermittent ; increased by 
motion, pressure, and posture ; and, moreover, it is generally accompanied by 
more or less febrile disturbance, and other evidences of indisposition, plainly 
marking its character, to say nothing of the history of the attack, which usually 
furnishes important light in regard to the diagnosis of the individual case. In 
spasm, the pain comes on suddenly, and, after having continued for a short time, 
intermits, or entirely disappears, only, however, to return again, and pass through 
the same course; in a word, it is paroxysmal, coming suddenly, and going 
suddenly ; relieved by pressure, and nearly always attended with eructations and 
rumbling noises in the bowels, supposing the case to be one of colic ; there is no 
fever — indeed, generally no constitutional excitement of any kind — and there is 
also an absence of the other local symptoms of inflammation, as heat, discolora- 
tion, and intumescence. 

In neuralgia the pain is sharp and lancinating, often darting through the parts 
with the rapidity of lightning, or like an electric shock ; accompanied by a sense 
of soreness or aching, and generally aggravated by pressure. It is usually 
paroxysmal in its character, coming on perhaps once every day, lasting a few 
hours, and then going off gradually, or even suddenly, to reappear about the 
same time the following day ; it is, in fact, generally an intermittent disease, 
with a distinct interval of freedom from pain, resembling, in this respect, an 
ordinary intermittent fever, and having often, like it, a miasmatic origin. The 
pain, moreover, is not always fixed, but is at one time here, and at another there, 
generally in the course of a sentient nerve. 

Severe pain, especially in a nervous, irritable person, is always a formidable 
occurrence, as it exhausts and depresses the powers of life, and is sure, if not 
timeously combated, to occasion serious, if not fatal, mischief. The rule, there- 
fore, is to arrest it promptly, and at all hazard, before the disease, of which it is a 
symptom, has made much progress. 

A sudden disappearance of pain, unless occasioned by the use of anodynes, is 
generally denotive of danger, as it implies a termination of the morbid action in 
the death of the affected structures. The occurrence should, at all events, excite 
suspicion, and lead to careful investigation. An individual, for example, has 
been the subject of strangulated hernia ; the constriction has lasted for several 
days, and has been characterized by severe suffering, both local and general ; 
suddenly the pain ceases, and the patient flatters himself that he will soon be well. 
The surgeon, however, comes to a widelv different conclusion ; for the sunken 
features, the clammy skin, the feeble and nickering pulse, the incessant hiccough, 
and the trembling hand, but too plainly foreshadow the approach of death from 
mortification of the bowel. 

Pain is not always present, even although the inflammation may be extremely 
violent. In typhoid fever, a disease attended with inflammation of the glands 
of Peyer, often terminating in extensive ulceration of these bodies, there is gene- 
rally an entire absence of this symptom, from first to last, unless the case is fol- 
lowed by perforation of the bowel, and an escape of its contents into the perito- 
neal cavity. In pneumonia there is frequently no pain whatever ; and the same 
thing is true in relation to inflammation of sotne of the other viscera. In scrofu- 
lous affections of the spine, particularly those forms of it known as Pott's disease 
and psoas abscess, pain, properly so called, is one of the rarest phenomena, espe- 
cially in the earlier stages of their progress. A painless inflammation is pecu- 
liarly dangerous, inasmuch as it is very liable to be overlooked by the profes- 
sional attendant, particularly by one who is in the habit of placing undue confi- 
dence in the ordinary phenomena of the disease. 



CHAF. III. LOCAL SYMPTOMS. 65 

How is pain prodoced f It has been supposed that it is caused by a develop- 
meDt of new ner?es ; but that this is not so is sufficiently established by the fact 
that this symptom is often present, and that in a very scTcre degree, almost at 
the very commencement of the morbid action, and consequently long before it is 
posdble for such an occurrence to take place. A more plausible opinion is that 
the soffering is occasioned by the compression of the nerves of the part by the 
dilated vessels and the effused matter, thereby impeding or interrupting the trans- 
mission of nerroas fluid ; but to render this theory complete it is necessary to go 
a step farther, and to assume that the various component structures of the nerves 
themselves are inflamed. It can hardly be imagined that these structures should 
escape this action even in its milder grades, much less when the disease is fiilly 
established. 

Of the intimate nature of pain nothing is known. All that observation teaches 
is that it is a peculiar mental perception, dependent upon a healthy state of the 
brain, without which it is impossible for it to occur. The individual must possess 
the faculty of consciousness, or he cannot take cognizance of the mischief that 
disease produces in the different organs and tissues of the body. We have a 
convincing proof of this in what occurs in apoplexy and paralysis of the lower 
half of the body, in which the most violent inflammation may be set up, both in 
the internal viscera and in the external structures, and yet the patient be utterly 
insensible of its presence. The brain and nerves are crippled ; hence the latter 
are unable to convey, and the former unable to receive, painful impressions of 
any kind. 

Although pain is undoubtedly a great evil, it is extremely fortunate that it is 
so generally present in inflammation, since it serves to warn the patient of his 
danger, and often imparts to the practitioner useful information respecting the 
natare and seat of the morbid action. How many persons formerly perished of 
typhoid fever simply because there was no pain to guide the physician to the 
tme lesions of the disease I Doubtless this affection has existed from time 
immemorial, but it has only been within the last quarter of a century that we 
have known anything definite of its seat and character. Were pain one of its 
prominent symptoms, it would long ago have pointed the practitioner to the 
condition of the glands of Peyer. 

What is termed throbbing is a peculiar form of pain, generally denotivc of the 
approach of suppuration. It is, however, sometimes felt at an early stage of the 
morbid action, especially when it involves the fibrous, fibro-scrous, and osseous 
ti»»ui»s. It is generally dependent, in the first instance, upon an unusually 
crowded state of the capillary vessels, impeding the onward flow of blood, and 
afterwards, when the disease is more fully developed, also upon the presence of 
inflammatory products. Posture exerts an important influence upon its produc- 
tion, ari is evinced in whitlow, odontalgia, and common furuncle. In the first of 
these affections the pain is increased a hundred-fold, almost in an instant, when 
the hand is permitted to hang down by the side of the trunk ; a decayed tooth 
that is free from pain in the day, while the patient is sitting up or walking about, 
will ache violently the moment the head touches the pillow at night ; and a boil 
on the buttock, which will cause hardly any uneasiness when the body is recum- 
bent, will throb violently when it is erect. These occurrences, which are easily 
explained by the increased determination of blood which the affected structures 
receive, under such circumstances, teach a valuable practical lesson in regard to 
the importance of position in the treatment of inflammation. 

3. Svoelling. — Swelling is seldom entirely absent in inflammation of the exter- 
nal parts of the body, although it may be in that of certain internal structures, 
however violent or extensive the morbid action. Under the latter head may 
be enamerated, in particular, the fibrous and serous membranes, tendons, carti- 
lages, bones, vessels, and nerves, along with most of the different viscera. The 
macous membranes also rarely suffer in this way; the principal points where 
swelling is liable to occur, as a result of inflammation, are the conjunctiva, glottis, 
tonsils, and vulva, for the reason that these parts are largely supplied with lax 

VOL. 1. — 5 



66 IXFLAMMATIOX. chap. hi. 

* 

cellular tissue, which, wherever it exists, is so permissive of infiltration of serous 
and other fluids. Hence it is that swelling is generally so conspicuous in inflam- 
mation of the subcutaneous and intermuscular filamentous substance, especially in 
the extremities, and sometimes even in the head, as is noticed in the more severe 
forms of erysipelas, where the scalp and face are occasionally pufifed up to an 
enormous extent, frightfully disfiguring the features. 

The progress of the swelling varies ; in general it is gradual, commencing early 
in the inflammation, and going on steadily increasing until the morbid action 
has attained its height ; even then, however, it does not always stop, but often 
continues until the vessels have parted with their more fluid contents, which 
sometimes occurs only after the disease has begun to decline. Occasionally, 
however, cases are met with where the swelling is most rapid and extensive, 
spreading, in a short time, over an entire limb, or even the greater portion of 
the body. The best examples of this occurrence are witnessed in certain inju- 
ries, as compound fractures and dislocations, phlegmonous erysipelas, and the 
inflammation consequent upon the application of steam, alkalies, acids, and cer- 
tain animal poisons, as that of the rattlesnake. 

The swelling varies in its character ; thus it may be soft or hard, transient or 
protracted, beneficial or injurious. A soft swelling is usually denotive of serous 
effusion ; a hard one, of a deposit of fibrin, or of the more solid elements of the 
blood. A transient swelling is a more desirable event than a protracted one, as 
it is less likely to interfere with the restoration of function. Swelling often 
proves beneficial, inasmuch as the eff*usion upon which it depends is a means of 
depletion employed by nature to relieve inflammatory action ; it answers, in fact, 
the same purpose as topical bleeding. When, however, the deposit is very large, 
or composed essentially of solid material, immense harm may be produced by it, 
from the manner in which it compresses the capillary vessels and interferes with 
the transmission of their contents ; in other words, the effusion acts obstruet- 
ingly, and thus causes fatal constriction. In swelling of the conjunctiva, tech- 
nically called chemosis, the matter poured out often compresses the vessels of the 
cornea in such a manner as to induce gangrene of this membrane ; and a like 
result occasionally follows phlegmonous erysipelas of the limbs and scrotum. 
Swelling may prove injurious in another way; by acting obstruct ingly, as in 
cedema of the glottis, which may cause death by preventing the ingress of air 
into the lungs. A similar effect may be produced by inordinate tumefaction of the 
tonsils. A swollen perineum may compress the urethra and occasion retention 
of urine. 

The immediate cause of swelling is twofold ; first, engorgement of the capillary 
vessels, and secondly, and mainly, effusion of serum and fibrin ; to which, in the 
more severe forms of inflammation, may be added pus and blood, the latter of 
which is sometimes poured out in considerable quantity. 

4. HeaJt. — An increase of heat is one of the most common effects of inflam- 
mation, and hence a valuable symptom of the disease. A good illustration of 
this occurrence is observed in tonsillitis, gastritis, pneumonia, and the so-called 
fevers, in which there is often a remarkable heat of the breath ; and also in many 
of the external varieties of inflammation, where the change is rendered apparent 
both by the sense of touch and by the rapid evaporation of our applications. 
The scalding tear.in inflammation of the eye is an evidence of the same fact. 

The degree of heat, emitted in the act of inflammation, has been supposed 
never to exceed that of the blood in the heart and large vessels. The researches 
of John Hunter would seem to countenance this opinion. He operated upon a 
man for the radical cure of hydrocele ; the temperature of the vaginal tunic 
immediately after the withdrawal of the fluid being 92°. The cavity was now 
stuffed with lint, and the next day the thermometer stood at 98f°, thus showing 
an increase of six degrees and three-quarters, which must have fully equalled the 
heat of the blood in the heart and large vessels of the subject of the observation. 
In repeating the experiment subsequently upon a muscular wound in the side of 
a dog, and upon the vagina of an ass, irritated by a solution of bichloride of 



CHAP. III. LOCAL SYMPTOMS. ' ^ ■'', 67 

mercury, he found no difference whatever, before and after the occnrrence of in- 
flammation, in the temperature of the parts. Hence, he naturally concluded that 
the extrication of heat daring the progress of this morbid process was either very 
slight or altogether inappreciable. Observations, however, made since the time 
of the English philosopher, conclusively show that there is frequently, if not 
generally, a decided increase of temperature in the inflamed structures ; and, 
although this increase may not render the temperature of the part equal to that 
of the heat of the blood in the heart, yet it is none the less real and positive. It 
is well known that the outskirts of the body, as the feet, hands, and ears, are 
habitually cooler than the trunk, head, and upper portions of the extremities, 
because they have naturally a more feeble circulation ; hence in inflammation, 
although their temperature may not reach 98° of Fahrenheit, yet if there be any 
elevation of heat over and above what these structures enjoy in the healthy state, 
it is to be considered as an actual augmentation. That this will generally be 
found to be the fact, in all the more severe forms of inflammation, my observa- . 
tions, many times repeated, fully convince me. In erysipelas of the skin of the 
trunk, in urinous infiltration of the scrotum, in acute abscess, in tonsillitis, orchitis, 
bubo, and other aff'ections, I have again and again seen the mercury rise in the 
instrument above 100°, and in some instances even as high as 105^, 106°, and 
107°. It has been ascertained that the oviduct of a frog ready to spawn is two 
degrees hotter than the heart ; and Professor Dunglison has seen the temperature 
of the uterus during labor as high as 106°. From all these facts, to which others 
equaJly convincing might be added, if space permitted, it is impossible to avoid 
the conclusion that there is generally an elevation of heat in inflammation, in 
whatever part of the body it may be situated, provided the action which accom- 
p»anio5 it is not too slight, or too limited in extent. 

Our knowledge of the nature of animal heat is hardly sufficient to justify us in 
expressing an opinion regarding the cause of its increase in inflammation. It 
may be supposed, however, in the absence of positive information, that it is due 
to the friction which the blood experiences in its passage through the vessels, not 
only in the inflamed parts, but in the system at large, and also to the rapid manner 
in which the oxygen of the air unites with the red particles of this fluid as it is 
propelled along in its turbulent course. The influence of an accelerated state 
of the circulation upon the production of animal heat is well eiaeniplified in what 
occurs in ordinary exercise when the feet are cold. A rapid walk, under such 
circunistances, in the open air, soon equalizes the circulation, and sends the blood, 
loaded with oxygen, to every part of the body, wanning and fertilizing it as it 
rushes on. If a horse he rode swiftly round the race track his whole body be- 
comes immensely heated, and his blood surcharged with fibrin and colorless 
globules ; both evidently the result of the increased friction of the blood against 
the coats of the vessels, and the rapid union of the oxygen of the air with that 
fluid. Irritating applications, as spirits of ammonia, blisters, sinapisms, and 
embrocations, by inviting a preternatural afflux of blood to the affected part, 
pro<luce an analogous effect, accelerating the circulation, and causing an elevation 
of temperature. Allusion has already been made to the fact that the uterus during 
parturition is much hotter than it is in the natural state ; a circumstance which 
can only be explained by the supposition of an increased activity of its vessels 
approximating a state similar to that which obtains in inflammation, although not 
identical with it. During the growth of the antler of the deer and other animals 
there is always a marked elevation of temperature ; and phenomena of a similar 
kind are often witnessed during the development of malignant and other tumors. 
Ail these occurrences bear directly upon the question under consideration, if they 
do not positively serve to establish its truth. 

5. A sense of tendon, pressure, weight or fulness is a prominent symptom in 
inflammation, and often greatly aggravates the local and general distress. It is 
particulnrly conspicuous in inflammation of the denser structures, as the fibrous 
membranes, tendons and cartilages, but it is also not unfrequently very severe in 
the looser ones, as in the mucous membranes and the cellular tissue. The imme.<l 



68 IXFLAMMATIOX. 



COAP. III. 



diate canse of the tension is the presence of effused flnids, as sernro, Ijiuph, and 
pus, which thus couipress and constrict the affected parts. It is not improbable 
that mere congestion, or inordinate distension of the capillary vessels, may produce 
a similar effect. In either event, however, it is necessary that the parts should 
be more or less severely inflamed, and abnormally sensitive ; otherwise the feeling 
cannot arise, as is proved by the fact that mere distension, however considerable, 
will not induce it, as is exemplified in anasarca of the lower extremities, the penis, 
scrotum and eyelids, where the accumulation is often enormous, and yet no sense 
of tension is experienced during any period of the attack. 

Great tension sometimes occurs in inflammation of the viscera, as the liver, 
spleen, kidney, and prostate gland. When combined with throbbing, it is gene- 
rally denotive of incipient suppuration. In orchitis tension is usually a prominent 
symptom. It is seldom, if ever, absent in boils, carbuncles, erysipelas and parony- 
chia. Occasionally tension seems to be a purely nervous phenomenon, as, for 
.example, in what is called sick-headache. 

6. Functional Disorder. — Disorder of the functions of the affected part is in 
general a most important symptom, being often present when all, or nearly all, 
the other phenomena are absent. It manifests itself in various ways, as well as 
in various degrees ; at one time in the form of increased sensibility or irritability, 
at another as a suppression, alteration, or augmentation of the natural discharge, 
and now as an abolition of some special sense ; at one time as the slightest pos- 
sible departure from the normal action of the part, and at another as a total 
suspension of it. 

An increase of sensibility is one of the most common effects of inflammation. 
In peritonitis, gastritis, and enteritis, the sensibility of the affected structures is 
often so great as to render the slightest pressure of the finger a source of pro- 
found distress ; and it is for the same reason that, under such circumstances, the 
weight even of ,a sheet is sometimes almost intolerable. Similar effects are noticed 
in some of the ^ternal diseases, as in boil, carbuncle, erysipelas, and in inflamed 
hemorrhoidal tumors, which are frequently the seat of the most exquisite tender- 
ness, hardly exceeded by that which attends an inflamed eye. Parts which are 
devoid of feelin^oir nearly so, in the sound state, as ligaments, tendons, bone, and 
fibrous membranes, generally become exceedingly sensitive in inflammation. The 
change in question is of great importance in a diagnostic point of view, inasmuch 
as it generally enab^es us to distinguish readily between inflammatory and spas- 
modic affections, the latter of which, as before stated, are often immensely relieved 
by pressure, which never fails to aggravate the former. 

An increase of irritability is a very constant phenomenon in all inflammations 
of muscular parts. In cystitis, one of the earliest and most prominent symptoms 
is a frequent desire to urinate, arising from involvement of the muscular fibres 
of the bladder ; in gastritis, the irritability of the stomach is often so excessive 
that the organ is incapable of retaining the smallest quantity of fluid, however 
bland ; and in dysentery, the greatest distress which the patient is obliged to 
endure, during the progress of that dreadful malady, arises from the incessant 
peristaltic action of the colon and rectum, the main seats of the morbid action. 
An increase of the contractility of the voluntary muscles is very common in 
fractures and dislocations, in severe sprains, and after amputation, usually mani- 
festing itself in spasmodic twitchings, which often require large doses of anodynes 
for their suppression. 

Again, inflammation has the effect of diminishing, or even completely suspend- 
ing, the special function of an organ. In ophthalmia, the eye cannot look at 
objects, however dim ; the moment the effort is made the lids contract spasmodi- 
cally, and the smallest ray of light that impinges upon the retina is productive 
of the greatest distress. In inflammation of the ear the slightest noise, which, in 
the healthy state would perhaps not be perceived, or which might fall as delight- 
ful music upon the tympanum, becomes a source of deep distress ; and the sense 
of hearing is almost destroyed by the buzzing and explosive sounds which suc- 
ceed the morbid action. In coryza, the s^nse of smell is abolished ; in inflamma- 



CBAP. III. CONSTITUTIONAL SYMPTOMS. 69 

tion of the skin the patient is deprived of the sense of touch ; and in glossitis 
there is a loss of the sense of taste. In laryngitis the voice is at first merely 
altered in its character, but as the disease progresses the individual often becomes 
completely aphonions. In cerebritis there is generally delirium, followed, if the 
case passes on to suppuration, by convulsions and coma, the precursors of speedy 
dissolution. 

Another prominent symptom of inflammation, one, indeed, which is seldom 
absent, is disorder of the secretions. Thus, in inflammation of the skin, there is 
suppression of the perspiration ; in hepatitis, of the bile ; in nephritis, of the urine. 
Or, instead of a total arrest of these and other secretions, important changes are 
effected in their composition, or in their physical, chemical, and microscopical 
properties. In pneumonia, the characteristic symptom is a rust-colored sputum ; 
in dysentery, a discharge of bloody mucus. 

The function of absQrption is often seriously impeded, if not completely arrested, 
in inflammation. The disorder, however, is generally much more conspicuous in 
the advanced than in the early stages of inflammation, in which this process is 
sometimes executed, even with a certain degree of vigor, as is demonstrated by 
the facility with which morphia and other substances are carried into the system 
when placed upon the skin after vesication by cantharides, ammonia, or hot 
water. In the more violent grades of inflammation, the function is usually 
kept in a state of abeyance, the action of the absorbent vessels being arrested 
by the morbid deposits. Afterwards, however, as the disease declines, the 
function of absorption is gradually re-established, and then often proceeds with 
great vigor, rapidly removing the fluids efi'used during the earlier stages of the 
inflammation. 

It is worthv of notice that while the absorbent vessels, when the inflammation 
is at its height, refuse to take up extraneous matter, as, for example, morphia or 
iK^Uadonna. and also effused fluids, they are often very busy in removing affected 
textures, even when they are of a very firm and resisting character. A familiar 
illustration of this occurrence is afforded in acute abscesses, the natural evacua- 
tion of which is frequently accomplished by the agency of the absorbent vessels, 
where the disease is most intense. In inflammation of the joints, cartilage and even 
bone often suffer extensively from this cause. There is no doubt that the pres- 
sure of the effused fluids always greatly influences and promotes the occurrence. 

2. CONSTITUTIONAL SYMPTOMS. 

Constitutional symptoms do not always attend inflammation. The morbid 
action may be so mild as to prevent its recognition by the system ; it is strictly 
a local affection, and therefore causes no general resentment. But the case is 
very different when the disease is severe, or wlien, even if it is comparatively 
slight, it involves an important structure ; then the whole frame feels its irritating 
effects, and evinces a strong interest in the impending struggle. The group of 
phenomena thus produced constitutes what is termed inflammatory, symptomatic, 
or sympathetic fever, and deserves consideration as expressive of the sum of 
suffering of each particular organ. The period which intervenes between the 
establishment of the inflammation and the occurrence of fever varies from a few 
hours to several days, depending upon the nature of the exciting cause, the con- 
dition of the patient, the intensity of the disease, and, above all, the importance 
of the organ attacked. Idiopathic inflammation is generally preceded by depres- 
sion or a sense of lassitude and uneasiness, attended with headache, pain in the 
liack and limbs, bad taste in the mouth, vitiated appetite, and slight chilliness, 
alternating with flushes of heat. Sometimes the patient is remarkably despond- 
ing, or annoyed with disagreeable dreams, and unpleasant forebodings respecting 
his recovery. He feels uncomfortably, both bodily and mentally, and has a disin- 
clination to exertion. In a word, he is unwell, or in a state intermediate between 
health and sickness. These phenomena, which are merely the precursors of the 
fever, which is as yet only in a state of incubation, may be compared, not unaptly, 
to the fleeting clouds which precede the outbreak of a storm ; they appear and 



70 INFLAMMATION. 



CUAP. III. 



Fanish for a time, but finally coalescing, thej assume their allotted station in tbe 
chain of morbid changes. When fully established, the fever never intermits so 
long as the cause which has produced it continues in operation ; but it generally 
remits slightly in the morning, and sometimes, though rarely, twice in the twenty- 
four hours. The vesperal exacerbation usually sets in late in the afternoon, and 
persists, with but little alteration, until towards morning, when the excitement 
relaxes its hold, as if in need of temporary repose to meet the gradually recurring 
emergency. During the calm which is now present, the patient often falls into a 
refreshing sleep, his thirst and restlessness subside, and the skin is bedewed with 
a gentle perspiration. Soon, however, the smothered fire is rekindled, and the 
same suffering has to be passed through as before, now, perhaps, augmented by 
the spread of the morbid action, and the development of new sympathies. 

In order to comprehend fully the nature of inflammatory fever, it is necessary 
that the surgeon should personally interrogate, as it were, every organ of the 
body which may be supposed to evince any sympathy with the affected structures. 
This inquiry should, as a general rule, embrace an examination of the heart and 
arteries, the countenance, skin and extremities, lungs, tongue, stomach, bowels, 
liver, kidneys, and bladder, together with the state of the muscles, brain, and 
assimilative powers. 

Derangement of the vascular system is chiefly denoted by the state of the pulse, 
the principal characteristics of which are frequency, hardness, fulness, strength, 
and quickness. The number of beats in a minnte ranges from seventy, seventy- 
three, or seventy-five, the average standard in the healthy adult, to eighty-five, 
ninety-five, one hundred, or even one hundred and twenty, according to the 
intensity of the disease and the vigor of the constitution. A hard pulse is firm 
and resisting, rolling under the finger like a tense cord, and as if the blood were 
sent into it with extreme power ; sometimes the arte'y thrills or vibrates, owing 
to a partial displacement synchronous with the contraction of the left ventricle 
of the heart. When the tension is uimsually great, it is difficult, by any pressure 
we can apply, to obliterate the caliber of the vessel. Fulness has reference to 
the volume of the pulse, which feels as if the artery were expanded beyond its 
normal size. Strength implies a sensation of preternatural resistance to the 
finger ; while a quick pulse is one in which each beat occurs with great suddenness 
or abruptness. This quality of the pulse is generally associated with frequency, 
from which, however, it differs essentially, as the latter has reference merely to 
the number of strokes in a given time, and not to the rapidity with which the 
' vessel dilates and contracts under the finger. Several of these states of the pulse 
may be absent, and yet the case be one of great disorder of the vascular system. 
Their entire co-existence, in fact, is rare ; perhaps the nearest approach to it is 
to be found in gout and rheumatism, hepatitis, pleurisy, splenitis, and the com- 
mencement of smallpox. 

In the examination of the pulse, it is not to be forgotten that its action may 
be materially modified by the nature and seat of the inflammation and by the 
idiosyncrasy of the patient. In cephalic affections, the pulse is slow, full, and 
laboring, in consonance with the oppressed condition of the heart ; in peritonitis, 
it is small, frequent, and wiry, sometimes, in fact, almost nndistinguishable ; and 
in acute inflammation attended with internal venous congestion, as in certain 
forms of fever and injury, it is obscure and apparently feeble, but generally rises 
under the effects of our remedies, or the natural powers of the system. Idio- 
syncrasy often singularly modifies the state of the pulse. I recollect a middle aged 
man, once my patient, whose pulse was habitually under forty; and still more 
remarkable examples of the kind have been witnessed by others. On the other 
hand. It may be abnormally frequent, beating constantly from eighty to ninety in 
the minute. 

The above peculiarities, whether the result of morbid action, or of individual 
organization, derive a special value from the influence which they must necessarily 
exert upon our diagnosis and treatment. Thus, in peritonitis, if the practitioner 
were merely governed by the state of the pulse, without any knowledge of the 
condition of the system which causes it, he would be almost sure to administer 



CHAP. III. CONSTITUTIONAL SYMPTOMS. 71 

Stimulants instead of applying leeches and blisters ; thereby fesding in place of 
diminishing the inflammation, and so hurrying on the fatal crisis. A pulse, 
habitually slow, might, in inflammation, hardly attain the normal standard of 
frequency, and yet the system might literally be consumed by symptomatic 
excitement. The surgeon, aware of the possibility of such occurrences, is wide 
awake ; and hence he is rarely, if ever, thrown off*his guard, whatever may 
happen. 

The counlenancef in inflammatory fever, is usually flushed, and often appears 
unnaturally full, as if it were slightly tumid. The eyes are reddish, suffused, and 
frequently intolerant of light. The skin is hot and dry, perspiration being kept 
in complete abeyance ; and the extremities are usually so warm and uncomfortable 
as to be unable to bear any covering. When the excitement is excessive, the 
sufferer generally finds it impossible to maintain the same posture beyond a few 
minutes ; he tosses about from side to side, and from place to place, in search of 
a cool spot 

The respiratory organs freely participate in the general disorder. The inspi- 
rations are increased in frequency, and are usually performed with a certain degree 
of labor ; various kinds of r&les are heard, and cases occur in which there are 
well-marked evidences of venous congestion. 

The digestive organs always sufi'er in inflammation, and therefore demand 
careful examination. The tongne is variously aff'ected ; sometimes red and almost 
clean, but generally loaded, either with a whitish, yellowish, or brownish fur, 
contracted, and somewhat reddish at the tip and edges ; nearly always dry, and 
easily protruded, though often a little tremulous, especially when the accession 
occurs in a person of nervous temperament. The taste is vitiated, or entirely 
abolished, the salivary secretion is suppressed, a thick, dark-colored mucus adheres 
to the lips, gums, and tongue, and there is a disagreeable arid feeling in the fauces 
and cesophagus. The thirst is intense, and can hardly be appeased by the most 
frequent and abundant draughts ; the appetite, on the contrary, is usually destroyed, 
and hence the patient often loathes food, in whatever form it may be presented to 
him. Nausea and a sense of gastric oppression, sometimes attended with bilious 
vomiting, are common attendants. The bowels are generally constipated, or 
alternately constipated and relaxed, distended with gas, and somewhat tender 
under pressure ; the alvine evacuations being fetid, and variously altered in color 
and consistence. Along with this condition of the digestive tube there is usually 
more or less disorder of the liver, manifesting itself in excess, deficiency, or 
vitiation of its secretion. Such a condition is very apt to be present in sympto- 
matic fever consequent upon accidents and idiopathic inflammation in malarious 
districts. In what manner, or degree, the functions of the pancreas are affected 
in this disease, we are ignorant The probability, however, is that it suffers very 
Ukuch in the same way as the salivary glands of the mouth, which it intimately 
n.-'sembles in its structures and uses. 

Among the more marked changes produced by inflammation are those in the 
renai secretion. These changes relate chiefly to the quantity, color, and consist- 
ence of the fluid. In the normal state, the average quantity of urine, in the 
twenty-four hours, is from thirty-five to forty-two ounces ; but in inflammatory 
fever it often does not reach one-half or even one-third this amount Moreover, 
instead of being of a clear amber hue, as it naturally is, it is commonly of a deep 
red tint, and surcharged with an unusual quantity of extractive matter, mucus, 
and lithic acid ; the latter of which always falls to the bottom of the receiver, in 
the form of brick-colored sediment. The specific gravity of the secretion is also 
very much increased, and the odor is often quite offensive from the presence of 
varicms kinds of animal substances. During the height of very acute inflamma- 
tion, the fluid is often slightly albuminous, and even pervaded by tubular casts. 
The chlorides, on the contrary, are commonly remarkably diminished, especially 
when there is much exudation with a tendency to cell growth. The excretion of 
the fluid is very much as in health, though occasionally it is greatly increased in 
frequency. In traumatic inflammation, as after fractures, dislocations, and 



72 INFLAMMATION. 



CHAP. II!. 



ampntations, the bladder is occasionally so much paralyzed as to require the aid 
of the catheter for the expulsion of its contents. 

The muticles are generally the seat of great discomfort in this form of fever. 
Already, during the stage of incubation, the patient is harassed with a sense of 
lassitude, stiffness, and aching or darting pains, which, gradually augmenting in 
severity, at length constitute a source of real suffering. The pains in the lumbar 
region are particularly violent ; they are always worst at night, and are often so 
intense as to deprive the patient completely of sleep. His back feels as if it 
would break into pieces, as if it were being sawed in two, or as if it were bruised, 
and mashed, and comminuted. Not unfrequently every joint is racked with pain, 
and the whole body is so exquisitely sensitive as to be intolerant of the slightest 
motion, pressure, or manipulation. It is this distress in the muscles that causes 
the patient such weary and painful nights, and which induces him to exclaim in 
the evening, " Oh that it were morning 1" and in the morning, " Oh that it were 
evening!" 

The suffering of the brain is evinced by a peevish and irritable state of the 
mind ; by loss of sleep ; by disagreeable dreams ; and by occasional fits of delirium. 
In many cases, there is more or less perversion of special sensation ; as is proved 
by the distracting noises in the ears, the intolerance of light, the vitiated taste 
and smell, and the impairment of the touch. 

Finally, the assimilcUive powers being in abeyance, the body becomes gradually 
emaciated, and the strength fails in proportion to the impoverished condition of 
the blood and solids. 

Such is the ordinary course of events in inflammatory fever. If the morbid 
action does not go on too long, or if the patient has unusual powers of resistance, 
he may be able to weather the storm, and finally come off conqueror. The dis- 
ease, and, along with it, the fever which it has produced, will now gradually 
subside, the occurrence being announced by a diminution of the patient's restless- 
ness, anxiety, and thirst, by a restoration of the moisture of the skin and mouth, 
and, in short, by a decided improvement in the condition of all the secretions. 
The sleep becomes more natural and refreshing, the appetite returns, the pulse 
descends to its nonnal standard, and the mind regains its natural equilibrium. 
The cessation of the fever often declares itself by the occurrence, either sudden 
or gradual, of a profuse sweat, to which the older pathologists applied the term 
critical, and by a general unlocking of all the secretions. In a word, the clouds 
which had so long obscured the horizon are once more succeeded by sunshine ; 
disease has vanished, and health is regaining its supremacy. 

If, on the other hand, the disease progresses, a downward tendency is gradually 
witnessed of evil, if not fatal, portent. The symptoms, losing their inflammatory 
type, now assume a typhoid character: the pulse becomes weak, soft, and frequent, 
beating from one hundred and thirty to one hundred and sixty in a minute ; the 
countenance assumes a peculiar shrunken aspect, denominated Hippocratic ; the 
surface is bedewed with clammy perspiration ; the extremities are inclined to be 
cold ; the tongue is dry and covered with a brownish or blackish fur ; sordes col- 
lect upon the teeth; hiccough and twitching of the tendons supervene; and 
there is rapid emaciation, with corresponding failure of the strength, and low 
muttering delirium. Recovery is still possible, although doubtful ; a well-directed 
plan of treatment, or even nature's unassisted efforts, may be sufficient to shake 
off the oppressive load, and enable the part and system to triumph over the 
ravages of the disease. 

But typhoid fever is not always a necessary consequence of the inflammatory ; 
it may, and often does, exist as an independent affection, coming on early in the 
attack, perhaps almost immediately after the commencement of the morbid action, 
and maintaining throughout a well-marked asthenic type. The most common 
cause of such an event is severe shock or loss of blood, occurring in an unhealthy, 
broken state of the system, or actual blood-poisoning, from the absorption of pus, 
or the operation of some specific virus, as that of malig^iant pustule, or that 
generated in the dead human body, and received by inoculation in dissection. In 
the more severe grades of erysipelas and carbuncle, the fever soon assumes an 



CHAP. III. CnAXGBS OF BLOOD IN INFLAMMATION. 78 

ftsthenic character, whatever may have been its original type, the system being 
speedily overwhelmed by the depressing influence of the morbific agent. 

The occurrence of typhoid symptoms early in an idiopathic, specific, or traumatic 
inflammation, always portends evil, as it is necessarily denotive of great and rapid 
waste of life-power, which neither medicine nor food can, perhaps, successfully 
counteract The nervous system is deeply involved in the morbid process ; the 
blood is gradually deprived of its plastic properties ; and, nutrition being at a 
stand, the body soon becomes pale, emaciated, and withered. The mind is early 
affected, and typhomania is generally a prominent symptom throughout. The 
vital forces diminish more and more, the patient, engaged in constant muttering, 
picks at the bedclothes, has hiccough and twitchings of the tendons, and is so 
weak as to be unable to support himself upon his pillow. Exhaustion, in fact, is 
extreme, and a few hours generally suffice to close the scene. 

There is another form of fever which is often seen during the progress of 
inflammatory affections, and to which the term irritative has not inaptly been 
applied, as it is generally met with in persons of a nervous, irritable temperament 
or habit of body. The best idea that can be given of it is that it bears the same 
relation to the nervous system that inflammatory fever, properly so termed, sus- 
tains to the vascular ; that is, the fever is characterized in the one case by irrita- 
bility, or excess of sensibility, and in the other by plethora, or redundancy of 
vascular action. We find, accordingly, that in irritative fever there is a lively 
perception of pain, and an unusual exaltation of sensibility, both of the part and 
sTc^tem ; the mind is peevish and fretful, easily dissatisfied, and often filled with 
despondency and unpleasant foreboding ; the pulse is quick, jerking, small, and 
sometimes wiry ; sleep is imperfect and disturbed by frightful dreams ; the skin is 
hot, dry, and difficult of relaxation ; the extremities are inclined to be cold ; and 
there are frequently nervous rigors, followed by marked reaction, and great rest- 
le?&saess ; severe suffering is generally complained of in the loins and muscles ; the 
slightest noise and light are a source of offence ; and the head is distracted with 
severe pain, which often assumes a neuralgic character, and thus becomes a cause 
of great distress. 

There are some low forms of inflammation in which the attendant fever nearly 
always assumes this peculiar type, being present almost from first to last. A 
good example of it is afforded in dissection-wounds, in certain injuries of the skull 
and brain, in phagedenic ulceration, in hospital gangrene, in sloughing chancres 
and buboes, and in tertiary syphilis, in nervous debilitated subjects. 

3. CHANGES OF THE BLOOD IN INFLAMMATION. 

That the blood, which plays so important a part in the economy in health, 
fshould be seriously altered in its properties in inflammation is what might, d 
Itriori, have been anticipated, and what observation has fully established to be a 
fact Sent with increased force and rapidity through every portion of the body, 
however constituted, or however remote from the heart ; subjected to new actions 
and new affinities in the suffering structures, as if it were exposed to the heat of 
a laboratory, and deprived, in great degree, of the stimulus of the oxygen of the 
air. it is not surprising that it should be almost totally changed in its physical, 
chemical, and vital properties. The most important alterations which the fluid 
experiences relate to the fibrin and colorless globules, the quantity and number 
of whioh are always materially increased in every well-marked case of inflamma- 
ti<in. To form a proper estimate of the extent of these alterations it will be 
necessary to inquire, for a moment, into the relative quantity of these ingredients 
of the blood in the healthy state. 

In healthy blood the proportion of fibrin to the entire mass is as 3 to 1000 ; in 
inflammation, however, it is generally very much increased, ranging from 6 to 8, 
fn>m 8 to 9, and from 9 even to 10^, according to the intensity of the disease and 
the general powers of the system. In what proportion the colorless globules are 
angmented in inflammation we are uninformed ; that their number is materially 
is sufficiently obvious, but whether the change, in this respect, is as great 



74 INFLAMMATION. 



CHAP. III. 



as in the fibrin, is still undetermined. In addition to tbis increase in their number 
there is a manifest augmentation of their bulk, as well as of their cohesive pro- 
perties, thereby greatly promoting their tendency to adhesion to each other and 
to the sides of the vessels, which forms so striking a phenomenon in well estab- 
lished inflammation. 

This excess of fibrin and white globules, which is generally observable at an 
early period of the inflammation, goes on gradually increasing until the morbid 
process has attained its maximum, when it begins to decline, and finally altogether 
disappears with the causes that induced it. Although it is most conspicuous in 
the higher grades of inflammation, there are few cases in which it is wholly absent, 
unless the disease is so slight as to be incapable of producing any serious struc- 
tural changes, or material embarrassment in the force and rapidity of the circu- 
lation in the part and system. Gout and rheumatism, pleuritis, pericarditis, 
pneumonia, hepatitis, splenitis, arteritis, and acute articular affections usually 
exhibit it in a marked degree. It is also present, but less conspicuously, in in- 
flammation of the skin, cellular tissue, and mucous membranes. What is singular, 
it also exists in the blood in the latter months of utero-gestation. Where or how 
this excess of fibrin and colorless globules is ^ieveloped is still a mooted question, 
which further observation alone can solve. It may be supposed, in the absence 
of satisfactory information, that it takes place in the arteries, in consequence of 
the manner in which the blood is agitated in passing through the different parts 
of the body, its various ingredients being forcibly pressed and rubbed against 
each other, and against the sides of the vessels by the increased powers of the 
heart. Thus a species of disintegration is brought about, which doubtless adds 
very greatly to the already existing excitement both of the part and of the system. 
The idea that attrition of the blood against the walls of the arteries is mainly in- 
strumental in the production of the change in question derives support, of a very 
plausible, if not positively confirmatory character, from what is observed when a 
horse is subjected to severe exercise upon the turf. If he be bled after having 
been ridden very rapidly round the track, it will be found that there is a great 
increase of fibrin and colorless globules, in consequence, apparently, simply of the 
increased momentum of the circulation, and the friction which the blood has ex- 
perienced in its passage through the vessels, especially the arteries. Now this is 
precisely what occurs in inflammation ; the greater the excitement of the heart, 
or, what is the same thing, the more intense the morbid action, the greater will be 
the amount of fibrin and white globules, and the reverse. 

This increase of fibrin and white globules is attended with inordinate contrac- 
tion of the crassamentum, and a separation of the red particles, leading to the 
formation of what is called the huffy coat of the blood. This consists in the ap- 
pearance of a whitish, bluish, or tallow-like pellicle, upon the top of the crassa- 
mentum, which begins to show itself the moment the blood commences to coagu- 
late, and attains its greatest height after the process of consolidation has been 
completed. Its thickness and density are greatly influenced by internal and ex- 
trinsic circumstances, as the state of the system, the intensity of the disease, and 
the manner in which the blood is drawn. In some instances it is a mere film, while 
in others it forms a layer several lines in thickness ; its density is also subject to 
considerable diversity, being at one time very feeble, and at another very firm, so 
much so, indeed, as to offer a good deal of resistance to the finger. When the 
blood is much impoverished by protracted disease, long abstinence, or unwhole- 
some food, the buffy coat is generally very thin, soft, dirty, and iridescent, forming 
a striking contrast with the characters which it exhibits in plethoric states of the 
system. 

Various extraneous circumstances materially influence the formation of the 
buffy coat. Of those the most important, in a practical point of view, are the 
shape and capacity of the receiver, the size of the stream, and the motion to 
which the blood is subjected in its passage from the vein. It has been ascer- 
tained that the phenomenon is most readily produced when the fluid falls into a 
deep and rather narrow vessel, and when it issues from a large orifice, at the rate 
of from two to three ounces in the minute. If the blood runs very slowly, or in 



CHAyQia OF BLOOD I^ INPLAMUATIOK. 



75 



Fig. 1. 




a tiny stream, or if the stream, although quite bold, is received into a cold or 
shallow basin, it will either Dot form at all, or so very imperfectly as to be scarcely 
appreciable. Sometimes the blood is merely sizy, the fibrin resting upon the top 
of the craor like a blnieh and imperfectly developed film. 

Chomically considered, the bnCy coat is fonnd to cODStst essentially of fibrin, 
in combination with albumen and earthy salts. In fact, it is perfectly identical 
with the plastic matter that is deposited in inSammation upon the free surfaces 
and in the interstices of the organs. By a little care it may easily be detached 
from the upper surface of the crassamentnm ; and, if it be well washed in cold 
water and then immeiBed in alcohol, it will assume 
not only the peculiar bnff-colored aspect, whence it 
derires its name, but also a dense, firm consistence, 
the two properties assimilating it rather closely in its 
physical characters to the sabatance of the nnimpreg- 
nated uterus. 

Of the manner in which the buffy coat is formed 
we are anable to offer any very satisfactory explana- 
tion. It was formerly supposed that it was owing to 
the more tardy coagulation of the blood, thereby per- 
mitting the red particles to disengage themselves 
from the fibrin and to sink, by their greater specific 
gravity, to the bottom of the crassamentum. But 
this was evidently a mistake ; for it is now well ascer- 
tained that inflammatory blood, instead of solidifying 
more slowly than healthy blood, generally concretes 
very rapidly and firmly, thus impeding instead of 
hToring the development of the buify coat. The 
most recent opinion upon the subject is that tbe 
occurrence is due to a vital repulsion between the 
fibrin and red particles; or, what amounts essentially 
to the same thing, to an unnatural aggregation of these bodies, which, acting tike 
a pponge, force out the fibrin from among them before the general mass of the 
blood is fully coagulated. Whether this explanation is correct or not, it is cer- 
tain that the formation cannot occur at all without a previous disunion of the 
principal constituents of the fluid, thereby predisposing them to the event in 
question. To ascertain whether this tendency to tbe development of the buRy 
coat cxisits it is not necessary to make use of a spoliativc bleeding, but simply to 
draw a few drops of blood, and to look at 
it with the microscope, which will at once 
detect the slightest deviation from the 
normal standard. The red corpuscles will 
be observed to run almost immediately 
into clusters of piles or rouleaux, as repre- 
sented in fig. 1. 

Id certain forms of inflammation and 
conditions of the system the blood is not 
only buffed, bat cupped ; that is the upper 
surface of the crassamentum exhibits a 
hollow appearance, a^ if it had been 
scuop«>d out with a knife. This occur 
rence usually denotes a higher degree of 
morbid action than the mere prestnce of 
naked fibrin on the top of thi clot, and 
yet it id not unfrequently witnessed under 
eirramstances which render it very 
quentionable whether tiiere is any in- 
flammation at all, as in anemia, in pro- 
fufie eracuatioDS from the bowels, skin, 
aod kidneys, in acurry, attd in chlorosis. 



Fig 2 




ooo^m umnokh f; 



76 INFLAMMATION'. 



CHAP. III. 



It is generally not easy to account for such anomalies, but of their practical im- 
port every practitioner must be fully aware. In my private collection is a beau- 
tiful specimen, which I obtained many years ago from bleeding a young man 
laboring und^r pleuro-pneumonia, in which both the buffed and cupped appear- 
ances exist in a marked degree on both surfaces of the crassamentum. The 
adjoining sketch, fig. 2, affords a good illustration of the preparation. 

4. INTIMATE NATURE OF INFLAMBtATION. 

In the definition of inflammation, given in the early part of this chapter, no 
attempt was made to specify its true character or essential nature. To do so 
would have been premature ; but now that we have studied its various local phe- 
nomena and traced its constitutional effects, we are fully prepared to enter upon 
the subject, and to ask the question, What is inflammation ? 

To answer this question in an intelligible and satisfactory manner, it is neces- 
sary to consider, 1st, the nature of the capillary vessels, in which the morbid 
action is mainly carried on ; 2dly, the character of the blood, which, as already 
seen, is so singularly changed in this affection ; 3dly, the part played by the 
nervous system, or, perhaps, more properly speaking, by the nerves of the affected 
structures ; and 4thly, the condition of the tissues at the seat of the disease. 

The capillaries are those minute canals which are everywhere interposed 
between the arteries and veins, of which, in fact, they are only so many continua- 
tions. That their structure is similar to these vessels is analogically extremely 
probable, although it is doubtless somewhat modified to enable them to fulfil their 
various duties, since they are not merely designed as channels for the transmis- 
sion of the blood, but also as organs for the elaboration of various kinds of fluids, 
as those of nutrition and secretion. With regard to their caliber, these vessels 
are divisible into two classes. The one embraces those minute tubules which, 
though invisible to the naked eye, are found, when microscopically examined, to 
be capable of carrying a continuous stream of blood, so as to give the part in 
which they are situated a red appearance. The other group includes those deli- 
cate vessels, the cavity of which is so small as to admit only a single globule at 
a time, and which it is often difficult to detect even with a strong magnifier. 

The blood, as it circulates through the body, and immediately after it has been 
drawn from a vein of the arm, has the appearance of a homogeneous fluid ; but a 
careful examination shows it to consist of numerous component elements, intended 
for widely different purposes in the economy. Coagulation separates it into two 
parts, one of which is solid, and hence called the crassamentum ; the other is 
fluid, and named the scrum. The crassamentum consists of a pale, whitish, 
transparent fluid, known as the blood-liquor, plastic matter, plasma, or coagulating 
lymph, and of minute particles, globules, or corpuscles, entangled in and sus- 
pended by it as the blood is passing the round of the circulation. The particles 
are of two kinds, the red and the colorless ; the former, which have long been 
familiar to anatomists, and which impart to the crassamentum its red hue, are 
exceedingly abundant, and vary in size from the ^xjW ^^ ^^^^ Wjsts ^^ ^^ ^^^^ ^^ 
diameter ; they are of a flattened, globular shape, and their office seems to be to 
absorb oxygen from the atmosphere and to convey it to the different parts of the 
system, for the purpose of invigorating its several organs and tissues. The color- 
less or pale corpuscles have only been recently discovered ; their number is very 
limited, except in certain forms of disease, when it is much increased ; they are 
round, much larger than the red, and finely granulated on the surface, thus giving 
them a rough appearance. What the precise office of the white corpuscles is has 
not been determined, but it seems probable that it is connected, in some way, 
with the process of nutrition, which is also the case, only more certainly, with the 
blood-liquor, which is essentially associated with this operation. 

In the vessels of the living body, the white globules seem to have no disposition 
to mingle with the red ; on the contrary, they keep in close contact with the inner 
surface of the vessels, coasting, as it were, slowly along in the blood-liquor, out- 
side of the general current The red particles, on the other hand, pass quietlj 



CHAP. III. INTIMATE NATL'BE OF IXFLAMM ATION. 77 

and gently along the centre of the vessels, regardless, so to speak, of the colorless, 
and in a mach more rapid and lively manner, without any adhesion to each other, 
to the white particles, or to the coats of the containing vessels. 

The essential elements of the inflammatory process, so far as we are able to 
comprehend them, are, 1st, slight contraction of the capillaries, with a retarda- 
tion of the flow of blood; 2dAy, dilatation of these vessels and an increased 
rapidity of the circulation ; and, 3dly, a quiescent state of the capillaries with 
complete stagnation of their contents. While these changes are going on in the 
interior of these vessels, important changes are wrought in the blood, both in 
regard to its consistence, its color, the arrangement of its globules, and the 
character of the plasma. Finally, the coats of the vessels themselves are seriously 
altered, being rendered preternaturally soft and fragile, and therefore temporarily 
incapacitated for transmitting the vital fluid. These various changes are so 
important as to demand for each separate consideration. 

If a drop of rectified spirits, or any slight stimulus, be applied to a capillary 
vessel in the web of a frog's foot, or the wing of a bat, the effect will be to cause 
slight contraction of its caliber, with a partial arrest of its contents, the particles 
of Mood moving to and fro for a few seconds, when they will be observed to 
regain their proper course, and to pass on as if nothing had occurred. If the 
irritation be more severe, as when a drop of tincture of capsicum is applied, the 
vessel, instead of diminishing, is instantly dilated, or, if there be any contraction, 
it is so slight and transient as to be inappreciable by the sight. However this 
may be, the dilatation soon becomes marked and decided, as is proved by the fact 
that the vessel now carries a much larger quantity of blood than in the natural 
state, the red particles being sent into it in increased numbers, as well as with 
increased force and velocity, evidently in consonance with the augmented action 
of the heart, which, beating perhaps from ninety to one hundred and ten in the 
minute, throws the blood with extraordinary impetus into the inflamed part. 

The disease advancing, the dilatation of the vessel steadily and regularly atig- 
ments, until, at length, its tunics having been expanded to their utmost, the artery 
becomes a mere passive tube, palsied and crippled in its action, and therefore not 
only incapacitated for transmitting its contents, but for performing any of its more 
delicate Ainctions as an organ of nutrition and secretion. 

In the condition now described, the capillary is not only distended to its utmost, 
but it is distinctly elongated and tortuous, sometimes almost knotty, as if it were 
affected with anenrismal enlargements, or real varices. Its coats ai*c also preter- 
naturally soft and lacerable, from intermolecular changes in their structure. 

The blood, which is the immediate cause of this dilatation, is literally impacted 
in the vessel, pressing everywhere upon its sides, and thus causing, by degrees, 
complete remora, stasis, or stagnation. The white and red particles, instead of 
pursuing an orderly, quiet, and independent course, as in the natural state, are 
now observed to be more or less intermixed, and so thoroughly crowded together 
that both are materially changed in their shape, being irregularly flattened, elon- 
gated, and distorted, as well as adherent to each other and to the sides of the 
vessel. When there is complete stoppage, the distinction between the two sets 
of globules is entirely lost, the blood forming a stagnant pool, of a dark homo- 
gen€*ous aspect. 

These various changes, which are brought about gradually, not suddenly, may 
be studied with great advantage in what occurs in inflammation of the conjunc- 
tiva. If this membrane be irritated, as, for example, by the contact of a foreign 
body, there will be an immediate rush of blood to the part, thus causing a great 
s^eeming increase of its vascularity. In a few minutes hundreds of vessels, pre- 
viously invisible, will be seen shooting out in different directions, and connecting 
themselves with the sides of those that appeared in the first instance. These 
are not new channels, but old ones appertaiQing to the second class of capillaries, 
rendered evident by the intromission of red particles, which, in the healthy state, 
pass along in so slow and gradual a manner as to elude detection. 

It is not to be supposed that the globules of the blood, as they are sent by the 
heart into the irritated arteries, are able, all at once, to pass through them with- 



78 



IKFI.A1IMATI0N. 




out any difficulty. Instead of this, after having proceeded a certain distance, 
they robound against themselves and the sides of the tcbscIb, ho as to nndergg 
a kind of oscillatory movement ; but gradually yielding to the force exerted upon 
them from behind, they are nrged onward and onward until they reach the cor- 
reeponding veins, into which, as their caliber ie much larger than that of the 
arteries, they nieb as into a vortex, and 
instantly disappear in the current be- 
yond. A similar oscillatory movement 
of the globules of the blood is observed 
when the circulation is about to be re- 
established after it has been completely 
arrested. Some time is required for the 
detachment of these bodies, and when 
they have finally sncceeded in effecting 
this, instead of passing on at once intn 
the corresponding vein, they are pro- 
pelled forward and backward until the 
diseased arteries have become sufficiently 
dilated to admit of their escape. 

The dilated condition of the vessels is 
weli seen in the accompanying cuts, re- 
presenting the two ears of a rabbit, one 
in the natural state, and the other in a 
state of inflammation, from the applica- 
tion of cold. They were injected sim- 
ullaneounly, and consequently with the 
same degree of force, with size colored 
with vermilion. Fig. 3 is the natural 
ear ; fig. 4, the inflamed one. The con- 
trast is striking. The vessele of the 
latter are not only mnch lai^r and more 
tortuous than in the former, but also 
apparently nmch more numerous ; the main artery in the one is likewise greatly 
increased in size, while in the other, namely, the natural one, it is quite small. 

But it rot|uiros no experiments upon the inferior animals to prove the exist- 
ence of increased vascularity in inflammation ; the remarkable change in the 
color of the part is sufficient evidence of the fact, to say nothing of the circum- 
stance that, if an incision bo made into it, the blood will gush out in much larger 
quantity than from a similar cut In the corresponding healthy structure. 

When the morbid action is fully established and very intense, without, how- 
ever, there being as yet complete cessation of the circulation, the contents of the 
affected vessels not unfrequcntly break through their soflened and lacerable walls, 
occasioning thus a real extravasation of blood, 
as in lig. 5, representing a magnified portion of 
inflamed serous membrane. Sometimes, again, 
although rarely, the blood escapes from the 
vessels, and, forcing its way through the cellu- 
lar tissue, forms new channels, through which 
it afterwards continues to circulate. 

Immediately around the seat of the greatest 
intensity of the morbid action, marked conges- 
tion exists, and the blood, consequently, passes 
along very slowly, and with difficulty. Beyond 
this point the phenomena are somewhat differ- 
ent ; the excitement is less considerable, bat still 
sufficient to cause active vascular determination ; 
the blood moves in a continuous stream, and with 
extreme velocity, but being unable, as it ap- 
proaches the focus of the inflammation, to make 




ISTIMATE NATURE OP IXFLAMMATION' 



79 



iu war throufrh the stagnant tubes, it is sent onward through collatoral chan- 
ncln, now for the first time fairly opened for its reception. Tlius it will be seen 
that, while at the centre of the morbid action Btagnatioa occurs, and around this 
> slu^sh circulation prevails, an increased activity is going on in its neighbor- 
Iwod. The arteries leading to the affected part are distended, and pulsate strongly, 
bat not, as some have asserted, with prct«rnatural frequency. 

The changes produced in inflammation are admirably depicted in fig. 6, from 
Beanett, representing a portion of the web in the foot of a young frog, after 




harin)^ been irritat«d hy a drop of strong alcohol ; it is magnified two hundred 
diameters, and exhibit^ a deep-seated artery and vein, somewhat out of focus, 
with c^iUaries running over them, the whole being interspersed with pigment 
nila. On the left of the figure the circulation is in its normal state ; at the 
evatTf it i(9 retarded, the vessels are crowded with corpuscles, and the column 
of blood i:« osK-illating ; on the right there in deep congestion, with exudation ; a 
reprcHfnt.-f the vein, occupied by dark blood, moving more slowly than in the 
artery, and running in the oppo^fite direction ; the lymph space on each side Is 
filled with yellowish plasma, and contains a number of colorle:~s corpuscles, some 
clinging to the sides of the vein, others moving tardily along ; b represents the 
anerr, with a rapid current, permitting nothing to be seen but a reddish -yellow 
broad streak, with lighter spaces at the sides. Opposite c, a vessel has given 
way. and caused an extravasation of blood, resembling a brownish-red pool. At 
d. there is complete congestion ; the corpuscles are closely adherent to each other 
and to the sides of the vessels, which they entirely fill, l>eing one semi-transpa- 
rent reddish mass. The interrascular spaces are abnormally thick and opar|ue, 
and occupied by exudation. 

The part played by the nerves in inflammation is very imperfectly understood. 
It is evident, however, that it is very important, although we arc unable to define 
its character, or specify its degree. In traumatic in II am mat! on, as well as in 
many caries of the idiopathic form of the malady, the primary impression is 
probably nearly always made upon the nerves, from which it is immediately 
n-flected uiK>n the capillary vcaaele, inducing, at first, contraction, and then dila- 
(aiion. of their caliber, with a preternatural influx uf blood, and, finally, an increase 
•if «ilor. The sensibility of the part being thus awakened, the heart is instantly 
mosed into action, followed by serious disturbance of the circulation at the seat 
4f the morbific impression, as if nature were making an effort to shake off the 
cauiK of the disease. It is this occurrence that generally gives the patient the 
first intimation of the impending mischief; the nerves, resenting the encroach- 
ment, apprise the brain, or cerebro-spinal axis, of the attack, and the conseijuence 
u that the heart, acting with unusual vigor, throws an undue quantity of blood 



80 INFLAMMATION. chap. hi. 

into the suffering structures. If this explanation be correct, it follows, almost as 
a necessary sequence, -that inflammation, instead of being, as has sometimes 
been imagined, a process of perverted nutrition, is in reality merely an attempt 
on the part of the affected tissues to rid themselves of some hurtful impression. 
All the rest of the process is easily understood ; the discoloration, swelling, pain, 
heat, and disordered function, being merely so many links in the chain of morbid 
action. 

As the inflammation increases in intensity, the nerves actively participate in 
the morbid process, their substance becoming injected, softened, compressed, 
and otherwise altered, in conformity with the peculiarity of their structure and 
function. The effect of such a change upon the welfare of the affected textures 
must be extremely pernicious, as it must materially diminish the nervous cur- 
rent, if not entirely arrest it, and thus weaken and prostrate the vital powers of 
the part. 

The joint agency of the nervous and vascular systems, in the production and 
maintenance of inflammation, has been happily illustrated by the researches of 
modern physiologists. It has been ascertained, for example, that, when the 
ophthalmic branch of the fifth pair of ner\'^es is divided in the cranial cavity of a 
rabbit at the Yarolian bridge, inflammation is speedily lighted up in the surface 
of the eye, eventuating in opacity of the upper segment of the cornea. What is 
still more remarkable is, that, when the nerve is cut on the petrous portion of the 
temporal bone, so as to involve the ganglion of Gasser, the resulting irritation is 
not only more violent, but much more deeply seated and deplorable, the conse- 
quence being complete disorganization of the organ. 

Analogous effects follow the division of the pneumogastric nerves. When these 
cords are cut high up in the neck, the lining membrane of the air-passages assumes 
a dark color, the lungs are engorged with black blood, and an abundance of 
serosity is poured out into the parenchymatous texture, as well as into the pul- 
monary vesicles and the minute branches of the bronchiae. The pleura generally 
participates in the irritation, and there is almost always more or less inflamma- 
tion of the stomach, with a suspension of the secretion of the gastric juice. 

A nimals in which the brachial plexus of nerves has been tied are soon seized 
with inflammation of the integuments of the remote parts of the limb, which 
gradually progresses until all the soft structures are invaded by gangrene. A 
friend of mine removed a section of the peroneal nerve on account of a neuroma ; 
the wound was long in healing, and two of the small toes sloughed before the 
patient recovered. These facts enable us to explain certain circumstances that 
have long been noticed by practitioners in particular morbid states of the system. 
A part affected, for instance, with palsy is much less capable of withstanding 
the ordinary impressions of physical agents than one receiving its customary 
supply of ner\'0U8 influence. A bum in a paralytic person creates much more 
serious mischief than in one that enjoys perfect health ; and the same is true in 
regard to blisters and other irritants, the injudicious application of which often 
leads to the destruction of large portions of the skin and subjacent cellular tissue. 
There is little doubt that the inflammation of the bladder, which always super- 
venes upon serious injury of the spinal marrow, is caused in a similar way ; that 
is, by the interruption of the natural supply of nervous influence. 

In whatever manner the parts are deprived of nervous fluid, it is presumable 
that they are brought under relations somewhat analogous to those of a frozen 
limb. The temperature is lowered, the sensibility impaired, the process of nutri- 
tion perverted ;' in a word, the natural connection between the vessels and nerves 
is broken up, and hence that series of phenomena known under the name of 
inflammation. 

The tissues at the seat of the inflammation, considered apart from the vessels 
and nerves which are distributed through them, and which, as has been seen, play 
such an important part in the morbid process, are variously altered, becoming 
not only the recipients of various deposits, but experiencing, especially in the 
advanced stages of the disease, marked softening, and sometimes also fatty de- 
generation, the latter being more particularly liable to occur when the morbid 



CHAP. III. INTIMATE NATUKB OF INFLAMMATION. 81 

action is tardy, and rather below the ordinary acat« standard. The principal 
deposits are serum and lymph, either alone or in unipn with pus and blood. 
When these products are very abundant, there will necessarily be much swelling, 
and the consistence of the parts will be soft or hard, according to the structure 
of the tissues and the nature of the effusions. 

A careful study of the inflanmiatory process leads to the conviction that, in its 
earlier stages, it is one of increased action, both of the capillary vessels and of the 
tissues through which these vessels pass, and of which, consequently, they form a 
most important integral part. Microscopical and clinical observations clearly 
prove the truth of this statement. Subsequently, however, when the disease is 
fully established, when the vessels are crowded to excess with blood, and when 
this fluid manifests a tendency to stagnation, or when stagnation has actually 
occurred, there is every evidence of decided debility. The capillaries are now 
partially paralyzed, and distended to the utmost with non-oxygenated blood ; the 
different tissues are surcharged with inflammatory products ; nutrition, secretion, 
and absorption, are interrupted, or completely suspended ; in short, everything is 
indicative of enfeeblement and prostration. 

Moreover, the tissues involved in the inflammatory process soon evince a dis- 
position to become disorganized, and to undergo the fatty degeneration, especially 
if they are loaded with plastic deposits. The earliest indications of these 
changes are the confused appearance of the affected structures when viewed with 
the microscope, and the presence of minute globules of oil scattered through 
their substance. If the fibrinous matter is spoiled, or transformed into pus, the 
quantity of oU greatly increases, and the tissues, acted upon by the absorbents 
and by chemical influences, are liquefied and destroyed. If, on the other hand, 
it becomes organized, the parts are in danger of falling into a state of atrophy, 
being partially robbed of their nourishment, and choked as vegetables are choked 
by weeds. 

Much discrepancy exists among writers and teachers in regard to what consti- 
tutes inflammation ; some, among whom I include myself, believing that but a 
slight dep^ree of action is necessary, while others maintain that the departure from 
tho healthy standard must be very great. Thus, Dr. Miller, Professor of Sur- 
gery in the University of Edinburgh, declares that true inflammation, properly 
8*> called, is always attended with suppuration ; apparently forgetting that 'thou- 
sands of human beings daily die Arom this affection, long before it has' attained 
this crisis. Dr. John H. Bennett, another eminent Scotch teacher, makes 
fibrinous exudation the indispensable condition of the process ; and he even goes 
so far as to propose the word exudation as a substitute for that of inflammation. 
For myself, I cannot see that such a change of nomenclature would have any 
other effect than that of confusing the mind of the student ; the term is ill chosen, 
and cannot, therefore, advantageously replace one which, although merely con- 
ventional, is yet sufficiently expressive for practical purposes. But there is still 
a more serious objection to the adoption of this word, and that is that it does not 
convey a correct idea of the nature and extent of the morbid process. Dr. Ben- 
nett, and those who think and reason with him on the subject, must be aware 
that there are inflammations of certain organs and tissues in which the morbid 
action is so great as to destroy life, and yet the most careful examination, micro- 
scopical and chemical, fails to detect the existence of fibrin in the affected struc- 
tures. It is only necessary to instance the arachnoid membrane, the aponeuroses, 
cartilmires, and nerves, in which this disease is often, if not generally, unattended 
by a deposition of fibrin. But while it is certain that inflammation is frequently 
present, and that, too, to a serious extent, without fibrinous exudation, it is 
equally true that this substance is usually poured out in this disease, especially 
if it has already made considerable progress. Much will necessarily depend 
upon the nature of the affected organs and tissues, some furnishing plasma much 
more rt*adily, and in much greater quantity, than others. Moreover, it requires 
very nice judgment, particularly in the living subject, to define the boundaries 
between congestion and inflammation, or to determine where the one terminates 

VOL. I. — 6 



82 IXFLAMMATIOX. 



CHAP. XII. 



and the other begins. Inflammation, in its iDceptive stages, may be compared 
to a latent or smothered fire, kept in abeyance by a redundancy of Burronndiug 
material interfering with its development; exudation cannot occur all at once; 
some time is necessary to prepare the vessels for their new office : so it is with 
the flame in the furnace, it does not break forth immediately on the application 
of the kindling, and yet no one would say that fire was not actually present 
Most of the disputes that have grrown out of this question have arisen from a 
misunderstanding on the part of observers as to the amount of disease, or change 
in the affected part, necessary to constitute inflammation ; and it is obTious that 
there never can be any fixed or settled views upon the subject so long as this is 
the case ; nor can the question be satisfactorily disposed of, unless it be studied 
with reference to the nature and functions of the different organs and tissues of 
the body ; or, if I may use the ex])ression, the conduct and habits of the orgaofl 
and tissues in their healthy and morbid relations. 

Another source of difficulty, in the settlement of this question, is the &ct that 
many pathologists are seemingly incapable of divesting themselves of the idea 
that inflammation must necessarily be treated by depletion, particularly by the 
lancet and leeches, purgatives and starvation. It is apparently impossible for 
them to disconnect the two things, and yet it requires very little reflection, and 
certainly no great amount of experience, to show the erroneousness of such a 
conclusion. Cases of inflammation are daily met with which imperatively demand 
the use of stimulants from their very commencement ; and it is not going too far 
to assert that there is a period in almost every attack of the disease, if at all 
severe, in which the patient will be greatly benefited by the use of brandy, wine, 
quinine, and nutritious food. 

Professor Virchow, of Berlin, whose cellular pathology is now attracting so 
much attention, asserts that inflammation is not a real entity, or a process every- 
whert; identical in its character, as has been so often alleged, but a process 
essentially similar to other morbid actions, differing, in fact, from them only in 
its form and course. He believes that irritation is to be considered as the start- 
ing-point in inflammation ; for it is impossible, he remarks, to conceive of such 
an occurrence without the application or inter\'ention of some hurtful stimulus. 
The principal sources of this irritation are three — the functional, nutritive, and 
formative — the first playing, as he imagines, the least important part in the 
process. 

" If, therefore/' to use Yirchow's own language, " we speak of an inflammatory 
stimulus, we cannot properly intend to attach any other meaning to it than that, 
in consequence of some cause or other external to the part which falls into a state 
of irritation, and acting upon it either directly, or through the medium of the 
blood, the composition and constitution of this part undergo alterations which at 
the same time change its relations to the neighboring structures, whatever may 
be their nature, and enable it to attract to itself and absorb from them a larger 
quantity of matter than usual, and to transform it according to circumstances. 
Every form of inflammation with which we are acquainted may be naturally 
explained in this way. With regard to every one, it may be assumed that it 
begins as an inflammation from the moment that this increased absorption of 
matter into the tissue takes place, and the further transformation of these sub- 
stances commences." 

Yirchow discards the idea that hyperemia, or vascular turgescence, is present 
at the commencement of inflammation, alleging that, in certain parts, as the 
cornea, the cartilages and tendons, in which no vessels exist, the changes pro- 
duced by this morbid process are in no respect different from those in the .vascu- 
lar structures. He also, as will be seen bv and by, asserts that fibrin is not a 
transudation from the blood-liquor, but a direct product of the inflamed structures 
themselves, brought about by a change in their condition, and by the local 
metamorphosis of matter. 



CHAP. III. TREATMENT OF INFLAMMATION. 88 

5. TREATMENT OF INFLAMMATION. 

Two leading indications present themselves in every case of inflammation 
when sufficiently grave to demand interference. The first is the removal of the 
exciting cause of the disease ; the second, the establishment of resolution. 

In regard to the first of these points, it is obvious that, although the disease 
may be modified in its character, or rendered comparatively harmless, by treat- 
ment, yet it will be impossible to arrest it completely so long as the exciting 
cause is operative. Thus, for example, in strangulation of the bowel, it would 
be folly to expect to establish resolution of the inflammation which the strangu- 
lation has produced, without the removal of the stricture which is the cause of 
the morbid action. In such a case, one of two things roust happen ; either the 
sufferer must die fW)m the effects of the disease, or he must be relieved by the 
knife, or by nature's operation, that is, the formation of an artificial anus. An 
inflammation of the lungs from the presence of a foreign body in the air-passages 
cannot be effectually cured so long as the foreign body remains, and keeps up 
the morbid action. The same thing is true in relation to inflammation of the 
bladder from hypertrophy of the prostate gland. The gland, acting obstruct- 
ingly to the flow of urine, is the cause of the cystitis, and just so long as the 
cause remains will the disease continue, although, as remarked above, it may be 
materially modified by our therapeutic measures. But it does not follow, on the 
other hand, that the inflammation shall at once subside because the cause which 
produced it has been removed. The malady may have already made so much 
progress as to render the restoration of the part either impracticable, or possible 
only after a long time and after much suffering. In our attempts to get rid of 
the exciting cause by mechanical means, it is hardly possible to exercise too 
much care and gentleness, or to institute them too early. All officious inter- 
fen*nce, rude probing, or rough manipulation, must be carefully avoided, lost wo 
add, as it were, fuel to the flame, aggravating and perpetuating the disease. 
Splinters, nails, needles, pieces of bone, are extracted with the finger and forceps ; 
the calculus is cut out of the bladder ; the speck of steel is picked from the cornea; 
and the aching tooth is lifted from its socket; all in as gentle and easy a man- 
ner as p<»ssible. 

It is not always, however, that the exciting cause of the malady can be de- 
tected, even if we avail ourselves of all the light we possess. Very frequently 
the cause is latent, the morbid action having, to use a very common but unphilo- 
sfiphical expression, arisen spontaneously. Such an occurrence is, of course, 
imp«>ssible ; there must necessarily be a cause for every disease, though it may 
not Ik* in our power to discover it ; hence, to wait for its removal before we begin 
our treatment, might sadly endanger both part and patient. 

The second indication is to establish resolution or to disperse the morbid 
action, with the least possible detriment to the structures and functions of the 
diseas4Kl i>arts. To effect this, various remedies may be necessary, some being 
addreiise<i to the general system, others directly to the affected parts : circum- 
stances which have given rise to the division of the treatment of inflammation 
into constitutional and local. 

I. Constitutional Treatment. — The constitutional treatment of inflamma- 
tion consists of bloodletting, cathartics, emetics, depressants, mercurials, diapho- 
retics, diuretics, anodynes, and the antiphlogistic regimen. It must not be 
support, however, that all these means, or even a majority of them, are neces- 
sary in every case of this disease ; so far from this being true, the morbid action 
often disappears spontaneously, or under the mildest and simplest remedies. 
Whenever constitutional treatment is demanded, it should be employed as early 
as possible, and with a determined hand, in the hope of being able to arrest the 
inflammation while it is yet in its inception, and, consequently, before it has 
made anr serious inroads upon the part and system. A few doses of medicine, 
jadiciousty administered at the outbreak of the disease, often do more good than 
twenty administered after it has attained its fall development 



84 IXFLAMMATIOX. 



CHAP. III. 



1. Bleeding. — General bleeding may justly be regarded as standing at the very 
head of the list of the constitutional remedies for inflammation, as it is at once 
the most speedy and the most efficient means of relief. The blood is nsaallj 
drawn from one of the larger veins, and is permitted to flow until a decided im- 
pression has been made upon the system. When we consider the singular 
changes which this fluid undergoes in inflammation, the fact that it is sent in an 
unusually large quantity to the affected parts, and the circumstance that it is 
mainly instrumental in supporting the powers of the heart, it will not be difficult 
to form a correct idea of the importance of this operation, or the influence which 
it exerts in combating morbid action. Its value was not over-estimated by the 
older writers when they designated it as the summum remedium in the treat- 
ment of inflammation ; yet, strange to say, bloodletting, notwithstanding the high 
rank which it has always occupied, as an antiphlogistic agent, has, of late, fallen 
very much into disrepute, particularly on this side of the Atlantic, where it had 
at one time so many advocates. A great change has come over the profession, 
in this respect, within the last fifteen years, and is steadily gaining ground, sub- 
verting all our preconceived notions upon the subject, and rendering it very 
questionable, in the opinion of many, whether bloodletting is really ever required 
as an antiphlogistic. Whether this change has been the result of a modification 
of the type of disease, of a more improved method of treatment with other reme- 
dies, or simply of the whim and caprice of a few prominent and influential practi- 
tioners, from whom the rest of the profession have imbibed their views, I am 
unable to assert,* but the fact does not admit of a doubt that more quarts of blood 
were formerly spilt than ounces are spilt now. Bleeding is no longer the fashion ; 
the operation is denounced by every one. Public sentiment has got to an ex- 
treme upon the subject, and wo may therefore soon look for a reaction in favor 
of the opposite opinion. For myself, I cannot but regret this state of things, 
because I feel satisfied that it does not rest upon a just and proper basis. • If we 
formerly bled too much, too frequently, too copiously and too indiscriminately, 
it is equally certain, at least to my mind, that the operation is not often enough 
resorted to at the present day. Many a deformed limb, blind eye, enlarged 
spleen, and crippled lung bear testimony, in every community, to the justice of 
this remark. 

General bleeding is employed with different views. In the first place, it 
diminishes plethora ; secondly, it changes the qualities of the blood, or, more cor- 
rectly speaking, it places it in a better condition for resisting the effects of inflam- 
mation ; thirdly, it weakens the powers of the heart and nervous system, and, 
consequently, the momentum of the circulation ; and, lastly, it promotes the action 
of other remedies. 

To obtain these effects in the most prompt and thorough manner, the blood 
should be taken irom a large orifice in a large vein, the fluid running in a bold, 
full stream to the amount of at least three ounces in the minute, the patient 
being either seated upon a chair or standing up at the time. If the operation 
is performed during recuml>ency, a much larger quantity will be required to 
be drawn before the syst<>m and part become sensible of the loss. When the 
object of the bleeding is merely spoliative, or intended to rob the vessels of an 
unusual amount of their contents, it may be done in this way ; but even then the 
lietter plan will be to bleed in the semi-erect position, reopening the vein a 
second and even a third time, if premature syncope should take place to interfere 
with the requisite abstraction. The difference in the effect of these two methods 
of bleeding is forcibly exemplified in conjunctivitis. The patient who is bled in 
the erect position soon begins to feel faint, and to experience relief from pain, the 
eye at the same time exhibiting a blanched appearance, instead of the scarlet hue 
which it had a moment before ; whereas the one who is bled in the recumbent 
position will retain his strength for a much longer time, and when, at length, he 
is rendered unconscious, the inflamed surface will be found to be still compara- 
tively discolored. The impression, moreover, will generally be much more per- 
manent in the former than in the latter, and the return, consequently^ of the 
capillary injection more slow and less perfect. 



CSAP. III. CONSTITUTIONAL TREATMENT. 85 

The circamstaDces which call for this operation are generally considered to be 
a hard, strong, full, and frequent pulse, a plethoric state of the system, and great 
intensity of morbid action. When such a conjunction exists, the surgeon cannot 
possibly go amiss in regard to the abstraction of blood, constitutionally considered. 
He may, perhaps, it is true, combat the disease without such recourse ; by the 
use of antimony, purgatives, and other means, he may gradually bring down 
inordinate excitement, and thus afford the affected structures an opportunity of 
throwing off the burden with which they are oppressed ; but if he wishes to make 
a prompt and deeided impression, spoliatiye and depressive, upon the part and 
system, he can accomplish his object much more readily and effectually with the 
lanoet than with any other remedy in the whole catalogue of antiphlogistics. If 
nauseants depress the heart's action equally with the lancet, they certainly do 
not produce the same effect in unloading the engorged capillaries at the scat of 
the inflammation, in restoring the circulation, and in reclaiming morbid structure. 
The operation of the odo is gradual, and, at times, almost imperceptible ; of the 
other, prompt and decisive, often cutting down the disease with a single blow ; 
or, at all events, leaving it in a condition to be afterwards easily dealt with by 
other and more simple means. 

When bleeding is required, the earlier it is performed the better. Ten ounces 
of blood taken at the beginning of an attack of inflammation will usually do more 
good than four times that quantity drawn after the disease is firmly rooted. 
Indeed, when a part is once overburdened with deposits, the salutary period for 
general bleeding may be considered as being passed ; for, although the operation 
may aid in reducing the force of the heart, and in promoting the action of other 
remedies, it certainly does not exercise the same happy influence upon the capil- 
lary vessels at the seat of the disease. 

The quantity of blood drawn at a single operation must vary according to 
circumstances, the object being effect, and not ounces ; for what would be a large 
bleeding for one person might be a small one for another. From sixteen to 
twenty ounces is a good average loss. Some individuals faint almost as soon as 
the blood begins to flow, while others can scarcely be made to faint, no matter 
how they are bled, or how much blood is drawn. The best plan, therefore, 
always is to continue the operation until it has made a decided impression both 
upon the nervous and vascular systems, avoiding actual syncope, but inviting an 
approach to it, and then guarding against the danger of excessive reaction. 

We now and thMi hear of enormous quantities of blood being removed for the 
cure of inflammation. The memoirs of the French Academy furnish us with 
instanees where thrive hundred ounces were abstracted within a week ; and equally 
remarkable examples are recorded among British writers. The late Dr. Francis, 
of New York, while laboring under a violent attack of croup and tonsillitis, was 
bled to the extent of nearly two gallons and a half in a few days. Such cases 
are remarkable as showing the wonderful power of endurance of the system, but 
they are not to be held up as examples for the imitation of the practitioner. It 
must be understood, however, that inflammation often engenders a tolerance of 
lileeding. Thus, a nervous person who in the healthy state will faint from the 
luss of a few ounces of blood, will, when laboring under severe inflammation, 
tiear with impunity the loss of perhaps ten times that amount. A similar tole- 
rance of remedies is frequently established by disease. In delirium tremens, 
opium may be given in doses that would destroy half a dozen healthy persons ; 
in pneumonia, the stomach acquires an extraordinary degree of tolerance for 
tartar emetic ; and in certain forms of syphilis mercury may be given in large 
quantities without salivation, the system being seemingly insusceptible of its 
influence. 

Th«* first effect of a loss of blood upon the system is a sense of muscular debility. 
Presently, the individual begins to look pale, to see indistinctly, to have a con- 
faejkion of ideas, to perceive noises in his ears, and to feel light in the head. If 
the flow be not immediately stopped, he will next become deadly sick at the 
Momach, convulsive tremors will pervade his limbs, the pallor of the countenance 
a ill increase to a deadly white, the respiration and pulse will nearly cease, and, 



86 INFLAMMATION". 



CHAP. III. 



if he is not supported, he will fall down in a stat« of unconseioosness. He has 
fainted. Such an effect is sometimes produced by the loss of a drachm of blood; 
at other times not until many ounces have been drawn. 

To recover a person from this condition, he must immediately be placed in the 
recumbent position, cold water dashed upon the face, and a free access of air 
obtained by throwing open the doors and windows of the apartment, aided, if 
necessary, by the fan. If he is slow in regaining his consciousness, the body is 
raised a little higher than the head, ammonia is passed under the nose, and 
sinapisms are applied to the extremities and the precordial region. Sometimes 
a draught of cold water will do more in reviving the patient than anything else. 
If, from idiosyncrasy or excessive loss of blood, the syncope assumes an alarming 
character, a stimulating enema is administered, and mustard is applied along the 
spine ; but nothing is given by the mouth, unless it is certain that there is some 
power of deglutition. 

The reaction which succeeds the stage of depression is characterized by a 
gradual return of the various functions of the body to their natural condition. 
Color reappears upon the cheeks, the heart and lungs act with more energy, the 
limbs regain their warmth, the surface often becomes slightly moist, and the 
mind recovers from its confusion. The only treatment necessary, during this 
stage, is proper vigilance, lest the reaction should become too vigorous ; depres- 
sion being rather favored, when the morbid action is at all severe, than rapidly 
relieved. 

When the loss of blood has been disproportionately great to the powers of the 
system, the stage of depression may be succeeded by dissolution, or reaction may 
at length occur, the struggle for many hours, perhaps, being one of life and death. 
This state may be induced by one copious bleeding, or by several small ones, 
establishing an undue drain upon the vital current. It is characterized by un- 
usual pallor of the countenance, feeble pulse and respiration, coldness of the 
extremities, clammy perspiration, frequent sighing, great thirst and restlessness, 
vigilance, and a tendency to delirium. While the system is in this condition, 
local congestion, followed by inflammation, is not uncommon, the organs which 
are most prone to suffer being the brain, the arachnoid membrane, and the lungs. 
Sometimes the symptoms here described arc mixed up with those of feeble reaction ; 
and then the countenance, perhaps, is flushed, the eye and ear are intolerant of 
light and noise, the respiration is quickened, the skin is hot and dry, and the pulse 
is thready, hard, and frequent. The proper treatment does notf vary essentially in 
the two cases, our main reliance being upon opiates in full doses, milk punch, 
ammonia, and quinine, with elevation of the head and cold applications, exclusion 
of light and noise, and blisters, if there is marked tendency to local determination. 
Further bleeding would only -cause further sinking. ' 

In the abstraction of blood various circumstances are to be taken into con- 
sideration, among which the most important are the age, temperament, and 
habit of the patient, the character and progress of the disease, the structure and 
functions of the affected organ, and the peculiar constitution of the atmosphere. 

As a general rule, young and robust individuals bear bleeding much better 
than children and aged persons, who often experience great exhaustion from the 
loss even of a few ounces. Old subjects, in particular, are prone to suffer in 
this way, the system being often a long time in reacting, while in not a few in- 
stances the operation is followed by sinking. Infants and children are also slow 
in recovering from the effects of bleeding, but reaction having taken place there 
is much less danger of ultimate exhaustion. Persons of a nervous temperament 
are less tolerant of the loss of blood than the sanguine and bilious. Corpulent 
persons are bad subjects for the lancet, and the habitually intemperate are often 
thrown into* delirium tremens by it. The inhabitants of densely crowded cities 
do not bear the loss of blood nearly as well as people residing in the country. 
In epidemics, as erysipelas, scarlatina, smallpox, measles, and puerperal fever, 
bleeding in any form is generally inadmissible. Finally, the abstraction of blood 
must be practised with the greatest circumspection in all cases of inflammation 
likely to be at all protracted, and in all persons suffering under grave accidents, 



CHAP. III. CONSTITUTIONAL TREATMENT. 87 

as fractures, dislocations, and lacerated wounds, attended with danger of excessive 
drainage and hectic irritation. After operations and injuj*ies, excessive loss of 
blood may seriously interfere with the restorative principle. 

The more violent the inflammation is the more reason will there be, other things 
being equal, for early and active bleeding ; so also if the organ affected be one 
highly essential to life. Blood is seldom taken when the inflammation is incon- 
sequential as it respects its degree and seat, milder means generally sufficing for 
its subjugation. 

In regard to the repetition of the bleeding, the practitioner must be governed, 
first, by the intensity and persistence of the morbid action ; secondly, by the 
importance of the organ attacked; and, lastly, by the state of the blood. The 
disease continuing with little or no mitigation, there will be the same reason for 
bleeding that there was in the first instance, and the last may now, perhaps, be 
borne much better, the previous abstraction having, it may be, engendered a 
certain deg^ree of tolerance. Intensity of action will be an additional reason for 
the act. The importance of the organ attacked must not be overlooked. An 
inflamed lung requires more energetic measures than an inflamed skin, and an 
inflamed skin than an inflamed finger. As it respects the bufify coat of the blood, 
its value as a sign of the necessity of a repetition of the operation has already 
been pointed out, and need not, therefore, be again discussed. Associated with 
a persistence of diseased action, and a vigorous state of the circulation, it is of 
some practical importance, but much less than was at one time supposed. 

2. Caihariics, — Cathartics constitute a most important class of remedies in 
the treatment of inflammation, being evei> more valuable than bleeding, because 
of their almost universal applicability. Their exhibition, however, should always 
be premised by the abstraction of blood, provided the nature of the case is such 
as to admit of it. Where this is contra-indicated, they may be given at once, 
and there are few surgical affections in which they will not prove eminently 
beneficial. Cathartics are usually divided into purgatives and laxatives, which 
differ from each other merely in the one being more active than the other. The 
distinction, however, is not without its importance in a practical sense. 

Cathartics, considered as antiphlogistic agents, are employed for diffierent pur- 
poses. In the first place, they may be administered simply to evacuate the 
bowels ; secondly, to deplete the mucous membrane, and thus diminish the quan- 
tity of blood in the system ; thirdly, to excite the action of the liver and mucous 
follicles ; fourthly, to produce a revulsive eff'ect, or to set up a new irritation at 
a distance from the original one ; and, finally, to stimulate the absorbents, thereby 
inducing them to remove inflammatory deposits. 

The importance of exhibiting cathartics as 'mere evacuants cannot be too 
strongly insisted upon when we consider that an overloaded state of the bowels 
is one of the most fertile sources of disease. Many of the so-called idiopathic 
inflammations evidently owe their origin to this cause, as is proved by the fact 
that a dose of active purgative medicine often promptly removes them, especially 
if administered at the commencement of the attack. An incipient ophthalmia, 
tonsillitis, or fever, is frequently cut short in a few hours simply by clearing out 
the contents of the bowels, and getting rid of irritating fecal matter and vitiated 
secretion.*?. Besides, as long as the bowels are constipated, it is impossible for 
other remedies to produce their specific effect, or for the various secretions to 
recover their natural tone. 

Sec«>ndly, this class of remedies proves useful in depleting the bowels, by ab- 
stracting the serous portions of the blood from the vessels of the mucous membrane, 
and thereby diminishing the quantity of fluid in the general system. This prac- 
tice i.«* often beneficially adopted in inflammation of the large intestine, in what 
is termed dysentery, and in the milder forms of inflammation in various parts of 
the hotly, where the loss of the red particles of the blood is of questionable pro- 
priety. An ounce of Epsom salts, or half a pint of citrate of magnesia, will 
often bring away from eight to twelve ounces of serum from the bowels in the 



88 INFLAMMATIOX. 



CHAP. III. 



coarse of a few hours, with the greatest advantage as it respects the morbid 
action. 

Thirdly, cathartics may be given with a view of stimulating the liver, pancreas, 
and mucous follicles of the bowels. There arc few inflammations, or disease of 
any kind, in which disorder of the liver does not play a conspicuous part, either 
in exciting or maintaining the morbid action. The quantity of fluid poured out 
by this organ, in health, in the twenty-four hours amounts, it is said, to nearly 
forty ounces, and it is, therefore, not difficult to form a tolerably correct idea of 
the ill effects that must result from the interruption, modification, or complete 
susi)onsion of its functions. The irritating material which it is destined to 
eliminate being retained in the blood, there must arise, as a necessary conse- 
quence, serious derangement of the nervous and vascular systems, as denoted 
by the excessive lassitude, headache, excited pulse, and other symptoms, so eon* 
spicuous in disordered states of the liver. But a diminished supply of bile is not 
the only difficulty; on the contrary, the fluid may be secreted in unnatural 
quantity, and yet, beng vitiated in quality, the efiects will hardly be less obvious. 
The pancreas, too, may have its functions deranged, which the well directed 
cathartic may readily restore to their normal condition. Of the vast influence 
exercised upon the health by the mucous follicles of the alimentary canal, it is 
hardly possible to form an adequate conception. Existing, as they do, every- 
where in vast numbers upon the mucous surface, the suppression of their func- 
tions, even for a short time, cannot fail to be folioweil by local inflammation in 
different parts of the body, or the material aggravation of it, if it has already been 
lighted up. Hence, remedies calculated to restore, modify, or improve the secre- 
tions of these several structures constitute important objects of treatment, not 
only as preventives, but as means of cure. 

Fourthly, the administration of cathartics proves useful on the principle of 
revulsion, metastasis, or counter-irritation, by establishing a i^ew action in a 
part more or less remote from that originally affected. During the operation of 
a brisk purgative, as well as for some time after, there is an unnatural afflux of 
blood to the alimentary canal, in consequence of which the suffering organ is 
temporarily relieved of vascular turgescence, on the principle that two morbid 
processes cannot go on, to any extent, at the same time. This operation may 
be intermittent or permanent, according to the character of the cathartic and the 
mode in which it is exhibited. In inflammation of the head, throat, eyes, and, 
in fact, of the supra-diaphragmatic portions of the body generally, this prin- 
ciple is never, for a moment, lost sight of by the practitioner, constituting, as it 
does, a most important element of treatment. 

Finally, cathartics, by clearing out the alimentary canal, and restoring the 
secretions, pave the way for the more successful action of other remedies, as 
diaphoretics, anodynes, diuretics, and sorbefaeients. They exert, in this respect, 
very much the same influence, only in a slighter degree, as venesection and 
leeching, diminishing the volume of the circulating mass, and diverting the 
blood from the suffering organ. Relieving obstruction, restoring secretion, and 
establishing new action, they enable the absorbent vessels to recover from their 
torpor, and to render themselves useful in removing inflammatory deposits. 

Cathartics are particularly valuable in inflammation of the brain and its 
membranes, of the eye and ear, throat, respiratory organs, liver, skin, and joints. 
In gastritis, enteritis, peritonitis, cystitis, wounds of the intestines, and strangu- 
lated hernia, they are either contra-indicated, or exhibited with the greatest pos- 
sible circumspection, and only in the mildest forms. In most, if not in all, of 
these affections, the best purgative is the lancet, aided by large anodynes, either 
alone or in union with calomel. Tranquillity, not perturbation, is what is sought 
for, on the principle that whatever excites peristaltic action must prove prejudicial 
to the inflamed surface. 

Cathartic medicines must not be exhibited merely with a view to the correc- 
tion of disordered alvine evacuation. Such a procedure could not fail to prove 
injurious. The action of these remedies is perturbating, and therefore aubversive 
of healthy function ; hence, it would be folly to expect that the passages should 



CDAP. iTi. COXSTITUTIOXAL TRKATMEXT. 89 

be entirely natural so long as they are exhibited. The more frequently they are 
given the more likely will this be the case. 

When these medicines act tardily, their operation may be aided by injections; 
and cases occasionally occur where the latter remedies may advantageously, and 
entirely, take the place of the former. 

The namber of porgatives and laxatives is very great, and the surgeon may 
therefore give himself considerable latitude in the choice of his articles. A few, 
however, either alone, or judiciously combined, will answer his purpose in nearly 
every case. Where a merely evacuant effect is desired, nothing is better than a 
dose of castor oil, rhubarb, or jalap ; the saline cathartics produce watery passages ; 
calomel, blue mass, and gray powder act specifically upon the liver ; and where 
an irritating, revulsive, or metastatic effect is wished for, the proper articles are 
compound extract of colocynth, scammony, gamboge, aloes, and podophyllin. 
In external iuflammations, as well as in inflammations of the supra-diaphragmatic 
organs generally, one of the most useful cathartics, as I have found from long 
experience, is an infusion of senna, or of senna and Epsom salts. It operates 
not only promptly and powerfully upon the bowels, but also upon the liver, 
stimulating this organ to increased action, in a manner hardly inferior to calomel 
and blue mass. The only objection to its exhibition is that it is apt to gripe, 
bat this tendency may usually be effectually counteracted by combining with it 
some carminative. Leptaudrin is also a good cholagogue, without so decided a 
porgative effect as pertains to calomel and senna, but this may be increased to 
any desirable extent by the addition of rhubarb, jalap, or podophyllin. Croton 
oil is rarely used, except to relieve obstinate constipation. It will hardly be 
necessary to say that the greatest caution is required in its administration. 

Injections, clysters, or enemas may be prepared of various articles, as gruel 
and common salt, water and mustard, castor oil, spirits of turpentine, infusion 
of senna, jalap, and other substances, according to the intended effect. What- 
ever material be used, the important rule is to mix with it a sufficient quantity 
of fluid, warm or cold, to distend the lower bowel. It may be administered with 
a common pewter syringe, having a long nozzle, and capable of holding at least 
from sixteen to twenty ounces ; or, where there is obstinate constipation, with 
an ordinary stomach tube. Recently an excellent enema-syringe has been 
manufactunni of gum-elastic, of the same shape as the old metallic one, only 
much superior in its mode of action, and much more easily kept in repair. 
Whatever instrument be employed, care must be taken that the patient be placed 
upon his side or l)elly during its introduction, and also that he be properly hold, 
for fear of accident, especially if he be delirious or otherwise unmanageable. 
Profe.ssor Pope, of St Louis, published, some years ago, the particulars of a case 
of a child that perished from perforation of the rectum during the administration 
of an enema. 

3. Mercury, — The reputation of mercury, as an antiphlogistic, has long been 
established. Although the precise mode of its action is still imperfectly known, 
its 1»ent*flcial effects are well understood. Its virtue in controlling inflammation 
is hardly inferior to that of the lancet and of tartar emetic, while, during the 
decline of the disease, as a powerful sorbefacient, or promoter of the removal of 
morbid deposits, it is without a rival in the materia medica. It may, therefore, 
b»* given during the height of the malady with a view of arresting its progress, 
and subsequently, after this object has been accomplished, for the purpose of 
gettinir rid of effused fluids, or reclaiming oppressed and disorganized structure. 
The effiraey of the remedy, in both these relations, is particularly conspicuous 
in the phlegmasias of the fibrous and fibro-serous tissues, in gout and rheumatism, 
synovitis, carditis, arteritis, hepatitis, splenitis, pneumonitis, laryngitis, iritis, 
orchitis, osteitis, and in syphilis. It is less apparent, though not without its 
value, in inflammation of the brain, the skin, and mucous membranes, bronchitis, 
nephritis, cystitis, and metritis. 

It is rarely that the treatment of inflammation is commenced with the exhibi- 
tion of mercury. It is only in very urgent or neglected cases that this rule is 



90 INFLAMMATION. chap. hi. 

departed from, its potency and activity being always augmented by previous 
depletion. Whenever, therefore, there is evidence of plethora, bleeding and 
purgation should precede its use. There is a mercurial point, so to speak, in 
influuimatory affections, prior to which the employment of this remedy eiUier 
proves positively injurious, or greatly disappoints expectation. This point is 
characterized by softness of the pulse, a relaxed condition of the skin, moisture 
of the tongue, and a general tendency to restoration of the secretions. Admin- 
istered during the height of the morbid action, when the whole system is enveloped, 
as it were, in flame, it can hardly fail to act as an irritant, and to increase the 
general excitement. For want of attention to this rule, a great deal of mischief 
is often done, and a remedy, otherwise of inestimable value, permitted to fall 
into disrepute. 

Of the manner in which mercury acts in relieving inflammation we bare, as 
already intimated, no very definite information. That it affords powerful aid in 
controlling the action of the heart and vessels, both large and capillary, is unques- 
tionable, but how this effect is produced, whether by any direct sedative impres- 
sion it may exert, or by merely correcting the secretions, is a point concerning 
which our knowledge is entirely at fault. Nor is our information any more reliable 
in regard to the changes which mercury induces in the state of the blood. We 
know very well how greatly the properties of this fluid are modified by inflam- 
mation, what increase there is of fibrin and white globules, and hoAv promptly, 
in many cases, these changes are corrected by the judicious use of mercury; but 
in what manner this is effected is, in the present state of the science, altogether 
inexplicable. 

During the decline of inflammation, and, indeed, in many cases long after the 
morbid action has been completely checked, the exhibition of mercury is of the 
greatest advantage in effecting riddance of the morbid products. Of the manner 
in which this is done we have occasionally direct ocular demonstration in some 
of the external phlegmasias. Thus, in iritis, if the system be placed under the 
influence of mercury, the effects of the remedy are rendered obvious by the daily 
progress which the affected structures make in freeing themselves of the plastic 
matter that was effused during the height of the inflammation, and which fre- 
quently proves so destructive to them by the changes which it induces in the 
pupil. Similar effects are witnessed in inflammation of the cornea, attended 
with interstitial deposits. The opacities which result from these deposits oft«n 
vanish in a short time under the influence of slight ptyalism, the effect being 
frequently apparent before the action of the medicine is fairly developed. In 
orchitis, after the disease has measurably subsided, the swelling and induration 
are, in general, promptly dispersed under the use of mercurials, aided by rest, 
light diet, and purgatives. In all these, and similar cases, the beneficial effects 
of the agent are evidently due to its sorbefacient properties, or to the manner in 
which it stimulates the absorbent vessels, compelling them to remove the products 
left by the previous action. 

Administered merely as a sorbefacient, the effects of this remedy are often 
insensible, its action being exerted in a very slow and gradual manner, yet hardly 
any the less efficiently. This kind of action is particularly desirable in chronic 
diseases, attended with a crippled condition of the tissues from semi-organized 
deposits, and an enfeebled state of the general system. Under such circum- 
stances, active mercurialization is altogether inadmissible, from its irritating and 
prostrating effects ; while a more gentle and persistent course is often followed 
l»y the greatest l)enefit, the gums being merely touched, or rendered slightly red, 
tumid, and tender, as an evidence of the silent operation of the remedy. 

The best form of exhibition of the remedy is calomel, blue mass, or mercury 
with chalk. Where a prompt and powerful impression is desired, as when there 
is high inflammatory action, likely to prove speedily overwhelming in its effects, 
not only threatening structure but life, the medicine should be given in large and 
frequently repeated doses, so as to keep up a decided and well-sustained infllDeiice. 
For this purpose the best article is calomel, in doses from three to five grabuBy 
administered every three, six, or eight hours, until we have attained the oljecl 



CHAP. III. CONSTITUTIONAL TREATMENT. 91 

of its exhibition. When the case is at all urgent, as, for example, in croup, 
pneomotiia, or carditis, no time is to be lost ; whatever is done mnst be done 
quickly, with a bold, vigorous hand ; the remedy mnst be given in full, not in 
small, insufficient quantities, or in a faltering, hesitating manner. There is but a 
short step between the disease and the grave, the struggle is one of life and death, 
and the victory must be accomplished, if accomplished at all, at all hazard, 
present or future. When the disease is less violent, or the organ involved less 
important to life, the medicine is exhibited in smaller doses^ and at longer inter- 
vals, and then, too, instead of calomel, the milder forms may be used, as blue 
mass, or gray powder. Where a chronic or insensible impression is desired, the 
bichloride may be given instead of calomel or blue mass, or the latter may be 
employed in smaller doses. Other forms of mercury, to be mentioned hereafter, 
as the iodide, cyannret, and dento-phosphate, are often beneficially prescribed in 
chronic diseases of the skin, in glandular enlargements, in chronic affections of 
the joints, and in tertiary syphilis. Mercury with chalk, or gray powder, is a 
great favorite with some practitioners in inflammatory diseases of children and 
aged persons ; but I now rarely use it, having frequently found it to be nauseating, 
and unworthy of reliance. 

To prevent the mercurial from running off by the bowels, it is usually necessary 
to combine with it a certain quantity of opium, as a fourth of a grain, half a 
grain or even more, with each dose, according to the particular exigencies. In 
children, and in all cases affecting the brain, opium should be given with great 
caution, especially during the violence of the morbid action. When the skin is 
hot and dry, the mercurial should either be entirely withheld until further deple- 
tion has been practised, or it should be united with some diaphoretic, as tartar 
emetic, ipecacuanha, or Dover's powder. Griping, which is so liable to occur 
during the progress of the treatment, should be counteracted by carminatives and 
laxatives, as oil, salts, or magnesia. 

The administration of so potent a remedy as mercury should be most faithfully 
watched. No judicious practitioner uses it heedlessly or sakelessly. He knows 
that it is a remedy for good or for evil, and he therefore employs it wisely and 
properly ; opportunely, not out of time. As soon as he discovers, by the fetid 
state of the breath, the red and tumid appearance of the gums, the metallic taste, 
and the increased flow of saliva, that the object of its exhibition has been attained, 
he either omits it altogether, or gives it only in very small quantity, and at lung 
intervals. He does not persist in its administration, as was once the custom, 
until the tongue is too big for the mouth, the teeth drop from their sockets, articu- 
lation, deglutition, and even breathing are almost impossible, and the countenance 
presents a distorted and hideous aspect ; he simply touches the gums, maintaining 
the impression thus made, if necessary, on account of the continuance of the 
morbid action, or letting it die out, if the disease has been arrested. 

There are certain individuals who, from idiosyncrasy, or the former use of 
mercury, cannot take this medicine, even in the smallest quantity, without being 
violently salivated. To avoid this occurrence, so exceedingly disagreeable both 
to the patient and the practitioner, due inquiry should always be made, with a 
view of ascertaining this fact, previously to the administration of the remedy. 
On the other hand, there are persons who cannot, under any circumstances, be 
constitutionally impressed with mercury, however largely it may be used. They 
are mercury proof. It apparently fails to enter the system in any form, com- 
bination, or mode of exhibition. In such cases, and also when the system 
is not as prompt in responding to the effect of the medicine as is desirable, 
the article should be coi^oined with some nauseant, as ipecacuanha or tartar 
emetic, so as to produce more thorough relaxation of the system. The operation 
of the medicine may also be aided with frictions of mercurial ointment upon the 
groin, the inside of the thighs, the arm, and axilla, thrice in the twenty-four 
boors, for fifteen minutes at a time, the inunction being performed near a fire 
with the hand well protected with a pair of gloves, otherwise the assistant may 
salivate himself long before he succeeds in affecting the patient. From one to 
two drachma of the ointment will suffice at each application. Employed in Ibia 



92 INFLAMMATION. chap. i:i. 

way, the cfifect is sometimes more rapid than when the medicine is given inter- 
nally, though the constitutional impression is more mild and evanescent. The 
practice, however, is a very filthy one, and has, on that account, become almost 
obsolete. 

Rapid ptyalism may be effected by the use of suppositories, composed each of 
a drachm of strong mercurial ointment, rendered stiff with a little tallow, and 
inserted into the rectum every eight hours, the bowels having been well emptied 
previously, and then locked up with a full dose of opium in order to secure reten- 
tion. Dr. J. Bell, of Scotland, by whom this method was first recommended, 
states that the gums occasionally become tender under its influence within 
twenty-four hours, and that in hardly any case the time required exceeds two 
days. 

There are circumstances which altogether contra-indicate the use of mercurials 
in almost any form. Most of the horrible effects which are so often witnessed 
in this country, especially in the southwest, where this medicine is more liberally 
administered than in any other section of the United States, are, I am satisfied, 
entirely attributable to the reckless and indiscriminate manner in which the article 
is given in all conditions of the system, and in every possible variety of disease. 
Persons of a strumous habit of body, the old, the infirm, the ill-fed, the badly- 
clothed, and the anemic, are particularly prone to suffer from the use of mercury, 
even when exhibited in very small quantity. It is in subjects of this descrip- 
tion, more especially, that we so frequently witness those frightful ravages of the 
mouth, teeth, jaws, and cheeks, that have almost led to the creation of a new 
department of surgery for their relief, and which have thrown so much discredit 
upon the American profession. 

Finally, should salivation accidentally set in, the best remedies are astringent 
gargles, cooling laxatives, emollient applications to the face and neck, and the 
liberal use of anodynes, to allay pain and nervous irritation. The lotion that I 
have found to answer better than any other is a solution of Goulard's extract, in 
the proportion of one drachm to eight ounces of water, used every hour or two, 
the only objection to it being that it discolors the teeth, an effect which, however, 
soon disappears of its own accord. Gargles of alum, tannin, copper, zinc, crea- 
sote, and other astringent substances also prove beneficial, especially if not em- 
ployed too strong. When the inflammation runs very high, leeches to the throat 
and jaws are indicated ; and it may even be necessary to scarify the tongue, to 
prevent suffocation. Excessive fetor is allayed by chlorinated soda. 

The best internal corrective of salivation is the chlorate of potassa, administered 
in doses of from fifteen to thirty grains three or four times a day, in a large quan- 
tity of sweetened gum- water, or lemonade, to render it more soluble. , This medi- 
cine seems to act with peculiar efficacy upon the digestive organs, and may often 
be advantageously resorted to as a prophylactic during the exhibition of mercury. 
It may be also beneficially employed as a gargle, from one to two drachms being 
dissolved in a pint of water, and the solution used every two or three hours. In 
very intractable cases of ptyalism, an emetic of ipecacuanha, morning and even- 
ing, will often answer w^hen almost everything else has failed. 

4. Emetics, — Emetics are not as often used now as they were formerly in the 
treatment of inflammation, their employment having been, in gpreat measure, 
superseded by cathartics and other evaouants. Their exhibition, at the present 
day, is limited almost exclusively to cases in which there is marked gastric and 
biliary derangement, as denoted by the nausea and vomiting, the headache, 
lassitude, and aching of the back and limbs which sometimes so greatly oppress 
the patient in the earlier stages of his illness. When these symptoms are presenti 
and there is no contra-indication, an emetic often acts like a charm, not only rid- 
ding the stomach of irritating matter, but allaying vascular excitement, promoting 
perspiration, and, in fact, unlocking all the secretions. Emetics are, of ooQiMi 
not used in the phlegmasias of the sub-diaphragmatic organs, as gaBtritiSy lint^hK/^ 
itis, peritonitis, hepatitis, and cystitis, for the reason that the concimlon riMP* 
by their action would inevitably prove injurious. For the same feaaai'tWJp 



CHAP. III. CONSTITUTIONAL TREATMENT. 98 

m'itfaheld in wounds of the intestines, hernia, fractures, and dislocations. In 
cephalic and cardiac affections thej should also be carefully avoided. 

The beat forms of administration are tartar emetic and ipecacuanha ; common 
salt, alum, and ground mustard, also occasionally answer a good purpose, their 
eifect being generally prompt and efficient. Whatever substance be employed, its 
ose should always be followed by large draughts of tepid water, chamomile tea, 
or infusion of valerian, the latter being particularly beneficial in nervous and 
hysterical subjects. As a general rule, tartar emetic should never be given, on 
account of its sedative and irritating effects, to very young children and to persons 
who have become enfeebled by age and disease. 

5. Depressants. — Depressants, or nauseants, are justly entitled to a high posi- 
tion in the scale of antiphlogistic agents. As their name implies, they are reme- 
dies which, by lowering the action of the heart, lessen the momentum of the 
circulation, and diminish the flow of blood to the affected tissues. This, how- 
ever, is not the only good which they are capable of doing ; by the impression 
which they make upon the nervous and sanguiferous systems, they become instru- 
mental in re-establishing and improving the secretions, and in thus indirectly 
controlling the morbid action. There is, in fact, not a single organ which does 
not feel, to a greater or less extent, their influence, or which is not brought, more 
or less, under their dominion. The effect of this operation is often witnessed 
during the exhibition of tartar emetic in nauseating doses, in the relaxed skin, 
the softened pulse, the moistened tongue, and the pallid countenance, all bearing 
testimony to the universal impression of the remedy. Judiciously employed, 
depressants are among the most valuable and efficient antiphlogistic means that 
we possess, and they have the advantage that they may often be used without 
any preliminary depletion of any kind. Their beneficial effects are particularly 
conspicuous in inflammation of the respiratory organs, of the eye, the joints, and 
fibrous structures ; also in certain forms of inflammation of the skin and cellular 
tissue. In many of these affections, if not in all, they have almost entirely super- 
seded the use of the lancet and other evacuants, their controlling influence over 
the morbid action being generally most striking and satisfactory. Their efficacy 
is hardly less apparent in many of the diseases of the sub-diaphragmatic viscera; 
but their exhibition here demands greater care and vigilance, as their emetic 
effects could not fail to prove prejudicial. Their employment is particularly 
adapted to the treatment of acute inflammation of young, robust subjects, whose 
systems require to be rapidly impressed in order to arrest the progress of their 
di^^a^es. Infants and children, the old, infirm, and decrepit, bear their use badly, 
and often sink under their injudicious administration. 

The most trustworthy depressants are tartar emetic and ipecacuanha, to which 
may l>e added aconite, veratrum viride, and digitalis, which, however, hold a sub- 
ordinate rank. Of the depressing effects of bleeding I have already spoken, 
ami p«>inted out the circumstances under which they may be most readily pro- 
du«.-ed. 

Tartar emetic, as a depressant, maybe administered in doses varying from the 
eighth to the fourth of a grain, repeated every two, three, or four hours, accord- 
ing to their impression, which should be steadily maintained until the object of 
the administration of the remedy has been fully attained. It will generally be 
safest to begin with a small quantity, and to increase it gradually if it be found 
to be borne well by the stomach. Sometimes the first few doses, even if small, 
will produce pretty active emesis, but this, so far from being injurious, will com- 
monly be highly beneficial, by relaxing the system and opening the emunctorics. 
By and by, gastric tolerance will be established, and then the remedy will often 
be borne in extraordinary quantities, though wo never employ it in the enormous 
doses recommended by Rasori, Thomasoni, and other disciples of the Italian 
•ebooL In thia coimtry, indeed, we seldom give as much at a single dose as half 
a graiB, the a«affa«a oaaotity rarely exceeding one-half or one-third of that 
ti* Ite. 1 'Mien, on the contrary, often gave five, ten, and 



94 INFLAMMATION. 



CBAP. III. 



The beneficial effects of tartar emetic, as a depressant, may often be greatly 
enhanced by the addition to each dose of a small quantity of the salts of morphia, 
just enough to produce a calming and diaphoretic impression. Such a combina- 
tion is particularly serviceable in nervous, irritable persons, and in sabjects who 
have been debilitated by intemperance and other causes of exhaustion. When 
the article, given by itself, is productive of vomiting, it should never be used in 
any other way. In children, too, such a mode of exhibition is, as a general rule, 
indispensable. Sometimes the article may be advantageously administered along 
with the neutral mixture. 

The dose of ipecacuanha^ as a depressant, varies from a fourth of a grain to 
a grain, and may be used alone or in combination with an anodyne, as, indeed, is 
usually found best. A nauseant effect may be kept up in this manner almost as 
long as may be desired, but the impression is less pervasive and far inferior, in 
every respect, to that produced by tartar emetic. On this account, however, the 
medicine is peculiarly adapted to the treatment of inflammatory affections of 
children, who, as already stated, usually bear the operation of antimony very 
badly. 

Whichever of these two articles be employed, it will be well to withhold all 
drinks from fifteen minutes to half an hour after the exhibition, as, when this 
precaution is neglected, they are very apt to cause vomiting. At the end of this 
time, however, diluents, cool or tepid, may be used with the greatest benefit, from 
their tendency to promote relaxation and secretion. 

Of digitalis I have not been led to form a very favorable estimate as a depres- 
sant or sedative. I was formerly in the habit of employing it a great deal in 
various forms and combinations, as well as in various forms and stages of inflam- 
matory disease, and yet it would be difficult for me to recall a solitary case in 
which I derived any appreciable benefit from it. I have, therefore, of late years 
altogether abandoned its use. 

Aconite is a powerful antiphlogistic. The form in which it is usually exhibited 
is the saturated alcoholic tincture of the root, prepared according to Fleming^s 
formula, the dose of which is from one to five drops repeated every two, three, 
or four hours, until it has produced its peculiar depressing effect. The best^ 
because the safest, plan is to begin with a small quantity, and to increase it 
gradually and cautiously until it brings down the pulse, which, in the course of a 
few hours, often descends from ninety-five or one hundred to sixty-five or even 
fifty, the surface at the same time becoming bathed with perspiration. In large 
doses, it is powerfully sedative and anodyne, but it should never be given in this 
way on account of its prostrating influence. It is particularly adapted to neu- 
ralgic, gouty, and rheumatic affections, and to the higher grades of traumatic 
fever; and my practice generally is to combine it with tartar emetic and sulphate 
of morphia, as this insures a more prompt and beneficial action than when given 
by itself 

Veratrum viride^ an American remedy, exerts a powerful influence upon the 
action of the heart and pulse, very similar to that of aconite, only, if possible, 
still more certain. The dose of the saturated alcoholic tincture of the root, the 
form of the medicine most generally employed, is from five to eight drops, repeated 
every two, three, or four hours, until it has sensibly reduced the force and fre- 
quency of the pulse, when it is either suspended or given in smaller quantity. 
As veratrum viride is an article of great potency, it is impossible to be too care- 
ful in its use. If carried too far, it causes nausea and vomiting, excessive pros- 
tration, faintness, vertigo, dimness of sight, and other dangerous symptoms. It 
is applicable to the same class of cases as aconite, and may be exhibited either 
by itself or in union with morphia and tartar emetic. The best means for coun- 
teracting its depressing effects are opiates and alcoholic stimulants. 

6. Diaphoretics. — Diaphoretics, in their mode of action, bear the same relation 
to the skin that cathartics do to the bowels. They constitute, therefore, a highly 
important class of remedies in inflammation, from the faculty which they possess 
of restoring and modifying the cutaneous perspiration, the suppression of which 



cnAF. III. COXSTITUTIONAL TREATMEXT. 95 

lit a frequent soarce of disease. The quantity of perspiration daily thrown off 
by the skin, in the normal state, varies from twelve to sixteen ounces, and the 
retention of snch an amount of material in the system must necessarily exert a 
most prejudicial influence upon the suffering organ. The importance of a critical 
i»weat, as it was called by the ancient physicians, in putting a stop to disease, 
has long been familiar to the practitioner, and the employment of diaphoretics is 
only an attempt to imitate nature's efforts, in removing a cause of morbid action, 
or restoring a secretion which has been suppressed in consequence of the changes 
which that action has induced in the general system. As in the case of purga- 
tives, depletion should always precede the employment of the remedy, so should 
it in the case of diaphoretics, a relaxed condition of the body always powerfully 
predisposing to a favorable action of the medicine. 

The class of diaphoretics is very large, but there are only a few that are really 
at all reliable, or that are much employed by the experienced practitioner. These 
are tartar emetic, ipecacuanha, and Dover's powder, aided, if necessary, by tepid 
drinks^ and sponging of the surface with tepid water. The spirit of Mindererus, 
in combination with a small quantity of spirit of nitric ether, makes a mild 
diaphoretic, and is often used in low states of the system. The efficacy of anti- 
mony, which deserves the highest rank in this class of remedies, will be greatly 
increased if given in union with morphia, the two articles thus counteracting the 
bad effects which they might produce if exhibited singly, at the same time that 
they subdue the heart's action, relax the skin, relieve pain, and induce sleep. 
The best form of exhibition is a watery solution, each dose containing from the 
sixth to the tenth of a grain of antimony, with Arom one-fourth to one-eighth of 
a frrain of morphia, repeated every two, three, or four hours. Ipecacuanha is 
adapted chiefly to children and old persons, and to the latter stages of the disease, 
and may be given alone, or, what is preferable, with some of the salts of opium. 
The ordinary dose of Dover's powder, for an adult, is ten grains, but I seldom 
nse less than fifteen, and frequently as many as twenty, repeated every eight, ten, 
or twelve hours. The action of these remedies should always be aided by tepid 
drinks, and, if there be much dryness of the surface, by frequent sponging of th^ 
body with tepid water. During very hot weather, and in high states of inflam- 
mation, cool ablutions are often more efficient, as well as more grateful, than 
warm. 

Bathing is not oAen employed in the treatment of acute inflammation, on 
account, chiefly, of the inconvenience and fatigue attending the operation. In 
the chronic form of the disease, however, it is a remedy often of great value, 
especially in affections of the skin, joints, and abdominal viscera. The water, 
which may be simple or medicated, is used at various degrees of temperature, the 
tepid bath ranging from 85 to 92 degrees of Fahrenheit, the warm from 92 to 96, 
and the hot from 96 to 1 12. A very excellent and convenient mode of conveying 
moist and heated air to the patient's body, as he lies in bed, consists in attaching 
one end of a tin tube, from three to four feet in length, to a teakettle filled with 
hot water, the other end being placed under the bedclothes. Copious perspira- 
tion usually promptly follows the application, which may be maintained for any 
deriirable period. The foot-bath is occasionally used with advantage, but to 
derive full benefit from it the patient should be well covered up in bed, his feet 
hanging in the water placed in a suitable tub upon a chair, the immersion being 
continued from thirty to sixty minutes. The hip-bath is employed chiefly in 
affections of the gen i to- urinary organs. 

7. Diuretics. — Diuretics are medicines intended to restore and modify the 
renal secretion, which is almost invariably more or less changed in inflammatory 
affections. Their employment is always, as a general principle, preceded by 
various depletory measures, and they are never given in inflammation of the 
kidneys and bladder. Their administration is usually accompanied by mucilagi- 
Doos drinks, but these are not at all necessary to their beneficial effects, ordinary 
flaids answering quite as well. They may be conveniently arranged under three 
distinct heads : — The first includes those articles which, when received into the 



96 INFLAMMATION". 



cnAP. III. 



system, depurate the blood, and increase the quantity of solid matter of the urine, 
as the nitrate, acetate, and bitartrate of potassa. The second class comprises 
colchicum, squills, and other vegetable diuretics, which carry oflf the watery por- 
tions of the blood ; and the third consists principally of copaiba and cubebs, 
which not only augment the renal secretion, but exert a peculiar influence upon 
the mucous membrane of the bladder and urethra, as is shown in cystitis and 
gonorrhoea. Of these various articles, the most important, in the treatment of 
acute inflammation, are nitrate of potassa and colchicum. The former may be 
exhibited in doses of fifteen to thirty grains every three, four, five, or six 
hours, in a large quantity of water. Colchicum is generally given in the form 
of the vinous tincture of the seed, in doses varying from ten to fifty drops, several 
times in the day and night. My own practice usually is to employ one drachm 
along with half a grain to a grain of sulphate of morphia every evening at bed- 
time. In this way the medicine produces a much more decided impression upon 
the system, as well as upon the renal secretion, increasing its quantity, and free- 
ing it of lithic acid, and probably, also, of other nitrogenized elements. Moreover, 
it usually acts upon the bowels, bringing away thin watery evacuations, especially 
when employed by itself; and in large quantities it often vomits. One full dose, 
administered in this manner at bedtime, is far superior to three or four small ones, 
which often only fret and irritate the kidneys and bowels, placing them in a con- 
dition ill calculated to correct morbid action. 

8. Anodynes. — There is no class of remedies which require a greater amount 
of nice judgment and correct discrimination in respect to their selection, mode 
of combination, and time of administration than that of anodynes. The subject, 
therefore, is one that should be carefully studied with reference to these particular 
points, by every one desirous of acquiring correct views of the practical applica- 
tion of anodynes to the treatment of inflammatory affections. My conviction is 
that these remedies are used much less freely than they should be, and that they 
are capable, if properly exhibited, of affording immense benefit, not only in allay- 
ing pain and inducing sleep, but frequently also in controlling morbid action, 
and, consequently, in abridging its course and preventing its ravages. 

The same rules, as respects the premising of depletory measures, are applicable 
to anodynes as to cathartics. Thus, first, whenever there is plethora, fecal dis- 
tension, or disorder of the secretions, their correction should, if possible, precede 
the exhibition of the opiate. Sometimes a full dose of morphia is made to 
succeed a large bleeding, or an active purgative, the medicine then exercising a 
decidedly sedative and soothing influence. Administered before the system has 
been properly relaxed, it rarely fails to increase the vascular action, to lock up 
the secretions, produce headache, prevent sleep, and augment thirst and restless- 
ness. 

Secondly, the medicine should always be exhibited in full doses, experience 
having shown that it makes a much stronger, as well as a much more soothing, 
impression in this way than when it is taken in small, and frequently repeated 
doses. With the precautions pointed out, an adult will bear, when the symptoms 
are at all urgent, from two to four grains of opium, or its equivalent of morphia, 
every twelve or twenty-four hours. The effects of the remedy must be steadily 
watched, especially if the patient be a child, or if there be any undue cerebral 
excitement. Should the pulse increase in fulness and vigor under its influence, 
the skin become more hot and dry, or the vigilance and restlessness augment, 
repetition is temporarily suspended, until, by farther depletion, the system is 
placed in a more favorable condition for its reception. 

Thirdly, the best period for the exhibition of the medicine, when there is no 
immediate necessity for its use, is towards bedtime, the patient being thus more 
likely to obtain quiet and refreshing sleep after the removal of the light and other 
external stimulants. 

Fourthly, when there is excessive pain along with gpreat dryness of surface, and 
the depletion has been already carried to a sufficient extent, the anodyne should 



CMAP. III. CONSTITUTIONAL TREATMENT. 9 7 

be combined with a diaphoretic, as ipecacuanha, or, what is better, tartar emetic, 
or, instead of this, a full dose of Dover's powder is given. 

Anodynes are particularly beneficial in all cases of inflammation attended with 
violent pain, which, by its persistence, might rapidly wear out the powers of life. 
Their value cannot be too highly appreciated in the phlegmasias of the skin and 
cellular tissue, the joints, the sub-diaphragmatic viscera, the eye, car, pleura, 
heart, and respiratory organs. Within the last ten years enormous doses of 
optttm have been g^ven in peritonitis with the most happy results, and I am sure 
that the same mode of treatment might be advantageously extended to inflam- 
natioD of many of the other parts of the body. The importance of absolute 
rest to the aifected organ is universally conceded, and is daily witnessed in the 
BMuagemeat of external inflammation. Instinct alone is often sufficient to secure 
it, bat where this fails the surgeon endeavors to procure it by means of various 
mechanical appliances. In the internal phlegmasias no such means are applicable, 
but here the object may be readily attained by opiates, given in full and sustained 
doased to control the movements gf the suflfering structures. In gastritis nothing 
so promptly and eflTectually quiets the muscular fibres of the stomach as a suit- 
able quantity of morphia; and the same treatment has long been successfully 
employed in dysentery, or inflammation of the lower bowel. In cystitis the most 
effKtnal remedy for allaying the excessive spasm and the incessant desire to 
urinate, is a full andoyne. In pleuritis and pneumonia, how is it possible to 
afford rest to the lungs and respiratory muscles, except by the same mean^? 
The more quietly the parts are kept while laboring under disease, the sooner, 
other things being equal, will the patient recover from its effects, and the less 
pain he will have to endure from the constant and rude contact of the affected 
suriSMres upon each other. Even in inflammation of the brain and its meninges, 
after proper depletion has been practised, anodynes are frequently indispensable, 
not only to allay pain and induce sleep, but to control the morbid action. And 
how do they do this ? Simply, in the first place, by subduing the action of the 
heart, and thus preventing it from sending out to the brain its accustomed 
quantity of blood ; and, secondly, by making a direct impression upon the brain 
itself, thereby, in some degree, controlling its movements, so injurious both to 
its own substance and to its coverings, when thus affected. Anodynes, in most 
of these cases, as well as in many others, literally constitute nature's splint. 

The best anodynes are opium and its different preparations, as the salts of 
morphia, codeia, and laudanum. These may be given either by the mouth or 
rectum, double the quantity being usually required to produce the same effect in 
the latter as in the former case. Sometimes the remedy is employed endermically 
or subcutaneously, in the form of injection. There are some persons who cannot 
bear opium in any form. When this is the case a substitute should be sought in 
lupuliue, hyoscyamus, aconite, Indian hemp, and other kiiLdred articles ; or, in 
what I have generally found to answer very well, a union of morphia with tar- 
trate of antimony and potassa, neutralized by lemon-juice. 

Many persons bear codeia better than any other form of opium, as it relieves 
pain and tranquillizes the system, without inducing any cerebral disturbance. The 
ordinary dose is from half a grain to a grain. 

9. Combination of Remedies, — There are few acute surgical diseases or severe 
accidents in which a combination of several of the remedies now descril)od may 
not be advantageously employed. In nearly every cose of the kind the patient 
will be found to be oppressed with fever, thirst, pain, and restlessness ; or, in 
other words, to labor under incited action of the heart and arteries, attended with 
diminished, if not suspended secretion, and all the evils consequent upon such a 
state of the systeoL To meet the indications of treatment, under such circum- 
stances, there is no prescription which, according to my experience, is capable 
of conferring gpreater benefit than the saline and antimonial mixture, as it is 
termed, consisting of the following ingredients : — 
VOL. I. — ^7 



98 INFLAMMATION. OBAP. IQ. 

9* ADtimonii et potasse tart. gr. iij. 

Magnesia sulph. $ij. 

Morphie sulph. gr. j|. 

Aqu8B destil. §z. 

Syr. zingiber, vel simplicis §!J. 

Acid, sulph. aromat. 5s8* 

Tinot. veratr. virid. 3^* 
M. 

Of this combination the proper average dose is half an ounce, repeated every 
two, three, four, or six hours, according to the exigencies of the ease. Should 
it produce emesis, or distressing nausea, the dose must be diminished. Properly 
administered, it rarely fails rapidly to subdue vascular excitement, to cause copious 
perspiration, to allay pain, thirst, and restlessness, to maintain the bowels in a 
soluble condition, and to induce sleep and general tranquillity. Instead of the 
veratrum aconite may be used ; but in general I give the former the preference. 
Colchicum may be added when there is a rheumatic or gouty stAte of the system, 
quinine when there is a tendency to periodicity, and copaiba when there is renal 
or cystic trouble. The quantity of morphia may be increased when there is 
much pain. 

10. Antiphlogistic Regimen, — ^Under this head are comprised the patient's diet, 
and the care which he may require during his confinement. The subject is one 
which rarely receives the attention its importance demands. 

Few persons, fortunately, have any appetite during the height of an inflam- 
matory attack, and hence the surgeon seldom experiences any difficulty in regard 
to the regulation of the diet. The stomach, oppressed with nausea, or a sense 
pf uneasiness, either loathes food, or rejects it almost the moment it is swallowed. 
It is well it should be so ; for any ingesta, however mild, taken at this period, 
would only become a source of further trouble, by increasing tlie morbid action, 
perhaps already progressing at a furious rate. When the appetite remains, it 
must be repressed, steadily and courageously, until all danger from over-excite- 
ment from its indulgence has been safely passed. The mildest and least nutritions 
articles only are admissible in the earlier stages of the disease ; such as panada, 
gruel, arrowroot, sago, and tapioca. Not even the lightest animal broth is per- 
missible, unless there is decided tendency to prostration, or an irritable state of 
the system, clearly dependent upon the want of proper nourishment, as occasionally 
happens in persons of a nervous, irritable temperament, or who are habitually 
huge feeders. The drinks should be cooling, consisting of iced water, gum-water, 
linseed tea, or barley-water, either simple, or slightly acidulated with lemon-juice, 
tamarind, or any of the subacid fruits ; care being taken that, while they are used 
freely, they are not employed in such quantity as to produce gastric and intestinal 
oppression. 

As soon as the violence of the disease has abated, or the vital force begins to 
flag, a more nourishing diet must be employed ; and the articles generally best 
calculated to meet this contingency are Liebig's beef essence, beef-tea, the dif- 
ferent kinds of animal broth, vegetable soups, eggs, broma, pap, and com starch, 
along with milk, wine whey, and milk punch, given at suitable intervals, and in 
sufficient quantity to supply the waste of blood and nervous fluid. The return 
to solid food should be very gradual, lest it rekindle morbid action. The starving 
cells mugt be fed slowly, not rapidly. When gastric irritability exists, along with 
excessive flatulence, there is no remedy which, according to my experience, affords 
such prompt and efiectual relief as small and repeated quantities of champagne 
administered in ice. 

The promptings of nature should not be disregarded during the progress of 
recovery ; for their tendencies are generally wholesome, and should therefore be 
gratified to at least a reasonable extent, unless there are well-marked centra-indi- 
cations. Acid drinks and food are particularly apt to be craved, and a moderate 
use of them is often eminently beneficial, not only in whetting the appetite, but 
in promoting the digestion, by supplying the exhausted stomach with substances 
calculated to atone for the want of a due amount of gastric juice, so essential to 



CHAP. III. LOCAL TREATMENT. 99 

healthy chjmification. Improper indulgence is, of course, avoided, and care is 
aIm) taken that the articles are of such a character as to prevent acidity and 
flatulence. 

Rest of mind and body must be carefully obsenred. The importance of this 
is so self-evident that it would be folly to attempt to enforce it by any labored 
argument Whatever has a tendency to excite the heart's action must necessarily 
increase the momentum of the circulation, and, through it, the inflammation. In 
all severe attacks the patient mast keep his bed, from which he must not rise 
even to answer nature's calls ; light and noise are carefully excluded from his 
apartment, especially in inflammation ot the eye, brain, or ear ; and no persons 
shonld be permitted to be about him, except his immediate attendants. Many a 
patient is killed by the kindness of his friends and relatives. 

A frequent change of posture is indispensable to the comfort and well-being 
of a sick person, and should be effected with the greatest possible caution, espe- 
c-ially when there is great debility. Violent pain, loss of sleep, excessive constitu- 
tional irritation, and dreadful bed-sores are sure to follow, in all low states of the 
pystem. where this precaution is neglected. When the patient is exhausted 
from shock or hemorrhage, as after a severe injury or a capital operation, great 
care must be taken not to raise his head too suddenly, or to let him be propped 
up with pillows, as he will need all the blood that the enfeebled heart is able to 
propel to the brain. 

Attention must be paid to the temperature of the patient's room, this being 
regulated, not by his feelings, which are often deceptive, but by the thermometer. 
On an average, it should not exceed 65^, but in some cases it may range as high 
as 7H*^, and in others as low as 60*^. The apartment should be frequently venti- 
lated. When it is recollected how soon the air becomes vitiated during sickness, 
and how important a due supply of oxygen is to the proper maintenance of the 
health, the importance of attention to this subject will not be doubted. Clean- 
liness of the body, and of the bedclothes, is another subject of vital importance 
in the treatment of inflammation, and one to which, I am sure, few practitioners 
|>ay sufficient attention. To medicate the inside of a patient while we neglect 
the outside is one of those singular inconsistencies of which w-e see daily proofs 
in the sick chamber. I would not insist upon too frequent ablutions and changes 
of the body and bedclothes, but they should certainly, in ordinary cases, be 
effected at least once in the twenty-four hoiirs ; care being taken to avoid unne- 
cessary exposure and fatigue during their performance. Even the arrangement 
of the furniture should l>e attended to, on the principle that an agreeable impres- 
sion, of whatever kind, is more conducive to comfort and recoverv than one of an 
opfK>site character. 

II. Local Treatment. — The local remedies of inflammation consist of rest 
and elevation of the affected part, the abstraction of blood, cold and warm appli- 
cations, compression, destructives, and counter-irritation. 

1. B^ft and Position, — Without rest, steady and persistent, of the affected 
part, little progress can be made toward the cure of inflammation. The practi- 
tion^T who neglects attention to this important circumstance, performs only half 
\kU <l«ty. The patient, ignorant of its advantages, often continues to exercise 
th«* afl"ected organ long after it has become unfitted for the discharge of its func- 
tion?*. much to his present discomfort and ultimate detriment. A simple conjunc- 
tivitis, that might be cured in a few hours, is often urged, for the want of a little 
rest «»f the eye, into a violent and protracted ophthalmia, perhaps, at length, eventu- 
atiiiir in total loss of vision. An inflamed joint is frequently, for the same reason, 
n*n«iered permanently stiff and useless. Hence, rest is universally considered as 
one of the most essential elements of the local treatment of inflammation. In 
general, it is easily procured, simply by the patient's own efforts ; but when this 
is not tlip case, it must be insured by appropriate splints, and other means, np- 
plie<l so as not to interfere with the other treatment. In inflammation of some 
of the internal organs, as the heart, stomach, peritoneum, bowels, and urinary 



100 INFLAMMATION. 



CHAP. III. 



hhidder, the object is attained Vjj the liberal use of anodynes, which, bj tempo* 
rarily paralyzing the muscular fibres of the affected structures, effectaally preveDt 
peristaltic motion, and thus place them in a better condition for speedy recorerj. 

But there is a period when rest must not be enforced too rigidly, for, if ooo- 
tinued too long, it may be productive of much harm. Its great utility is in the 
earlier stages of inflammation, when morbid action is gravescent, and for some 
time after it has reached its culminating point. As soon as recedence has fairly 
begun, motion, gently and cautiously conducted, is often of g^at utility. 

Not only should the part be kept at rest, but it should also be maintained in ai 
elevated position, the success of the treatment l>eing thereby greatly enhanced. 
The importance of attention to this point is well exemplified in many familiar 
dideases. The patient himself is often conscious of it, and, therefore, resorts to 
it, as it were, instinctively. Who that has ever had an attack of whitlow, does 
not remember the great relief which he experienced from carrying his hand in as 
elevated position ? The effect of position is nowhere more strikingly erinced 
than in odontalgia. During the day, the patient, while attending to business, is, 
l>orliaps, hardly sensible of suffering, but, at night, no sooner does his head touch 
the pillow than the tooth begins to ache and throb, compelling him to get up and 
pace his room. In orchitis, the beneficial effects of our remedies are always 
greatly aided by elevation conjoined with rest of the affected organ. It is quite 
easy to understand why this should be so. In inflammation, the vessels carry an 
extraordinary quantity of blood, which is still further increased when the suffering 
structures are placed in a dependeiLt position, because the flow, not being opposed 
by gravity, has then free scope, thus crowding the already distended capillaries 
to the very utmost, and proportionately aggravating the morbid action. 

Finally, the inflamed part should also be maintained in as easy a position as 
possible, mere rest and elevation not sufiicing to insure comfort. Ail restraint 
must be taken off; all muscular contraction counteracted. Thus, in inflammation 
of the knee-joint, the limb should recline upon its outer surface, a pillow being 
placed in the ham, this being the best position for preventing tension. In syno- 
vitis of the elbow-joint, the forearm is bent at a right angle with the arm; and 
in hip-joint disease, the thigh is slightly flexed upon the pelvis, and turned towards 
the sound one. 

2. Local Bleeding. — Blood may be abstracted locally by scarification, puncture, 
leeching, and cupping, each being more or less serviceable, in its own way, in par- 
ticular cases and under particular circumstances. 

The manner in which topical bleeding affords relief is sufficiently evident in 
some of these forms of depletion, but not very apparent in others. Thus, in 
scarifying and puncturing a part, the blood is taken directly from the engorged 
vessels, which are thus drained of their altered and vitiated contents. If the 
operation be carried to any considerable extent, as it often may be, especially in 
the former of these procedures, we may, at the same time, make a powerful im- 
pression upon the general system, nearly as rapidly and quite as effectually as 
when blood is drawn from a vein at the bend of the arm, although, in general, 
such an effect is neither aimed at nor desired. A similar influence is exerted by 
leeching and cupping, provided the operation is performed upon the inflamed 
surface, or in its immediate vicinity. Frecjuently, however, it is performed at a 
remote point, and then its mode of action is rendered more difficult of compre- 
hension. Thus, in inflammation of the brain, it is difficult to determine how 
leeches and cups, applied to the nape of the neck, the temples, or back of the 
ear, afford relief to the affected organ. It is certainly not possible, in such a 
case, to make any direct impression upon the seat of the disease ; whatever in- 
fluence is exerted must be exerted through the general system. This is a self- 
evident proposition. The vessels of the neck and scalp have no direct communi* 
cation with the vessels of the brain ; hence, in leeching and cupping these parts, 
we can no more drain the cerebral capillaries than we can drain those of the 
hand, chest, or any other distant part We may assume, then, that, when topical 
•bleeding is practised by cither of the latter methods, its beneficial effects are dne^ 



CHAF. III. LOCAL TREATMENT. 101 

not to any direct drainage of the enffering structures, but indirectly to the de- 
pressing influence which it exerls upon the heart and nervous system, and, 
throagh them, upon the morbid action, diminishing the momentum of the circu- 
lation, and, coDseqaently, the flow of blood in the capillaries at the seat of the 
inflammation. 

Topical bleeding, to be effective, should always, if possible, be preceded by 
general depletion. When the force of the morbid action has thus been broken, 
the rest of the malady is often well dealt with by local abstraction of blood. It 
is only when the disease is very mild, or when there is no marked constitutional 
disorder, that this rule should be disregarded. Under such circumstances, the 
treatment may occasionally be very properly commenced with the application of 
leeches, cups, or scarification, followed or not, as the e.\igencies of the particular 
case nwy seem to require, by other measures. The manner of taking blood topi- 
eilly will be pointed out in the chapter on Minor Surgery. 

3. Cold and Warm Applications, — These remedies, which are more particu- 
larlv adapted to external inflammations, comprise a great number of articles, in 
the'form of water dressings and cataplasms, with the character of which every 
practitioner should be perfectly familiar. Both classes of remedies may be simple 
or medicated, according to the tolerance of the part and system, and the nature 
of the morbid action. 

(1.) Cold tracer has been employed in the treatment of inflammation almost 
from time immemorial ; but its beneficial effects were nearly forgotten, until 
attention was recalled to it by some of the military surgeons of Europe, early in 
the present century. Its value is now universally acknowledged, and there is no 
remedy which is so frequently applied both in private and in hospital practice. 

It is not difficult to conceive how cold operates in subduing morbid action. 
Its chief effect is evidently that of a sedative, lowering the temperature of tho 
part, and clausing contraction of the vessels, thereby relieving pain, swelling, and 
tension. It is particularly applicable to inflammation in its incipient and graves- 
cent stages, while there are, as yet, little effusion, and no serious structural lesion. 
When the action has reached its acme, threatening suppuration, or, what is worse, 
tending to gangrene, it is usually hurtful both to part and system, and must be 
promptly discontinued. Besides, it should not be forgotten that cold, when intense, 
or prrjtracte<l, may of itself cause gangrene. Young and robust persons usually 
tijlerate such applications much better than the aged and feeble ; they arc also 
better bonie in summer than in winter. As it is impossible always to predeter- 
mine what their effects will ))e, their action should be carefully watched, in order 
that, if they should become a source of annoyance, they may either be entirely 
dispensed with, or employed in a modified form. 

The water may )>e rendered anodyne, astringent, or antiseptic, according to 
circumstances, by the addition of o|)ium, acetate of lead, or some of the chlorides. 
The best way to use it is to cover the affected part with a piece of old porous 
linen, and to direct upon it a constant flow of water from a basin with a stop- 
CH'k, slung to the top of the l>edstead, the limb lying on an oil-clolh trough, from 
which the fluid is conducted into another vessel standing near the bed. Or the 
part may be covered with a wide, thin piece of sponge, spongio-piline, or common 
linen, over which is placed a bladder partially filled with pounded ice. Or the 
water may be conveyed from a basin by means of a candle wick to a layer of lint 
upon the inflamed surface, the wick acting on the principle of a syphon. Finally, 
when ice cannot be obtained, the water may be rendered cold by means of ahrohol, 
in the proportion of one to six parts of the fluid ; by pyroligneous acid and alcohol ; 
or by the admixture of a strong solution of hydrochlorate of ammonia and mtrate 
of potassa. In whatever manner the fluid is employed, the surface to which it is 
applied should 1>e constantly exposed to the air, to favor evaporation. 

(i,) The use of warm wafer is also of great antiquity, having been employed 
by Hippocrates and other practitioners in gangrene and various cutaneous affec- 
tfoos. It has, however, only been within the last twenty years that it has assumed 
anything like the rank to which its importance as an antiphlogistic remedy entitles 



• • 



102 INFLAMMATION. CHAP. izi. 

it. I generally give a decided preference to warm water over cold, the impressioii 
made by it u[)on the part and system being usually more agreeable and Boothing, 
while there is ninch less danger of metastasis, or of a sudden transfer of disease 
from the external to the internal parts of the body. It is particularly adapted 
to nervous, irritable individuals,, who are easily chilled by cold applications, and 
to cases in which the inflammation has already made considerable progress, where 
there is much tension and swelling, or where suppuration is impending, or has 
already taken pla^e. A good rule, both in regard to wai*m and cold applications, 
is to consult the feelings of the patient, using one or the other acconling to the 
tolerance of the part and system, or simply so long as they seem to be beneficial 
AVhen a change becomes requisite, care must be taken that it is not too sudden, 
lest it produce harm. Thus, hot applications should be succeeded first by warm, 
then by tepid, afterwards by cool, and finally, if necessary, by cold, the transition 
being gradual and wary, not great and sudden, so as to shock the part and system, 
and thus cause undue reaction. 

Warm water may generally be advantageously combined with opium, or with 
opium and acetate of lead, or with opium and hydrochlorate of ammonia. The 
latter is the preparation which I generally prefer, the opium and ammonia being 
dissolved in hot water, in the proportion of about two drachms of the former 
and an ounce and a half of the latter to the gallon of fluid. A piece of old 
flannel of suitable size, and arranged in several thicknesses, is then wrung out 
of the solution, and laid upon the inflamed surface, a covering of oiled silk, or, 
what is better, and much cheaper, parchment paper prepared with sulphuric acid 
being spread over the cloth to confine the heat and moisture. As the cloth 
becomes dry, it is wet, from time to time, not by re-immersion, but simply by 
pressing the solution upon it from a sponge ; dressing by substitution being 
necessary only in thp event of the flannel becoming soiled and offensive by the 
discharges. The only objection to the hydrochlorate of ammonia is its liability 
to cause slight pustulation, especially in persons of a delicate skin ; when this 
happens, its use must be suspended. In the employment of cold water, the part 
is exposed ; in the use of warm, it is covered. The former does good by con- 
stringing the inflamed tissues, and opposing effusion; the latter by relaxing 
them, and favoring effusion. 

(3.) Fomentations, which may be considered as a species of local bathing, are 
often beneficially employed in inflammation of the joints and of some of the 
internal viscera, being particularly calculated to relieve pain, tension, and spasm. 
In cystitis, gastritis, enteritis, and peritonitis, as well as in wounds and other 
injuries of the pelvic and abdominal organs, their employment can rarely be 
entirely dispensed with. The most simple fomentation consists of a large, thick 
flannel cloth, wrung out of hot water, or water near the boiling point, by means 
of two sticks turned in opposite directions, and applied lightly to the part as hot 
as it can be borne. If a soothing narcotic, or sedative influence is required, 
chamomile flowers, poppies, hops, or, what is much better, laudanum, or lauda- 
num and alcohol, will be found to form valuable additions. In whatever manner 
they are used, they should bo frequently renewed, care also being taken that 
there are two cloths, so that, while one is taken off, the other may be immediately 
applied, all danger of shock and reaction from exposure to the air being thus 
avoided. 

(4.) Stuping is a variety of fomentation, particularly serviceable in affections 
of the eye, nose, ear, mouth, and throat. It is conducted with a piece of flannel, 
rolled into a kind of ball, which the patient holds in a small pitcher, at such a 
distance from the affected surface that the vapor may ascend to it, care being 
taken ^ to wet the cloth as often as it becomes cool. The remedy may be medi- 
cated, if desired, with laudanum, camphor, belladonna, hemlock, or any other 
article, anodyne, astringent, or sorbefacient. 

When it is desirable to apply steam more directly, a funnel may be inverted 
over the hot fluid, and the tube held towards the affected surface at a suitable 
distance, ^team may be conveyed to any part of the patient's body, under the 



CBAF. III. LOCAL TREATMENT. 103 

bedclothes, bj meaDS of a large gutta-percha tube, attached to a small tin boiler, 
placed opon a table, and heated by a spirit lamp. 

(5.) Poultices, technically called cataplasms, are an important class of remedies 
in tended for external application in inflammation, wounds, ulcers, abscesses, and 
other affections. They are modifications of fomentations, and are made of vari- 
ous sabatances, either simple or medicated, according to the object they are in- 
tended to fulfil. They should be of such consistence as to accommodate them- 
selves accurately to the surface to which they are applied, without being so 
tenacious as to adhere firmly to the skin, or so thin as to spread over the neigh- 
boring parts. They should never be heavy nor bulky, and they should be reuewed 
as often as they become dry and cold ; otherwise they lose their good effects and 
are converted into irritants. In geueral, it is sufficieut to chauge them thrice a 
day ; but in warm weather, or when there is much discharge, it may be necessary 
to reapply them every four, five, or six hours. Their temperature should be 
about the same as that of the body, that is, from 85 to 92 degrees of Fahrenheit, 
and they should be placed directly upon the affected surface in a uniform layer of 
from three to four lines in thickness, a piece of bobbinet, gauze, or thin netting 
being interposed to prevent sticking and facilitate removal. For retaining the 
heat and moisture of a poultice the most suitable application is a piece of oiled 
silk or oiled paper. 

The action of a poultice is usually limited to the skin, or, at all events, to the 
parts to which it is immediately applied ; it is only when it is composed of very 
strong materials that its influence is more deeply felt. In using medicated cata- 
plasms, it is necessary, especially when there is ulceration or abrasion of the skin, 
to be aware that the active ingredient may be absorbed, and thus produce the 
same effects as when introduced directly into the stomach. Poultices differ very 
much in their mode of action ; thus, some are altogether emollient, that is, they 
soften and relax the parts to which they are applied, at the same time that they 
promote exhalation and absorption ; some are anodyne ; some astringent ; some 
antiseptic ; some stimulant. 

The following list comprises nearly all that are now in use, with brief direc- 
tions for their preparation : — 

The bread poultice is made by pouring boiling water upon the crumbs of stale 
wheat bread, and stirring the mixture in a basin with the back of a spoon until it 
iif of a thick, mushy consistence. It is then spread upon a piece of folded cloth 
large enough to cover not only the affected surface, but also a portion of healthy 
skin. Milk may be used as a substitute for the water, but a poultice, thus pre- 
pared, requires to be more frequently changed, as it soon becomes sour and 
offensive. 

The arrowroot poultice is prepared in the same manner as when that article is 
used for food, only that it is rendered more consistent ; the powder being mixed 
St first with cold water, and then with a sufficient quantity of boiling water to 
convert it into a thick, gelatinous paste. This poultice is admirably adapted for 
irritable sores, and deserves to be more frequently employed than it is 

The slippery-elm poultice is prepared from the powdered bark of the slippery- 
elm, moistened with hot water. It is very light and demulcent, and, therefore, 
well adapted for burns, excoriations, and irritable sores. 

The linseed poultice, the l)est and most convenient of all, from its emollient 
properties, is made of ground linseed mixed with boiling water, and stirred until 
it is converted into a thick, cohesive mass. This poultice is always very easily 
prepared, retains its heat for a long time, and has a sufficiency of oil to keep it 
•oft and prevent it form adhering. 

Excellent emollient poultices may be prepared from apples, carrots, turnips, or 
any of the more tender culinary roots, by boiling them, after having removed the 
skin, and mashing them into a soft pulp. They possess, however, no peculiar 
rirtaes, and are therefore seldom used. 

A poultice may be variously medicated. Thus it may be rendered astringent 
by the admixture of acetate of lead, Goulard's extract, alum, or a decoction of 
oak bark ; anodyne, by laudanum, opium, morphia, poppy-heads, or hemlock ; 



104 INFLAMMATION. 



CHAP* III. 



Stimulating, by chloride of sodium, vinegar, or port wine ; absorbent, by iodine and 
other articles ; disinfectant, by Labarraque's solution, or permanganese of potaasa. 

The fermenting poultice, used in foul, fetid, and painful nlcers, in hospital 
gangrene, and in mortification, is prepared by incorporating a pound of wheat 
flour with half that quantity of yeast, the mixture being afterwards exposed to 
a gentle heat until it swells. The port-wine poultice, which belongs to the same 
class as the fermenting, is made in a similar manner, except that it is not boiled. 

The charcoal poultice, also a good antiseptic application, though now rarely 
used, is prepared from recently burned charcoal, reduced to a very fine powder, 
and mixed with bread, oatmeal, or ground flaxseed. The objection to this poal* 
tice is its liability to discolor the affected parts, so as to prevent as from olraerr- 
ing their real condition. This may, however, be obviated, in great measure, by 
the interposition of a thin linen cloth. 

A poultice may be rendered refrigerant by means of a freezing mixture, or a 
bladder partially filled with pounded ice and spread over its surface. Such an 
application, however, for reasons ah*eady stated, requires great care. 

4. Nitrate of Silver. — There is no article which enjoys a higher reputation, 
as a local antiphlogistic agent, than nitrate of silver ; certainly none that is more 
frequently employed. Without understanding its precise mode of action, expe- 
rience has taught us its great value in the treatment of a large number of inflam- 
matory affections, some of which it would be exceedingly difficult to cure without 
it, while nearly all are more or less benefited by it Ever since its introduction 
into practice by Mr. Higginbottom, of England, as a topical antiphlogistic, it 
has been employed in almost every form of external inflammation both in a solid 
and a fluid state. Its beneficial effects in diseases of the eye, throat, and genito- 
urinary organs have long been acknowledged by practitioners. In cutaneous 
affections, too, it enjoys a high and well-deserved reputation. In erysipelas it 
is perhaps more frequently used than any other single remedy, iodine alone 
excepted. Its value in the treatment of this disease, so common in this and 
other countries, is fully established, both in a curative and prophylactic point of 
view. In inflammation of the tonsils and fauces, whether the result of ordinary 
causes, of a strumous diathesis, or a syphilitic state of the system, no article is 
so generally employed, or enjoys so great a reputation, as nitrate of silver. 
In gonorrhoea and gleet, in strictures and morbid sensibility of the urethra, in 
spermatorrhoea, in vaginitis, and metritis, nitrate of silver has become an indis- 
pensable means of cure. Indeed, it would be difficult to find an accessible dis- 
ease, attended with preternatural vascularity and disordered structure, in which 
its application would not be productive of benefit. 

Nitrate of silver may be used as a vesicant, as when it is applied to the skin, 
or simply as an alterant, or modifier of diseased action ; for, as already stated, 
nothing definite is known of its mode of operation. When employed for blister- 
ing purposes, the solid form is usually preferred, the stick being passed lightly 
but efficiently over the surface, previously a little moistened with soft water, until 
there is evidence of slight coagulation of the albuminoid matter of the epidermis. 
A cloth, pressed out of wai*m water, is then applied, when vesication will soon 
follow. The same result may easily be produced by a saturated solution of 
nitrate of silver ; but, as the remedy is less manageable, it is not often employed 
with that view. Unless applied in a very concentrated form, and for an unusual 
length of time, nitrate of silver never acts as an escharotic, or as a destroyer of 
the tissues. 

The solid nitrate of silver is often used with great advantage in ulceration of 
the mouth and throat, cornea, skin, vagina, and uterus, the application being 
usually made very lightly, and repeated not oftener than once every third, fifth, 
or eighth day. Employed too frequently or too abundantly, it often does im* 
mense harm, not only occasioning severe pain, but sometimes seriously aggra- 
vating the morbid action. These effects may be produced equally by a strong 
solution as by the solid stick. A strong collyrium of nitrate of silver has 
destroyed many an eye, or urged on an inflammation, perhaps on the very verge 



CRAP. III. LOCAL TRBATHENT. 105 

of reiH>lution, to a most distressing extent. Urethritis is often aggravated, and 
gremtly protmcted, by a strong injection of this description. Much judgment, 
then, it will be perceived, is requisite in the local use of this remedy, not only as 
it respects its strength, but also the mode and time of its application. Carefully 
adapted to the exigencies of each particular case, it exerts a powerful antiphlo- 
gistic impression upon the diseased structures, diminishing vascular action, 
relieTing pain, and destroying morbid sensibility, often so conspicuous in inflam- 
mation of the eye and throat, and which nothing else can so well control. 

5. Iodine. — ^Hardly less valuable than nitrate of silver, as a topical remedy in 
inflammation, is iodine, first introduced to the notice of the profession, in this 
relation, by Mr. Davis, an English surgeon. Tt is generally used in the form of 
the officinal tincture, either pure or diluted with alcohol. Its great value seems 
to consist in its alterant and sorbefacient properties, changing the action of the 
capillary vessels, and promoting the removal of effused fluids. That this is the 
case i9 safficiently apparent from what takes place in erysipelas of the skin, where 
the effects of the remedy may always be easily watched. Within a few hours 
after the application has been made the swelling is usually observed to be so much 
diminished as to cause a marked corrugation of the surface, attended with a dimi- 
nation of pain and hardness ; circumstances plainly denotive of lessened vascular 
activity, and progressive absorption. Similar effects are witnessed when the 
application Is made to an (Edematous uvula, scrotum, or eyelid, there being not 
only no forther effusion afterwards, but a removal of what was previously de- 
posited. From these facts, it may be inferred that iodine, locally applied, is not, 
as has sometimes been asserted, merely a sorbefacient, but also an alterant, or 
modifier of secernent action. 

Although exceedingly valuable as an antiphlogistic, it is questionable whether 
iodine has received the attention it really deserves, or whether we are sufficiently 
acqaainted with the class of cases to which it is more particularly applicable. Its 
reputation in erysipelas is fully established, and I have certainly myself found no 
article at all comparable to it in that affection as an endemiic remedy. It is also 
of great service in boils, carbuncle, whitlow, corns, bunions, and inflamed, irrita- 
ble ulcers of the extremities. Its beneficial effects arc hardly less conspicuous in 
active oedema of the uvula and tonsils, the legs, scrotum, prepuce, and puden- 
dam, a single application often sufficing to produce the most marked change in 
the condition of the part. As a coUyrium and an injection, the value of iodine 
has not been sufficiently tested to enable us to form any definite opinion, but the 
trials that have been made with it, in this respect, are encouraging, and deserving 
of repetition. 

For external use, I generally employ the tincture of iodine with an equal 
amount of alcohol, applying the mixture by means of a camel-hair pencil until 
the skin becomes of a deep yellowish color. The application may be repeated 
once every eight, twelve, or twenty- four hours, according to the exigencies of 
the case. If the remedy be used stronger than this it will be very apt to produce 
severe pain and to excite capillary action ; two circumstances concerning which it 
is imp«j3sible to exeroise too much caution. When intended for the tonsils, uvula, 
and other delicate parts, the dilution should, for the reason just mentioned, be 
still greater. 

6. Comprenmon, — Compression, as an antiphlogistic agent, has been too much 
neglected, nor has it always been judiciously used when resorted to. That it is 
capable of doing an immense deal of good, when employed with proper care, and 
under suitable circumstances, my experience fully justifies me in asserting. Why 
it is so rarely used, it is difficult to determiue, unless it is tliat practitioners do 
not possess the requisite skill in its application and mode of management. 

Although more particularly applicable to the latter stages of inflammation, 
compression is not without its value in the incipient and gravescent periods of the 
disease. Affording support to the affected structures, it is well calculated, when 
cariy employed, to give tone to the distended capillaries, enabling them to urge 



106 INFLAMMATION. CHAP. ill. 

on their sluggish contents, and, consequently, to prevent their effusion into the 
surrounding cellular tissue. Immense good is often done in this way, as every 
one knows who has ever treated erysipelas, wounds, fractures, and dislocations, 
by compression. If two cases of any one of these affections, of precisely the same 
character, could be treated, one with the bandage, and the other without the 
bandage, simply by the ordinary topical remedies, the difference would be most 
striking. The compressed limb would be comparatively free both from pain and 
swelling, whereas the other would be highly sensitive and greatly enlarged, from 
inflammatory deposits. We see, in such circumstances, how, in the one limb, 
action is controlled, and how, in the other, it pursues its wayward course. Bat 
this is not the only benefit which systematic compression is capable of affording. 
When judiciously employed, it controls muscular contraction, and thus prevents 
spasm, both of which are frequently so annoying in fractures, dislocations, ampu- 
tations, and various affections of the joints. Another effect, and that by no means 
the least striking and important, is the sorbefacient influence which it exerts, 
rousing the absorbent vessels, and compelling them to remove the fluids that were 
deposited prior to the employment of the remedy. It is for this reason that com- 
pression may be so advantageously used in the latter stages of most of the exter- 
nal inflammations, attended with effusions of serum and fibrin, there being no 
means known to the surgeon so well calculated to effect this important object, 
and to assist in restoring the functions of the suffering parts. The treatment of 
orchitis by compression affords a beautiful and satisfactory illustration of the 
mode of action of the remedy under such circumstances. When this disease has 
been shorn of its violence by depletion, the swelling and induration, consequent 
upon the morbid action, often promptly disappear under the influence of sys- 
tematic compression ; generally, indeed, in one-fifth of the time in which they 
disappear under the use of mercury and ordinary sorbefacients. The absorption 
is frequently so rapid as to render it necessary to change the dressings twice in 
the twenty-four hours. Similar effects are sometimes observed in inflamed and 
enlarged joints. 

The means of compression are the common bandage and adhesive plaster, ap- 
plied in such a manner as to make gentle and equable pressure over the whole of 
the affected structures. Whenever the part admits of it, the bandage deserves 
the preference, as it is more easily managed, and equally efficient ; but there are 
certain organs, as the testicle and mamma, where adhesive strips alone can be 
used. When an additional sorbefacient effect is desired, strips of ammoniac and 
mercurial plaster may be substituted for the ordinary plaster. 

7. Destructives, — Destructives are remedies which the surgeon employs to de- 
stroy the germs of certain diseases, as that of chancre, hydrophobia, and malignant 
pustule ; and to neutralize certain poisons, as that of the snake, and the dead sub- 
ject. Their action is either curative or prophylactic ; most generally the latt». 

The most speedy and effectual remedy for an incipient chancre is excision, or 
the destruction of the affected tissues with some escharotic substance, as nitric 
acid, bichloride of mercury, or acid nitrate of mercury. This plan should always 
be adopted whenever it is found that the poison has not yet had a chance of dif- 
fusing itself among the surrounding parts, inasmuch as it not only at once removes 
the local disease, but protects the system effectually from contamination, the little 
sore left by the knife or escharotic generally healing in a few days. The struc- 
tures inoculated by the poison of hydrophobia and malignant pustule should be 
treated in a similar manner. When the knife is not admissible, on account of the 
timidity of the patient, the best remedy, according to my observation, is acid 
nitrate of mercury, in the form of Bennetts formula, applied by means of a soft 
piece of wood, as a common match, or the point of a probe, inserted, if possible, 
into the part, and held there until the tainted tissues are completely devitalized. 
The same remedy, either pure, or properly diluted, is admirably adapted to the 
treatment of phagedenic ulcers and spreading gangrene, by whatever cause in- 
duced. It should not, however, be used without due precaution, as it is an agent 
of great power, and may extend its destructive influence far beyond the dis^lsed 



CHAP. III. LOCAL TBEATMBXT. 107 

limits. The ordinary nitric acid is less manageable than the acid nitrate of mer- 
cory from its liability to diffuse itself over the adjacent parts, and is now seldom 
nseil as an escharotic. Bichloride of mercury, dissolved in alcohol, in the pro- 
portion of two scruples to the ounce, is a most efficient caustic, producing a thin, 
soft, greyish eschar, which separates in a few days. It is used chiefly in venereal 
buboes, and acts most promptly when its application is preceded by a blister. A 
powerful escharotic effect may be produced by a combination of three parts of 
bichloride of mercury with one of opium, made into a thick paste with concen- 
trated sulphuric acid. The only objection to these preparations is the excessive 
pain they occasion, which is sometimes almost insupportable. 

Similar means may be employed for neutralizing the poison of the rattlesnake 
and other venomous reptiles, and for destroying the virus of wounds received in 
the dissection of dead bodies. In the former case, free excision is practised, fol- 
lowed by the use of the hot iron, or some escharotic substance ; in the latter, the 
part is held for a considerable time under a stream of cold water, then well sucked, 
and next thoroughly cauterized with acid nitrate of mercury. 

8. Caunier-Trritants, — Counter-irritants are remedies which, when applied to 
the surface of the body, excite a new disease, or a new action, in a part more or 
less remote from the one originally affected. They are never used, or at least 
very seldom, until after pretty thorough depletion has been practised, by which 
the inflammation has been robbed of its violence, as their effects are then always 
more prompt and decisive. The new disease is generally established close to the 
original one, but occasionally at some distance from it. Thus, in inflammation 
of the hip-joint, the counter irritant is applied as near as possible over the aceta- 
bulum and head of the thigh-bone, the immediate seat of the morbid action, and 
80 with the other articulations. In disease of the neck of the bladder and pros- 
tate gland, it is applied to the perineum ; of the pleura and lungs, over the nearest 
point of the chest In inflammation of the eye, on the contrary, the irritation is 
established on the nape of the neck, behind the ear, or on the arm, not in the 
immediate vicinity of the suffering organ. Great judgment is often required to 
determine the precise point where, as well as the precise time when, the new action 
ought to be instituted. If it be too near the original affection, it may run, as it 
were, into it, and thus aggravate instead of mitigate the mischief; if, on the 
other hand, it be too remote, it may entirely fail of the object for which it was 
employed. Counter-irritation, as already stated, is never resorted to until the 
system has been relieved of plethora, and the morbid action weakened by other 
remedies. Used in the height of the morbid action, it can scarcely fail to be 
productive of local and constitutional disturbance, calculated to exercise a pre- 
judicial influence upon the progress and termination of the case. 

Although the class of counter-irritants comprises a large number of articles 
of a very diversified character, they may with great propriety be arranged under 
two heads, according to their mode of action, as vesicants, and suppurants. 

(1.) Vetftcants are remedies which, when applied to the skin, elevate the epi- 
dermis in the form of blisters filled with serum. They are of great value in the 
treatment of inflammation, both acute and chronic, and are applicable to a great 
variety of circumstances, with which the practitioner should be fully acquainted. 
The articles commonly used for this purpose are cantharides, either in powder or 
in the form of collodion-liquid, ammonia, and hot fluids. In acute disease these 
means, especially the first, are always preceded by active depletory measures, 
since it is well known that, if they are employed before there has been a proper 
reduction of the system, they are liable to do mischief by increasing the local 
and general excitement In chronic inflammation, however, they may often be 
advantageously used at the very commencement of the treatment The vesicat- 
ing agent is generally plac<Ml as near the affected part as possible ; sometimes, 
indeed, directly over it 

BhMeris, properly so called, are prepared with the common fly ointment of the 
ihops, and vary in shape and size according to the object they are intended to 
fitlfil, or the region to which they are applied. The part, if covered with hair, 



106 INFLAMMATION. oaAP. in. 

on their sluggish contents, and, consequently, to prevent their effusion into the 
surrounding cellular tissue. Immense good is often done in this way, as every 
one knows who has ever treated erysipelas, wounds, fractures, and dislocations, 
by compression. If two cases of any one of these affections, of precisely the same 
character, could be treated, one with the bandage, and the other without the 
bandage, simply by the ordinary topical remedies, the difference would be most 
striking. The compressed limb would be comparatively free both from pain and 
swelling, whereas the other would be highly sensitive and greatly enlarged, from 
inflammatory deposits. We sec, in such circumstances, how, in the one limb, 
action is controlled, and how, in the other, it pursues its wayward course. But 
this is not the only benefit which systematic compression is capable of affording. 
When judiciously employed, it controls muscular contraction, and thus prevents 
spasm, both of which are frequently so annoying in fractures, dislocations, ampu- 
tations, and various affections of the joints. Another effect, and that by no means 
the least striking and important, is the sorbefacient influence which it exerts, 
rousing the absorbent vessels, and compelling them to remove the fluids that were 
deposited prior to the employment of the remedy. It is for this reason that com- 
pression may be so advantageously used in the latter stages of most of the exter- 
nal inflammations, attended with effusions of serum and fibrin, there being no 
means known to the surgeon so well calculated to effect this important object^ 
and to assist in restoring the functions of the suffering parts. The treatment of 
orchitis by compression affords a beautiful and satisfactory illustration of the 
mode of action of the remedy under such circumstances. When this disease has 
been shorn of its violence by depletion, the swelling and induration, consequent 
upon the morbid action, often promptly disappear under the influence of sys- 
tematic compression ; generally, indeed, in one-fifth of the time in which they 
disappear under the use of mercury and ordinary sorbefacients. The absorption 
is frequently so rapid as to render it necessary to change the dressings twice in 
the twenty-four hours. Similar effects are sometimes observed in inflamed and 
enlarged joints. 

The means of compression are the common bandage and adhesive plaster, ap* 
plied in such a manner as to make gentle and equable pressure over the whole of 
the affected structures. Whenever the part admits of it, the bandage deserves 
the preference, as it is more easily managed, and equally efficient ; but there are 
certain organs, as the testicle and mamma, where adhesive strips alone can be 
used. When an additional sorbefacient effect is desired, strips of ammoniac and 
mercurial plaster may be substituted for the ordinary plaster. 

7. Destructives, — Destructives are remedies which the surgeon employs to de- 
stroy the germs of certain diseases, as that of chancre, hydrophobia, and malignant 
pustule ; and to neutralize certain poisons, as that of the snake, and the dead sub- 
ject. Their action is either curative or prophylactic ; most generally the latter. 

The most speedy and effectual remedy for an incipient chancre is excision, or 
the destruction of the affected tissues with some escharotic substance, as nitric 
acid, bichloride of mercury, or acid nitrate of mercury. This plan should always 
be adopted whenever it is found that the poison has not yet had a chance of dif- 
fusing itself among the surrounding parts, inasmuch as it not only at once removes 
the local disease, but protects the system effectually from contamination, the little 
sore left by the knife or escharotic generally healing in a few days. The struc- 
tures inoculated by the poison of hydrophobia and malignant pustule should be 
treated in a similar manner. When the knife is not admissible, on account of the 
timidity of the patient, the best remedy, according to my observation, is acid 
nitrate of mercury, in the form of Bennet's formula, applied by means of a soft 
piece of wood, as a common match, or the point of a probe, inserted, if possible, 
into the part, and held there until the tainted tissues are completely devitalized. 
The same remedy, either pure, or properly diluted, is admirably adapted to the 
treatment of phagedenic ulcers and spreading gangrene, by whatever cause in- 
duced. It should not, however, be used without due precaution, as it is an agent 
of great power, and may extend its destructive influence far beyond the 



en vp. III. LOCAL TREATMENT. 107 

limit-s. The ordinaiy nitric acid is less maoageable than the acid nitrate of mer- 
cury from its liability to diffuse itself over the adjacent parts, and is now seldom 
iL««ti as an escharotic. Bichloride of mercury, dissolved in alcohol, in the pro- 
portion of two acmples to the ounce, is a most efficient caustic, producing a thin, 
luift, grayish eschar, which separates in a few days. It is used chiefly in venereal 
baboes. and acts most promptly when its application is preceded by a blister. A 
powerful escharotic effect may be produced by a combination of three parts of 
bichloride of mercury with one of opium, made into a thick paste with concen- 
trated solphuric acid. The only objection to these preparations is the excessive 
pain they occasion, which is sometimes almost insupportable. 

Similar means may be employed for neutralizing the poison of the rattlesnake 
and other venomous reptiles, and for destroying the virus of wounds received in 
the dissection of dead bodies. In the fonner case, free excision is practised, fol- 
lowed by the use of the hot iron, or some escharotic substance ; in the latter, the 
part is held for a considerable time under a stream of cold water, then well sucked, 
and next thoroughly cauterized with acid nitrate of mercury. 

8. CounteT'Irritantft, — Counter-irritants are remedies w^hich, when applied to 
the surface of the body, excite a new disease, or a new action, in a part more or 
less remote from the one originally affected. They are never used, or at least 
very seldom, until after pretty thorough depletion has been practised, by wliich 
the inflammation has been robbed of its violence, as their effects are then always 
more prompt and decisive. The new disease is generally established close to the 
original one, but occasionally at some distance from it. Thus, in inflammation 
of the hip-joint, the counter irritant is applied as near as possible over the aceta- 
balnm and head of the thigh-bone, the immediate seat of the morbid action, and 
BO with the other articulations. In disease of the neck of the bladder and pros- 
tate gland, it is applied to the perineum ; of the pleura and lungs, over the nearest 
point of the chest In inflammation of the eye, on the contrary, the irritation is 
established on the nape of the neck, behind the ear, or on the arm, not in the 
immediate vicinity of the suffering organ. Great judgment is often required to 
determine the precise point where, as well as the precise time when, the new action 
oufrht to be instituted. If it be too near the original affection, it may run, as it 
were, into it, and thus aggravate instead of mitigate the mischief; if, on the 
other hand, it be too remote, it may entirely fail of the object for which it was 
employed. Counter-irritation, as already stated, is never resorted to until the 
system has been relieved of plethora, and the morbid action weakened by other 
remedies. Used in the height of the morbid action, it can scarcely fail to be 
pniductive of local and constitutional disturbance, calculated to exercise a pre- 
judicial influence upon the progress and termination of the case. 

Although the class of counter-irritants comprises a large numl>er of articles 
of a very diversified character, they may with great propriety be arranged under 
two heads, according to their mode of action, as vesicants, and suppurants. 

(1.) Veincanls are remedies which, when applied to the skin, eh^vate the epi- 
dermis in the form of blisters filled with serum. They are of great value in the 
treatment of inflammation, both acute and chronic, and are applicable to a groat 
variety of circumstances, with which the practitioner should be fully accjuainted. 
The articles commonly used for this purpose are cantharides, either in powder or 
in the form of collodion-liquid, ammonia, and hot fluids. In acute disease these 
means, especially the first, are always preceded by active depletory measures, 
since it is well known that, if they are employed before there has been a proper 
reduction of the system, they are liable to do mischief by increasing the local 
and genera] excitement. In chronic inflammation, however, they may often be 
advantageously used at the very commencement of the treatment. The vesicat- 
ing agent is generally placed as near the affected part as possible ; sometimes, 
indeed, directly over it 

Buyers, properly so called, are prepared with the common fly ointment of the 
■hops, and vary in shape and size according to the object they are intended to 
fiilfil, or the region to which they are applied. The part, if covered with hair, 



108 INFLAHHATION. 



CHAP. III. 



is previously shaved, and the plaster is confined with a compress and roller, or, 
what is better, with a few adhesive strips. To prevent strangury, an object of 
great importance, particularly in nervous persons and young children, the surface 
of the blister should always be sprinkled with a few grains of morphia and cam- 
phor. Tiie same end may be obtained, though less certainly, by the interposition 
of a piece of tissue paper, steeped in spirits of camphor. In addition to these 
precautions, the patient should be requested to make free use of some mucilagi- 
nous drink, as jQaxsced tea, or gum Arabic water, cither alone or combined with 
a little spirit of nitric ether. If strangury should occur, prompt relief may 
usually be afforded by a laudanum enema, and hot fomentations to the genitals 
and hyi)ogastric region, aided, if necessary, by a dose of morphia by the mouth. 

A blister should, on an average, remain upon the part from six to eight hours, 
unless the skin is very delicate and sensitive, when a shorter period will suffice. 
In children, the desired eflfect is usually produced in from two to four hours, and 
it is necessary in them to be very careful, otherwise violent inflammation and even 
gangrene may be the result. I have seen horrible suffering, and, in two instances, 
death, follow the application of a small blister in children. In the very aged 
and infirm, similar accidents occasionally happen. Parts affected with paralysis 
often suffer severely from the protracted use of blisters. The plaster need not, 
in general, be kept on until there is thorough vesication ; it is sufficient if the 
skin is quite red, or if there is here and there a little vesicle, the process being 
speedily completed by the warm-water dressing, or an emollient poultice, which 
are always the most suitable applications after the fly has been taken off. It is 
of great consequence to remove every bit of the salve, and also not to break the 
epidermis, but simply to puncture it with a large needle or small bistoury, to 
admit of the necessary drainage, it being a matter of great moment to exclude 
the atmosphere from the raw surface beneath. The dressings already mentioned 
may be continued until new skin has formed. Should the surface, however, be- 
come red, inflamed, and irrita.ble, bleeding upon the slightest touch, and rendering 
the patient feverish and restless, recourse must be had to the starch, arrowroot, or 
slippery-elm poultice, or, what is more soothing than anything else, common white 
lead paint, put on in a thick layer, covered with cotton, the whole being supported 
by a roller. Pencilling the part with a weak solution of nitrate of silver has 
sometimes a good effect, and so has also the dilute ointment of the oxide of zinc, 
especially when the surface is studded with large irritable granulations. 

Cantharidal collodion is a more elegant preparation than the common fly 
plastiT, and may therefore advantageously take its place. It is best applied by 
means of a camel-hair brush, the surface to be vesicated being thoroughly covered 
with it, and the evaporation of the ether restrained by a piece of oiled silk, placed 
immediately upon the part. Unless this precaution be used, the article will 
require nearly as long a time to produce its specific effect as an ordinary blister. 
The principal advantages of cantharidal collodion are, that it can be more evenly 
applied to the skin, that it does not shift its position, that it is more rapid in its 
action, and that it is less liable to produce strangury, especially if it contain 
morphia in solution, an addition I would always advise. 

Cantharidine blistering tissue is another elegant preparation for vesicating 
purposes ; easily applied and removed, producing its effects promptly without 
strangury, and leaving no sores. 

Ammonia is used only when the effect is desired to be strong^and immediate, 
as, for example, in croup, where the inflammation, if not promptly checked, may 
speedily destroy life. Equal parts of lard and powdered hartshorn will produce 
small vesicles in five or six minutes ; and similar effects will follow the applica- 
tion of Granville's lotion or liquid ammonia. Boiling water, the concentrated 
mineral acids, and the heated iron, cause rapid vesication. All these applications, 
however, are very painful, and they can never take the place of cantharides. 
Perhaps the least exceptionable article of this class of vesicants is the nitrate of 
silver, which often blisters the skin in a few minutes, especially when it is rather 
delicate, and has been previously well cleansed. The remedy is particularly well 



CHAP. III. CHRONIC INFLAMMATION. 109 

adapted to infants and children, as it is never followed by sloughing and other ill 
effecta. 

(2. ) Suppuranis are the most powerful counter-irritants wc possess. They 
are much more permanent in their character than yesicaiits, and are therefore 
more serviceable in eradicating chronic disease. As their name implies, the dis- 
charge which thej produce is of a purulent nature, and hence they are sometimes 
described under the name of pyogenic counter-irritants. The class com])ri8es 
permanent blisters, setons, and issues, which will receive particular attention in 
the chapter on Minor Surgery. 

SECT. III. — CHRONIC INFLAMMATION. 

Chronic inflammation is distinguished from acute by a variety of circumstances, 
which it is of the greatest importance to be able thoronghly to appreciate and 
understand. Its study, in fact, is of paramount consequence, and I am sure it 
is not placing too high an estimate upon its value when it is asserted that there 
is mach greater merit in being able to diagnosticate a chronic disease, than to 
determine the nature and seat of an acute one. When a lesion declares itself, 
openly and boldly, by a well-marked train of symptoms, the practitioner must 
indeed be ignorant, if not |>usitiveiy stupid, if he cannot discriminate with toler- 
able accuracj between it and other affections which may simulate it, or bear some 
resemblance to it ; but it is very different when the malady is of an obscure, 
chronic character, lurking in the system, no one, perhaps, knowing wiiere, even 
after the closest and most patient scrutiny. It is under such circumstuuees that 
the intelligent pathologist and observant practitioner often appears to the greatest 
advantage, by turning his knowledge to the best account for his patient. 

It does not comport with the design or scope of this work to enter into any 
of the more minute details of this subject ; a large volume might be written upon 
it. and even then it would not be exhausted. A mere sketch of its more promi- 
nent features is all that I shall attempt 

Chronic inflammation is of great frequency, and is liable to appear in all organs 
and tissues of the body ; it is grenerally a consequence or sequela of the acute 
form, but cases occasionally arise in which it would seem to l)e a primary affection. 
Strictly speaking, such an occurrence is of course impossible ; all that is meant 
when the word is used in this sense, is that the disease which it serves to designate 
i« of so stealthy and insidious a character as to escape, at least for a considerable 
time, the attention both of the patient and his physician ; the person is unwell, 
perhaps occasionally a little feverish, or the subject of headache, want of appetite, 
or a sallow complexion and c<mstipated bowels ; or, it may be, he has a cough, 
and a pain in his side ; or a joint becomes sore and stiff; and still he is uhle to 
go aliout. and attend to business, although he is soon fatigued, and rendered 
uncomfortable by it Thus a week, a fortnight, or a month may be passed, when, 
a careful examination being instituted, the discovery is made that there is grave 
diseai^e in some important organ, and that it has perhaps already gone so far as 
to render recovery absolutely impossible, however skilfully the case may now l)e 
treated. The disease has been latent, or nearly so ; it has failed to make itself 
known by any distinctive train of phenomena, and both ])atient and practitioner 
liave l>effii lulled into fatal security. The morbid action has been lying all this 
time in ambush, and is now, in the true sense of the term, chronic. Such cases 
are by no means infrequent, and they should serve to admonish us never to neglect 
anv symptoms, however trivial, in our clinical investigations. A pain, a soreness, 
a coogh, a halt in the gait, may, if properly interpreted, afford useful information 
in reganl to the diagnosis of chronic disease, and should teach us the value and 
unportance of patience and caution in the examination of the sick. The slightest 
neglect may be fatal ; a little spark may kindle a devouring flame. 

Chronic inflammation, however provoked, is generally tardy and sluggish in 
its movements, creating little constitutional disturbance, but not, on this account, 
the less surely and effectually undermining the part and system. In the acute 
variety, the action is rapid, bold, daring ; suffering is severe ; and constitutional 



110 INFLAMMATION. 



OBAP. III. 



response load and unmistakable. In chronic inflammation, on the other hand, 
the synii)tonis are, as already stated, often obscure, if not absolutely masked, and 
the embers of disease never break out into open flame. The disease may continue 
for weeks and months ; now stationary, smothered, or apparently receding, and 
now advancing, and seemingly almost ready to assume the acute type. 

The origin of chronic inflammation is often, if not generally, intimately con- 
nected with disorder of the digestive apparatus ; seemingly, at all events, the 
first link in the chain of morbid action is frequently referable to the state of the 
stomach and bowels, especially to the eflfocts of dyspepsia or constipation. Idio- 
pathic iuflamination of the eye and other organs often owes its origin to gastro- 
intestinal irritation. At other times the disease is awakened by derangement 
of the menses, defective action of the kidneys, suppression of the cutaneous 
perspiration, or disorder of the biliary secretion. Anxiety of mind, grief, anger, 
fatigue, intemperance in eating and drinking, and inordinate sexual indulgence 
are all so many predisposing and exciting causes of chronic inflammation. 

The effects of this form of disease are various ; if not closely watched and 
soon checked, it may prove fatal by the induction of serious structural changes, 
which neither nature nor art may be able to n>pair. The most common and 
important of these changes are suppuration, ulceration, softening, adhesion, con- 
traction, induration, and enlargement, according to the intensity of the morbid 
action, the texture and situation of the aflected organ, and the condition of the 
general system. The formation of pus and molecular disintegration, whether by 
soft(*ning or ulceration, are exceedingly common attendants upon this variety 
of inflammation, and often proceed to a most destructive extent. Adhesion is 
most liable to occur in the serous tissues ; contraction in the bloodvessels and 
excretory tubes. Induration and enlargement usually coexist, although occa- 
sionally they occur independently of each other. Examples of these two changes 
are constantly met with in surgical practice, especially in the lymphatic ganglions 
of the neck, axilla, and groin, in chronic disease in and around the joints, in 
various affections of the skin, cellular tissue, and bones, and in inflammatory 
hypertrophy of the tonsils, testicle, mamma, and prostate gland. When existing 
in a high di»gree, they lead to serious functional embarrassment of the affected 
parts, growing out of alterations of structure, which the best directed efforts of 
the surgeon often fail to relieve. 

Gangrene, as an effect of chronic inflammation, is rare ; nevertheless it is occa- 
sionally met with, as is witnessed, for instance, in the mortification of the toes 
and feet, so graphically described by Pott, and dependent upon ossification, in- 
flammation, or embolism of the arteries. In most cases, when the disease passes 
into gangrene, it first assumes the acute type, which renders the transition much 
easier, and, in some degree, a necessary preliminary. 

The symptoms of chronic inflammation are generally much less prominent 
than those of the acute variety ; the pain is less, and usually also more dull or 
obtuse ; the discoloration is dusky, livid, or purple ; the swelling, often consider- 
able, is characterized by unusual hardness, or by hardness and oedema ; and the 
heat is nearly always less conspicuous than in acute inflammation. Functional 
disturbance is variable, being extensive at one time, and slight at another. 
Symptomatic fever may be entirely wanting, and it is this circumstance which so 
frequently causes this variety of inflammation to be overlooked, especially when 
it is of idiopathic origin. In time, the fever may a-ssume a hectic type, or it may 
be of this character almost from the commencement. When the disease is ex- 
tensive, or seated in an important organ, adynamic fever generally exists. 

The vessels of the affected parts are generally very much dilated and distended 
with red and white globules, on which account the blood is propelled through 
them in a v<^ry tardy and sluggish manner, strikingly contrasting with the force 
and rapidity with which it is transmitted in the acute form of the disease, where, 
especially in its earlier stages, all is power and activity. AVhen the inflammatioQ 
is very protracted, many of the smaller vessels have a varicose, tortuous appear- 
ance, and are so crippled as to be almost unable to send on their contents at tlL 



CHAP. III. CHRONIC INFLAMMATION. Ill 

Ileno**, oongestion, often deep and extensive, is generally present, both at the 
fucu:« of the morbid action and for a considerable distance around. 

Treatment. — In the tn^atment of chronic inflammation, the indications are, 
first, to remove the exciting cause of the disease ; secondly, to correct constitu- 
tional disorder ; and lastly, to promote the absorption of effused fluids and restore 
the tone of the crippled and dilated vessels. 

The removal of the exciting cause of the disease obviously demands the same 
attention here as in the acute variety of inflammation ; whenever it is accessible 
it should be promptly disposed of. All officious interference must of course bo 
avoided. 

ReMoration of the Bccretions constitutes a most important indication, as it is 
upon their derangement or suppression that the morbid action in chronic inflam- 
mation so often depends. The remedies that are chiefly to be relied upon, for 
thii parpoae, are mercury, tartrate of antimony and potassa, iodine, bromine, 
nitro-muriatie acid, purgatives, and a judiciously regulated diet. 

In placing mercury at the head of this list of remedial agents, I am only 
endeavoring to show the high estimate that is so justly attached to it in the 
treatment of chronic inflammation. If its administration is of doubtful propriety 
in many cases in the acute variety of the disease, there are few instances of the 
chronic in which it may not be beneficially exhibited, and yet, in making this 
remark, it must not be understood that I would give mercury indiscriminately or 
sakele&sly. Its value is unquestionable, but, still, there are cases and circum- 
stances in which it is utterly inadmissible ; this is cs]>ecially true of those cases of 
chronic inflammation which are so often met with in scrofulous children, and in 
persons of enfeebled and broken constitution, where mercury, in almost any form, 
is generally most pernicious, the smallest quantity sometimes producing profuse 
ptyalism, or gangrene of the mouth. 

In ailmiuistering this remedy for the cure of chronic inflammation, the surgeon 
has it in his power to make choice of a much greater number and variety of 
articles than in acute inflammation, in which he is obliged to restrict himself 
chiefly to calomel and blue mass. In the chronic form of the disease, he has, in 
aildition, the bichloride, the protoiodide, cyauuret, and ])hospliate, which exert a 
most salutary influence in changing the capillary action of the part, and pro- 
moting the removal of effused fluids. Whatever substance be selected, the 
dose should be very small, and not repeated oftener, on an average, than twice or 
thrice in the twenty-four hours. The object is to produce a slow and gradual effect, 
and for this purpose it will generally l>c necessary to continue the remedy for 
s«*veral successive weeks. Active ptyalism is carefully avoided ; it will be quite 
sufficient if we succeed in obtaining slight soreness of the gums. If calomel 
be used, a good average dose will be from one-sixth to one-half of a grain. 

In children, the most suitable mercurials are blue mass, corrosive sublimate, 
and hydrargyrum cum cret&, or gray powder, given either alone or in union with 
s«xlii, soda and columbu, quinine, or Uuxham's tincture of bark. 

Iodine and its various preparations, as io<lide of potassium, iodide of iron, 
iiKlide of cadmium, iodide of ammonium, and Lugol's solution ; bromide of potas- 
sium; barium; and tartar emetic; often exert a most salutary influence over 
c*ininic inflammation, and are particularly indicated where a slow, altcTant effect 
is required. With the exception of mercury, 1 know of no article of the materia 
niedica which pnxluces so powerful an effect as tartar emetic in controlling chronic 
iuflammation, and favoring the absorption of effused fluids. My i)raetice is to 
give it in small d«>ses, as the eighth, tenth, or twelfth of a grain, in combination 
with a little morphia, three times in the twenty-four hours. 

The different acids are sometimes administered with advantage, especially the 
dilute nitromuriatic, which was formerly so much employed in the treatment of 
hepatic affections. They are particularly indicated in chronic sy[)hilitic and 
MTofulous inflammations, attended with impaired digestive powers. 

The b^jwels mu.st l)e kept in a soluble condition, the nature and dose of the 
purgative lieing regulated by the exigencies of each particular case. The com- 
pound calomel pill, which, while it operates on the bowela. alao ezdtes the action 



112 INFLAMMATION. gbap. iii. 

of the liver and skin, constitutes one of the most eligible cathartics we possess 
in the treatment of chronicjuflammation, accompanied with Tisceral obstmction. 

Particular attention should be paid to the skin. This will appear the more 
necessary, when we consider that, in most cases of chronic disease, the perspira- 
tion is either entirely suppressed, or greatly changed in its properties. Frequent 
ablutions with cool, tepid or warm water, impregnated with common salt, soap, 
mustard, or potash, and followed by dry frictions, will often prove eminently 
serviceable. In many cases the cold bath will be found extremely valuable, 
especially if followed by dry friction. The renal secretion should also receive 
proper attention ; sometimes elaborate chemical and microscopical examinations 
will be required to determine its character, and enable us to direct a suitable 
plan of treatment 

Exercise in the open air, either on foot, in a carriage, or on horseback, will 
often effect a wonderful improvement in cases of chronic inflammation, especially 
when of long standing, and attended with great debility. At other times, nothing 
but the most perfect rest will answer the purpose ; as, for example, in serious 
disease of the brain, bones, and joints. 

The subject of diet claims special attention in the treatment of chronic inflam- 
mation. The indiscriminate use of food in this form of disease cannot be too 
severely reprehended. Too great abstinence, however, is often as injurious as too 
great indulgence. As a general rule, it may be stated that all stimulating and 
indigestible articles should be avoided, as being calculated to increase the local 
disease, and exercise a prejudicial effect upon the patient's recovery. If the 
system is inclined to plethora, the diet should be of a strictly farinaceous cha- 
racter, and be limited daily to a few articles, varied from time to time as they 
become disagreeable to the palate, or offensive to the stomach. If, on the other 
hand, the patient is pale and feeble, it should be partly farinaceous, and partly 
animal, the meat being taken at breakfast and dinner, and its effects carefully 
watched. The different kinds of animal and vegetable broths, beef-essence, milk, 
arrowroot, rice, sago, and tapioca, are all eligible articles in chronic inflammation, 
and often prove of the greatest service in nourishing and sustaining the system. 
Their flavor and efficacy may be improved by the addition of spices, wine, and 
brandy, as may be deemed proper. When the patient is much exhausted, the 
use of brandy, wine, ale or porter, will often be indispensable to recovery. When 
marked debility exists along with emaciation, recourse may be had to cod-liver 
oil ; rather, however, as an article of nourishment than with a view to the attain- 
ment of any alterant effect it may be supposed to possess from the presence of 
iodine and bromine. The dose should then be as large as may be consistent 
with gastric tolerance. 

Finally, in the female, proper regard must be had to the state of the menstrual 
function ; prompt measures being adopted for its improvement, or, in the event 
of its suppression, for its n^storation. There are numerous complaints which 
owe their origin, either directly or indirectly, to disorder of the uterine functions. 

The local treatment of chronic inflammation is often a matter of paramount 
importance. It comprises, first, rest and elevation of the parts, the same as in 
acute disease ; secondly, leeching, scarification, blistering, iodine, and nitrate of 
silver, especially in the earlier stages ; thirdly, counter-irritation by croton oil, 
tartar emetic, issues, setons, and the actual cautery ; and, lastly, sorbefacients, 
such as stimulating liniments, embrocations, and unguents, the cold douche, com- 
pression with the bandage, or adhesive strips, electricity, and dry friction. 

09§PER MEDICAL C 

SAN «ANCrSC 

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GBAP. IT. D£LIT£3C£yC£ AND BESOLUTIOX. 118 



CHAPTER IV. 

TERMINATIONS AND RESULTS OP INFLAMMATION, 

BKCT. L — ^DEUTESCINOB AND BBSOLUTION. 



tisnns are used to denote the restoration of the inflamed structures to 
their normal condition. The word delitescence is of Latin derivation, and lite- 
rally sigmifies to abfcond ; it was introduced into surgical nomenclature by the 
French writers, and is employed to designate the sudden disappearance of inflam- 
BMtion, before it has passed through its different stages, and, consequently, be- 
fore it has occasioned any serious structural changes. It is unquestionably the 
most desirable mode of termination, and may occur either spontaneously, or from 
the alightest treatment A catarrh, caused by exposure to cold, and perhaps 
threateniDg to be quite severe, often aborts during a profound sleep induced by 
a warm bed, or a hot foot-bath and a grain of opium. An inflammation of a 
lymphatic ganglion of the neck, coming on late in the evening, and attended 
with great tenderness on motion and pressure, together with considerable swell- 
ing, often rapidly disappears under similar measures. An incipient gonorrhoea 
frequently aborts under the use of a mild injection of nitrate of silver or acetate 
of lead ; and who has not seen a bubo promptly vanish under steady, systematic 
compression, aided by the application of a solution of iodine? Inflammation 
prodoced by the presence of a foreign body generally rapidly disappears after the 
removal of the exciting cause of the morbid action. 

The above fiurts, wiUi many others that might be bronght forward, if it were 
deemed necessary for my purpose, teach us two most important lessons : the first 
if always to remove as early as possible the exciting cause of the inflammation ; 
and the second, to enter upon the treatment of every case of the disease without 
the least delay. The object should invariably be to save structure, and the best 
way to do this is to make the disease abscond, or delitesce. Such an event, how- 
ever, is only desirable when the inflammation can be dislodged more or less com- 
pletely without the risk of throwing it upon some other and, perhaps, more 
important organ. Thus, an attack of gout in the great toe would be a trifling 
aifair in comparison with an attack of gout in the heart, brain, or stomach ; 
and hence it wonld be fiftr better, where there is danger of such a translation of 
irritation, to let the original disease pursue its course than to attempt to arrest 
it by means calculated to favor such a result A severe injection may suddenly 
arrest an incipient gonorrhcea, but it may do infinite harm by the rapid induction 
of orchitis, which perhaps no treatment, however judiciously conducted, may be 
able to dispel completely under several weeks, if, indeed, under several months. 

The sudden disappearance of inflammation from one structure, or set of struc- 
tnres, and its invasion of another, usually known by the term metastasis, suggests 
the importance of proper watchfiilness on the part of the surgeon to prevent such 
an occurrence ; or, if it have already taken^^ilace, to employ such means as may 
be calculated to recall the morbid action as speedily and effectually as possible 
to its original situation. For this purpose free us^ should be made of counter- 
irritation, in the form of stimulating •en^|i)rocations, sinapisms, and blisters, aided, 
if the organ affected be one of great importance to life, by the abstraction of 
blood and taU doses of opiates. I( in this way, the disease cannot be recalled, 
vol.. I. — 8 



114 . TERMINATIONS OF IXFLAMHATION. ohap.it. 

the treatment will go far to put a speedy stop to its violence and its tendency to 
extension. 

The term resolution denotes the gradual dissipation of inflammation after the 
disease has made some progress and done some mischief, bat before it has 
reached the suppurative crisis, or committed such ravages as to prevent the 
affected tissues from regaining their original properties. With such an issue 
effusion of serum and lymph is not at all incompatible, as these fluids may be en- 
tirely absorbed ; a similar remark is applicable to pus, provided it exist in small 
quantity, and not in the form of an abscess, in which there is always more or 
less wast« of tissue ; and even to pure blood, which, if not too abundantly effused, 
or deprived of its vitality, is generally readily amenable to the action of the 
absorbents. 

When resolution is about to occur there is a gradual and steady subsidence of 
the morbid action, as denoted by the changes in the local and constitutional 
symptoms. The discoloration, heat, pain, and swelling become less and less in 
consequence of the contraction of the vessels and the absorption of the effused 
fluids ; the febrile disturbance goes off; and the part and system, no longer feel- 
ing the effects of the disease, at length regain their former condition. Often many 
weeks, and even several months, elapse before the restoration is finally completed. 
The absorbent vessels, kept in abeyance by the vascular action and the effused 
fluids, are slow to resume their functions ; they act at first hesitatingly, as if 
afraid to enter upon their labor, but as the work progresses they acquire confi- 
dence, and, at length, setting about it in good earnest, they ere long finish their 
task, drinking in, as it were, all that their oppressors, the secements, had pre- 
viously poured out, and thus leaving the parts in a condition to regain their 
primitive characters. The bloodvessels usually remain dilated, feeble, and slug- 
gish for some time after the complete subsidence of the disease, and there is also 
frequently more or less perversion of special sensation. 

SECT. II. — DEPOSITION OP SERUM. 

A deposition of serum, or of the w^atery elements of the blood, is a common 
attendant upon inflammation, and in some cases constitutes the principal, if not 
the only evidence of its presence. The structures which, when thus affected, 
supply it in greatest abundance, arc the cellular and serous, the secernent vessels 
of which are generally extremely active, even when the disease is comparatively 
mild. Large quantities of serum are also occasionally poured out by the mucous 
membrane of the alimentary canal, especially by that of the colon and rectum, as 
is observed in certain forms of diarrhoea and infantile cholera. Inflammation of 
the skin, unless produced by scalds, blisters, erysipelas, and the various bnllar 
diseases, yields this fluid generally very sparingly. Very little is also effused in 
inflammation of the muscles and fibrous membranes, the nerves and vessels ; while 
tendon, cartilage, and bone do not afford any, however severe the lesion. A simi- 
lar remark is applicable to inflammation of the parenchymatous and glandular 
organs, as the lung and liver. In the cellular tissue serous accumulations are 
particularly liable to occur wherever this substance is most loose and abundant; 
hence they are very common in the eyelids, scrotum, prepuce, labia, nymphsB, legs, 
and feet, which are often enormously distended in consequence. (Edema of the 
glottis is an example of watery deposit in the submucous cellular substance of 
the edges of the windpipe. In the splanchnic cavities and the movable joints 
serum often collects in immense quantities ; sometimes as an effect of acute, but 
more frequently of chronic inflammation. 

Particular epithets are employed to designate certain collections of serum, 
based either upon the appearance of the part, or the anatomical name of the 
cavity that serves to receive the fluid. Thus we are in the habit of speaking ai 
oedema of the glottis, oedema of the eyelids, and oedema of the legs, simply 
because these structures, when thus affected, have a swollen, glossy aspect The 
older writers applied the word anasarca to all aqueous accumulations of the 
inferior extremities, as the appearance thereby produced bears some fancied resem* 



CBAF. !▼. DEPOSITION OF SERUM. 115 

blance to a mass of flesh. Dropsy of the legs is another familiar expression 
intended to designate the same thing. The latter term, however, is generally 
restricted to the collections of serum in the various cavities of the body. Thus, 
when we speak of water in the peritoneum, we say that the individual has dropsy 
of the abdomen, and so of the chest, head, pericardium, joints, and vaginal tunic 
of the testicle. Or, instead of this term, we use a Greek one, either simple or 
compound, as being somewhat more classical. In this manner a dropsy of the 
abdomen becomes an ascites ; of the chest, a hydrothorax ; of the head, a hydro- 
cephalus ; of the vaginal tunic, a hydrocele. 

The appearance of the serum is generally limpid, but cases occur in which, 
from the admixture of extraneous matter, or hematin, it is yellowish, milky, or 
even quite dark. The latter appearance is generally present in the peritoneum 
in strangulated hernia, and is to be viewed as an evidence of intense inflammation. 
A similar phenomenon is witnessed in the blebs of incipient gangrene, and in the 
enormous seroos accumulations which occasionally occur in the limbs in conse- 
qaenoe of snake bite and other severe injuries. 

The fluid occasionally contains flakes of lymph, pus, and pure blood, although 
the latter is uncommon. It is often quite unctuous to the touch, is saline in its 
taste, but free from odor, and is readily coagulablc by alcohol, acids, and corro- 
Bve sublimate; circumstances which show that it is composed principally of 
albumen, in combination with some of the earthy salts, especially the sulphates. 
Its qnantitj in acute inflammation is usually small, except in the splanchnic 
cavities, where it is sometimes immense, amounting to many quarts, or even 
Kveral gallons. Under such circumstances, too, it always contains more or les» 
fibrin. 

Moch diversity of sentiment has been expressed in relation to the kind of action 
by which this fluid is produced ; some declaring that it may be deposit^'d without 
the aid of inflammation, while others maintain that it is invariably the result of 
this morbid process. I have long been impressed with the truth of the latter 
doctrine, and have strenuously advocated it in my writings, as wcN as in the 
lectare-room, for the last twenty-five years. I cannot, indeed, see how it is 
possible to reach any other conclusion, unless we assume, which, however, I am 
not inclined to do, with certain pathologists, that there is no true inflammation 
without suppurative action, or, at all events, plastic exudation. Such a doctrine 
as this wonld, of course, be fatal to the idea that serous effusion is the result of 
inflammation. But these pathologists, notwithstanding their attempts at theo- 
rizing, are well aware that inflammation often, if, indeed, not generally, proves 
fatal long before it reaches this height. There is, therefore, but one alternative 
in regard to this question ; we must assume either that there may be inflammation 
without exudation of fibrin and the formation of pus, or that thousands of persons 
daily perish without any disease whatever, simply from perverted nutrition, or 
functional disorder. To entertain such an opinion would be absurd, and we are 
therefore forced to the conclusion that, whenever there is an effusion of serum, 
inch an effnst(»n is denotive of the existence of inflammation, even when there has 
been no tangible evidence of the ordinary phenomena of the disease, as heat, 
pain, and discoloration. We have an illustration of this fact in chronic dropsies, 
where the inflammation is often so extremely mild that, save the mechanical 
inc«.»nvenience which the fluid occasions, the patient is hardly conscious of any 
raffering whatever. Yet even in such cases it will generally be found, on dissec- 
tion, that the serous membrane which furnished the water, exhibits sufficient 
iadication of the lesion in the opaque and thickened condition of its substance. 
It may be questioned whether mere congestion is capable of producing serous 
effusion. At first sight such an occurrence would seem to be quite probable ; 
but a careful examination of the subject soon dispels the illusion. Permanent 
obstmction of the abdominal cava will cause ascites ; not from congestion of the 
vessels of the peritoneum, but as a consequence of its inflammation, the result of 
the previous vaiftcular engorgement. It is easy to see that vessels habitually 
distended must soon take on incited action, followed by abnomal deposits. A 
liMailiar illustration of this is afforded in the coi^nnGtiTai ^'^ *'' *^ Tesseli 



116 TERMINATIONS OF INFLAMMATION. chap.it. 

are at all engorged even for a sliort time, inflammation is sure to follow, unless 
the exciting cause of the determination be removed. If this mode of reasoning 
Ije correct, it follows that obstruction of the circulation, however induced, will, 
if permitted to continue, be soon succeeded by inflammation, of a grade and 
character sufficient to cause at least an effusion of serum, if not also of other 
fluids. 

Of the nature of the morbid action, when serum is rapidly supplied, or when 
it is associated with other deposits, as lymph or pus, there can be no doubt ; it 
is eminently inflammatory, and nothing else. The concomitant symptoms, and 
dissection after death, clearly establish the fact. The rapid and projfuse serous 
exhalations which occur in a<;ute pleurisy, peritonitis, and arachnitis admit of 
explanation in no other way ; they are the appropriate products of these stmo- 
tures, and hence they are generally poured out quite early in the disease. 

Effusion of serum is often associated with, if not remotely dependent upon, an 
impoverished and watery condition of the blood, accompanied by a marked 
decrease of fibrin and red particles. If, under such circumstances, inflammation 
be lighted up in almost any of the tissues, especially the cellular and serous, 
scrum cannot fail to Ije supplied in large quantities, since, in consequence of the 
diminution of the plastic properties of the blood, there is nothing to restrain its 
exudation. Hence such action is very prone to be followed, externally, by ana- 
sarca, or oedema, and intenially by dropsy. 

The symptoms produced by this deposit are such, mainly, as are denotive of 
mechanical obstruction. In the eyelids, scrotum, prepuce, vulva, glottis, and 
legs, it is marked by a soft, inelastic swelling, which pits on pressure, and imparts 
a peculiar glossy appearance to the affected surface ; attended, especially in the 
inferior extremities, with pain, heat, and more or less discoloration, usually of a 
pale dusky hue. A sense of distension is also commonly a prominent symptonL 
In oedema of the glottis there is serious impediment in the respiratory function, 
while in accumulations of water in the splanchnic cavities there must necessarily 
be more or less oppression, with displaecment of the contained viscera. A large 
collection of water in the chest may not only cause collapse of the lung on one 
side, but greatly encroach upon the opposite one, and at the same time throw the 
heart completely out of its natural position, depress the diaphragm, and tilt up 
the intercostal spaces so as to give the thorax a vaulted configuration. In infil- 
tration of the cellular tissue of the legs, feet, scrotum, and vulva, the fluid may, 
by its pressure upon the capillary vessels, cut off the supply of blood from the 
skin, and thus become a source of mortification, as we see exemplified in erysipelas 
and anasarca. 

Treatment, — In the treatment of serous effusions, the main indication is to 
promote the absorption of the offending fluids by the use of hydragogue cathar- 
tics, diuretics, and mercurials ; followed, when these means fail, by a puncture 
for their efficient evacuation. The most important cathartics, after thorough 
purgation, are jalap and bi tartrate of potassa, citrate of magnesia, and elaterium, 
given in doses proportioned to the strength of the patient and the tolerance of 
tli<; stomach and bowels. These remedies, as well as others of a kindred nature, 
produce their beneficial effects by establishing a drain upon the serous capillaries 
of the alimentary canal, which leads indirectly to the absorption of the serous 
accumulation. When mercurials are required, as they will be when there is 
obstruction of the portal circle, with deficiency of the biliary secretion, the most 
eligil)le articles will be calomel, blue mass, or corrnsive sublimate, either alone 
or in union with elatenum, squills, digitalis, or antimony, according to the nature 
of the collateral disorder. Deficiency of the renal secretion must be met by 
suitable diuretics. 

When the accumulation of serum is very great, as in dropsy of the chesty 
abdomen, or pericardium, all internal treatment will be likely to prove abortiTe, 
as it is generally impossible, under such circumstances, to rouse the absorbents, 
owing to the fact that the pressure of the fluid keeps them in a crippled and 
paralyzed condition, altogether incompatible with the healthy exercise of their 
functions. Hence, instead of wasting our time and the strength of the patient^ 



cbap.it. LYMPHIZATION. 117 



ifl anfortunatelj too-often done in such cases, early vent ^ould be afforded to 
the peot-ap matter. I am certain, from frequent observation, that serious and even 
btal errors are constantly committed by practitioners from their indisposition to 
early iBtcrfereoce with the trocar in these accumulations. They forget that their 
porgmtiTe, diuretic, and alterative remedies, if available at all, can prove bene- 
ficial only at the expense of much distress and exhaustion of the system, which 
too often leave the saflerer, in the event of his recovery from the disease, with 
shattered and broken health for years afterwards, if not during the remainder of 
his life. An operation, on the other hand, generally affords prompt and efficient 
relirf to the urgent symptoms, and places the part in a condition to be influenced 
by sorbefacient measures. 

Local remedies are available chiefly in serous effusions in the external parts 
of the body. In oedema of the extremities vast beuefit is often derived from 
steady and persistent elevation, and regular, equable compression with the 
bandage, extending upwards from the distal portion of the limb. In this way 
support ia given to the capillaries, while a salutary stimulus is imparted to the 
absorbents, well adapted to rouse them into action. This treatment often derives 
insportant aid from frictions with sorbefacient unguents, liniments, and embroca- 
tioDS, and the ^plication of the dilute tincture of iodine. When the distension 
ia inordinate, or threatens to eventuate in gangrene, early punctures and even free 
iacisions are called for. In oedema of the glottis nothing short of prompt and 
decisive scarification will prevent suffocation. 

SECT. ni. — LY3IPH1ZATI0N, OR FIBRINOUS EXUDATION. 

Lymphixation is the act of separating lymph from the blood and depositing 
it into the organs and tissues, or upon their free surfaces. The term, which I 
was the first to introduce into science, has been objected to, on the ground, as is 
alleged, that it is not well chosen, because the word lymph is given to the fluid 
contained in the lymphatic vessels. I can perceive no reason, however, why it 
ehoald not be retained and generally adopted, for it is certainly quite as appro- 
priate and classical, in reference to the substance which it serves to designate, 
as the word suppuration is in relation to pus, which is the product of that act. 
I am the more inclined to this view, seeing that the word ** lymph" is still in 
general nse, notwithstanding the attempts that have recently been made to dis- 
card it by substituting the term "plasma," which is, if possible, still more 
objectionable. Perhaps the least obnoxious term is "fibrin," which is now also 
much in vogue, and which is expressive of at least one of the most important 
attribates of that substance, namely, its chemical constitution. The phrase 
" plastic matter" would be very appropriate, were it not that it is too circuitous 
for easy use. 

There is rarely any inflammation, however slight, in which there is not some 
deposit of lymph. Indeed, in many cases, and in certain situations, it constitutes 
almost the only product of the morbid action. Thus, in croup and peritonitis, 
the chief evidence of the existence of these diseases, after death, is the presence 
of lymph ; in general, however, it is associated with other deposits, especially 
seram, which is often poured out along with it in large quantities. When the 
inflammation is at all severe, and particularly if it has already made considerable 

{iro^reds, there may be, in addition, puriform matter, pus, and even pure blood. 
ts presence, whether occurrring singly or combinedly, is generally denotive of 
a higher grade of action than the mere effusion of serum. 

The capacity of furnishing lymph, in inflammation, is possessed in different 
degrees by different organs and textures, depending upon the peculiarities of 
their organixation. It is always, other things being equal, poured out most 
freely by the serous membranes, especially the pleura and peritoneum, by the 
cefloJar tisane, and by certain portions of the mucous system, as the fancial, 
laryngeal, intestinal, and uterine. Very little is effused, nnder any drcnmstanceSy 
l^ the fibrous membranes, the muscles and their tendoniL ^ '^ 

cartilages, and bones, except in cases of fracture and oth 



118 TERMINATIONS OF INFLAMMATION. chap. 2T. 

sometimes thrown out in great abundance. In the parenchymatous organs, the 
same diversity obtains in respect to this deposit as in the tissues, properly so 
called. In some, as in the brain, liver, and kidneys, it is usually supplied verj 
sparingly, whereas, in inflammation of the lungs and spleen, it is often effused 
quite freely, leading to rapid solidification of their proper structure. Large 
quantities of lymph are sometimes exhaled during the progress of abscesses, 
many of which it serves to inclose in a distinct cyst, known as the pyogenic 
membrane. 

The deposit of lymph gpnerally begins soon after the inflammatory action, and 
often continues for an iudeiinite period, increasiug and declining with the disease. 
It is surprising how soon it sometimes shows itself. From my experiments upon 
the inferior animals, as well as from observations upon the human subject, I have 
been led to believe that it commonly commences much earlier than is usually 
supposed. In 1841, I had occasion to see repeated proofs of this fact, while 
engaged in an elaborate series of experiments upon dogs, with a view of eluci- 
dating the nature and treatment of wounds of the intestines. I found, in many 
of these animals, that the bowels had become extensively adherent, not only to 
each other, but likewise to the walls. of the abdomen, within a very few hours 
after the operation. In the case of a gentleman whose abdomen I opened some 
years ago, on account of a twist in the small intestine, I ascertained that, although 
death happened at the end of four hours, nearly the whole peritoneum, visceral 
and parietal, was coated with a thin film of fibrin, of which hardly any traces 
existed anywhere at the time of the operation. In another case, that of a young 
lad, who died within nine hours after he had been shot in the side, the ball wound- 
ing the abdomen, diaphragm, and chost, large quantities of lymph were seen both 
upon the peritoneum and pleura. The flaps made in amputation become speedily 
glazed with fibrin,, and a similar phenomenon is often witnessed upon incised 
wounds, the edges of which frequently adhere quite firmly within a very short 
time after the application of the dressings. 

From the preceding facts, it may be concluded that the process of lymphization 
generally begins at an early period of the inflammation, and that, if the circum- 
stances are at all favorable, it proceeds with great vigor. If the reverse, however, 
be the case, then it goes on comparatively slowly, or it may even fail entirely. 
Such an event will be most likely to happen in low and depraved states of the 
system, attended with an impoverished condition of the blood, and consequent 
lesion of the innervation. 

Lymph, plasma, or fibrin, considered as an effect of disease, is a direct product 
of the vessels of the affected structures, the process by which it is elaborated 
being one of a vital character, analogous to, if not actually identical with, secre- 
tion. No one, so far as I know, doubts this opinion, except Virchow, who main- 
tains that this substance has an extra-vascular origin ; or, in other words, that it 
is a local product of the tissues, on and in which it is found, being essentially 
composed of the material generated in the inflamed part itself through the 
changes in its condition. He denies that there is, in the ordinary acceptation of 
the term, any inflammatory exudation whatever ; or, what is the same thing, he 
insists upon it that there is no real transudation from the blood-liquor. 

Recently effused lymph exhibits a whitish, pale straw, or opaline appearance, 
though occasionally it is somewhat reddish, from the admixture of hematin. In 
cases of protracted, jaundice, it is occasionally of a pale orange hue. It is of a 
soft, unctuous consistence, like hot glue, or a thin solution of starch, without 
smell and of a faint saline taste. Its chemical constitution is fibrin, in union with 
albumen and scrum. Immersion in alcohol renders it tough, and changes its 
color from white to buff. 

It consists of numerous globules, of a spherical shape, nearly homogeneous, 
and about the ^^jf of an inch in diameter. Delicate fibrils, straight, parailely 
and interspersed with innumerable granules, are also visible in it. It is derived 
directly from the blood by a process of secretion, and is identical with the buil^ 
coat and the blood-liquor ; possessing vital and organlzable properties, and there- 
fore capable of performing important duties in the economy. Being always 



LTHPHIZATIOX. 



119 



deposited in a flaid state, it soon arran^res itself in various forms ; now as an 
amorphoua mass ; now as a tube, as in the larynx and bowel ; at one time as a 
lamella, and at another as a distinct baud ; its conformation being materially 
mfloMkced by that of the organ, tissue, or cavity in which it is effused. 

Tbis Bobetance does not always exhibit the same appearances either under the 
microseope or to the naked eye. In this respect it shares the same fate as other 
morbid products. I cannot, therefore, recognize the doctrine of an essential 
difference in the character of the effused substance, so strenuously maintained by 
mme pathologists, believing, as I do, that this difference is entirely due to a 
difference in the state of the part and system in different individuals, localities, 
and grades of the morbid action. Corpuscular lymph, as it has been termed, 
differs from ordinary lymph only, or chiefly, in having a greater number of exuda- 
tion globules, and less of healthy fibrin. Hence, it is generally met with in 
persona of deficient vital powers, with an impoverished state of the blood, and 
osnallj manifests a disposition to break down and become effete. 

Fig. 7 displays a portion of recently effused lymph, opaque, white-colored, 
friable, aod magnified about 3B0 diameters, from an inflamed pleura. It is com- 
posed of globules, smaller molecules, and granular matter in a hyaline matrix. 
In the lower part of the figure the granules and molecules are shown as floating 
In aeroDS fluid. In fig. 8, the structure of the effused matter is somewhat differ- 
ent. It forms, in fact, a sort of false membrane, magnified 800 diameters. 
Numerous corpuscles are seen, more or less globular, and having the character 
of primary celts ; the intervening texture is formed of most delicate fibrils. A 
few minute granules are interspersed throngh the tissue. 



Rg. 7. 



Fis- 8. 




The period at which the organization of this substance takes place varies with 
a nnmber of circumstances, of w'hich the most important are, the plasticity of 
the effused matter, the nature of the affected tissue, and the state of the general 
Bjstem. To enable it to attain this point at all it is necessary that it should 
have a strong cell-life, or cell-force ; when this is wanting the development of 
cytoblasts and nuclei is either impracticable, or it occurs so imperfectly as to l^e 
Booo arrested, or, at all events, very much impaired. When everything is favora- 
ble, the development proceeds very rapidly ; cells and nuclei are formed in great 
nombers, and these, connecting themselves with each other, arc gradually spread 
out into fibres, lying, for the most part, in straight, parallel lines, and profusely 
inlaid with grannies, as in fig. 9. Soon after this process lias bpgun, vessels 
■bow themselvea in the new product, either as an offspring of a new epigenesis, 
or as an extension from the neighboring structures, the Iatt4.'r being by far the 
more common soarce of the supply. The walls of the vessels are, at first, very 
(rail and yielding, so that the least pressure is sufficient to rupture them and 
cause an extravasation of their contents. Gradually, however, as they gow 
older, they become better qualified for the discharge ot their functions, anU in 
tfane acquire all the propnties of ths natonl twhIi. When IbUy developed. 



120 TERMINATIONS OF INFLAUlfATION. evAf. tr. 

tbey can easily be discovered with the naked eje, and readily admit fine iqjecting 
matter. Tlie reins are usually disproportionately large to the arteries, bat thii 



Li f 



mm 



TlgL 8 ud 10, (toa Bi 




w DOiltl nd will dnrlnpli 



ihIth lata tint: whtlit If. i: 



defect also nitimately disappears. Nerves and Bbaorl>ents likeiriBe exist, bat 
whether they are supplied by the Eurrounding tissues, or by the inherent powers 
of the effused matter is undetermined. 

The arrangement of the newly-formed vessels is represented in the annexed 
sketches. Fig. 12 is a portion of coagulating lymph attached by a narrow neck 
to the peritoneal coat of an inflamed intestine. The rcsEels have a ramiform 
disposition, and freely anastomose with each other. Fig. 13 is a piece of false 



Rg. 12. 



Fig. 13. 







membrane of the pleura. The vessels are large, numerous, and &rther advanced 
than in the other sketch. 

When the process of organization is unusually rapid, the newly-formed vessels, 
in consequence of their very tender and brittle condition, occasionally give way, 
either under the influence of external violence, or the force with which the blood 
is impelled into them by the heart's action. Such an occurrence may be productive 
of considerable hemorrhage. 

There are some situations where iibrin is never organized, however strong it« 
vitality may be at the moment of its deposition. Such an occurrence, for exam- 
ple, is nearly always impossible in the alimentary canal and urinary bladder, for 
the reason that the irritating and heterogeneous contents of these reaervoirs 
speedily deprive the lymph of its organizabJe properties. Site, then, exercises 
ui important influence upon the process, which, it may be added, is also materially 
affected by the state of the blood and solids ; the more feeble and impoverished 
these are the less likely will the effused snt^tance be to form celle and nuclei, 
vessels, nerves, and ahnorbents. 

Lymph is susceptible of absorption both in its fluid state and after it has been 
changed into blastema and flbro-cellular tissue. This, however, does not occnr, 
at least not to any extent, during the height of the inSEunmation, by which it ha* 
been produced ; on the contrary, there must always be a marked r«luction of the 
morbid action before the absorbent vessels can be induced to take hold of it ; bot 



ciir, )T. U8B8 OF PLA.STIO HATTEB. 121 

rtntiiiB point has once been attained, the process often ^oea on very rapid!;, 
uuwitneflMd in frscturea, diBlocatianB, wouads, and other injuries, iii which the 
nelhnf, cfaieflj caused by fibrinous dcpoeitH, occasionally completely vanishes 
ii 1 few daja. The absorption will necesaariij be more difficult when the lymph 
ku becooM oi^anixed, when, in fact, it not unfrequently efFectualty resists all the 
dHtithat the surgeon can employ to get rid of it. The opaque spot on the 
toatt often remains despite the moat protracted treatment. It is probable that 
iniph, before it can nndergo absorption, even in its liquid state, is broken up 
ud disHilTed in the fluids of the affected parte ; being thus brought more readily 
mder the ioflnence of the vessels. In fig. 14 the fibrous matter is undergoing 



Flf. 14. 



Jtg. 16, 




Tkf. U. Th* tfmrb »( plHrilU, 



absorption, some parts of the layer being completely removed, while others are 
becoming softened and attenuated. 

Moreover, lymph is liable to various kinds of degeneration, both in its early 
and in ita more matured stages. When recently effnsed, it may be converted 
into pas, especially if it is aplastic and exposed to the air ; under which circum- 
stances it also frequently becomes hard, dry, and shrivelled, losing its vitality, 
and assuming the character of an effete substance. It also nndei^oes fatty de- 
generation, both before and after vascularization, as exhibited in fig. 16, from 
Jones and Sieveking; and, finally, there are cases in which it is inlaid with pig- 
mentary matter. 

Lastly, organized lymph forms the basis of what are called the analogoas 
tiseoes, and may, therefore, like the original structures with which it is in contact, 
beeome the seat of inflammation, cancer, and -tubercle. 

L'lita of Planlic Mailer. — The great value of this substance ia strikingly illus- 
trated in numerous diseases, injuries, and operations. As a reparative agent, it 
is impossible to overestimate it. If it were not for this material, no wound, sore, 
or nlciT, however insignificant, could ever heal. In the treatment of an incised 
wound, the duty of the surgeon is strictly mechanical, consisting simply in the 
approximation of the raw suri'aces, and in their retention by suitable dressings. 
>atare does the rest by the effusion and organization of plasma, generally well 
aod quickly, provided the parts are kept perfectly cool and quiet. Very little 
inflammation is required. The great danger is in overaction, thereby thwarting 
the efforts at repair. Under proper management the wound generally heals in a 
few days, the bond of union becoming hourly more and more firm by the gradual 
eonversioD c^ the plasma into flbro-cetlular matter, of which, however, very little 
ordinarily remains when the process is perfected. 

Parts completely separated from each other, and immediately replaced, will, if 
Jodidoosly managed, often reunite, and be nearly, if not quite, as useful as bernre. 
Numerous cases, of a well-authenticated character, are upon record of bits of 
fngers, the nose, and the ear having been successfully treated in this wise. 

It was npon a knowledge of the plastic properties of coagulating lyni]>h that 



122 TEBUINATIOXS OF INFLAMMATION. chap. it. 

Taliacotius founded his world renowned operation, which is now oniversaUj 
known by his name, of repairing mutilated noses, lips, and ears. His attention 
was originally directed to the subject by watching the effects of the grafting of 
trees ; he observed that the transplanted portion not only contracted firm adhe- 
sions in its now situation, but that it generally grew with great vigor, and ere 
long produced most excellent fruit, altogether superior to, and different from, that 
of the parent stock. Possessed of a profoundly inventive genius, he was led to 
believe that a similar operation might be performed upon man, and it was not 
long before he put his reasoning to the test of experiment. Qis success was 
complete, and the result was that he became the great rhinoplastic surgeon of 
his day. His method consisted in raising a flap of integument from the arm, 
and after having thoroughly pared the mutilated organ, in sewing the raw edges 
accurately together, care being afterwards taken to maintain the parts in contact 
with each other until they had become closely and inseparably united. The 
Indian method, as it is termed, differs from that of Taliacotius mainly in this, 
that the flap of skin is generally borrowed from the immediate vicinity of the 
deformed organ, its pedicle being twisted upon itself in such a manner as not to 
interfere injuriously with its circulation. 

Du Hamel, near the middle of the eighteenth century, executed some curions 
experiments, which, as having a direct bearing upon the present subject, deserve 
passing notice, notwithstanding they are old and trite. They consisted in in* 
grafting the spur of a cock upon the comb of the same animal, where, especially 
if the spur was a young one, it generally promptly united. In one instance he 
found that the spur, although not larger than a hemp-seed when the operation 
was performed, acquired in the course of three to four years a length of several 
inches. The experiment was subsequently repeated by John Hunter with 
similar results. He ascertained not only that what Du Hamel had said was per- 
fectly true, but that, if the testicle of a cock be transplanted into the abdomen 
of a hen, such complete union will occur between them as to permit minute 
injecting matter readily to pass from the vessels of the one into those of the 
other. 

The fact that a tooth, extracted by mistake, will, if immediately replaced in its 
socket, speedily reunite, and ultimately regain its former hold, has long been 
familiar to dentists. It was formerly supposed that the adhesion was always 
imperfect, but that this is not so is shown by the circumstance that the vascular 
connection between the tooth and the socket may be demonstrated by injection. 
The knowledge of this fact led to the painful and disgusting practice, so much in 
vogue in the last century, of transplanting teeth from the mouth o( one person 
into that of another, and which was finally abolished only when it was discovered 
that it was fraught with danger, on account of its liability to transmit disease. 

Finally, there is, as an additional illustration of this interesting subject, the 
singular experiment of John Hunter of inserting a fresh human tooth into the 
comb of a cock, where it took root, and became firmly fixed, new vessels extend- 
ing up into the cavity of the fang, as was ascertained by injection after the death 
of the animal. 

Curious and instructive as the above experiments are, they hardly equal, in 
point of interest, many of those that have been performed by the modern surgeon 
upon the human subject for the relief of mutilated structures. Whether science 
has attained its highest triumphs in the department of plastic surgery, or whether 
it is capable of still further achievements, time alone can determine. 

The good effects of plasma are exhibited in various other processes, as in the 
suppression of hemorrhage, and the radical cure of hernia. In the former, the 
patient would inevitably bleed to death if it were not for the agency of lymph in 
sealing up the mouth of the vessel by attaching the internal clot firmly to its 
surface. In hernia a radical cure can only be effected through the intervention 
of plastic matter, thrown out in consequence either of the pressure of a well- 
adjusted truss, or the injection of some irritating fluid, causing inflammatory 
action in the parts around. 

Plastic matter is often useful in circumscribing morbid action, and in inclosing 



CKAF. !▼. 



INJURIOUS EFFECTS OF PLASTIC liATTER. 123 



foreign bodies. In abscess a wall of lymph is geDerall j formed around the pus, 
eflectuallj preventing its diffusion among the surrounding tissues. Occasionally 
the flaid is inclosed by a distinct membrane, derived from the fibrin of the blood, 
and possessed of a high degree of organization. In carbuncle and erysipelas the 
l3rmph is usually of an aplastic nature, and therefore unable to prevent the ex- 
tension of the disease. Balls, needles, pins, and various other foreign bodies are 
oocmsionally inclosed in a manner similar to pus, and, in consequence, often re- 
main harmless tenants of the body for many years. 

Again, plasma is of service in obviating accidents. Thus, in abscess of the 
long, if it were not for the intervention of fibrin, the matter would often break 
into the chest, and rapidly destroy life. How is this untoward occurrence pre- 
vented f Simplj bj the development of inflammation in the pulmonary pleura, 
followed bj a deposit of lymph, which thus becomes a bond of union between 
this membrane and the costal pleura ; so that by the time the matter reaches the 
Borface an effectual barrier is opposed to its effusion, in consequence of which it 
generally discharges itself through a contiguous bronchial tube. A similar oc- 
currence takes place in abscess of the li?er in relation to the peritoneum and 
intestinal tube. In typhoid fever the glands of Peyer are often perforated, and 
jet it seldom haj^ns that the contents of the bowels escape into the abdominal 
cavity, simply because of this wise provision of nature in gluing together the 
eontiguons seroos surfaces. 

Finally, lymph is of use in obliterating serous cavities. In the radical cure 
of hydrocele, a disease of the vaginal tunic of the testicle, an operation is per- 
formed for the purpose of provoking a deposit of fibrin, just sufficient to cover 
the opposing surfaces, and to insure their permanent agglutination. Serous 
cysts are treated upon similar principles; and modem surgery has been em- 
boldened to inject even some of the movable joints, the abdomen, and ovarian 
tumors with irritating fluids, for the radical cure of dropsical diseases of these 
parts. 

Injurious Effects of Plastic Matter, — ^But lymph is capable of producing 
iDJurious effects as well as beneficial ; nature's operations cannot always be con- 
trolled by art, and it is therefore not surprising that she should often overleap 
the bounds of discretion when she is depleting the inflamed structures by effusion 
of plastic matter. Immense mischief is frequently done in this manner, within a 
few hoars after the commencement of the morbid action ; mischief which it may 
require months of the most judicious and persevering efforts of the surgeon to 
endicate. 

Among the more common and obvious effects of this description are the follow- 
ing: 1. Mechanical obstruction of the natural outlets of the body. 2. Change 
of structure by interstitial deposits. 3. Abnormal adhesions. 4. Induration 
and enlargement. 

a. An example of mechanical obstruction from a deposit of lymph is afforded by 
what occurs in the windpipe in plastic croup, the principal anatomical character 
of which is the formation of a false membrane* which often moulds itself accurately 
to the shape of the tube, and which, especially when it extends high up into the 
larynx, may cause suffocation by impeding the entrance of air into the lungs. In 
rare cases the membrane is detach^ and expectorated ; but generally it remains 
in spite of our remedies, and speedily destroys the patient. Even an artificial 
opening into the trachea will seldom avert this event. 

In some of the mucous canals this matter is poured out beneath the lining 
membrane instead of upon its free surfieM:e, where, becoming organized, it leads to 
permanent contraction of the tube. It is in this manner that stricture is formed ; 
when the case is a very bad one, lymph may also be effused into the substance 
of the lining membrane, and even upon its free surface, as, for example, in what 
is called the bridle-stricture of the urethra, which, however, is exceedingly rare. 

6. Change of structure from interstitial deposit of lymph occurs in almost all 
cases of inflammation, however slight or however situated. In pneumonitis, it 
closes np the air-cells and minute bronchial tubes, as well as the cells of the con- 
aective tissae, producing what is called hepatization of the lungs. Opacity of 



124 TERUINATIONS OF INFLAMMATION. chap. it. 

the cornea, acting obstructinglj to the rays of light, is the in variable remilt of a 
deposit of plastic matter either beneath its co^janctival coYering or in its inter- 
lamellar stracture. 

c. All abnormal adhesions are occasioned by this substance, and are necessarilj 
more or less prejadicial. In the thoracic cayity, they confine and restrain the 
movements of the heart and langs ; in the abdomen, they often become a source 
of internal strangulation ; in the mucous outlets, as in the vagina and uterus, they 
may produce complete occlusion of their orifices ; and in the vessels, especially 
the arteries, they sometimes induce obliteration of the largest sized trunks. 
Abnormal adhesions between the bowel and the sac in hernia are sometimes a 
cause of its irreducibility. 

Great mischief is often done by lymph deposited into a joint If the matter 
be not promptly removed by the absorbents, nature makes an effort to organixe 
and to convert it iuto an adventitious structure, which, undergoing various mu- 
tations, at length assumes the properties of the osseous tissue, at the same time 
that it efiectually destroys the motions of the articulation. The case, in fact, is 
one of bony anchylosis, and no treatment can be of any avail in reclaiming the 
functions of the part. 

d. Among the more frequent and distressing evils of plastic deposits are indu- 
ration and etilargement, or hardening and thickening of the organs and tissues. 
Such occurrences are generally exceedingly annoying, often severely taxing the 
patience of the sufferer and the skill of the professional attendant. They are the 
direct result of interstitial effusions, which often manifest an early tendency to 
organization and transformation, and which none but the most determined perse- 
verance in the use of remedies can enable us ultimately to overcome. The stiff 
and thickened joint, the indurated and enlarged testicle, the hypertrophied spleen, 
liver, and lymphatic gland, the hardened and enlarged tonsil, so frequently seen 
in practice, are sad illustrations of the truth of this statement 

When lymph is effused upon an open surface, as a wound or an ulcer, its appear- 
ance may generally be taken as a true index of the precise character of the action 
that is going on in the affected part, as to whether that action is healthy or un- 
healthy ; and it is, therefore, capable of affording valuable therapeutic indications. 
When it has the requisite degree of vitality, it is promptly converted into healthy 
granulations and new tissue ; but when the reverse is the case, it rapidly perishes, 
and is finally thrown off as an effete substance or species of slough, the surface 
beneath exhibiting an irritable, inflamed, phagedenic, or gangrenous aspect, and 
discharging a thin, serous, or bloody fluid, more or less fetid, and entirely desti- 
tute of the properties of laudable pus. This local action of the part is generally 
associated with a depraved, vitiated, scorbutic, or typhoid state of the system, 
and is liable to run into the very worst forms of pyemia and erysipelas, especially 
during the prevalence of epidemics, among the inmates of crowded, ill-ventilated 
hospitals, and other establishments for the accommodation of the sick and 
wounded. Under such circumstances the lymph is nearly always aplastic, so 
much so, indeed, that, as has been observed by Professor Andrews, of Chicago, 
the patient may be said to be laboring under a real aplastic diathesis. 

TREATMFiNT. — The treatment of lymphization is conducted upon general anti- 
phlogistic principles ; undue action is repressed, and the absorption of effosed 
matter promoted. To accomplish the first of these objects, the ordinary local 
and constitutional measures are employed; for the second, sorbefacients are 
necessary, as mercury and iodide of potassium internally, and the tincture oi 
iodine, liniments, and embrocations externally. In the acute stage of the disease, 
while secretion is still active, purgatives and antimonials, with the liberal exhibi- 
tion of calomel, constitute the chief means of relief; but the tendency to deposit 
having ceased, their use is dispensed with, all except the mercury, which is now 
given in minute doses, and with a view strictly to its alterative effect ; it is often 
carried to slight ptyalism, the mouth and gums being maintained in a tender con- 
dition for perhaps several weeks consecutively ; or, with an occasional interval, 
for even a much longer period. In the latter event, the bichloride freqnently, if 



CEAF. IT, SUPPURATION AND ABSCESS. 125 

not generallj, forms a valuable substitato for the calomel ; less likely to act hurt- 
fally, and jet, at the same time, very effectually stimulating the absorbents. In 
rack cases, too, small doses of tartar emetic often produce a most salutary influ- 
ence ; its action being hardly inferior to that of mercury itself, 'with which it may 
frequently be advantageously combined. When the inflammation has measurably 
nbsided, its prodncts, especially the serous and plastic, are generally easily gotten 
rid of bj h jdrochlorate of ammonia, or iodide of potassium, administered in doses 
Ttrring from three to twenty grains, in aqueous solution, three times in the 
twenty-foar hours; strict attention being paid, meanwhile, to the diet and 
bowels. When the case is obstinate, an occasional mercurial will constitute a 
Ttlaable addition. 

Among the more beneficial topical means are, the dilute tincture of iodine, ap- 
plied twice in the twenty-four hours ; inunctions with mercurial and other unguents, 
ptrticnlarly that of the iodide of lead ; stimulating embrocations ; and steady, 
UDiform support with the bandage. Various kinds of plasters, as the common 
mercurial, the compound galbannm, and others of a kindred nature, are also fre- 
quently serriceable. Washing the part well, when accessible, twice a day with 
hot water and Castile soap, and then using dry friction upon it, often do more 
good than anything else. In some cases, agrain, cold, especially in the form of 
the douche, acts very beneficially, affording relief when everything else seems to 
fail In the joints passive motion must be carefully performed, at first once, and 
then twice a day, to prevent anchylosis from the organization of the fibrinous 
bands which are so liable to form during the progress of synovitis. 

When the object is simply to assist nature in her efforts at repairing injury, as 
a wound or fracture, care should be taken, on the one hand, that the attendant 
action is not too low, and, on the other, that it does not transcend the fibrinizing 
limits. Bj over-officiousness the system may be so exhausted as to render the 
proper sapplv of lymph in the part a matter of impossibility, or such a state of 
the constitution may be brought about by the effects of previous disease, intem- 
perance, or inadequate nutrition from the want of proper food. However induced, 
it i&hould claim prompt attention, every effort being made, by the use of tonics, 
e?|>eciaUT quinine and tincture of iron, stimulants, and other invigorating measures, 
to supply the blood with the requisite material for the deposition of fibrin ; all 
debilitating topical applications being at the same time discontinued. Over- 
actioD, on the contrary, is met by the usual antiphlogistic means, carefully and 
warily applied, lest harm should result from the too rapid reilnction of the vital 
powers. The management of the reparative process always demands great judg- 
ment and vigilance. 

SECT. IV. — SUPPURATION AND ABSCESS. 

Suppnration is the process by which pus is formed, and is one of the most fre- 
quent, as it is certainly one of the most important, of the results, events, or con- 
ditions of inflammation. Its presence, as a general rule, is denotive of a hiprher 
frrade of excitement than a mere dei>osition of serum and plastic matter, which, 
h'lwever, are nearly always associated with it. But it mu.st not be snpposcd that 
the reverse of this proposition is true ; for inflammation often exists in a severe 
degree, with an abundant effusion of the watery and fibrinous elements of the 
blood, and yet there is not the slightest evidence of suppuration. 

It was formerly supposed that suppuration might occur without the agency 
of inflammation, and there seems to be still a lingering disposition on the part 
of some pathologists to adhere to this doctrine, if not by direct advocacy, at 
lea^t by implication. The opinion doubtless had its origin in the fact that there 
are occasionally cases of suppuration in which large quantities of pus are thrown 
off. without any evidence of the ordinary phenomena of inflammation, such, 
especially, as pain, heat, and discoloration of the structures in which the matter 
is formed, or any constitutional disorder; the whole process being apparently 
eonducted as if both the part and system were unconscious of what is going on. 
Such cases are by no means infrequent, and yet if they be carefully investigated, 



126 TERMINATIONS OP INFLAMMATION. ohap. it. 

or traced through the various stages of their progress up to the dissection of 
the affected tissues, the most satisfactory proof will be afforded of their phlogislie 
nature. In a cold, strumous or scrofulous abscess, for example, which has so 
often served as the basis for this, now nearly exploded idea, and the formation 
of which is sometimes the work of several months, inflammation is just as much 
conccnied in the production of its contents, as in a phlegmonous boil that is 
developed in three or four days. The only difference is that, in the one, the 
morbid process moves on slowly and almost imperceptibly, while in the other it 
proceeds very rapidly, and is accompanied by such well-marked symptoms as to 
render it impossible to mistake their character. 

Matter may form without any breach of continuity of the affected parts. This 
mode of suppuration is, in fact, very common, not only in the serous cavities, 
but throughout nearly the whole of the mucous system. It is not, howerer, 
confined to these textures. In the cellular substance, lungs, brain, liver, and 
other viscera, nothing is more frequent than suppuration, without any ulceration 
whatever in the inceptive stages of the morbid action. 

Suppuration does not take place with equal facility in all the organs and tex- 
tures. Of the viscera, those which are most prone to take on this action are the 
liver, lungs, and brain ; of the tissues, the cellular, cataneous, mucous, and serous. 
In the fibrous, cartilaginous, tendinous, and osseous textures, matter forms with 
difficulty, and is seldom of a thick, consistent nature. Of the mucous system 
some portions are more liable to suppuration than others. Thus, it is much 
more common to meet with it in the colon than in the stomach or ilenm, in the 
vagina than in the uterus, in the urethra than in the urinary bladder, in the nose 
than in the mouth, in the fauces than in the oesophagus, in the bronchia than in 
the larynx. So, likewise, in the serous system, suppuration is more frequent in 
some situations than in others ; as, for example, in the pleura, the vaginal tunic 
of the testicle, and the lining membrane of the larger joints. In the subcuta- 
neous cellular texture, pus is most readily formed in parts remote from the 
central organ of the circulation. The bloodvessels do not often suppurate, 
except when wounded ; and the same, so far as can be ascertained, is the case 
with the absorbents. The lymphatic ganglions, however, are very frequently 
affected in this way, especially those of the axilla, groin, mesentery, and base of 
the lower-jaw, particularly in persons predisposed to scrofulous disease. The 
nervous tissue seldom suppurates ; the muscular still more rarely. From all 
these facts we may deduce the axiom that those structures are most prone to 
form matter which contain the largest amount of loose cellular substance, and, 
convert^ely, that those which possess this tissue sparingly always suppurate with 
difHculty, requiring in general a much longer period, and elaborating a less per- 
fect fluid. 

The period at which suppuration may occur after the establishment of inflam- 
mation varies, on an average, from twenty-four hours to three or four days, 
depending upon the nature and situation of the affected tissues, the intensity of 
the morbid action, and also, in a very material manner, upon the condition 
of the system, and the character of the exciting cause. Mucous membranes, 
especially if exposed to the air, generally suppurate very readily, having, as it 
were, a predisposition to take on this kind of action ; serous membranes, on the 
contrary, suppurate with difficulty, one reason of which is that, being arranged 
in the form of shut sacs, they do not feel the stimulus of the atmosphere ; another, 
doubtless, is the fact that such structures, when irritated, are naturally inclined 
to furnish lymph rather than pus, their organization peculiarly fitting them for 
that office. The same difference exists between the veins and arteries, and it is 
practically fortunate that it does ; otherwise the danger of wounds, whether the 
result of accident or design, requiring ligation of the principal arteries, would 
be much greater than experience has shown it to be. No surgeon likes to tie a 
large vein, well knowing that the operation may be followed by fatal suppuration 
of its lining membrane. In some of the internal viscera, as the brain and liver, 
pus occasionally forms with great rapidity, as is seen in cases of injuries of these 
organs. Matter, other things being equal, forms much sooner when the inflam* 



CHAP. !▼. 8UPPUKATI0K AND ABSCESS. 127 

mation is rerj intense than when it is comparatiTely mild. A wound inflicted 
upon an onhealthy or intemperate person will be more likely to run speedily 
into sapporation than one of a similar character occurring in an individual of 
■oand constitution and regular habits. A phlegmonous boil will usually begin 
to deposit pas in from twenty-four to thirty-six hours, whereas a hard chancre 
does not famish any, so far as we are able to judge, until the beginning of the 
fourth day. In rariola, the suppurative process is generally not fully established 
before the ninth day. 

Exposure of an inflamed surface to the air greatly promotes suppurative 
action, and is, therefore, directly hostile to adhesion. The more nicely the edges 
of a woand are approximated, the greater, other things being equal, will be the 
probability of speedy and permanent reunion, and conversely. Serous membranes, 
as already stated, have naturally a disposition, when inflamed, to pour out lymph, 
and become glued together ; but whenever they lose the character of closed sacs, 
as they nec^sarily do when they are accidentally opened, the morbid action, 
consequent upon the injury, is certain to be followed by the formation of pus, 
e^ipecially if the air is permitted to have free access to them for any length of 
time. 

Pas, the product of suppuration, originally appears in the form of distinct 
globules, which are dispersed through the affected structures, and may be easily 
recognized by their pale yellowish color. As the purulent particles increase in 
namber, they graduslly become confluent by the removal of the parts coucerned, 
and in this way the matter is at length collected into an abscess. 

The symptoms which characterize the suppurative process will claim special 
attention under the head of abscesses. Meanwhile, it will suffice to observe, in 
general terms, that they are such as denote the existence of ordinary inflamma- 
tion, with an increase, more or less considerable, of the local and constitutional 
ditfturfaance. 

Pus, when genuine, or, as it is not unaptly termed, good, healthy, or laudable, 
is of a white, yellowish tint, opaque, homogeneous, of a sweetish taste, without 
any particular smell, and of the consistence of thin cream. It is heavier than 
water, in which it is partly dissolved, emits a faint, mawkish odor on being heated 
to the natural temperature of the body, resists putrefaction with remarkable per- 
tinacity, and is coagulated by heat, alcohol, and hydrochlorate of ammonia. Pus 
freezes less rapidly than water, and when thawed does not regain its original pro- 
perties. 

The specific gravity of pus is liable to considerable variation. It is less than 
that of blood, and greater than that of serum. According to Guetorbock, it 
ranges from 1030 to 1033. In seven distinct examinations of pus, taken from 
abscesses in different situations — as the thigh, arm, axilla, back, pleura, and the 
lung in pulmonary phthisis — Dr. John Davy found the specific gravity as low in 
one as 10:21, and in another as high as 1042. This great disparity is mainly 
attributable to two circumstances, the unusual quantity of the solid ingredients, 
and the variable density of the liquid part. 

The chemical constitution of pus has been examined by a great number of 
experimentalists, and the results of their investigations tend to show that it con- 
tains most of the elements of the blood. The following analysis is by Gueter- 
bock, from the pus of an abscess in the human breast : — 

Wat«r ......... 8C.1 

Fat, tolable onl J in boiling alcohol . . .1.6 

Fat and oflmaxome, sdnble in cold alcohol . .4.3 

Albamen, pjine, pus globules and granules, soluble neither in hot nor 

in cold alcohol ....... 7.4 

Lots .••....•• 0.6 



100.0 



Lehmann has investigated the chemical composition of the different elements 
of pus with great care. Normal pus he found to contain firom 14 to 16} of solid 
eonstitnents, of which from 5-6} belonged to mineral or inorg^ic substances. 




128 TBRUINATI0N8 OF INPLAllHATION. CHAP. I«. 

The most usual insoloble lalts of pua ore the plosphatea of lime and mBgneaio, 

with sulphate of Hmc ; the principal part of the soluble salts is fnmiBhcd bj 

chloride of sodium. The quantity of bt was found to vaiy from 3-6g ; the 

quantity of albumen in the serum from l.S to 3.7g. Casein and the coloring 

matter of the blood do not occur in normal pus. A substance which neiullj 

enters into the composition of pue is pyine. Queterbock, who discoTered it, 

considers it as & peculiar animal principle. Its exact nature is not onderstood. 

It is supposed by some to be au oside of protein, by others a form of fibrin. 

It can be precipitated from pus by acetic acid, or by alum. It is soluble in water, 

but iusolnble in alcohol. 

Pua occasionally contains a peculiar substance, denominated pyocyanine f it 

imparts a blnieh or greenish hue to the contents of 

Fig. IS. certain abscesses, and to the discharges of certain 

ulcers, but its real nature is not well uuderstood. 

With regard to the composition of the compoond 
part of tha pus globules we possess no positiTC 
knowledge. The cell walls, contents, and nndd 
react like protein bodies, and are probably of an 
albuminous nature. The cell walla are dissolved by 
acids, but resist the action of alkalies. 

Pas, microacopicatly examined, is found to be 
composed of numerous corpuscles suspended in a 
thin, transparent fluid, called the pus-liqnor. These 
tittle bodies, which hare received the name of pas 
globules, are generally of a spherical form, and from 
the ^^ts^th to the ^TiVirt'i <>f '■'^ ^'^^^ i" diameter. 
poKi.- ft AW.moce »fwr ih« TUey are mostly very granular, and posaesB a deli- 
iii>;Lici.ii..u uf u«iic Hc^. cate cell wall, which becomes distinct on the adiU- 

tion of water. They are nucleated; some contain- 
ing one well-defined nucleus, others two, three, or mure small nnclear bodies. 
Fig. IC exhibits pus corpuscles in their natural state as well as their appearance 
whcD acted upon by acetic acid, which has the effect, especially if used undiluted, 
of increasing tbcir size and rendering their walls and cell-contents more or leas 
transparent. 

These corpuscles float in the pns-liquor, and are intermixed with various other 
solid elements, as granules, shreds of fibrin, and exudation corpuscles ; also, at 
time?, with small homogeneous, non-nucleated corpuscles, termed pyoid. 

Pus is liable to be modified in its properties by the presence of extraneoiu 
substances, such as grumous blood, fibrin, cholesterine, and tlie debris of the 
organs and textures in which it is formed. In common phlegmon, it often con- 
tains jihreds of cellular tissue, of a dirty grayish color, not unlike wet tow. The 
brownish matter found in certain abscesses of the liver probably derives its color 
and consistence from the intermixture of the softened and broken-down hepatic 
parenchyma. In suppuration of the differeat glands, the pus is not unfreqnently 
mingled with the product of their secretion. Thus, in the kidney, it may blend 
itself with the urine, in the liver with the bile, in the mamma with the milk, in 
the testicle with the semen, and in a gouty joint with urate of soda. Purulent 
matter is sometimes very fetid, probably from the extrication of sulphuretted 
hydrogen. 

The different varieties of pus have received different names. When the fluid 
is of a whitish color, creamy in its consistence, and composed of a great number 
of globules, it is said to be healthy, pure, or laudable, in reference to the process 
by which it is produced, which is Of a healthy, sanative, or restorative nature. 
It is usually met with in suppurating wounds, in healing ulcers, and in phlegmon- 
ous abscesses. Its properties have olreody been sufficiently described. 

Sanioua, serous, ichorous, or sanguinolent pus is thin, almost transparent, of 
a yellowish, oily, or reddish color, and generally so acrid as to erode the parts 
with which it comes in contact It is a product of unhealthy inflammation, and 
is principally observed in caries of the bones, iiritable ulcers, and open cancer. 



CVAP. IT. SUPPURATION AND ABSCESS. 129 

This Tariety of pas is frequently blended with gnimous blood, flakes of fibrin, 
and the debris of the affected tissues. 

Fibrinous pus consists of common pns in combination with lymph. It is of 
a whitish, grayish, or cineritioas color, and of a semi-liquid, concrete, or larda- 
ceoQS consistence. Under the microscope, it displays the globules of healthy 
pas. with nameroos other cells and fibres of irregular shape. It is commonly 
foand ID the joints, the splanchnic canities, metastatic abscesses, and carbuncular 
inflaaimation. Its presence denotes a high degree of morbid action. 

Scrof ulcus pas is mostly seen in pulmonary caverns, cold abscesses, scrofulous 
disease of the joints, and chronic inflammation of the lymphatic ganglions. 
After standing a little while, it usually separates into two parts, of which one is 
thick, straw-eoloredy and inodorous ; the other, which rests on the surface, is oily 
io appearance, thin, ropy, and mixed with small, opaque, curdy flakes. When 
scrofoloaB pas is long retained it may acquire a disagreeable, nauseous Bmell, not 
inlike the pollen of the chestnut ; at other times it is excessively fetid. The 
attendant action is usually very languid. 

There is a variety of pus to which, from its admixture with mucus, the term 
muco-purulerU is applied. It is usually a product of a high degree of inflam- 
mation of the various outlets of the body, particularly the nose, eye, bronchial 
tabes, and genito-urinary apparatus. The mucus which proceeds from these 
Rirfaees in the healthy state is composed of a transparent fluid, and of abraded 
epithelial cells, flat, and irregularly sided with a central nucleus. In addition to 
these, the microscope detects numerous granular masses and spherical globules, 
similar to those of pus; the whole being suspended in a viscid, transparent, 
ductile fluid. Under inflammation, the epithelial cells are cast off so quickly 
that they have not time to become flattened out, and the globules are not only 
greatly augmented in number, but they acquire somewhat the character of those 
of pus. 

Finally, there is what is called puriform matter, a substance which, as the 
name implies, is not true pus, but an imperfect liquid bearing merely some re- 
semblance to it. It is found chiefly in bad forms of inflammation, as erysipelas, 
c*arbancle, and pyemia, and consists essentially of broken-up lymph and shreds 
of tissue, interspersed with fatty substance, granules, abortive cells, and a few 
globules, smaller than those of pus, and not affording the usual reaction under 
acetic acid. 

Certain kinds of pus, as those, for example, of smallpox, varioloid, gonorrhcea, 
and chancre, are contagious. In what particular element of the fluid the vims 
or specific secretion is contained, or whether it exists as an entity, is undetermined. 
The vitality of the organ by which it is elaborated is not necessary for the pre- 
servation of its peculiar effects. Once formed, it becomes independent of its 
source, and retains, for a considerable period, the power of contaminating the parts 
to which it is applied, pro<lucing a disease of the same character. Various chemical 
agenti«, however, as the alkalies and acids, have the property of neutralizing or 
destroying it, so that, if inoculation be afterwards attempted, no effects will 
ffillow. If the pns of a chancre be examined with the microscope, it will often 
be found to contain animalcules, particularly the vibrio lineola. 

Pus, formerly supposed to be a product of secretion, is merely altered fibrin, or 
plasma, so abundantly effused in inflammation, especially at the focus of the 
morbid action. In what manner, or by what agency, the change is effected, has 
not lH*en ascertained. The probability is that it is partly of a vital, partly of a 
chemical nature. All that is certainly known respecting it is that the pus cor- 
puscles, in their size, shape, and structure, resemble lymph corpuscles, and that 
the former always contain more or less oily matter, which, formed during their 
metamorphosis, constitutes one of their characteristic attributes. 

In addition to these changes in the lymph, observations, made chiefly by Yir- 
chow, Billroth, Buhl, Bdttcher, Burkhardt, and other German pathologists, would 
seem to show that the formation of pus is always preceded and accompanied by 
impr>rtant changes in the affected structures themselves. These changes consist 
mainly in the elongation and subsequent division of the nuclei of the cellular 
' VOL. I. — 9 



180 TERMIXATIOXS OF IXFLAMM ATIOX. ghap.it. 

eloDicnt of the parts. The nuclei are thus greatly multiplied, 80 that crowds 
may be seen where only a few were visible previously, and as the morbid action 
advances, they gradually assume all the characteristics of pus corpuscles. The 
hard, solid feel which attends the early development of an abscess is supposed 
to depend chiefly upon the proliferation of these nuclei, while the sabseqaent 
softening which it experiences is due to the conversion of these bodies into 
purulent matter, interspersed with oil globules, and separated by a fluid intercel- 
lular substance. When suppuration occurs upon a free surface, as the cutaneous, 
mucous, or serous, pus may be formed either in the sub-epithelial connective tissue, 
or endogenously in the epithelial cells themselves. In the latter case, as has been 
shown by Mr. William Tumor, the epithelial cells burst, and the pus corpuscles, 
developed in their interior, are set free. 

The more aplastic or degraded lymph is, at the moment of its deposition, the 
more likely will it be to be transformed into pus ; hence what has been called 
corpuscular or croupous lymph is much more prone to assume this character 
than the fibrinous, or more organizable variety of this product. The degencrm- 
tion is also, as already stated, materially influenced by the softened and disinte- 
grated condition of the affected tissues, in the meshes of which the lymph is 
situated, such a change being highly favorable to the development of pus germs, 
or, what is the same thing, inimical to the ])roduction of healthy blastema. 

Pus is susceptible of absorption, probably in all its varieties, as well as in 
almost every locality. Satisfactory proof of this fact is afforded by what occurs 
in abscesses in the different external parts of the body ; and it is therefore analo- 
gically reasonable to infer that it may also take place in the internal organs and 
cavities. Great doubt has recently been expressed, especially by some of the 
French pathologists, respecting the possibility of pus being taken up in this 
manner, on the ground, chiefly, that the accumulations which occasionally disap- 
pear, both spontaneously and under treatment, are really not abscesses, but 
collections of plastic matter. Every surgeon, however, of experience knows 
that pus, or puriforra fluid, is sometimes removed by the agency of the absorbents, 
after its existence has lK»en satisfactorily tested by the exploring needle. Par- 
ticular remedies are often employed for the attainment of this object, and our 
efforts are certainly not unfrequeiitly crowned with success, although probably 
not as often as is generallx supposed. 

Pus, as pus, is never al)Sorbed. It is extremely probable that the thinner 
parts are at once carried into the system, without any previous change ; whereas, 
the pus globules are no doubt obliged to undergo a species of degeneration and 
disintegration before they can be acted upon by the absorbent vessels. Whether 
the fatty matter remains, or whether it, also, is removed, has not been determined. 
How pus is disposed of, after it has reached the circulation, is likewise unknown; 
the most reasonable conclusion is that it undergoes oxidation, and that it is ex- 
creted by the liver and kidneys, if not, also, by some of the other emunctories. 

ABSCESSES. 

An abscess is a circumscribed cavity of abnormal formation, containing pus. 
When the matter is poure<l out into a natural cavity, as the chest, or into a joint, 
the collection constitutes what is called a purulent effusion. An abscess may 
be superficial or deep, acute or chronic, common or specific. It is said to be 
superficial when it is immediately beneath the common integuments or in the 
cellular substance among the su])erficial muscles. The word deep, on the con- 
trary, is used when the matter is lodged in an internal organ, in a bone, or 
among muscles. The terms acute and chronic have reference merely to the time 
occupied in the formation of the abscess. A common abscess is one produced 
by ordinary inflammation ; while the specific abscess is the result of the operation 
of some particular poison, as the virus of chancre, smallpox, or glanders. Finally, 
an abscess is circumscribed, as when it is bounded by plastic matter ; or diffuse, 
as when its contents are sent abroad through the connecting areolar tissoa 

The most philosophical division of abscesses is into phlegmonous, scrofoloas, 



CflAP. IT. PHLEGMONOUS ABSCESS. 181 

ind metastatic, the first being incident to all persons, while the second is capable 
of occurring only in certain classes of individuals, or snch as are afiected with a 
fitnimous taint of the system. The term " metastatic," foimerly so much in vogue, 
is employed to designate those collections of pus which are consequent upon 
WTere injaries, operations, and diseases, and might be advantageously abolished, 
is it is only calculated to convey false impressions respecting a form of suppura- 
tion which properly comes within the definition of phlegmonous, although, as 
will be shown by and by, it is generally supposed to have its origin in a toxical 
condition of the blood. It has rdcently been described under the term " multiple," 
and will claim particular attention under the head of pyemia. It is not easy, in 
the present state of the science, to assign an appropriate place to the dififuso 
abscess, as it is often impossible to determine its real character. The specific 
abscess will not require any special consideration, since, apart, from its exciting 
caase, its mode of formation does not, so far as we are able to comprehend it, 
differ at all from that of the common phlegmonous abscess. 

1. PHLEGMONOUS ABSCESS. 

A phlegmonous abscess is one which runs its course with unusual rapidity, 
and which is always accompanied by well-marked inflammatory symptoms. The 
part feels, as the name implies, as if it were on fire, being hot, tender, and ex- 
quisitely painful. A tensive, throbbing sensation is generally present; it is 
i»ynchronous with the contraction of the left ventricle of the heart, and is always 
greatly aggravated by dependent position ; it is particularly severe at the focus 
of the morbid action, and is a valuable diagnostic symptom, as it is generally 
denotive of suppuration. Its immediate cause, as explained elsewhere, is 
obstructed circulation, and consequent pressure upon the nerves of the affected 
structures. 

The anatomy of a phlegmonous abscess constitutes an interesting study. In 
the first place, the matter is obliged to have a receptacle for its accommodation. 
This is usually furnished by the cells of the connecting areolar tissue of the 
part : but as the accumulation, which is at first drop-like, progresses, this sub- 
stance is destroyed by ulcerative action, and in this way a cavity is gradually 
formi'd, often capable, in the cud, of holding an immense quantity of fluid. While 
the process of deposition is going on, plastic matter is poured out at the periphery 
of the cavity, gluing up the cellular tissue, and forming thus a kind of boundary 
line around the pus, by which its diffusion among the surrounding structures is 
dTectually guarded against. No distinct cyst is built up, for nature has not time 
for such an enterprise, nor is she at all in need of it, although the occurrence is 
not impossible even in acute abscess, especially in one of the liver. The next 
circumstance to be observed is the effort which the matter makes to reach the 
nearest surface, for this is one of the laws of interstitial suppuration. To this 
ubject the matter it.self is eminently contributary, the pressure which it exerts 
npon the superimposed parts greatly promoting and expediting the ulcerative 
action, by whose agency evacuation is finally attained. Thus, at least three 
z^arate and distinct processes are going on during the formation of an abscess ; 
a deposit of pus, an effusion of lymph, and ulceration. The importance of an 
effusion of plastic matter is shown by the fact that, when it fails to be furnished, 
the contents of the abscess are widely diffused among the surrounding structures, 
committing extensive havoc in the connective tissues, and causing frightful 
si^paration of the muscles. These evil effects are often witnessed in phlegmonous 
erysipelas, where, in consequence of the cacoplastic character of the lymph, the 
matter occasionally burrows to a great distance, destroying everything within its 

reach. 

The great law which presides over the evacuation of abscesses, by which their 
contents are enabled to reach the nearest surface, is attended with the most fortu- 
nate results, for it not only abridges suffering, but also saves structure. Thus, 
in abscess of the liver, a long time would elapse, and an immense amount of pain 
and constitutional disorder would be caused, if the matter, instead of emptying 



182 TERMIXATIOXS OF IXFLAMXATIOX. CBAP. IT. 

itself, as it usually does, into an adjoining coil of intestine, were compelled to 
travel across the walls of tiie alxiomcn. 

The contents of the phlegmonous abscess usually partake strongly of the 
nature of well-elaborated pus, being of a whitish, or pale straw color, and of a 
thick, cream-like consistence, with an abundance of large and well-matured pus 
corpuscles. Intcnnlxed with them are often flakes of lymph, and the debris of 
the affected structures. Tims, in abscess of the external parts of the body, it is 
nut uncommon to meet with shreds of areolar tissue ; in abscess of the liver, 
with broken-down hepatic substance. Occasionally, again, the pus is blended 
with the peculiar secretion of the part, as semen in abscess of the testicle, bile 
in abscess of the Hirer, milk in abscess of the mamma. A knowledge of these 
facts is of great practical value, as a means of diagnosis, the nature of the 
adventitious matter often pointing directly to the seat of the disease. Some 
forms of acute abscess, as those more particularly which follow upon seyere 
accidents and capital operations, and to which the term metastatic is sometimes 
applied, are made up almost entirely of fibrinous matter, the quantity of pus cor- 
puscles being extremely small. 

The contents of certain abscesses are excessively fetid. This is especially 
true of abscesses around the anus from the proximity of the pus to the bowel, 
or from the actual intermixture of fecal matter. The same circumstance occa- 
sionally obtains, although generally in a less degree, in abscesses in some other 
situations, as the tonsils, bones, and lymphatic ganglions. 

Abscesses sometimes contain air, the fluid resting upon the top of the matter. 
Such an occurrence is most liable to happen in the perineum, about the sacrum, 
in the ileo-lumbar region, and in front of the abdomen, in consequence of the 
existence of a communication with the intestinal tube. A similar phenomenon 
is occasionally witnessed in suppuration of the chest, when the matter contained 
in that cavity makes an effort to escape externally through one of the intercostal 
spaces, after an opening has been made into a bronchial tube. In general, the 
pus, when thus admixed, is excessively fiitid, and the abscess is distinctly 
emphysematous, crepitating under pressure, and often emitting a peculiar gurgling 
noise. 

Phlegmonous abscesses are liable to occur at all periods of life, and in all 
classes of individuals. We occasionally meet with them within a few weeks 
after birth, especially in the mamma and in the lymphatic ganglions about the 
neck and in the axilla. They may be traumatic, or idiopathic; or, in other 
words, dependent upon external injury, or constitutional causes, as derangement 
of the digestive organs, or the suppression of some important secretion, as that 
of the liver, kidney, or uterus. Abscesses are sometimes of a secondary cha- 
racter, one forming after another, as if there existed a species of pyogenic dia- 
thesis. Such an occurrence often proves exceedingly untoward, sadly interfering 
with recovery, especially when it manifests itself during the progress of conva- 
lescence after protracted fevers and severe injuries. 

Abscesses of this kind may form in any part of the body ; but they are most 
commonly observed in the areolar tissue, beneath the skin, among the muscles, 
and around the lymphatic ganglions, as well as in the substance of these bodies, 
especially in those of the neck, axilla, and groin. Among the internal organs, 
those that are most liable to suffer arc the liver, lungs, and brain, but even here 
phlegmonous abscesses, except as a result of external injury, arc extremely rare. 

The number of abscesses varies from one to a great many, and is generally in 
an inverse ratio to their size. Two or three large ones occasionally exist simul- 
taneously in different parts of the body; and, on the other hand, the whole sur&ce 
is sometimes, as in variola, lit4?rally covered with small ones. The sise of a 
phlegmonous abscess ranges from that of a mustard seed up to that of an adults 
head. 

The symptoms which precede and accompany the formation of a phlegmonooB 
abscess are subject to much variety. In general, they are such as characterise 
ordinary inflammation. The part, when open to inspection, is found to be red, 
hot, swollen, and painful, beating and throbbing synchronously with the oontrai^ 



CHAP. IT. PHLEGMONOUS ABSCESS. 133 

tion of the left ventricle of the heart. As the matter accumulates, all these 
symptoms augment in severity, especially if the fluid is bound down by hard, 
unyielding structures, interfering with its extension. Under opposite circum- 
stances, however, the pain often diminishes, the part feeling relieved almost as 
soon as the deposition of pus has fairly begun. However this may be, the dis- 
coloration of the skin always increases as the matter approaches the surface, 
and generally assumes a dusky, purple, or livid aspect, particularly at the focus 
of the abscess. The swelling also augments, and the part often pits on pressure, 
more or less serum being effused into the subcutaneous cellular substance. The 
heat is much greater than it is in the surrounding structures, and there is always 
serious functional disorder. 

The morbid action continuing, the centre of the abscess becomes acuminated, 
and the matter, in surgical language, is said to point. The skin hero is not only 
greatly discolored, but thin and impoverished; and giving way at the most 
prominent part of the tumor, allows its contents to escape, generally by a small 
orifice, which is often entirely inadequate to thorough clearance. The period 
which intervenes between the commencement of the inflammation that leads to 
the formation of the abscess, and the evacuation of the pus, varies from a few 
days to several weeks. 

When an abscess of this kind is small, or situated in a comparatively unim- 
portant part, the constitution may fail to take any cognizance of it whatever. But 
this is rather the exception than the rule ; for, in the majority of cases, the sys- 
tem warmly sympathizes with the local trouble, and manifests the interest it feels 
in it by well-marked inflammatory symptoms. If an abscess is about to form in 
an internal organ, the patient will be seized with rigors, often violent and long 
continued, alternating with flushes of heat, and generally followed by copious 
sweats. This frequently happens even when the abscess is of very trivial size ; 
the importance of the affected structures giving proportionate force to the mor- 
bid action. Rigors also generally occur in abscess of the bones and joints, but 
comparatively seldom when the disease is seated in the subcutaneous cellular 
substance. Al>scess of the ear, parotid gland, tonsils, anus, and perineum are 
nearly always attended with high constitutional excitement. If the case is at all 
severe, delirium will be apt to be present, lasting either until the part is relieved, 
or until the disease proves fatal. The countenance is generally flushed, the eyes 
are suffused, and there is often a hectic spot upon the cheek, especially in 
internal suppuration. The pulse is full, strong, and frequent ; the skin hot and 
dry : the urine scanty, high-colored and loaded with uric acid. Great thirst and 
restlessness usually exist. When the abscess is fully formed, the constitutional 
symptoms, as well, indeed, as the local, often greatly abate, comparative comfort 
iiucceeding the violent perturbation. The pulse becomes soft and calm, the sur- 
face is bathed with perspiration, the renal secretion increases in quantity and 
improves in quality, and the patient, grateful for the happy change, falls into a 
tranquil sleep. 

Diagnosis. — Notwithstanding that the symptoms of phlegmonous abscess arc 
usually well marked, cases now and then arise where the diagnosis is so obscure 
as to cause serious doubt respecting their true character. Indeed, there is proba- 
bly no department of surgery where so many mistakes are constantly committed 
as in this. If the records of the science could be thoroughly explored, they would, 
I am sure, be found to abound in blunders of diagnosis in this kind of disease. 
As it is, we frequently hear of encephaloid tumors, aneurisms, and hernias being 
opened for abscesses, and life either instantly destroyed, or placed in great ulti- 
mate jeopardy, by the operation. Such mistakes are hardly less injurious to the 
surgeon than to the poor patient ; for they but too certainly ruin his prospects 
and reputation as a practitioner. Attention to the following circumstances, 
will, I trust, enable the reader to steer clear of difficulty : 1. The history of the 
cmse ; 2. Pointing ; 3. Fluctuation ; 4. (Edema ; 5. The use of the exploring 
needle. 

1. The first object that claims attention is the hir*''^ '^ ♦*"* -stBe. Upon 
inqnirr, it wOl usually be found that the diiette ^ 'ding ; 



181 TEBUINATIOXS OF INFLAM3f ATIOX. ohap.it. 

having commenced with the ordinary symptoms of inflammation, and gradnaUj 
increased until the supparative point was attained, the ferer being high, and tlw 
local distress often extreme. Rigors are looked for if the abscess is deep seated, 
extensive, or among important strnctares. The pain is tensive and throUnBg; 
steady and persistent, not intermittent, or severe at one time, and absent at 
another. The countenance is expressive of great suffering, and with a snrgeon 
of experience, this symptom alone is sometimes sufficient to establish the diagnosis 
of the case. If the abscess is lodged externally, the swelling is observed to be 
gravescent, unnaturally hot, excessively tender, intolerant of manipalation, and 
of a dusky reddish color, especially at its most prominent point Its career is 
comparatively brief, a few days, a week, or, at most, a fortnight, saffidng to readi 
its acme. Then comes the period of dissidonce, if the matter is not evacuated; 
the symptoms abating in severity, the pulse and skin becoming soft, and the pain 
losing its throbbing character. 

2. Pointing is a symptom of great importance in the diagnosis of a phlegmonous 
abscess. It is always most conspicuous where there are, or were, most pain ud 
discoloration. The skin looks dusky, purple, or livid, and feels thin and attenn- 
ated as if it were ready to give way, as, in fact, it generally is. A tumor, benig;n 
or malignant, may also point, but a careful consideration of the history of the 
case will commonly suffice to show the difference. 

3. Fluctuation in an abscess necessarily implies the existence of mobility. If 
the matter lies neur the surface, it may readily be displaced on one side, and ren- 
dered correspondingly prominent upon the opposite. Two methods may be 
adopted in conducting the examination. In one, alternate pressure is made with 
the hands or fingers resting upon opposite points of the abscess. As one hand 
or finger sinks in the other is elevated, and whenever this is the case there can be 
no question about the existence of fluid, although the fluid may not be purulent 
The other method consists in percussing the tumor with one hand, the other hand 
being placed upon the opposite side. If matter be present, an undulatory mo- 
tion will be imparted, one of the surest signs of suppuration. This method, how- 
ever, is less delicate than the other, and is applicable only to abscesses of nnnsnal 
volume. Finally, when the matter is seated superficially, its presence may often 
be detected by passing the finger over the most prominent part of the swelling, 
when, if there be pus, it will generally sink in a little, in consequence of the skin 
at that part being less resistant than at the periphery of the tumor. This method 
of examination is particularly valuable in small abscesses of the scalp, perineum, 
tibia, clavicle, fingers, and other superficial portions of the skeleton. 

There are certain parts of the body which, under the inflnence of disease and 
injury, impart a deceptive sensation of fluctuation. These parts, as was first 
clearly pointed out by NelatDii, are the dorsal surface of the hand, the forearm 
on a level with the head of the radius, the calf of the leg, the upper and onter 
aspect of the thigh, and the inner and upper portion of the thigh on a level with 
the iliac and psoas muscles. A similar state of things occasionally exists in the 
temple. Without a knowledge of these facts, the occurrence of swelling in these 
regions might readily induce the surgeon to use his bistoury when there is no 
matter. 

4. Valuable information is often afforded by the appearance of the swelling. 
Thus, when the matter is very deep seated, as in abscess of the thigh, the exist- 
ence of oedema is nearly always decisive of the nature of the case, especially when 
it is conjoined with a hard, brawny state of the parts. The fluid cannot reach 
the surface on account of the manner in which it is bound down, but its presence 
causes inflammation in the skin and subjacent cellular substance, leading to an 
effusion of serum, and consequently to more or less pitting under the pressure of 
the finger. In empyema, or purulent collections in the pleura, oedema of the 
chest, directly over the seat of the fluid, is usually a prominent, and, indeed, in 
many instances, a characteristic symptom. A puffy, oedematons state of the 
scalp is often denotive of abscess of the brain and dura mater, in injury of the 
skull. 

Although oedema is in general a valuable sign in suppuration, it occasionally 



CHAP. IT PHLEGMONOUS ABSCESS. 135 

czisu in a eiy hign degree without any pus. A few years ago I saw a case of 
•cute eucephaloid of the hip and thigh in a young lady of twenty-six, where the 
qoaDtity of serum in the subcutaneous cellular tissue was so great as to produce 
Uie most decided fluctuation at various points of the swelling, and yet not a par- 
ticle of matter followed the insertion of the bistoury. 

5. The affections which are most liable to be mistaken for abscess are ence- 
phaloid, aneurism, and hernia. From the first of these the history alone of the 
case will generally suffice for a correct diagnosis. Encephaloid is a chronic 
affection ; a phlegmonous abscess, an acute one ; the first is attended with little 
or no pain until ulceration sets in ; the latter is attended with a great deal, gene- 
rmlly from the moment it begins until it is evacuated. 

An abscess may be mistaken for an aneurism, especially if it be seated over a 
tolerably large artery, which communicates to it its impulse. I recollect a notable 
catw of this kind which occurred, many years ago, in the Louisville Ilospital, and 
which created quite a sensation at the time. The patient, a young English sailor, 
had a globular tumor, of the volume of a foetal head, in the epigastric region. 
It had existed there, in a marked degree, for upwards of a month, and as it 
received a distinct impulse from the aorta, it was believed by the surgeons in 
attendance to be an aneurism of that vessel. The patient was apprised of the 
Boppotfed nature of his disease, and his only regret was that he should never be 
able to reach his native country. The man soon after this fell into the hands of 
Dr. Donne and myself, when, upon introducing an exploring needle, we found 
that the tumor was not an aneurism, but an abscess seated deeply in the wall of 
the abdomen. 

A strangulated hernia of the groin, abdomen, or upper part of the thigh might 
be mistaken for an abscess, but such an accident could hardly happen in the hands 
of an experienced surgeon. The history of the case, the peculiar character of 
the swelling, and the existence of symptoms of strangulation will always be suffi- 
cient to clear up any doubt that may arise respecting the nature of the case. 

6. When, notwithstanding the most thorough scrutiny of the case, its nature 
remains undetermined, recourse must be had to the exploring needle, which often 
decides the question in a moment. The instrument which I usually prefer is an 
ordinary cataract needle, introduced at the most prominent part of the swelling 
down to its very centre, and freely rotated upon its axis, in order to condense 
the walls of the puncture, and thereby facilitate the flow of fluid. If the con- 
tents be purulent, the circumstance will be revealed by the appearance of a drop 
of pus at the orifice ; whereas if the swelling be an aneurism, the discharge will 
be sanguineous. If the tumor ho encephaloid, probably nothing will escape, 
except a little blood consequent upon the penetration of the instrument. 

Frognoais. — The prognosis of this disease is influenced by a variety of cir- 
cnmstauces, of which the most important are the size, number, and seat of the 
abscesses, and the age, habits, and constitution of the pati(^nt. 

A large accumulation of pus is, other things being equal, more dangerous than 
a small one, because it not only produces more havoc among the tissu(^s, but it 
exerts more severe pressure upon the surrounding parts, and establishes a greater 
drain upon the system. Number has an important bearing upon the prognosis. 
A man may struggle through several abscesses, even when of considerable bulk, 
but when he is laboring undrr a great many he must, indeed, be extremely for- 
tunate if he do not sink under them. Smallpox is always a dangerous disease, 
chiefly on account of the enormous number of abscesses which attend its pro- 
gress ; few patients being capable of witlistanding the irritation and consequent 
proi-tration occasioned by their development The situation of the matter is an 
object of importance. Thus a small abscess of the perineum may cause fatal 
retention of urine, as a small abscess of the fauces may induce death by com- 
prezuion of the glottis. Importance of structure also influences the issue of the 
case. An abscess of an internal organ, as the liver, is more dangerous, and more 
likely to prove fatal, than an abscess of an external part of the body, as a lym- 
phatic ganglion. 

The recovery of a person laboring under phlegmonous abscess is often mate- 

This hook ia ihu ^i ^ . 

ooovEK mm 



136 



TERMINATIONS OP IliPLAKHATIOK. 



Fig. 17. 



riallj influenced by his sge, habits, and state or constitution. Young adnlta ted 
middle-agi'd subjects usually get on better than children and very old penom, 
who often mei't such attacks very poorly, making a very feeble sbov at raBwUMC. 
The intemperate man has a worse cbaticc than one of good habits, and the mu 
of bad previous health than one who has always had an excellent coDStitntioB. 

Treatment. — The treatment of phlegmonoas abecess is conducted npoD genenl 
antiphlogistie prindpleH ; by depletion, purgatives, antimonials, and the ordinaij 
topical means, to limit deiiosit and Eave structure, and afterwards by the lancet 
tu &vor evacuation and reparation. Sumetimes spontaneous removal te looked 
for, as when ttic abdce^a ix seated just beneath the periosteam, as an effect of 
tertiary syphilis, or when it occupies a lymphatic ganglion, and has yet mide 
littto progruea ; favored, if necessary, by tho ad mini strati oo of mercury and iodide 
of potassium, and the application of iodine, blisters, and other sorbebcienta. Bat 
such cuses arc exceptional, and do not affect the general rule of practice, which 
always seeks nn early outlet for the pent-up fluid. In some situations we do 
not even wait for well-marked pointing, much less distinct fluctuation; bat, 
assured that matter is prest^iit, make an early and free incision, thus abridging 
Bufferiiitr and saving etractare. The benefi- 
cial effects of this practice are atrikioglj 
illustrated in abscosscs in various parta c^ 
the body. Thus, in purulent coUectiou 
around the anus, an early outlet is indispcD- 
sablo to prevent the matter from bnirowing 
along the side of the rectum and perforating 
its walls, thereby fonniog an anal fistnle. 
Abscesa of the perineum requires prompt 
interference to prevent retention of nrine 
and the establishment of urethral fistnle ; of 
the fingers, to prevent tho matter from travel- 
ling along the sheaths of the tendons and so 
producing extensive sloughing and necrosis ; 
of the fauces and tonsils, to prevent suffoca- 
tion by the pressure of the swelling upon the 
glottis. The torturing pain of a gum-boil, 
on abscess of tlie jaw, is oflen instantly re- 
lieved t)y an early and free incision. The 
same procedure in deep-seated absceBS of 
the extremities not only relieves pain and 
constitutional irritation, but prevents the pns 
from burrowing among the muscles, and thus 
causing extensive destruction of the connect- 
Mr. Li.inn-- «M. ». Tii» «ifrD«i npfninit ing Cellular tissuc. 
of wb»i wi.. an .h.™-.. n. Tho uw aii-j ^^ absccss sliould bc Opened early when, 
liTtrtl^r^'iu" i«ir".«'U«B'Iii«j omb'T ^'^i^ itB proximity to a large vessel, there is 
Tii» imoumuBuirio'oerrl. danger that a communication may be estab- 

lished between them, thus leading to fatal 
hemorrhage. Such an event will be more particularly liable to occur in delicate 
children lal)oring under the effects of scarlatina, measles or smallpox, and to 
elderly subjects worn out by long suffering and an impoverished state of the 
blood. Tho arteries most subject to this danger arc those alKiut the neck. In 
Mr. Liston's celebrated case, the abscess opened into the external carotid ; it 
was punctured and the patient perished from hemorrhage. The parts are repre- 
sented in fig. 11. 

Artificial evacuation may be effected with tho knife or with caustic. The 
latter, at one time so much in vogue, is now seldom employed, and it would be 
difficult to conceive what poBsibIc advantage it can possess over the former, which 
is incomparably more cxpeditioas, less painful, and more certain. I would not 
so for humor a patient as to use caustic when my judgment plainly condemned 
it, simply because be was foolishly timid, especially now that we can bo readily 




CHAP. IT. 



PHLEGMONOUS ABSCESS. 



187 



Fig. 18. 



prerent all apprehension and saffering by the administration of anesthetics ; nor 
woald I, on the other hand, resort to caustic with the view of promoting sappu- 
ratine action, since we have always at our command articles infinitely more 
desirable and efficacious. If, however, such a remedy should be called for, the 
beet one is the Vienna paste, applied as in making an orainary issue, the eschar 
being afterwards penetrated, if need be, by the bistoury, now no longer dreaded 
by the patient 

Yarloos instmments are employed for opening abscesses. The awkward, 
dumsy thamb lancet, which formerly figured so conspicuously in every pocket 
case, is now seldom used, having been advantageously superseded by the scalpel 
and bistoory. The scidpel ip, however, rarely 
employed, except in very large abscesses, where it 
is necessary to make a very free division of the 
overlying stmctnres. By far the neatest contriv- 
ance for the purpose is the little bistoury, repre- 
sented in fig. 18, which I have used, almost ex- 
clusively, for many years. It consists of two very 
narrow, sharp-pointed blades, one straight, and the 
other slightly curved, short, yet long enough to 
reach to the desired depth in almost any conceiv- 
able case. Selecting the most prominent, and, if 
possible, also the most dependent, portion of the 
abscess, the instrument is plunged perpendicularly 
through the skin, into the very midst of the matter, 
its arrival there being indicated by a want of re- 
sistance and probably also by an escape of a few 
drops of fluid, especially if this be rather thin. 
The puncture thus made is then converted into an 
incision, by depressing the handle of the bistoury, 
and cutting from within outwards, the length of 
the opening varying, on an average, from a third 
of an inch to an inch, according to the volume of 
the abscess. In general, it is better that the open- 
ing should be too large than too small, as the 
object always is to afford firee vent to the pent-up 
fluid. Care, of course, is taken, in introducing 
the bistoury, not to interfere with any important vessels and nerves, or to perforate 
any important cavity. 

In large abscesses, attended with great destruction of the cellular tissue, and 
extensive separation of the muscles, the course of the arteries is sometimes com- 
pletely changed, by the pressure of the accumulating fluid ; and hence the sur- 
geon, if hot fully upon his guard, may cause very serious, if not fatal, hemorrhage. 
The best way to avoid such an accident is to ascertain carefully, beforehand, the 
situation of the vessel, as may usually be done by its pulsation. 

When the abscess is very deep seated, as, for instance, when it occupies the 
mui^eles of the thigh, the walls of the abdomen, the groin or axilla, the safest plan 
will be to divide the skin and fascia freely with the knife, and then to push, very 
cautiously, as has been suggested by Mr. Hilton, a grooved director or pair of 
forceps into its interior. 

Penetration having been effected, the matter usually escapes of its own accord, 
simply by the pressure of the atmosphere ; but the evacuation may be aided, if 
neces<4«ary, by the hand or finger, used, however, with the greatest gentleness, 
otherwise it may not only cause severe pain but an aggravation of the inflam- 
matory action. Too much caution, indeed, cannot be observed in this particular. 
Nothing can be more reprehensible than the rude manipulations that are so often 
practised after this operation, even by surgeons otherwise well educated. To 
prevent the incision fh>m healing by the first intention, and the necessity of the 
rppemted use of the knife, a small tent, well oiled, made of old linen, is interposed 
between its edges, one extremity being carried a short distance into the now 




AbsceM bUtoarj. 



188 TERMINATIONS OF INFLAMMATION. cbap. it. 

empty sac, and the other left slightly pendent externally, substitution being 
effected once in the twenty-four hours. The best application for the surfoce of 
the abscess is an emollient cataplasm or warm water-dressing ; but this should 
not bo made until bleeding has ceased, otherwise troublesome hemorrhage migfai 
ensue. As soon as the parts have become perfectly comfortable, the warm dressing 
is discontinued, on account of its relaxing tendency, a piece of lint, spread with 
simple cerate, or wet with olive oil, being used in its stead. 

When the matter is seated in a bone, evacuation must be sought with the 
trephine ; but the operation is not always successful, owing to the difficulty of 
the diagnosis. 

When the abscess is of large size, or when it has been productive of extreme 
separation of the mnscles, its sides should be approximated, after evacuation, hj 
means of a thick and well-adjusted compress, secured by adhesive strips, or, in 
the event of the matter being seated in an extremity, by the common roller, ex- 
tending upwards from the distal part of the limb ; care being taken not to interfere 
with the artificial opening. In this way a cavity that would othennise not close 
under several weeks, will often be effectually obliterated in a few days. 

An abscess is sometimes prevented from healing by the unfavorable position 
of its opening, whether natural or artificial, the matter accumulating in a kind 
of sac, situated between the orifice and the bottom of the swelling. Such a con- 
dition calls for what is termed a counter-opening^ which is easily established 
by making an incision at the most dependent part of the sac, upon the end of a 
grooved director, introduced through the previous and now useless aperture. 
Counter-puncture is often necessary in abscess of the neck and parotid rejopon, 
from the gravitating tendency of the matter in these situations. Sometimes, 
again, an opening of this kind is called for on account of a change in the position 
of the part after the first operation, performed perhaps well enough at the time. 
Whatever may be the causes demanding it, patency is maintained with more care, 
if possible, than under ordinary circumstances. 

Again, reparation may be rendered tedious, if not impracticable, by the exist- 
ence of a sinuH, extending, perhaps, deeply among the surrounding parts, or, it 
may be, communicating with some natural cavity. When this is the case, the 
most speedy and effectual remedy is incision with a bistoury upon a grooved 
director, inserted into the lx)ttom of the track, the parts being thus laid into one, 
and permitted to heal by granulation, readhesion being prevented by the constant 
interposition of a piece of lint. In the milder cases, steady and systematic 
compression sometimes succeeds in obliterating the abnormal channel; sometimes, 
again, gently stimulating injections are useful ; and, finally, there is a class of 
cases in which the seton is worthy of trial. In general, however, these means 
only serve to amuse the patient, and annoy the surgeon, who is at last compelled 
to have recourse to the remedy which his judgment tells him he should have 
employed in the first instance. 

Hemorrhage is not common after this operation, but it may take place in spite 
of the utmost precaution on the part of the surgeon, and may prove quite trouble- 
some from the difficulty of finding its source. The proper remedy is the ligature, 
the vessel being seized and drawn out with the tenaculum, or surrounded with a 
curved needle. Gentle compression sometimes answers the purpose, especially 
if the bleeding be venous, or if it proceed from a number of small points. If an 
artery of considerable size has been opened, and cannot be easily reached, the 
incision should be dilated to effect the necessary exposure. 

The healing of an abscess, whatever may be the manner of its evacuation, is 
effected by the contraction and approximation of its walls, which generally begin 
the moment the matter has escaped, and steadily progress until the sac is com* 
pletely obliterated. The raw state of the opposed surfaces strongly predisposes 
them to unite with each other; an occurrence which is always favored by an 
effusion of plostic substance. If the cavity of the abscess were obliterated, aa 
was formerly supposed, by granulations, the part would remain hard and prominent 
for a long time ; but this is not the fact. On the contrary, it soon shrinka, be- 
comes soft, and drops down to a level with the surrounding surface. The opening 



CBAP. IT. DIFFUSE ABSCESS. 139 

alone unites in this way ; bat even this is not always so, for cases constantly 
occur where it closes by the first intention. 

Although, as a general rule, the outer wall of the abscess soon recovers its 
pristine softness and pliancy, occasionally the reverse is true, the parts remaining 
bard, tender, and enlarged, being seemingly reluctant to throw off their inflam- 
matoiy burden. To expedite resolution, the affected surface may be covered with 
an ammoniac and mercurial plaster, commonly the very best remedy that can be 
used for the purpose ; or it may be rubbed several times a day with some sorbe- 
fiurient liniment, unguent, or embrocation, aided, perhaps, by the bandage and a 
few alterative doses of mercury. 

2. DIFFUSE ABSCESS, OB PUEULENT INFILTBATION. 

The above is one variety of phlegmonous abscess; the circumscribed, in which, 
united with rapidity and severity of action, the matter is bounded by a distinct 
wall of fibrin, serving the puq)ose of a cyst, although in reality there is no such 
formation. In the present variety, already incidentally adverted to, there is no 
eonnectiive exudation, and the consequence is that the pus is widely diffused among 
the surrounding structures, dissecting and separating them from each other in 
the most frightful manner. Such collections, which are generally attended with 
intense suffering, are often described under the appropriate and expressive appella- 
tion of purulent infiltration. 

The diffuse form of abscess is met with under a great variety of circumstances, 
both as it respects the nature of the exciting cause and the condition of the 
general system. It is most common in persons whoso constitation has been 
dilapidated by intemperance in eating and drinking, by want and exposure, and 
by organic affections of the heart, lungs, liver, bowels, and kidneys, leading to 
anemia, obstructed circulation, and exhaustion of the vital powers. When such 
persons meet with a serious accident, or suffer from a prolonged attack of fever, 
suppuration is extremely prone to take on this kind of action, often sadly compli- 
cating the original disease. Diffuse abscesses are also sufficiently common after 
severe injuries, as compound fractures and dislocations, lacerated, railway, gun- 
shot, and dissection wounds, and capital operations, especially amputations of 
the larger limbs and resections of the bones and joints. Persons of a scrofulous 
constitution are, on the whole, more liable to suffer from diffuse suppuration than 
any other class of individuals, their vital powers being too feeble to enable them 
to furnish a sufficiency of fibrin to limit the purulent matter that is so often effused 
under the above circumstances. 

Diffuse abscesses may occur independently of any other appreciable disease, 
or they may take place in conjunction with erysipelas, pyemia, or phlebitis, which 
they resehible very much both in their mode of origin and in the character of their 
symptoms. Their presence, in fact, is always deuotive of a bad or depraved 
state of the system ; in some cases the fault apparently lies in the blood, either 
in a defect of some of its more important constituents, or in the ingress of some 
morbid poison ; in others, again, it seems to depend upon imperfect action of the 
skin and kidneys, excess of food and drink, the respiration of impure air, over- 
action of the brain, or exhaustion of the nervous system. 

The symptoms of this variety of abscess are ordinarily bold and well defined. 
In general, the disease is ushered in by considerable shivering, if not by a severe 
rigor, followed by heat and perspiration ; the pulse soon becomes small, quick, 
frequent, and irritable, the extremities are cold, the urine is scanty and high- 
colored, the appetite is destroyed, the tongue is covered with a brownish fur, the 
strength rapidly fails, and the patient soon sinks into a state of delirium. Great 
irritability of the system exists ; the pain is often excessive, sleep is interrupted, 
and the mind is peevish and fretful. Frequently the symptoms are of a typhoid 
character from the beginning ; if not, they are sure soon to become so ; and yet 
not merely typhoid, but typhoid and irritative, the two classes being generally 
well balanced throughout. 

The local symptoms are those of ordinaiy inflammation, only that they are 



140 TERMINATIONS OF INFLAMMATION. obap. it. 

more severe, especially when the matter is deep seated. The disGoloration is 
of an erysipelatous nature, the parts are swollen and pit on pressure, the pain 
is smarting and pulsatile, and the skin feels hot, stiff, and numb. If the matter 
lies immediately beneath the surface, or among the more superficial muscles, a 
boggy sensation will be imparted to the hand of the examiner, and a little pres- 
sure will be sufficient to push the fluid about from one place to another, sometimes 
to a distance of many inches. When, on the contrary, the pus lies far below the 
surface, bound down by muscles and aponeuroses, its early detection will generallj 
be very difficult ; under such circumstances, the best guide to its situation wiD 
be the history of the case, the deep-seatod pain, the presence of cedema of the 
skin and areolar tissue, and the character of the constitutional phenomena. If 
any wounds or sores exist, they speedily dry up, and assume an unhealthy appear- 
ance. 

Any part of the body may become the seat of diffuse abscesses, but their most 
common situations arc the limbs, in which the matter often burrows to a great 
extent, both beneath the integuments and among the muscles ; in some of the 
worst forms that I have ever seen, it lay in immediate contact with the bones, 
separating them from the soft structures, and even from the periosteum. In a 
case which was under my observation some years ago, the purulent fluid had 
spread along the posterior surface of the lower extremity, in close contact with 
the femur and the bones of the leg, from the hip as far down nearly as the heel 

The matter which accompanies this variety of abscess is always of an unhealthy 
character ; it is generally thin, saniou^, irritating, acrid, and excessively offensive, 
often tainting the atmosphere of the apartment for many feet around, and fasten- 
ing itself upon the hands and clothes so as to be perceptible for hours afterwards, 
notwithstanding perhaps the liberal use of the chlorides. In fact, the stench is 
usually most disgusting. In some cases the fluid approaches more nearly to the 
properties of ordinary pus, but this is uncommon. Occasionally extensive sloughs 
form, especially in the cellular tissue ; so that the disease may be said to partake 
of the character both of suppuration and of gangrene. 

The prognosis of this form of abscess is generally most unfavorable, there 
being few constitutions that can withstand its depressing effects. The very fact 
that snch a disease is in operation shows, as already stated, that the system is in 
a depraved condition ; and when it is recollected that some of this foul matter 
must necessarily find its way into the circulation, contaminating every thing with 
which it comes in contact, it is not difficult to anticipate what the result will be 
likely to be, even when the purulent collection is not very extensive, especially 
in persons already exhausted by shock, loss of blood, or lesion of some important 
organ. 

The treatment of diffuse abscess is sufficiently obvious. The leading indica- 
tions are to evacuate the matter, and to support the system. The first is fulfilled 
by early and free incisions, practised at the most favorable site for ready drain- 
age, with the precaution of avoiding hemorrhage, the smallest quantity of which is 
sometimes sufficient, in such an event, when life is, as it were, quivering in the 
balance, to bring on fatal exhaustion. Counter-openings are often necessary. 
After the fluid has been thoroughly evacuated, recourse is had to the bandage, 
for the purpose of effecting ap[)roximation of the sides of the abscess ; a means 
of support which is frequently of the greatest consequence, not only in preventing 
the extension of the matter, but in promoting the healing of the parts. When the 
fluid is excessively offensive, the cavity of the abscess should be well syringed 
several times a day with tepid water, charged with a suitable quantity of chlo- 
rinate<l soda, which, w^hile it allays fetor, will be instrumental in imparting a 
healthy action to the disabled structures. If sloughs form, they should be speedily 
removed, the knife being used, if necessary, to effect their separation. The parts 
are placed in a proper position for facilitating drainage, and are enveloped in 
warm water-dressing, or an emollient poultice, medicated with acetate of lead and 
opium. 

Among the more important internal remedies are anodynes, quinine, iroiit 
and brandy, with animal broths and soups, and a pure atmosphere, which is of 



CBAP. IT. SCBOFULOUS ABSCESS. 141 

pmramoant importance to the recovery of the sufferer. For this purpose, the 
wiodowB and doors of the apartment should be frequently thrown open, the dress- 
ings changed, and disinfecting agents used. Anodynes are iudispcnsable to allay 
pain and induce sleep, and should be administered in full doses, either in the form 
of morphia, opium, or black drop. The best tonics are quinine and brandy, given 
in the same manner as in typhoid fever ; the tincture of the chloride of iron, in 
doses of from fifteen to twenty drops, every three or four hours, will also be of 
eenrice ; and, in many cases, ammonia, in camphor mixture, will meet the exi- 
gencies of the case better than almost any other remedy, especially when there is 
hiccough with twitching of the tendons. 

3. SCROFULOUS ABSCESS. 

The scrofulous abscess is of such frequent occurrence, and possesses, withal, 
goch distinctive features, as to entitle it to separate consideration. It is known 
by varions names, some of which have reference to its progress, some to its symp- 
toms, some to the nature of its contents, or to the state of the constitution which 
precedes and accompanies its formation. Thus, it is often described as the chronic 
abacess, tardy development being one of its characteristic features ; the word cold 
is fireqaenUy employed on account of the absence of inflammatory symptoms ; but 
scrofalons is the appellation by which it is generally known at the present day. 
As implying the same thing, the terms strumous and tubercular are much in vogue. 
There is a form of this abscess to which the name congestive has been applied, 
from its tendency to change its position, although it is impossible to discover any 
etymological fitness in it. 

The scrofulous abscess is altogether a singular production ; singular in its origin 
and progress, and singular in respect to its treatment. It is never met with, 
except in the strumous constitution. The phlegmonous abscess is common to 
all persons, of every age, grade, and condition in life ; the scrofulous, on the 
contrary, can occur only in persons who have a predisposition to scrofulous affec- 
tions, whom nature has stamped, so to speak, with a peculiar diathesis, or state 
of the system, rendering them prone to phthisis, coxalgia, caries of the spine, 
and other kindred maladies. Its sphere of action is, therefore, comparatively 
limited, a hundred cases of phlegmonous abscess occurring to one of a scrofulous 
character. 

The progress of scrofulous abscess is peculiar. It is always slow, weeks and 
months often elapsing before it acquires any considerable bulk. Ucnee the term 
dironic, by which it is so frequently designated. Phlegmonous abscess, on the 
contrary, is always rapid in its progress, generally attaining its full development 
in a very short time. Another peculiar feature of the strumous abscess is the 
absence of the ordinary inflammatory symptoms. There is neither heat nor red- 
ness of the skin ; instead of this, the surface is cold and blanched, the part feeling 
and looking as if there were great deficiency in its circulation. Hence this 
variety of abscess is often termed cold, especially by the German surgeons, who 
were the first to describe it. Pain, too, is absent, or, if it exist, it is so trivial as 
hardly to attract attention. Functional disorder also is very slight, especially in 
the earlier stages of the disease. Looking at the constitution, we find the same 
QDCommon train of phenomena. The general health may be somewhat impaired ; 
the strength may slowly and almost imperceptibly decline ; and the countenance 
may have a pale, sallow appearance ; but there are none of the open and well- 
marked inflammatory symptoms which attend the march of a phlegmonous ab- 
scess, and which, especially when the disease is located in an important internal 
organ, suggest the idea of great and immediate danger. Thus, as far as appear- 
ances are concerned, the affection is one seemingly of little moment ; its discovery 
is oflen purely accidental, and, for a while, both patient and surgeon may be 
wholly unconscious of its true character. It is, indeed, as completely different 
firom the ordinary abscess as it is possible for one disease to be from another. 
Searlatina and measles are not more unlike each other. 

The stromoos abscess is very frequent in the lymphatic ganglions^ aobcntane- 



142 TERMINATIONS OF INFLAH HATION. chap.it. 

ons cellular tissue, and dorso-lumbar region. The testicle, breast, and liver are 
also sometimes its seat. It is, however, more common in the lungs than any- 
where else, for there it is the immediate product of the softening of tabercnlar 
matter, eventuating generally in the formation of what are termed vomica, or 
pulmonary caverns. In the external parts of the body it is usually situated in 
the neck, on the chest, in the axilla, on the loins, in the groin, or upon the supe- 
rior portion of the thigh. Large strumous accumulations sometimes form in 
connection with the movable joints. 

Some diversity obtains in regard to the size and number of these abscesses. 
In certain situations, as in the lungs, they are always small, but at the same time 
often quite numerous ; while in others, as in the cervical glands, on the chest, in 
the groin, and on the back, they are usually single, and from the volume of an 
orange to that of a foetal head. 

The strumous abscess is nearly always furnished with a distinct cyst, bag, or 
capsule, technically called the pyogenic membrane, which, while it serves to indi- 
vidualize it, separates it effectually from the surrounding parts. At what period 
of the suppurative process the membrane begins to be formed is not determined, 
but that it is developed at an early stage is unquestionable. It has been sup- 
posed that its formation, at times, precedes the deposition of the pus; but for 
such an opinion there is certainly no well-founded reason. The subject, however, 
does not admit of easy demonstration ; for it is seldom that an opportunity is 
afforded of inspecting an abscess of this description until after it has attained con- 
siderable bulk, and the membrane has acquired some degree of development 
The most plausible conjecture, perhaps, is, that the membrane is formed out of 
the necessity of the case, nature intending it as a means of limiting the diffusion 
of the pus, which would otherwise inevitably happen in consequence of its tardy 
but steady deposition. To accomplish this object she sets up around the puru- 
lent depot, at an early period of the morbid action, a species of adhesive inflam- 
mation, by which, in the first place, the cells of the neighboring tissues are 
effectually occluded, the process being precisely similar to that which occurs in 
an ordinary phlegmonous abscess. Thus, the secretion is temporarily circum- 
scribed, but, as may readily be perceived, the barrier thus opposed would soon 
yield before the accumulating burden, and thus thwart nature's intentions, if it 
were not that a wall of plastic matter is next constructed, which no amount of 
pus, however great, can, for a time, break down or destroy. The thickness of this 
wall varies from the eighth of a line to the eighth of an inch ; its density steadily 
increases with its age, and hence it is often fonnd to be of a fibrous consistence, 
with here and there a semi-cartilaginous patch. Its outer surface is rough and 
intimatc'ly united with the surrounding structures ; the inner, on the contrary, is 
either perfectly smooth, or studded with minute granulations, not unlike the villi 
of the small intestines, only not so regular and numerous. Its vascularity, which 
is always considerable, is easily distinguisliablo by the naked eye, as well as by 
minute injection. It also, no doubt, contains nerves and absorbents, although 
they cannot be demonstrated. 

No one can reflect upon the structure of this membrane without being impressed 
with the conviction that it is invested with important functions. In the first 
place, as has already been stated, it protects the tissues in the immediate neigh- 
borhood of the abscess from the diffusion of its contents ; a circumstance which 
could not fail to be productive of great injury, inasmuch as the matter, burrowing 
about in different directions, might occasion extensive separation of the muscles, 
which it would afterwards bo extremely difficult to remedy. Secondly, the 
membrane is an important secreting structure, since it furnishes the matter which 
it incloses, not directly, but through the agency of lymph, which is speedily 
transformed into pns. Thirdly, it is also an absorbing structure, as is proved by 
the fact that the matter which it contains occasionally disappears, either sponta- 
neously, or under the influence of treatment. Finally, the membrane possesses 
important sympathies with the rest of the system. Left to itself, it silently 
enjoys its parasitic existence, preying upon the parts around without any serious 
general detriment, but the moment it is opened or disturbed by rough manipula- 



tmt.r. IT. 8CB0FUL0US ABSCESS. 143 

tiao, it rvseoU the aggression, aud ia Bare to give rise to ecvere conBtitntionol 
denuigeineDt. 

The pas of the Btramoos abscesa is generallj of a whitish or yellowish cast, 
slightly incliDiDg to greenish, of a tolerablj thick consisteace, free from odor, 
amd iatcrmixed with caseous particles, looking and feeling very much like pieces 
of soft-boiled rice. Instances occur, especially in scrofuloaa cUsease of the lym- 
phatic ganglions of the neck, where it is very thin, pale, and full of curdy sub- 
stance, consisting ^tparently of imperfectly broken-down tubercular matter. 
When long retained, or situated near the ano-rectal region, scrofulons pus is 
■OBietimes ezcessirely fetid, either from actual decomposition, or the preseace of 
mlpboretted hydrof^en. If it be permitted to staud for some time, it separates 
into two parts, one of which is thin, whey-tike, or sero- oleaginous in its appear- 
ance, the other thick and cordy, the former being always upon the top of the 
latter. Like the pas of the phlegmonoos abscess, it occasionally, although 
nrely, contains the debris of the organs in which it is formed, and alxo some of 
their pecotiar secretion. Thns, a strnmoua abscess of the liver occasionally con- 
tains bile; of the breast, milk; of the spine, osseous particles. The microscopic 
^aracters of scrofulous pas are illustrated in fig. 19, from Jones & Sievekiiig. 

In regard to quantity, there is much variety in the pus of this form of abscess. 
In paoaa abscess, which is one of the best examples of the disease, the accumn- 
laUoD is sometimes enormous, reaching several quarts, or, perhaps, even a gallon, 
lo scrofnlous abscess in the glands of the neck, there 
is also occasionaUy a good deal of pus, although, in 
general, it is small. Large collections of stramoua 
matter are sometimes seen in chronic abscess beneath 
the skin, especially in the lower extremity. A young 
woman, a patient at the College Clinic, had an abscuss 
of this kind on the left thigh, containing nearly a 
gallon of pus. 

The diagnosis of this form of abscess may be gath- 
ered from the remarks that have been made respect- 
ing that of phlegmonous abscess. The only two 
auctions with which it is at all likely to be confuundcd 
are encepbaloid and aneurism ; but from these it may 
osoally be easily distinguished by the history of the 
caae, the flnctaatiag character of the swelling, and, if P"' 'rom • Mr .fui..ui »b-ci!... 
necessary, the use of the exploring needle. 

Treatment. — The treatment of this abscess differs essentially from that of the 
phlegmonoos. In the latter, the system often bears energetic measures -, in the 
former, seldom, if ever ; in the one, the surgeon docs not hesitate to make an 
early and free incision into tho swelling, with a view to the early evacuation of 
its contents; in the other, ho waits and hesitates, well linowing that such an 
operation b often the prelude to serious constitutional disturbance, if not death. 
The one is the work of a few days, or, at most, of a few weeks, taking the part 
and system, as it were, by surprise, and, therefore, requiring prompt interference ; 
the other is the work of time, affording the part and sf stem an opporiunity of 
accommodating themselves to its presence, and, therefore, often intolerant of 
interference. When the quantity of matter is small, removal is occasionally 
effected by absorption, the process being sometimes advantageously aided by 
internal and external remedies, especially the iodide of potassium and the bichlo- 
ride of mercory. together with sorbefacieut plasters, unguents, and embrocations. 
These means are more particularly available iu chronic abscesses of the glands 
of the neck, groin, and axilla, and in those of the mamma and subcutaneous cel- 
lular tissue. In psoas and lumbar abscesses, on the contrary, little or no benefit 
nsoally results from their employment, beyond the influence which they may exert 
in improving the general health, and in eradicating the strumous diathesis. When 
geaeral debility exists, relief shoald be attempted with tonics, as quinine and 
iron, along with milk punch, and change of air- 

CoDcemiDg the evacuation of the strumous abscess, no one hesitates to interfere 




144 TERMINATIONS OF INFLAMH ATION. obap.it. 

when the disease is seated in an external part of the body, as the mammary 
gland, a lymphatic ganglion of the neck, or the subcataneoas cellular tiasiie. In 
such cases, indeed, wc can hardly make too early or too free an indsion ; for, 
not only is there, as a general rule, no danger of causing constitntioDal distuib- 
ance, but the procedure is eminently calculated to save structure and promote 
recovery. The matter being evacuated, the cavity usually at once contracts, and 
the tendency to secretion gradually diminishing, the part finally heals by graim- 
lution or adhesion. Besides, such a procedure always enables the surgeon to 
watch the morbid action, and apply his remedies directly to the affected surface. 

The best local applications, after the abscess has been punctured, are emollieol 
poultices, rendered slightly stimulating by the addition of a little common salt; 
or tincture of iodine, spirituous lotions, or some sorbefacient plaster, as the 
ammoniac and mercurial, soap, compound galbanum, or iodine plaster, care being 
taken to leave an appropriate opening for the discharge of matter. 1 can speak 
with great confidence of the beneficial effects of these agents, especially the first, 
having used them for a long time in the treatment of strumous abscess of the 
neck, mamma, and subcutaneous cellular tissue. When the cavity of the abscess 
is slow in healing, in consequence of the torpor of its vessels, or the existence 
of a strong pyogenic membrane, nitrate of silver, nitric acid, or acid nitrate of 
mercury may be employed, in the form of weak injection, as local stimulants 
until there is a disposition to the formation of healthy granulations. Sometimes, 
as in the case of the subcutaneous abscess, a seton may advantageously be intro- 
duced, retention being maintained until the sac has become obliterated by inflam- 
mation. Or, instead of this, a counter-opening may be made, and a tent inserted. 

When the abscess is connected with disease of tne bones, as it always is when 
it takes the name of psoas or lumbar abscess, the treatment usually followed is 
that originally suggested by Mr. Abernethy, and which consists in making a 
valve-like opening inr the most prominent and dependent portion of the swelling. 
The object of this procedure is to exclude the atmosphere, not that this is of 
itself at all injurious, as was at one time erroneously supposed, but because its 
contact with the purulent matter has a tendency to cause decomposition ; an 
occurrence which cannot fail to be succeeded by bad consequences, by awakening 
all the constitutional sympathies of which such a disease is capable. Educated 
in a school in which this practice was strongly inculcated, and warmly prepos- 
sessed in hs favor, on account of the high authority of its originator, I was led 
to expect from it all that the most sanguine feeling could anticipate ; but, after 
an experience of upwards of twenty-five years, I am compelled to say that it has 
utterly disappointed me, in the only class of cases to which, in my judgment, it 
is at all applicable. I cannot, in truth, recall to my mind a solitary instance in 
which I have found it productive of the least permanent benefit. My experience 
is that the opening, however judiciously made, will, at no distant day, be followed 
by ulceration, and thus lead to all the bad effects that are usually caused by mak- 
ing a free incision in the first instance. I believe that this generally occurs, 
whatever may be the amount of matter evacuated, whether small or large, and 
whether the operation be repeated at long or short intervals. It has appeared 
to me that any interference, however trivial, is always sure to be resented, and 
that, instead of benefiting the case, we only render it worse. Hence, I am 
satisfied that, when the pain from the presKiire of the accumulated fluid is not so 
great as imperatively to demand its withdrawal, it is best, as a general rule, to 
let the part alone, patiently waiting for spontaneous evacuation, and the accom- 
modation of the part and system to the approaching event. 

When artificial evacuation becomes necessary, it may be effected simply with 
the knife, the trocar, or the knife and trocar together. Whatever instrument is 
employed, care is taken to carry the point some distance between the skin and 
sac, before the latter is penetrated, so as to give it the valvular form so mnch 
insisted upon by the advocates of this mode of treatment. From two-thirds to 
four-fifths of the matter having been withdrawn, the orifice is accurately closed 
with two broad strips of adhesive plaster, arranged crucially, and supported by 
a compress and bandage. Care is also taken to prevent the orifice from being 



CHAP. IT. IIULTIPLB AB3CBSS, OR PYEMIA. 145 

pressed apon by the reaccnmulating flaid, lest it should reopen spontaneously. 
The operation is repeated from time to time as the matter collects, an opportunity 
being thns afforded to the abscess to contract, and finally to become obliterated ; 
an event, however, that is certainly extremely rare. 

It was proposed, some years ago, to open these abscesses while the patient's 
body 18 immersed in water, on the ground that there would thus be less likelihood 
of the introduction of air ; but we may well ask whether the ingress of the former 
fluid would not be quite as injurious as that of the latter ? The truth is, it is 
hardly possible to perform the operation without some risk of this kind ; still, 
if proper care be taken, the quantity will be so small as not to produce any serious 



As to iodine injections, which have been recommended for the radical cure of 
this form of absc^, the experience of the profession has nothing to offer in their 
CiTor. The practice, considered in a purely theoretical point of view, is suffi- 
ciently plausible, since its object is to change the character of the secerning 
nriaee of the pyogenic membrane, by inviting an effusion of plastic matter, 
whidi shall lead to the obliteration of its cavity. It was evidently suggested by 
the beneficial effects which are known to follow the use of iodine injections in 
hydrocele and other kindred affections, but to insist upon a similarity of structure 
of the sac of a chronic abscess and of the vaginal tunic of the testicle certainly 
diaplays a very imperfect knowledge of morbid anatomy. It is not surprising, 
therefore, that the practice should have failed, and that its employment should 
have been attended, in most cases, with considerable risk, from its tendency to 
create undue irritation both in the part and system. 

Whatever mode of treatment be employed, it .is of paramount importance to 
sustain the system by tonics and to allay pain by anodynes. 

4. MULTIPLE ABSCESS, OR PTEMLA. 

The fact that some injuries and operations are occasionally followed by the 
development of abscesses in some of the internal organs of the body did not 
escape the attention of some of the older surgeons. Ambrose Pare makes dis- 
tinct mention of the occurrence ; and Pigrai, about the same period, had an 
opportunity of noticing that, during one particular year, nearly every person who 
was so unfortunate as to have a wound of the head died of suppuration of the 
liver. These observations were afterwards confirmed by Morgagni, Bertrandi, 
and Andonille, and, more recently, by Schmucker, Kern, Klein, Hennen, Larrcy, 
Guthrie, and other military surgeons, as well as by many hospital and private 
practitioners. Mons. Velpeau, however, was the first to investigate the lesion in 
a really scientific manner, and to institute a thorough and elaborate examination 
into its etiology, pathology, and treatment. 

The name pyemia, by which this affection is now generally known, literally 
signifies an alteration of the blood by pus, or, perhaps more properly speaking, 
an admixture of the two fluids, giving rise to what has been called septicemia, or 
purulent infection. It is a corruption of pyohemia, first applied to this disease 
bj Piorry, and is synonymous with ichorhemia, a term recently introduced into 
pathology. 

The exciting causes of pyemia, or blood-poisoning, are not only numerous but 
of a highly diversified character ; they may be stated, in general terms, to be 
such as are productive of great shock to the system, loss of blood, or depression 
of the vital powers. As following severe injuries of the head, it was, as already 
stated, long ago noticed by many of the older pathologists and surgeons, although 
they &iled to offer any correct or even plausible theory of its occurrence. Since 
attention was first prominently called to it, in 1823, by Velpeau, it has been 
m«ch oftener notic^ after compound fhu^tnres and dislocations, lacerated, con- 
tused, and gunshot wounds, and amputation of the larger limbs, than after any 
other accidents. In lying-in females it is also sufficiently frequent, and is, in 
bet, a considerable source of the mortality consequent upon the puerperal state. 
It has been known to supervene upon erysipelas, carbuncle, smallpox, scarlatina, 
VOL. I. — 10 



146 TKRHINATIONS OF IXFLAHMATION. CHAr. IT. 

typhoid fever, and even gonorrhoea. One of the first cases of the disease I erer 
saw occurred, many years ago, in a young woman who had an attack, apparently 
not a severe one, of erysipelas of the leg. On dissection, I found a safficie&t 
cause for death in a pyemic abscess in the left lung, about the volume of a large 
almond, filled with plastic matter, and surrounded by highly inflamed and softened 
pulmonary tissue. No appreciable disease existed in any other part of the body. 
The secondary purulent collections so often met with in glanders and dissectira 
wounds evidently belong to this class of affections. Pyemia occasionally sacceeds 
to the use of the trephine, the extirpation of tumors, lithotomy, lithotripsy, the 
perineal section for the cure of stricture of the urethra, and the operation for 
aneurism. Sometimes, indeed, apparently the most trifling operation is followed 
by it. In 1831, I attended, in consultation, a man who lost his life bj blood* 
poisoning consequent upon bleeding at the bend of the arm; and a similar 
case occurred a number of years ago in my own practice at the Lonisville 
Marine Hospital. The patient, a colored woman, laboring under chronic disease 
of the wrist-joint, was bled, at my request, by the resident physician, at the 
median basilic vein. In a few days violent phlebitis supervened, followed by 
large purulent collections in nearly all the great joints, as well as among the 
muscles of the arm and shoulder, terminating fatally in less than a week. The 
injury inflicted in the removal of a small piece of dead bono has been known to 
cause death by ichorhcmia. In 1848, I lost a young man, twenty-eight years 
of age, from pyemia, brought on by tying three hemorrhoidal tumors. Death 
occurred on the eighth day ; and, on dissection, the cellular tissue of the meso- 
rcctum was found to be studded with hundreds of abscesses, from the size of a 
currant to that of a small pea. 

Pyemia occasionally follows the suppurative inflammation consequent upon a 
badly-healed stump, perhaps weeks and even months after the amputation, and 
long after the patient is apparently out of all danger. The discharge, perhaps 
never entirely arrested, suddenly increases in quantity, the parts become tender 
and irritable, the constitution is seriously affected, rigors soon set in, and, in 
short, all the symptoms of blood-poisoning are fully declared. 

No period of life is probably entirely exempt from this disease. It has been 
met with even in children at the breast. A case has been reported of an infant, 
only ten days old, in whose body, affected by erysipelas, not less than nine large 
abscesses of this kind had formed, causing death in a short time. On the other 
hand, it occasionally appears at a very advanced age. Young and robust sub- 
jects, however, have appeared to me to be most liable to it, especially after severe 
railway, gunshot, and other accidents, attended with severe shock and excessive 
loss of blood. Wounds of, and operations upon, the veins are very prone to be 
followed by blood-poisoning. There can be no doubt also that pyemia is more 
common among the inhabitants of crowded cities than among those who enjoy 
the benefit of pure country air, good wholesome food, and an abundance of ex- 
ercise and sleep ; it is likewise more frequent in hospitals, almshouses, and other 
receptacles for the poor than in private practice ; circumstances of no little interest 
both in an etiological and therapeutic point of view. 

Such being some of the remote causes of pyemia, the question may now be 
asked. What are the immediate causes of the disease, or the circumstances whose 
operations are more directly concerned in its production f This subject has led 
to much speculation ; and, although it has been ably discussed by a number of 
pathologists, our knowledge respecting it is still extremely meagre and ansatis- 
factory. 

The old notion that pyemia is the product of metastasis ; or, in other words, 
that it is due to the absorption of pus from the part originally affected, and to 
the transportation of this fluid to some other, more or less remote situation, where 
it is collected into a focus, and thus becomes a source of new irritation and dis- 
ease, has still its advocates and adherents. It rests upon the supposition that 
the pus corpuscles are admitted, unchanged, into the open mouths of the veins 
at the seat of the wound, as, for example, the surface of a stump after ampntatioDy 
and that, being so introduced into the circulation, and pushed onward by the blood. 



CHAF. IT. MULTIPLE ABSCESS, OK PYEMIA. 147 

they are finally arrested in the minnte capillaries, which are anable to transmit 
them, as they do the red particles of the blood, in conseqaence of their larger 
size. The mechanical obstruction thas caased forms, it is alleged, a new cause 
of morbid action, which is soon followed by the development of an abscess, or a 
deposition of pus, and, if the new depots be numerous, by purulent infection. 
In opposition to this doctrine, it has been contended that pus corpuscles never 
gain access in this way into the circulation, and that those who profess to have 
seen them there were deceived by the resemblance which these corpuscles bear to 
tie colorless globules of the blood. Moreover, it is asserted that there is nothing 
ill the corpuscles of healthy, laudable pus of an irritating nature, and that, even 
supposing they got into the veins, it would be impossible for them to occasion 
maltiple abscesses. 

Cniveilhier, from some experiments which he performed upon dogs and other 
animals, came to the conclusion that pyemia and multiple abscesses might be 
ittdaced by any irritating fluid, accidentally introduced into the system, and 
incapable of spontaneous elimination. On injecting ink, mercury, and other 
substances into the blood, he found that purulent depots occurred wherever the 
extraneous matter became impacted in the minute vessels. Granting that these 
experiments caused precisely what has been alleged of them, it is difficult to see 
why they should have been brought forward as a proof of the manner in which 
pyemia is developed in the human subject. There is certainly no similarity, 
hardly, indeed, any analogy, between the substances used by Cruveilhier in his 
experiments and those that are formed in a suppurating wound, or on the surface 
of a stump after amputation. 

Mr. Uenry Lee, of London, in a small treatise on the Origin of Inflammation 
of the Veins, published in 1850, advanced the ingenious, and, at first sight, very 
plausible, idea, that these purulent deposits are essentially due to the coagulation 
of the blood in consequence of the admixture of pus within the veins. He found 
that when healthy, recently-drawn blood was mingled with pus, it solidified more 
rapidly and more firmly than ordinarily ; and coupling this occurrence with the 
well-known fact that the veins are often obstructed by large clots in phlebitis, he 
concluded that coagulation must be the first link in the chain of morbid action. 
The inspissated blood, unable to make its way through the living body, would, 
Mr. Lee thinks, soon adhere to the sides of the vessels, which would thus become 
so many centres of inflammation and purulent deposits. It will be perceived that 
this theory, like that of the older pathologists, previously adverted to, rests 
essentially upon the idea that pus may enter the veins without any change in its 
composition, and that it difi'ors from it only in assuming, what is doubtless true, 
that it possesses the power of coagulating the blood with which it comes in 
contact. 

Finally, there is another class of pathologists who attenipt to account for the 
formation of purulent deposits by supposing that they are caused by the develop- 
ment of a peculiar poison, derived from certain kinds of pus, which, entering the 
circulation, contaminates the blood and solids, and thus brings about that adyna- 
mic and atonic state of the system so characteristic of pyemia. According to 
this doctrine, one of whose ablest advocates is Professor Bennett, of Edinburgh, 
puj» corpuscles do not enter and mingle with the blood, what have been taken 
for these bodies by various observers being merely so many colorless cells of 
the blood, the distinction between the two being often extremely difficult, if not 
impracticable. 

Of the fon*going explanations the last, it seems to me, is not only the most 
plausible, but also the most consistent with facts. Agreeing with its advocates 
that it is impossible for pus corpuscles, as such, to enter the circulation, except 
in the cai^e of open-mouthed veins communicating with a suppurating surface, I 
think it perfectly certain that the more attenuated and watery parts of pus ; or, 
perhaps, more correctly speaking, the more ichorous, sanious, or sanguinolent 
varieties of this fluid, frequently become commingled with the blood in suppu- 
rating wounds and in the stumps of amputated limbs, thereby speedily and 
tibocooghly contaminating both solids and fluids, and, consequently, effectually 



148 TERMINATIONS OF INFLAMMATION. chap. it. 

undermining the constitution. It is not improbable that this poisonons matter, 
soon after its admission into the circulation, excites inflammation in the capillaiy 
vessels, as well as in some of the larger veins, rapidly followed bj deposits ojf 
fibrin and pus, or the development of purulent collections. The coagula, bo 
often met with in the veins of those who die of this disease, are a direct resah 
of this inflammation, their formation being favored by the plasma thrown out by 
the inner surface of the affected vessels. The occurrence, in fact, is similar to 
what takes place, at times, in inflammation of varicose veins in the lower ex* 
trcmities of laboring people, which are occasionally completely clogged up in 
this way. Thus, it is not unlikely that the first link in the chain of morbid 
action in this affection is a poisoned and disorganized state of the blood ; the 
second, the development of inflammation in the capillaries and veins ; the third, 
the formation of adherent coagula, clots, or concretions ; and the last, as the 
necessary and inevitable effect of the others, a deposition of pus, or pos and 
fibrin. 

Of the nature of the poison of pyemia we are entirely ignorant My own 
opinion is that it is similar to, if not identical with, that which so frequently leads 
to such bad effects in dissection wounds. However this may be, it is certain 
that it is sometimes, if not g(>nerally, inoculable. I have myself seen evidence 
of this fact ; aud Dr. J. A. McArthur informs me that, after the battle of Gettys- 
burg, in 1863, he saw two nurses contract fatal pyemia from pricking their fingers 
while engaged in dressing suppurating wounds. 

Is pyemia, as the name denotes, always a result of the admission of vitiated 
secretions, or prutrescent matter into the circulation ? Instances occur, as when 
the disease complicates typhoid fever, scarlatina, and various other asthenic affec- 
tions, where the reverse would seem to be the case, and yet, it must be confessed, 
it is not always possible, even here, to determine whether the individual is entirely 
free from antecedent suppurative action. It is probable that, under such circam- 
stanccs, mere disorder of the blood, such as undoubtedly attends the worst forms 
of these maladies, may be quite adequate to the production of secondary abscesses 
of a very bad character. 

The period of latency of pyemia is often, if not indeed commonly, very shorty 
frequently not exceeding a few days from the time of tbe accident or operation 
giving rise to it. There are cases, however, although they are infrequent, in 
which a much longer time elapses. As a general rule, it may be assumed that 
the briefness of the period of latency will be in proportion to the shock of the 
system, the amount of hemorrhage, and the ill state of the patient's health prior 
to the injury. The time is usually shorter in traumatic than in idiopathic affec- 
tions, in the latter of which the secondary lesion occasionally does not come on 
until near the period of apparent convalescence. 

The approaches of pyemia are generally very stealthy and insidious ; hence it 
often happens that the young and inexperienced practitioner is thrown completely 
off his guard in respect to the nature of the formidable disease with which be 
has to grapple. If the case is one, for instance, consequent upon an amputation, 
he probably feels concerned to find that the stump gives evidence of being in an 
unhealthy condition, that it is unusually tender and painful, that it mauifests no 
disposition to heal, and that the discharge is not only profuse but of a thin, 
sanious, bloody, or ichorous nature. The patient, although not inclined to com- 
plain much, is restless and ill at ease, looking pale, sallow, and anxious, as if 
some serious evil were impending. His pulse is irritable and too frequent, the 
cheek is marked by a sinister flush, the appetite is impaired, and the secretions 
are deranged. This prodroma is of short duration ; often hardly lasting twenty- 
four hours. Violent rigors now set in, which, after having continued from fifteen 
minutes to several hours, are succeeded by violent reaction, and this, in tarn, faj 
profuse sweats, often completely drenching the surface and even the body clothei. 
These rigors may return twice or even thrice in the twenty-four hours, or they 
may come on at regular periods, not unlike the paroxysms of an intermittent 
fever, for which the unwary sometimes mistake them. The severity is nol 
always the same ; cases occur in which they are replaced, as it were, by ehillj 



CBAF. IT. XULTIPLB ABSCESS, OR PYEMIA. 149 

aensadons, ilternating with flushes of heat, and not unfrequently lasting for 
■everal days together. In whatever manner this outbreak displays itself, the 
disease at once assumes a more bold and decisive character. The skin and con- 
jnnctiTa exhibit a well-marked icterode appearance ; the features are shrunken 
and withered, the nose being pinched and the eye sunk in its socket ; the pulse 
is small, frequent, and feeble ; the breathing is accelerated and performed with 
umsoal effort ; the tongue is dry and clammy ; the thirst is urgent ; the sleep 
and appetite are interrupted ; the bowels are irregular, being at one time relaxed, 
and at another constipated ; the stomach is irritable and nauseated ; the urine 
is iiigh-colored and scanty ; the extremities are cold ; the mind wanders ; and 
the body is often racked with excruciating pain, especially in the joints and 
■nudes, which are not nnfreqnently exquisitely sensitive to the slightest touch. 
Occasionally the patient complains of severe pain in some internal organ, to which 
he refers all his principal suffering. Cough is sometimes present, and is then 
generally dependent upon more or less serious lesion of the pulmonary tissues, 
or of the lung and pleura. As the disease progresses, red blotches, swollen, and 
excessively painful, appear upon the larger joints, and serve as the forerunners 
of approaching suppuration in the interior, as well as in the tissues immediately 
srooiid them. Similar marks occasionally show themselves in the course of the 
principal yeins and in the situation of some of the muscles, particularly the del- 
toid and pectoral. 

The symptoms, long before the disease has reached this crisis, are of a typhoid 
daracCer, the whole system seemingly laboring under the depressing influence 
of a deadly poison. The downward tendency is rapidly progressive ; the ma- 
chinery of life moves alternately forward and backward ; the pulse becomes more 
and more feeble ; the respiration is frightfully oppressed ; the body is remarkably 
emaciated ; and the patient lies in a comatose condition, from which he is destined 
never to awake. This, however, is not uniformly the case ; for the instances are 
not infrequent, where the mind retains its consciousness almost to the last. The 
period at which death occurs, after the disease has once fairly commenced, varies 
from three to ten days or a fortnight, the average being about one week, or 
perhaps a little less. 

Although there are, strictly speaking, no pathognomonic symptoms of pyemia, 
it is seldom that any one who has ever seen a case of this disease, or who has 
made himself thoroughly familiar with its history and progress, can possibly con- 
found it with any other complaint. Its very mode of invasion generally suffi- 
ciently stamps its true character. The sudden, violent, and unexpected rigor ; 
the unhealthy character of the suppurating sore or wound, if. any exist ; the 
icterode and shrunken state of the features ; the rapid supervention of typhoid 
symptoms ; the great mental anxiety and excessive restlessness ; the horrible 
aching pains in the joints, limbs, and other regions ; and, lastly, the rapid abduc- 
tion of the fiit, leaving the body in a wasted and emaciated condition, far beyond 
what occurs in almost any other affiection, excepting, perhaps, cholera ; are signs 
which, if they do not unerringly mark the nature of pyemia, will always excite 
the serious suspicion of the attendant, and induce him to scrutinize his case in 
the most careful and thorough manner. The only disease with which blood- 
poisoning is liable to be confounded is intermittent fever ; but here the distinc- 
tion is so easily drawn as to render mistake impossible, unless the most stupid 
carelessness is evinced by the practitioner. The diagnosis of traumatic pyemia 
will, in genera], be less difficult than that of the idiopathic variety, or that arising 
from internal causes ; for the violent rigor, the icterode countenance, and the 
rapid prostration and emaciation will usually afford sufficiently characteristic evi- 
dence of the nature of the complaint to prevent mistake. 

The dissection of patients dead of pyemia reveals, as might be supposed, 
important and interesting changes both in the solids and fluids. Of those affect- 
ing the solids, the most constant are abscesses and purulent depots in various 
organs, cavities, and tissues. The former, generally known under the name of 
metefltalur, or multiple abscesses, are most common in the lungs, then in the liver 
and spleen, and, lastly, in the heart, brain, and kidneys. They sometimes occur 



150 TERMINATIONS OF INFLAlil MATION. OBAr. XT. 

in the sabcutaneoas cellular substance, and beneath the peritoneam. In one 
instance, previously referred to, I found an immense number in the aieolar 
tissue of the meso-rectum. Their presence has also been detected in the pTostete 
gland. 

Metastatic abscesses vary in number in different instances from one to twentj, 
thirty, fifty, or even a hundred. Occasionally, indeed, the surface of the affected 
organ is completely studded with them, more than a thousand having been 
observed in a single case, principally in the deep-seated viscera. Their size ii 
also very variable. While some do not exceed that of a hemp-seed or a garden 
pea, others are as large as a hazelnut, a marble, a pigeon's egg, or an orange. 
When very numerous, they are usually proportionately small. In their figure 
they are generally oval, spherical, or angular ; sometimes remarkably irregular. 
When seated near each other, they occasionally become confluent, like the pastnles 
of smallpox. 

The contents of a metastatic abscess are seldom of the nature of well-elaborated 
pus ; on the contrary, they are almost always of a semi-concrete consistence, of a 
dirty grayish, cineritious, or drab color, and composed mainly of aplastic lymph. 
This is particularly true of recent cases ; in those of ionger standing, the contoitB 
are more decidedly purulent, but even then they are often blended with grumoos 
blood and flakes of fibrin. 

The textures immediately around the abscess may be natural, or yariously 
altered in their appearance and consistence. In most cases they are engorged 
with blood, heightened in color, softened, or even completely pulpified. The coats 
of the vessels are inflamed, thickened, and infiltrated with serosity, while their 
canals are filled with pus, semi-fluid blood, or fibrinous concretions. The capiilaiy 
veins usually participate in the inflammation. 

Purulent collections, as a consequence of ichorhemia, are most frequently met 
with in the chest, being rare in the peritoneal cavity, the arachnoid, and pericar- 
dium. The reason of this difference seems to be that the lungs nearly always 
suffer whenever there is serious involvement of the system, whereas the abdominal 
viscera, heart, and brain, commonly escape. 

Professor Sddillot, of Strasbourg, who has studied this disease with great care, 
and who has combined the results of his observation in a highly instructive and 
interesting monograph, published in 1849, remarks that in 100 cases of pyemia, 
we should find the lungs affected in 99 ; the liver and spleen in I of 12, the mus- 
cles in I of 15, and the heart and peripheric cellular tissue in I of 20: the bnun 
and kidneys are comparatively seldom involved. 

The joints often suffer very severely. In some of the cases which I have had 
an opportunity of examining after death, matter was found in nearly all the 
larger ones, and also in quite a number of the smaller. In many cases the pus 
is situated on the outside of the joints, as well as within. 

Large collections of purulent fluid are sometimes discovered in the subcu- 
taneous and intermuscular areolar tissue ; the veins also occasionally contain a 
considerable quantity, either lying free in their cavities, or, as is more common, 
commingled with the blood in the interior of fibrinous concretions. 

The pus that occurs in these various localities is of the same nature as that 
contained in metastatic abscesses, properly so termed, that is, it is ill-elaborated, 
and intermixed with a large proportion of aplastic material. Both in the veins 
and in the intermuscular areolar tissue, it is generally, as just stated, inter- 
spersed through fibrinous concretions, coagula, or blood-clots, giving the latter 
a peculiar appearance, as if they were pervaded by small specks of lymph, or 
lymph and pus. 

The prognosis of pyemia is most unfavorable ; few patients recover, and these, 
for the most part, -remain for a long time in a debilitated and crippled condition, 
liable to other attacks of disease from the slightest causes. Of forty cases, mostly 
gunshot fractures, treated at the Letterman Hospital after the battle of Gettys- 
burg, not one, as I am informed by Dr. J. A. Mc Arthur, was saved. As 
already stated, death usually occurs within the first week after the commence- 
ment of the malady, being apparently dependent npon the severe exhaustion 



CBAP. IT. XULTIPLS ABSCESS, OR PYEMIA. 151 

eonseqaent upon the excessive pain and obstructed circulation, which form such 
conspicuous features in the progress of this affection. In most cases a return to 
hemlth is announced bj the appearance in the urine of an unusual quantity of 
Ihhic acid. 

Treaimeni. — In the treatment of ichorhemia two indications present themselves 
which should, throughout, receive the most earnest and faithfal attention of the 
prmctitioner. These are, first, the removal of the exciting cause of the disease ; 
and, secondly, the support of the system, in order to enable it, if possible, to 
shake off the toxical influence under which it is so plainly laboring. 

If the disease has been induced by an accident or operation, attended with an 
open, suppurating surface, much may be done, in many cases, by the promotion 
of cleanliness, to prevent further mischief from the ingress of purulent fluid. 
This object is best attained by diligent, almost incessant attention to the dressings 
and position of the part, the former being frequently changed, and the latter so 
arranged as to favor the escape of the secretions as fast as they take place. 
Detergent lotions are often serviceable, especially if they contain chlorinated 
soda, but care must be taken that they are not so strong as to irritate, and it will 
be well, particularly if we have to deal with a foul stump, to throw them freely 
apon the parts with a large syringe, as this exerts a much better and wider influ- 
ence than mere irrigation with a sponge. It will also be advantageous to keep 
the dressings constantly sprinkled with the chlorides, both with a view of allaying 
fetor and of purifying the air of the apartment, which must be frequently renewea 
by opening the doors and windows. 

To prevent the further ingress of purulent fluid into the system is not so easily 
accomplished, if, indeed, it can be accomplished at all. If the surface is not too 
extensive, the best remedy will be the officinal solution of acid nitrate of mercury 
diluted with two parts of water, applied rapidly and freely with a mop, the 
intention being not so much to produce an escharotic as an alterant effect, thereby 
inviting a rapid change in the action of the capillary vessels and an abundance 
of exudation matter, so as to close up the mouths of the vessels, and cause con- 
solidation of the affected tissues generally. When the vessels are large and 
patoloos, they may sometimes be closed by well-regulated methodical compres- 
sion. The actual cautery, recommended by the French surgeons, for sealing the 
sapparating surface, should never be employed for this purpose, unless it is 
drawn over the parts, previously well wiped, in the most careful and considerate 
manner. 

The second indication is best fulfilled by stimulants and tonics, as brandy, 
wine, ammonia, camphor, iron, and quinine, with animal broths, and other suitable 
means of support Opiates should be given freely to allay pain and induce sleep. 
The recurrence of rigors, or chilly sensations, is usually easiest prevented by 
quinine and morphia, the dose of the former being not less than ten grains to 
half a grain of the latter, every four or six hours, until a decided impression has 
been made upon the system. No benefit can accrue, under such desperate cir- 
cumstances, from administering these articles in smaller quantity, as they only 
serve to tease the system, and permit the play of morbid affinities. The irrita- 
bility of the stomach, so often present in pyemia, is generally best controlled by 
sinapisms, abstinence from drink, the use of ice, and the exhibition of aromatic 
spirits of ammonia. When dependent upon the lodgment of bile, or vitiated 
ingesta, a gentle emetic may be of service. 

Inflammation of the joints and muscles must be treated by soothing measures, 

warm medicated dressings, aided by the frequent application of iodine. If 
form, evacuation must be afforded by early and free incisions, the open- 
ings being made in such a manner as to prevent accumulation and bagging of 
iuids. Determinations to internal organs, as the lungs, heart, spleen, or liver, 
most be counteracted by dry cupping and blistering. The secretions, generally 

much disordered in ichorhemia, should }^ corrected with blue mass or calomel, 
being taken not to provoke ptyalism, as this could hardly fail to prove pre- 
jodidal. 

Bleeding, both local and general, is invariably inadmissible in all diseases 



152 TERMINATIONS OF JNFLAHMATION. chaf. it. 

attended with blood-poisoning. The system, oppressed and borne down by th« 
toxical influence, needs all the support it can derive from this fluid ; the whole 
current, it is true, is vitiated, and its life-power greatly impaired, bat, althoagh 
this is the case, no sensible practitioner would attempt to improve the oonditm 
of the affected part 'by such a procedure. Good nourishing food and drink, with 
supporting medicines, alone can be confided in under such circamstances, when 
the loss even of a small quantity of blood would inevitably hasten the fatal crisia 

When marked tendency to hemorrhage exists, in consequence of a dissolved 
and broken-down state of the blood, recourse must be had to some of the pre- 
parations of iron, especially the tannate and tincture of the chloride ; the fornrar 
being given in doses of from five to ten grains, and the latter of from twenty to 
twenty-five drops, in a suitable quantity of water, every three or four hours. The 
same remedies will generally answer excellently well for suppressing the oopiooB 
sweats so cfften present in different stages of pyemia. Sometimes adds, as the 
nitric and sulphuric, may be advantageously exhibited, both with a view to their 
tonic and their anti-diaphoretic effects. 

Throughout the whole treatment, great attention should be paid to cleanliness; 
the bed and body clothes should be frequently changed, the surface of the patient 
sponged with tepid salt water, or weak chlorinated washes, and the apartment 
constantly ventilated. Should recovery take place, a change of air and a rigid 
observance of hygienic measures will be required to insure ultimate restoration. 
The convalescence will always be tardy, and the slightest exposure or irregolaritj 
of diet will be certain to endanger life. 

6. HECTIC PEVEE. 

Hectic fever, although not necessarily dependent upon suppuration, is yet so 
closely connected with it, as a common result of that process, that it may veiy 
properly be described under the same head. Its existence is nearly always indica* 
tive of serious organic lesion, of which it, therefore, constitutes merely the general 
expression. The word hectic, literally signifying a bad habit of body, was 
originally employed to designate the peculiar train of phenomena attendant upon 
pulmonary phthisis, of which it forms so remarkable an attribute as to have 
attracted the attention of practitioners in all ages. It is, however, no longer 
restricted to such narrow limits ; for the group of symptoms which it serves to 
characterize follows a great number of diseases, accidents, and operations, and, 
therefore, claims the special consideration alike of the surgeon and the physician. 

Hectic fever never occurs, as was once supposed, as an idiopathic alfection ; 
on the contrary, it is always symptomatic of some particular disease, generaUy 
of the presence of profuse discharge, as of pus or blood, or the development of 
an abscess in some important structure, as the brain, lung, or liver. One of the 
most remarkable circumstances connected with its history is, that it rarely, if 
ever, appears until the malady which it serves to represent has made considerable 
progress, or induced serious structural changes, along with grave inroads upon 
the constitution. Thus, in phthisis, it is seldom witnessed until softening of the 
tubercular matter is about to take place, sometimes, indeed, not until pretty large 
cavities have formed ; on the other hand, there are cases, as in psoas abscess, 
where pus frequently exists in large quantity, perhaps, for several months, and 
yet none of the ordinary signs of hectic fever arise. Serious as the local disease 
apparently is, the general system does not seem to be disposed to take any par- 
ticular notice of it ; the pulse, sleep, appetite, bowels, and secretions all go on 
nearly in their accustomed manner ; and, if there be any loss of flesh and strength, 
the alteration is so gradual and imperceptible as almost to elude the attention 
even of the patient himself. But sudden and often most alarming changes occur 
in the constitution if, in consequence of a large opening, air is freely admitted 
into the cavity of such an abscess, causing decomposition of ita contents. The 
shock is violent, and resentment of the injury is close at hand ; soon a severe 
rigor comes on, lasting, it may be, several hours, when it is succeeded by violent 
fever, as this, in its turn, may be followed by copious sweat. Such is not unfre- 



■ AP. IT. HECTIC FEVER. 153 

[aentlj the commencement of an attack of hectic fever, a bad habit of body, 
rhich often ceases only with the patient's life. Thus, it will be perceived that 
lecUc fever, like every other form of fever, at least so far as we can comproheud 
to nature and type, is not a disease, but a symptom of disease, an expression of 
reneral suffering, dependent upon some special local lesion, not always, ]>erhaps, 
fcppreeiable by oar senses, yet, nevertheless, in active operation, and effectually 
locomplishing its work. 

In traamatiG affections, hectic fever often sets in at an early period after the 
locident ; perhaps there may have been grave shock, and profuse hemorrhage, 
lad the two are soon followed by copious suppuration, which thus still further 
Biidermines and exhausts the vital powers ; or it may be that more or less of the 
pof has been carried into the circulation, and that the whole system has become 
poisoned by the nnfortunate admixture, every blood cell and every fibre and atom 
of aolid matter feeling the baneful influence. The brief struggle which ensues 
■ay be characterized by the inflammatory type ; but this is evanescent, hectic soon 
tatdng its place, and thence on steadily maintaining the ascendency, no intercurrent 
dreomstances ever changing its reaW character, although they may temporarily 
diagniae it, or for a time keep it in abeyance. 

Hectic, then, is a continued, remittent fever, persisting generally as long as the 
cause which induced it lasts ; subject to distinct paroxysms of exacerbation and 
remission, but at no period, perhaps, completely absent, although apparently it 
may be. Its outbreak is often sudden and violent, sweeping over the system with 
the fary of a hnrricane ; at other times, and more generally, it creeps on gradually 
and stealthily; in the former case, it is marked by severe rigors, in the latter 
merely by a sense of chilliness, or slight horripilations. Whatever may bo its 
mode of attack, its actual invasion is always prect*ded by more or less indisposi- 
tion amounting ordinarily to a mere state of malaise, or a feeling of lassitude 
and discomfort, which the patient struggles in vain to throw off. His appetite 
and sleep are impaired ; his tongue is inclined to be dry, perhaps somewhat 
coated ; more or less thirst exists ; and there is often considerable fever, either 
of the inflammatory, irritative, or typhoid type. In short, hectic, like every 
other fever, passes through a stage of incubation, brief in one case, protracted 
IB another. The crisis being attainiKl, the chill appears, and thus the disease is 
fairly inaugurated ; taking its position in the system, which, as already stated, it 
never abandons until the removal of the exciting cause, and often not then. 

The febrile exacerbation is usually vesperal, coming on late in the afternoon, 
or early in the evening; lasting, on an average, from six to nine hours, and then 
gradually going off, to reappear, in a similar manner, about the same time the 
next day, thus giving the disease a distinct periodical character, not unlike that 
of an ordinary intermittent. Not unfrequently there are two paroxysms in the 
twenty-four hours ; one in the evening, and the other perhaps late at night, or 
during the course of the morning ; the latter being generally much the milder 
of the two. The chill ushering in the fever is often very long and severe, the 
patient occasionally shivering for several hours, his teeth chattering violently, 
and the whole body feeling as if it were wrapped in ice ; at other times, as 
already intimated, the sensation of cold is very slight, and perhaps ))erceived 
chiefly along the spine, shoulders, and lower extremities, its duration being 
variable, now short, now quite protracted. The chill passing off, reaction suc- 
ceed2«, usually violent in proportion to the previous depression, and gradually, 
sometimes suddenly, merging into a profuse sweat, the harbinger of returning 
ease and comfort. All the secretions are again unlocked ; the mouth regains its 
moisture ; the urine is poured out in increased quantity ; the thirst rapidly sub- 
sidea ; the pulse becomes soft and comparatively calm ; and ere long the poor 
patient, tortured and racked with suffering, falls into a tranquil and refresliing 
sleep. 

In the interval of the paroxysms, the patient, although comparatively com- 
fortable, is by no means entirely free from excitement. The pulse, in particular, 
is always preternatural ly frequent, often even quick and smad ; seldom entirely 
normal in any caae or at any time ; easily disturbed by exercise and mental 



154 TKBMINATIONS OF INFLAMMATION. cbap.it. 

emotion. The countenance exhibits well-marked evidence of the inward tronble; 
in the morning it is pale, shrunk, and careworn ; in the afternoon, on the cod* 
trary, it has generally a somewhat full appearance, and a circumscribed blush, 
too plainly denotive of the vital decay, rests upon the cheeks in striking ind 
often mournful contrast with the surrounding pallor. The eyes have a peculitr 
lustrous expression, and gradually retreat more and more within their sockets. 
Emaciation begins early, and is steadily progressive, proceeding from bad to 
worse, until the body is literally wasted away to a skeleton. Amidst all these 
evidences of decay, it is remarkable how well the appetite frequently sustiuns 
itself; the patient often eats voraciously in the intervals of his paroxysms, and 
digestion goes on with little or no interruption, assimilation alone being at fault 
The tongue is variously affected ; in general, however, it is clean, or nearly clean, 
but, perhaps, a little too red at the tip and edges. At times it is remarkably 
smooth and glossy ; and cases occur in which it appears to be glazed, as if it 
were coated with a thin layer of mucus. A foul tongue is a rare phenomenon 
in this form of fever. Hectic patients are usually easily impressed by atmospheric 
vicissitudes ; the slightest exposure produces chilliness, and hence they always 
require an unusual amount of clothing. The feet and legs, in particular, are 
nearly incessantly cold ; the hands, on the contrary, are generally dry, hot, and 
burning. 

As the disease occasioning the hectic progresses, the symptoms gradually 
manifest more and more of a downward tendency ; the appetite fails, the sleep 
is interrupted, the perspiration becomes more profuse and exhausting, aphthiB 
make their appearance upon the tongue and fauces, and the bowels are constantly 
harassed with diarrhoea, the discharge being thin, watery, and excessively fetid. 
Thus, the case goes on, steadily but almost imperceptibly, from bad to worse, 
until the patient dies literally exhausted from the want of nourishment, and per- 
haps also in consequence of the severity of his bodily pains. During all this 
struggle, it is ostonisliing to see how the mind, rising above the mortal decay 
around, maintains its supremacy ; being not only clear and strong, but hopefvd 
and often even sanguine to the last. 

The prognosis of hectic fever is influenced by such a variety of circumstances 
as to defy anything like a definite statement. In general it promptly disappears 
with the removal of the exciting cause, provided the inroads made by that cause 
have not been productive of any serious disorganization ; should this have hap- 
pened, the case will probably have an unfavorable issue, the hectic continuing in 
a modified form down to the fatal crisis. The fortunate manner in which hectic 
disappears after the removal of the disease that occasioned it, is much more 
frequently witnessed by the surgeon than the physician, whose practice more 
generally brings him in contact with all kinds of incurable organic maladies. I 
have repeatedly seen a severe and protracted hectic, consequent upon the disor- 
ganization of a tuberculosed joint, completely vanish in less than twenty-four 
hours after the removal of tlie limb, and the system rapidly recover from the 
effects of the previous disturbance. 

The indications in the treatment of hectic fever plainly are, first, to remove 
the exciting cause, and, secondly, to support the system until time is afforded to 
it to shake off the effects of the morbid action. 

The first of these objects is frequently best accomplished by the knife, as when 
the disease depends upon, and has been kept up by, a tuberculosed joint, or a 
suppurating compound fracture, the removal of which often promptly restores 
health and tone to the prostrate system. If the cause be inaccessible, the case 
must be treated upon general principles, in the hope that, by and by, as the 
strength improves, the patient will have sufficient recuperative power to dislodge 
the source of irritation, and so rid himself of his malady. 

The second indication is to be fulfilled by tonics, nutritious food, anodynes, 
the suppression of unnatural discharges, change of air, and attention to cleanli- 
ness. 

The use of tonics is generally indispensable in almost every case of hectic, 
however induced, particularly in its more advanced stages, when there is a 



ciAP. IT. HEMOBKHAQB. 155 

wretchedly xmpoyerished condition both of the blood and solids. The articles 
most to be relied upon are quinine, aromatic tincture of bark, and the di£ferent 
preparations of iron, of which, according to my experience, the sulphate and the 
tincture of the chloride deserve the preference. Whatever substance be selected, 
its operation should be aided by a nutritious diet, consisting of the richer kinds 
of animal broths, milk-punch, tapioca, arrowroot, and milk, wine whey, ale, or 
porter. When the emaciation is steadily progressive, and dependent upon a 
tubercular diathesis, cod-liver oil will be of service, and should be given in as 
large doses as may be consistent with the tolerance of the stomach. 

Anodynes are among our most valuable agents in the treatment of hectic, as 
they serve to allay the inordinate action of the heart, to relieve pain and irrita- 
tion, and to procure sleep, which is generally so much impaired in cases of this 
kind. They should be given in full doses, not too often repeated ; and the best 
period for their exhibition is usually towards bedtime, so that their appropriate 
effects may be realized during the night in refreshing tranquillity. Morphia will 
generally be found to be borne better than opium, but when there is much sweat 
or diarrhoea it may often be advantageously replaced by the latter, as more likely 
to produce an astringent influence. 

The exhausting effects of diarrhoea and perspiration, especially when they are 
of a colliquative character, must be promptly counteracted by suitable remedies, 
of which opium, as just stated, is one of the best. When the diarrhoea is de- 
pendent upon vitiated fecal matter, a mild laxative should be given, and blue 
mass, or csalomel, in minute doses, if it has been caused by derangement of the 
bQisry secretion. Sometimes it is most readily checked by astringents, as rhatany, 
prepared chalk, or tannin, in union with an anodyne. 

Night sweats, which are often a source of so much prostration, will be best 
met by the free use of aromatic sulphuric acid, tannate of iron, or oxide of zinc, 
with frequent ablutions of the surface with tepid alum water. Sometimes they 
may by effectually prevented by a full opiate administered a short time before the 
expected rigors. 

Whenever the local disease, inducing the hectic, will admit of it, exercise 
should be taken in the open air, which frequently conduces more to the restora- 
tion of the patient's appetite and strength, and the relief of the colliquative diar- 
rhoea and sweats, than all other means combined. Children may be carried 
about in their nurses' arms, or in hand cars, while adults may ride about in a car- 
riage, or walk, as may be most agreeable and convenient. Occasionally a resi- 
dence at the seaside will be found to be eminently beneficial. 

Finally, the greatest attention should be paid to cleanliness ; the body fre- 
quently washed and rubbed ; the excretions carefully and promptly removed ; 
and the apartment thoroughly ventilated at least twice a day. 

SECT. y. — HEMORRHAGE. 

A discharge of blood, as an effect of inflammation, is, on the whole, an uncom- 
mon occurrence. It may take place in the interstices of the organs and tissues, 
or upon their free surfaces, and is generally a result of the rupture of some of the 
vessels of the part, in consequence of the manner in which the blood is sent into 
them by the heart, at a time when their walls, weakened by the morbid action, 
are incapable of offering much resistance. It is probable that, when the blood is 
in a dissolved condition, as occasionally happens in scurvy, typhoid fever, and 
other low states of the system, the hemorrhage may occur as a product of secie- 
tion, or, rather, perhaps as a mechanical transudation, the fluid percolating 
through the coats of the vessels as water does through a bladder, the globules 
passing off in an altered and disintegrated form. 

The fluid may present itself in a pure state ; or, as is more generally the case, 
be mixed with other morbid products, as serum, lymph, pus, and mucus, which 
may thus essentially modify its properties, if not, in a great degree, mask its cha- 
acter. The quantity of the effused blood varies, in different cases and under 
different circumstances, from a few drops to a number of ounces. The largest 



156 TERMINATIONS OF INFLAMMATION. ohap.it. 

hemorrhages of this kind commonly occar in connection with the serous and 
mucous surfaces, and the subcutaneous and intermuscular cellular tissue, espe- 
cially in diffuse erysipelas, and in inflammation consequent upon snake-bite, in the 
latter of which the dissolved state of the blood powerfully predisposes to the ex- 
travasation. In scorbutic affections, where a somewhat similar condition of the 
fluid exists, inflammatory hemorrhages arc by no means infrequent. Considera- 
ble effusions of blood occasionally take place in the air-cells of the longs and the 
minute bronchial tubes in pneumonitis. In dysentery, a discharge of blood and 
mucus is one of the characteristic symptoms of that disease. 

Inflammatory hemorrhage rarely comes on until the action of which it is a pro- 
duct has made considerable progress ; hence its appearance may generally be 
regarded as denotive of a higher grade of excitement than a mere deposit of 
serum, plasma, or even pus. When the discharge is copious, it may, provided 
it do not go too far, prove serviceable in the way of depletion, answering pretty 
much the same puq)ose as local bleeding by leeching, scarification, or pnnctnre. 
In general, however, it is too small to confer any substantial benefit in this way; 
while, on the other hand, if it be very copious, it may speedily lead to fatal ex- 
haustion, or, at all events, to such a degree of depression as to interfere materially 
with recovery. Besides, it may cause serious mechanical obstruction, as when it 
is effased into the interstices of organs, thus sadly impeding their Ainctions. 

In the treatment of inflammatory hemorrhage reliance is to be placed mainly 
upon the ordinary antiphlogistic measures, employed more or less vigorously 
according to the exigencies of each particular case. If the discharge be at aU 
copious, so as to threaten exhaustion, recourse may be had to the administration 
of acetate of lead in union with opium, and injections of the same article, or, 
what will be better, of the perehloride of iron, a substance which possesses a 
remarkably controlling influence over all kinds of capillary bleeding, whether in- 
flammatory or otherwise. They must, however, be used with great caution, lest 
they should excite undue irritation. Sometimes the discharge may readily be 
arrested by cold applications, as cloths wrung out of ice water, and frequently 
renewed, or by the steady employment of a bladder partially filled with pounded 
ice, or some refrigerating lotion. When the blood has been poured out into the 
cellular tissue beneath the skin, or among the muscles, and acts injuriously by 
compressing the capillary vessels, nothing short of early and free incisions wifi 
be likely to avail. When the hemorrhage is internal, proceeding fh)m a seroni 
membrane, as the pleura or peritoneum, sorbefacient remedies are indicated ; but, 
these failing, as they will be likely to do, when the deposit is uncommonly large, 
evacuation must be attempted with the trocar, although such a proceeding will 
generally be extremely hazardous, to say nothing of its inefficacy when the 
effused blood has undergone coagulation, thus rendering its escape impracticable. 

SECT. VI. — MORTIFICATION. 

Mortification may be defined to be the death of a part, the rest of the organism 
retaining its vitality. The word, as usually employed in this and other coun- 
tries, is synonymous with gangrene, so much in vogae among French writers. 
Formerly the term gangrene was used to denote that state of a part which imme- 
diately precedes its dissolution, while sphacelus was employed to signify the 
complete extinction of life, without any possibility of its recovery. When we 
speak of the death of a bone, necrosis is the expression generally used. It would 
save much trouble, and prevent confusion, if alL these terms, excepting the first, 
were abolished. 

Mortification may be acute or chronic, moist or dry, common or specific, 
according to the rapidity of its progress, the condition of the dead part, or the 
nature of the exciting cause. There is really no material difference between 
acute and moist mortification, or between dry and chronic, and hence these terms 
may very properly be employed in a convertible sense. The word specific implies 
the operation of a peculiar virus in the production of the death of a part, as the 
poison of the rattlesnake, of chancre, or of malignant pustule. 



CMAT. IT. ACUTE MOBTIFICATION. 167 

1. ACUTE MORTIFICATION. 

Acute mortification, whether the result of traumatic or idiopathic causes, is 
liable to occur in all parts of the body, with, perhaps, the sole exception of the 
heart. There are some organs and tissues, however, which possess this tendency 
in a much greater degree than others, or which, more properly speaking, are 
better adapted to withstand its assaults. As a general rule, it may be stated 
that those textures are most prone to perish from the effects of inflammation 
which stand lowest in the scale of organization, and which, consequently, have 
naturally a feeble life. Hence the fibrous membranes, tendons, ligaments, car- 
tilages, and bonea, generally perish very readily, and often to a great extent. 
The cellular tissue is also very liable to suffer, its areolar structure adapting it 
in a very special manner for the reception of morbid products, the pressure of 
which, inducing mechanical obstruction in its vessels, is a frequent cause of 
mortification in erysipelatous and other forms of inflammation. When the supply 
of blood is cut off fh>m the skin, in consequence of infiltration of the cellular 
substance beneath, this structure also dies very readily, notwithstanding its 
wonderful nervous and vascular endowments. Next in order come the mucous 
and serous membranes, the lymphatic ganglions, muscles, nerves, and bloodvessels, 
the latter of which, especially the larger trunks and branches, generally die with 
great reluctance, as is proved by the fact that they often retain their vitality in 
the midst of the sphacelated parts, as, for example, occasionally happens in 
malignant scarlatina, attended with mortification of the glands and cellular tissue 
of the neck. 

Mortification of the internal organ is extremely rare. In the lungs such an 
event occasionally occurs as a consequence of pneumonia, but it forms the excep- 
tion, not the rule. It is likewise noticed, but still more rarely, in the liver, 
spleen, kidneys, uterus, and ovaries. The testicle, mamma, tonsils, and salivary 
glands sometimes perish from the effects of erysipelas, and the prostate from 
urinary infiltration. Of mortification of the heart I am not acquainted with a 
solitary well-authenticated instance. Gangrene of the brain, from wounds of its 
substance, although infrequent, is occasionally witnessed. 

In regard to the causes of acute mortification, they are the same as those of 
acute inflammation ; whatever has a tendency to produce the one may occasion 
the other. It is not necessary, therefore, to enter into any minute discussion 
respecting them, although it must be apparent that the subject is too important 
to be passed over entirely in silence. They may be divided, in reference to their 
character, into five distinct classes : 1. Intensity of inflammatory action. 2. 
Mechanical obstruction of the circulation. 3. Chemical agents. 4. Defect of 
nervous energy. 5. Constitutional debility. 

I. It has already been seen how intensity of inflammation acts in producing 
obstruction in the capillary vessels of the affected part ; how the blood, rendered 
adhesive by the increase of fibrin and white globules, becomes attached to their 
walb, and how these walls, softened and dilated, at length yield under the pressure 
of their contents, which are often, in consequence, extensively effused into the 
surrounding tisstues, thus matt^rially aggravating the local trouble. As the disease 
progresses, the capillary engorgement rapidly augments, the blood becoming more 
and more stagnant, and there is almost complete suspension of the nervous fluid. 
In short, the greatest perversion of structure and function exists, the part is in 
an utterly helpless condition, circulation and innervation are entirely at fault, 
and doath. already actively engaged at the focus of the inflammation, soon accom- 
plish^^s its work. 

Mortification fh>m intensity of action is generally very rapid in its progress, a 
large amount of tissue, and sometimes even an entire limb, perishing in the course 
of twenty-four hours from the commencement of the process. Some of the most 
characteristic forms of this species of gangrene are met with in compound frac- 
tures and dislocations, in lacerated, contused, railway, gunshot, and poisoned 
woondn, in bums and scalds, in carbuncle, and in erysipelas, in which the tissues 
often succumb under the resulting inflammation with amazing rapidity. Hence, 



lo8 TEBllINATION'3 OF IlfFLAHlIl.TION'. ciaf.it, 

such c&scB, of which dg. 20 affords ui excellent illastr&tion, are generally lud to 
be acute -, and, as the parts are always infiltrated with an abundance or flnidi, 
the term " moist" is also often ased to designate them. 




irllBeUlsB.npId In It* pnrnM, knd tUtndtd vllh Buh ■mlllig and B»l(tu*. 



11. Mortification from mechanical obatrucHon of the circulation may be cansed 
by direct injury to the arteries, or indirectly through disease of the heart, iiite> 
ruptin)t the flow of blood to the part. Ligation of the femoral artery for tba 
cnre of aocuriEm of the popliteal, is occasionally followed by mortification of the 
foot aud leg ; and a eiinilar accident sometimes happens from the pressure which 
a tumor of this kind exerts upon the terminal branches of this TeBsel. The cir- 
culation being thus impeded, inflammation, generally of a very active kind, is 
liable to he awakened, which soon overpowers the affected tissues. Laceration 
of the principal artery of a limb olteu results in the death of the structures which 
it supplies with blood. Disease of the valves of the heart, leading to vascular 
engorgement of the feet and legs, along with cedema of the sulKutaneons cellular 
ti^Hue, not uufrequently produces similar effects. Tight bandaging, pressure of 
the body fVom prutractt^d decubitus, and inordinate constriction of the bowel, in 
strangulated hernia, arc so many causes of mortificatiou from interruption of the 
circulation. 

Gangrene is occagionally produced by obgtmction of the arteries by emboli, or 
detached clots. Instances of cerebral gangrene, from this canse, have been wit- 
ncpscd by different observers; and Mr, Paget has collected the particulars of 
ScTcntcen cases in which it gave rise to mortification of the Inngs. The influence 
of the puerperal state in favoring tlie formation of fibrinous concretions has long 
been familiar to pathologists. Within the last ten years a number of examples 
of gangrene of the extremities from detached cardiac clots, or emboli, have been 
published, and there is reason to tielieve that the occurrence is sufficiently common, 
A. highly interesting case of this form of mortification was kiudty shown to me 
in 1862', liy Dr. James H. Hutchinson, of this city. The patient, a girl, aged 
eleven years, had long been affected with disease of the heart, attended latterly 
with considerable anemia. Gaiigiene of tlie foot and leg set in early in March, 
and terminated fatally on the 13th of April following, a line of demarcation 
having previously formed two inches below the knee, and the foot dropped off 
near the ankle. The limb, at first of a mottled, livid aspect, ultimately became 
pcrfcetly dark ; and the girl suffered the most intense pain throughout her illness. 
The heart was found to bo dilated and hypcrtrophied, the mitral valve greatly 
contracted, thu left auricle distended with an old grumous clot, and the right 
common and external iliac arteries completely obstructed by a Arm concretion, 

Em))oIigm occasionally induces mortification with astonishing rapidity, as in a 
remarkable case, in a girl six years old, the particulars of which were communi- 
caled to me by Dr. Leonard, of Indiana. While seemingly in tolerably good 
henllh, she was suddenly seized with excessive prostration, accompanied with 
delirium, unconsciousness, and great depression of the temperature of the whole 
body. In a short time the left lower extremity became livid, and by next 
morning the foot was foand to be dead as high up as the ankle, the Burfkco being 
black, dry, cold, and insensible. At the end of about a week a line of domarctp 



CHAP. IT. ACU'^B MORTIFICATION, 159 

tioQ be^n to appear, and ampatation being performed below the knee, the case 
resalted in a good recovery. It is worthy of remark that the little patient was 
throughout almost entirely free from pain and constitutional disturbance. 

HI. The influence of chemical agents in producing inflammation and mortifi- 
cation is exemplified in various ways. The contact of the alkalies and acids, 
if very slight, will, in general, cause merely a rubefacient effect ; if more severe, 
it will induce vesication ; while, in its worst form, it will occasion instantaneous 
destruction of the tissues The application of heat and cold acts very much in 
the samo manner. In all these cases life is destroyed, either by the primary 
impression of the chemical agent, or as a consequence of the violence of the 
resulting inflammation. In persons of feeble organization, especially in young 
children impoverished by starvation and disease, the application of a common 
blister is often followed by extensive sloughing ; and a similar effect is occa- 
sionally witnessed as a result simply of the protracted use of a mustard plaster. 
The infiltration of urine in the cellular tissue of the perineum often produces 
wide-^read gangrene of the scrotum ; and portions of peritoneum sometimes 
perish from the contact of bile and feces. 

Althoagh nothing of a definite character is known of the nature of animal 
poisons, yet it is highly probable that they induce inflammation and gangrene 
very mnch in the same way as the acids and alkalies. Some of these poisons 
are the product of a peculiar secretion with which the animal is provided, as a 
Beans of defence ; others, on the contrary, appear to be developed in consequence 
cf a peculiar septic action, which is particularly strong during the last moments 
of life, and for a short time afterwards, before the tissues have undergone much 
decomposition. However generated, their insertion into the living structures 
usaallv awakens a peculiar form of inflammation, which not unfrequently tormi- 
aatcs in the death of the affected structures ; often with extreme rapidity, as, for 
instance, in snake-bite, chancre, and malignant pustule. 

IV. Defective nervous energy is an occasional cause of mortification. A 
palsied limb, for example, is much less capable of resisting the influence of 
ordinary physical agents than a sound one, and when inflamed, the morbid action 
is much more liable than usual to terminate in mortification. In apoplexy and 
injury of the spinal cord, attended with lesion of innervation, the most trifling 
puncture, nay, even the application of a blister, will sometimes be followed by 
the death of the part. The occurrence of bad bed-sores, from the same cause, 
is a matter of daily observation. The division of the peroneal nerve in the 
removal of a tumor of the leg has been succeeded by mortification of the small 
toes ; and Magendie, long ago, ascertained that, if the ophthalmic branch of the 
fifth pair of nerves be cut, the resulting inflammation will end in sloughing of 
the cornea. 

V. The occurrence of mortification from general debility is well illustrated in 
typhoid fever, scarlatina, measles, smallpox, and scurvy, as well as in other states 
of the system, attended with loss of innervation, and an impoverished condition 
of the blood. During the progress of these diseases, local inflammation, how- 
ever induced, is extremely liable to assume a bad type, and to terminate finally 
in mortification. In typhoid fever, extensive sloughs often form upon the hips 
and sacrum, despite all the attention that can be bestowed upon the patient in 
warding off pressure; and in scarlatina and other eruptive maladies, mortification 
of the neck and throat is by no means uncommon from an inflammation, which, 
nnder ordinary circumstances, would readily resolve itself in a few days, but 
which, now that the system is exhausted by the operation of the peculiar poisons 
of these affections, is promptly followed by the death of the part. Inflammation 
of an organ, lighted up immediately after the occurrence of profuse and debili- 
tating hemorrhages, is very liable to eventuate in the same disastrous manner. 
Mercury given in low states of the system, to the induction of ptyalism, often 
leads to violent sloughing of the g^ums and cheeks, and to necrosis of the jaw and 
teeth, followed by the most horrible disfigurement of the features. 

In Germany, a form of mortification of the lower jaw has long been kno>vn 
among the operatives engaged in the manufacture of lucifer matches from the 



I 



160 TERMINATIONS OF INFLAMMATION. cbap.it. 

pernicious effects of phosphorus ; and within the last fifteen years nnmeroas 
cases of a similar nature have occurred in this country. What the mode of 
action of the article is in producing this result, is still a mystery. It is Bopposed 
by some that it makes its impression locally ; but, if this were so, it ia reasonaUe 
to presume that it would also injure the soft parts, which, however, is not the 
fact. We may therefore conclude, in the absence of reliable information, that it 
acts through the constitution, but why it should affect the lower jaw-bone, in pre- 
ference to other portions of the skeleton, is not known. Possibly its operati(m 
may be similar to that of mercury. 

When acute inflammation is about to terminate in mortification, there is, io 
general, a sudden aggravation of all the previous symptoms, both local and con- 
stitutional. The pain and sensibility become more keen and intolerable, the 
redness assumes a more vivid aspect, the swelling and tension materially increase, 
effusion is unusually active, and functional disorder is at its maximum. If sorei 
or wounds exist, all discharge generally ceases. Along with these local phe- 
nomena, there is marked augmentation of the constitutional trouble ; the fever is 
excessive, the pulse is frequent and often quite strong, the thirst is intense, and 
thcTc is great restlessness, commonly with more or less delirium. The type of 
the constitutional symptoms exhibits much diversity. In young and robust 
individuals it is generally of a sthenic character, or denotive of strength ; but, 
when the disease has been unusually violent, or the system has sustained a 
serious shock, whether from the present attack, or from previous suffering, it is 
commonly indicative of prostration, the tongue and mouth being dry, the pulse 
frequent and feeble, tlie stomach irritable, and the surface iMithed with cold 
perspiration. 

The complete cessation of vitality is denoted by the livid, black, or mottled 
discoloration of the skin, supposing that the mortification is external ; by all 
absence of boat and sensibility ; by a peculiar fetid, or cadaverous odor; and by 
more or less crepitation, in consequence of incipient decomposition. Immediately 
beyond the seat of the mortification the ordinary phenomena of inflammation are 
still visible ; the surface is of a scarlet hue, hot, dry, tumid, and painful, and the 
dead and suffering structures are usually insensibly blended or separated by a 
faint, indistinct line. 

The part having actually died, the general symptoms are no longer of an 
equivocal character, whatever they may liave been during the previous struggle. 
They arc clearly of a typhoid nature, and, consequently, fully denotive of the 
exhausted condition of the system. The pulse is small and feeble, and from one 
hundred and forty to one hundred and sixty in a minute ; the surface, bathed with 
a cold clammy sweat, has a yellowish, withered appearance, and exhales a pecu- 
liarly disagreeable odor, not unlike that of moist earth ; the respiration is short, 
hurried, and difficult ; the countenance is pale and shrunken ; the eyes are devoid 
of lustre and sunk in their sockets; the nose has a singularly pinched appearance; 
the lips are incrusted with dark scabs ; the tongue is dry, contracted, and 
covered with a thick blackish fur ; the al)doinen is tympanitic ; and there are 
frequent twitchings of the tendons, with hiccough, and low, muttering delirium. 
The strength is so much exhausted that the patient, unable to sustain himself 
upon his pillow, constantly sinks down in the bed ; the stomach is harassed with 
nausea, and occasionally with bilious vomiting ; and, towards the last, there are 
often involuntary discharges from the bowels, with retention of urine. 

The cause of this depressed condition of the system is probably twofold. In 
the first place, it may be supposed to depend upon the shock which such an 
occurrence must necessarily inflict upon the great nervous centres ; and, secondly, 
upon the absorption of vitiated matter, which, by its union with the blood, con- 
taminates both solids and fluids, thereby incapacitating them for the discharge 
of their appropriate functions. 

The color of the mortified parts vanes in the different organs and tissues. 
The skin, as already remarked, is usually purple, black, or mottled, while the 
cellular tissue beneath it generally, in great measure, retains its normal com* 
plexion, unless, as sometimes happens, it has been infiltrated with bloody matter, 



CBA*. ir. ACUTE HOBTIPICATION. 161 

when it will, of conrse, be of a reddish or modenA color. The aponeuroses, 
nnseles, tendons, nerves, Tesncls, cartilages, and bones, nndergo very little 
cbuig« in this respect In mortification of the lun^, the color is black ; of the 
brmin, grajish or ashy ; of the liver, reddish or yellowish. The serous mem- 
brftoes are commonly of a pnrple tint; the mucous, of a black, brownish, or 
duct, with almost every possible interraediatc shade. As a general rale, it may 
be aasnined that the depth of the color of the sphacelated stmcturcs is in direct 
ratio to their vascularity and the violence of the antecedent action. 

The consistence of the dead part is also variable ; in general it is quite soft, 
■nd, aa it were, broken down, from the infiltrated condition of the cellular 
tiaaae and of the intennolecular spaces of the proper structure of the affected 
Ofigsa. In mortification of the limbs, involving all the component tissues, the 
■art feela iwoUen, soft, and crepitant, because it contains both gas and different 
Kinds of flnids, as serum, pus, end blood; but if we examine the individual 
lextvrea, they will all be found, with the exception of the areolar, to be very 
nearly ot their normal consistence, particularly if there is as yet but little decom- 
poaiUoo. In the parenchymatous organs, aa the brain and lungs, the loss of 

■ ' a is always very great, the mortified mass being of a soft, pap-like con- 



thejetor in mortification is peculiar and characteristic. It evidently depends 
upon the extrication of sulphuretted hydrogen gas, and is sometimes, as in mor- 
titicatioo of the langs, almost in supportable. 

The efftcin of mortification upon tlie general system vary with many circum- 
■tancea ; they may he so severe as to destroy life in a few hours, or, at most, in 
a few days, as occasionally happens in the traumatic form of the lesion ; or, on 
tbe other hand, so slight as to bu hardly felt even as a serious inconvenience. 
In tbe latter case, an attempt is generally made, after some time, to detach the 
dead parts fh>m the living, by the estabiisbment of ulcerative action, the first 
cridmce of which is the formation of a circle of vesicles, usually filled with a 
sero-BangninoIent flnid. Presently these vesicles burst, and then a faint reddish 
line is observable, technically called the tine of demarcation, which, as it is 
denotive of the cessation of the 

gangrene, is always looked for F>g- 21. 

with great anxiety by the at- 
teadaaL The process, which 
constitntes a species o\ natural 
ampntation, seen in fig. 21, 
often proceeds with consider- 
able rapidity, one part sepa- 
rating after another, gi'nerolly 
akin and cellular tissue first, 
then muscle, next tendon and 
aponeurosis, then vessels and 
nerves, and. lastly, cartilage 
and bone ; the latter being al- 
ways detached with extreme m, m r i r j 

difficulty, on account of the .i„u.'." , "',',"^,,' 'i",a '".'^,"'ui.,'u'"wiu*' 'x«u!T«w''Mmni'ija 
targeqaantiiyoftheearthy sob- frgm.hebum. "' ' ' » • "« 
itance which it contains. It is 

owing to this circumstance that several months commonly elapse before the con- 
aectton is finally severed, and then the proceeding is of^en anything hut surgical, 
the stamp thn^ made being rarely well covered with integument, a matter of so 
BDch consetiuence in the subsequent progress of the case, and the ultimate well- 
being of the patient. 

The separation of the dead parts is always accompanied with more or less pain, 
discharge, and fetor, adding thus still farther to the prostration of the system, 
■ad tbe danger of constitutional cm lamination. Tbe pain is sometimes ix- 
eessive; at other times it is insignificant, depending upon the extent of tlie 
norbid action, and the state of the constitution. In general, it is sharp, smart- 

▼OL. I. — 11 




162 TEBHINATIONS OF INFLAMMATION. chap.it. 

ing, or burning:. The discharge, which is often quite profhae, is always, at first, 
unhealthy, ichorous, or sanguiuoleut, and irritating ; by degrees, howe?ef, it 
assumes a more favorable character, and at length acquires all the properties of 
laudable pus. The fetor is generally most horrible, sickening, and OTerpowering; 
tainting the atmosphere of the apartment, and exerting a most prc|jadicial effect 
upon the patient, unless prompt and effectual measures are adopted for its cor- 
rection. The emanation is, of course, rather from the dead parts, now called a 
slough, than from the gap, or trough, which lies between them and the living. 
As the separation progresses, granulations gradually spring up along the nw 
border, exhibiting the usual appearances of healthy bodies of this kind in other 
situations, and furnishing an abundance of thick, yellowish pus, which, while it 
serves to shield them from the rude contact of the air, affords the surgeon an ex- 
cellent opportunity of judging of the nature of the ulcerative action, or, in other 
words, of the state of the part and system. 

While these changes are going on between the dead and living parts, for the 
riddance of the former, and the benefit of the latter, all the ordinary phenomena 
of inflammation are plainly visible in the structures above the breach, nature 
being busy in throwing up her walls of defence by pouring out a liberal supply 
of plastic matter into the meshes of the cellular tissue. In this way, the surviv- 
ing structures are solidified and fortified against the ingress of air, and also, at 
least in some degree, against the absorption of pus. 

The manner in wliich the vessels are closed in mortification, so as to prevent 
hemorrhage during sloughing, is worthy of passing notice. As was before stated, 
both the arteries and veins possess an astonishing conservative power, by which, 
at least in many cases, they are enabled to maintain their vitality in the midst 
of the dead and perishing structures. At length, however, they also yield to 
the devastating influence, but not before their contents have become thoroughlj 
coagulated and firmly adherent to their inner walls, thereby hermetically sealing 
' their orifices. Hence, no bleeding can occur ; and for the same reason there is 
often no hemorrhage whatever during the artificial section of the part, inasmuch 
as the clots of blood frequently extend a considerable distance beyond the line 
of demarcation. 

Treatment. — The treatment of acute mortification is to be conducted upon the 
general principles applicable to that of inflammation. When this event is al)out 
to occur in a person of strong, robust habit, with a vigorous pulse, and a red, 
fiery, and painful condition of the part, the indication is to draw blood by vene- 
section and leeching, to make free use of the antimonial and saline mixture, along 
with a sufficiency of morphia to allay pain and quiet the heart's action, and to 
cover the affected surface with a large blister, to paint it with iodine, or to keep 
it constantly wet with saturnine and anodyne lotions, either tepid or cold, as 
may be most agreeable. When the local action is accompanied with severe swell- 
ing, punctures, scarifications, or incisions should be made, freely and early, in 
order to afford vent to effused fluids, to relieve congestion, and to moderate pain 
and tension. The approach of gangrene may often be averted, certainly mate- 
rially checked, by the timely use of a blister, large enough to cover in not only 
the whole of the inflamed part, but also a portion of the healthy skin, and retained 
sufficiently long to effect thorough vesication. I am satisfied, from observation, 
that there is, in general, no more efficient remedy, and I therefore rarely ever 
omit its employment. It is particularly valuable in the idiopathic form of the 
disease, although it is not witliout its benefit in the traumatic. I was first led to 
use it from its great efficacy in erysipelas, where it unquestionably very fire- 
♦ quently averts the occurrence of gangrene altogether, and it is well known to 
the American surgeon that it was a favorite means, in this affection, in the hands 
of Physick. 

When mortification has actually occurred, our line of conduct must of coarse 
be different from what it is when we are watching its approaches. The symp- 
toms may still be of a sthenic nature, as will probably be the case when the 
patient is young and robust, and the part invaded is of trifling importance in the 
scale of organic life. Nevertheless, it would hardly be proper, even then, to 



CBAP. IT. ACUTE HORTIFICATIOy. 163 

iiidalg« in farther depletion, certainly not in depletion of a general character ; 
leeching maj be admissible, and we may perhaps continue, in a moderate degree, 
the internal nse of antiphlogistics ; cautiously and warily, however, lest they 
be instrumental in bringing on premature exhaustion, and thus placing life in 
jeopardy. When, on the contrary, the patient is feeble, the pulse small and fre- 
quent, and the tongue already covered with a brownish fur, clearly denotive of 
an asthenic state of the system, stimulants and tonics must be employed, and, in 
fact, every means taken to husband the remaining powers of the constitution. 
The best remedies then are quinine, tincture of iron, camphor, and opium, 
alone or variously combined, together with wine-whey, pure wine, or, what is far 
better thui either, brandy, gin, or whiskey. The diet must be as nourishing and 
concentrated as possible, that, while it affords the greatest amount of sustenance 
in the smallest space, it may not oppress by its weight and bulk. The most 
snitable articles, generally, arc the different animal broths, beef essence, arrow- 
root, tapioca, sago, broma, and com starch, which are commonly well borne by 
the stomach, especially if they be properly seasoned. In most cases the best 
treatment will be found to consist of quinine, or quinine and iron ; of full doses 
of opium, to allay pain and procure sleep ; and of brandy, in the form of milk- 
punch. Little, if any, confidence is to l)e placed in carbonate of ammonia, 
musk, castor, and valerian, so much vaunted by some of the older writers, 
and still occasionally exhibited by modem practitioners ; these articles possess 
no blood-generating power, and rarely do much good even ns nervines. The 
system, in such a state, re(|uirc8 something more active and permanent, and there 
are no means so well calculated to fulfil this indication as those just mentioned. 

Whatever measures, of a general nature, be adopted, the utmost attention 
mast be paid to cleanliness, and to the ventilation of the patient's apartment. 
Sponging the surface several times a day with tepid salt-water, or, if there is 
much perspiration, with a strong solution of alum, will be highly beneficial, espe- 
ciallj if not carried to fatigue ; the body and bedclothes must be frequently 
changed ; and the windows should either be constantly open, or raised at least 
several tim<'S in the twenty-four hours, in order to secure the admission of pure 
air, so essential to the healthful reaction of the system in disease. 

The object of the local treatment is to allay fetor, which is generally so exces- 
sive in acute gangrene, and to promote the rapid se])aratiou of the sloughs. The 
first of these measures is best accomplished by the liberal use of the chlorides, 
the hypermanganate of potassa, or Labarraque's disinfecting liquid, sprinkled 
freely upon the parts, as well as upon the body and bedclothes ; the second, by 
the stea4iy application of fermenting cataplasms, or the warm-water dressing, 
simple or medicated. The charcoal poultice, formerly so much in vogue in such 
oar*e«, is now seldom employed, on account of the manner in which it discolors 
tand obscures the inflamed surface, thereby interfering with a proper examination 
of its true condition. The ordinary yeast poultice is, on the whole, as eligible 
an application as can well be made ; where an additional stimulant is required, 
recourse may be had to the nitric acid lotion, camphor water, pyroligneons acid, 
or chlorinatcKi soda ; pieces of lint wet with any of these fluids being laid in the 
gap, and kept in place by the cataplasm. 

When the sloughs are tardy in separating, advantage may be derived from the 
nse of the knife, but care must be taken, in making the dissection, not to inter- 
fere with the living ti.ssues, much less with any important vessels. For want of 
due precaution in ])erforming this little operation, much suffering is sometimes 
entailed, and I have witnessed several cases where the patient was absolutely 
destroyed by it ; for, when the powers of life are greatly reduced by the efl'eets 
of the gangrene, the most insignificant bleeding and the most trifling shock may 
prove fatal. 

Clearance having l)een effected of the dead and putrid mass, the next object is 
to promote the granulating process, by the steady use of emollient and soothing 
dressings ; aided, if necessary, by the nitric acid lotion, nitrate of silver, solutions 
of copper, lead, or zinc, balsam of Peru, tincture of benzoin, creasote, and similar 
articles. Proper attention must also be paid to the state of the system, every 



164 TEBHIKATIONS OF INFLAMMATION. cbap.it. 

effort being made to rebuild it by suitable tonics, noarishing food, and change 
of air. As soon as the granulations begin to assume a healthy aspect, as indi- 
cated by their florid color, and the thick, yellowish character of the discharges, 
the healing process will generally progress best under the most simple dressingSi 
serving merely as protectives against friction and rude exposure; as, opiate 
cerate, or a light linseed poultice. If the sore be large, cicatrization may be pro- 
moted by touching its edges lightly once a day with solid nitrate of silyer, and 
drawing them gently together with adhesive strips. 

In connection with this subject the question of amputation necessarily arisei. 
Under what circumstances is this operation necessary or proper ? Should it be 
performed while the mortification is still in progress, or postponed until it is 
completely arrested, and a line of demarcation is formed ? These are important 
points, and they should therefore in every case receive due consideration ; for it 
is the solemn duty of the surgeon not only to save the life, bnt also, if possible, 
the limbs of his patient. His object should ever be to preserve, not to mutilate ; 
for it is a thousand times more creditable to his skill and judgment to save one 
extremity than to lop off a hundred, however adroitly it may be done. 

In attempting to settle this question special reference must be had to the 
nature of the mortification, or the causes under whose influence it is developed ; 
for experience has shown that the two forms of the disease generally require dif- 
ferent treatment. Thus, in idiopathic gangrene the rule now is never to amputate 
until the surgeon is assured, by the establishment of a circle of demarcation, that 
both the part and system arc in a condition to bear the shock of the operation, 
and that death has been completely arrested. Even further delay may be 
demanded, if, upon careful investigation, it be found that the patient is still 
feeble from the effects of the mortification ; that he looks pale and wan ; that he 
has a weak and shattered pulse ; in short, that everything is denotive of a broken 
state of his constitution. To amputate under such circumstances would greatly 
endanger the result, if not positively destroy the patient ; proper allowance must 
also be made for the loss of blood and the shock which must of necessity follow 
the use of the knife, both of which, even when the greatest care is taken in per- 
forming the operation, are often most serious. If, on the other hand, the powers 
of the system are sufficiently active, if there is no apparent contamination of the 
fluids and solids, and, above all, if nature is making a vigorous effort to arrest 
the extension of the malady, there is no reason for delay, and hence the sooner 
the offensive parts are removed the more likely will the case be to have a fevor- 
able termination ; the system is prepared for the emergency, and will soon react 
from any depression that may ensue from the employment of the knife. Longer 
delay, in truth, should not be thought of, seeing what pernicious influence the 
retention of the dead structures must, by their putrid and fetid condition, exe^ 
cise upon the system, already weakened to an unreasonable extent by the disease, 
before the tissues were fully deprived of vitality. 

From this treatment that of traumatic gangrene is altogether different ; here 
the extinction of vitality is usually more rapid and extensive, and hence to wait 
always, or even generally, for the appearance of a line of demarcation would be 
virtually, in many cases, to consign the patient to the grave without making an 
effort to rescue him from the impending danger. When injury of an important 
artery, nerve, or joint is the caase of the mortification, amputation can hardly be 
performed too soon ; nothing, certainly, can be gained by delay, which, even in a 
few hours, may put the case beyond our reach, such, not unfrequently, is the 
swiftness with which death travels along the affected limb. This is particu- 
larly liable to happen in railroad, factory, and steamboat accidents, which are so 
common in this country, and which are often of the most frightfal nature, pulpi- 
fying the soft parts, laying open large vessels and joints, and literally crushing 
the bones into atoms. Under such circumstances the judicious surgeon will of 
course amputate at once, the very moment sufficient reaction has taken place to 
enable the system to bear the operation ; but instances often occur where the 
case has been neglected, or ill managed, and where death of the parts has already 
set in before we arc consulted. Now it is precisely in such a case as this thii 



nr. It. CHRONIC MORTIFICATION. 

the question will arise id regard to tLe propriety of immediate action, and niuiA'l 
juilpment sod experience arc frequently required to enable us to come to a cor- 1 
mrt dfcisiob. The proper procedure, I tliinic, is not to hefiitate, if the stale of tho ] 
mtem is such as to warrant tiie belief that it will be able to )>ear the Bhock of 
Ik* opentioD ; but I ahuutd certainly refrain from it if the patient was so far ex- 
Uwtod Bd to render it probable that he would sink under it. ]n that event, I 
■lliihiil endeavor to rally him by the free use of conliala, as wine, brandy, and 
qpinhte. and ase the knife as soon as a farorable chanj^e occorred. If this did 
not wise, I should prefer to let him perish from the effects of liis injury rather i 
than become his execntioner. I 

The question of amputation in gangrene fNim embolism is an important one, J 
but tu the existing state of the science, unrtecidable. It may be stated, however, I 
in general terms, that ihp operation should be performed without delay when thVB 
deatractive action is rapidly advancing, provided the patient is tree from seriouv I 
organic disease, and is otherwise in a condition to sustain the shock and loss of I 
Idowl. When the reverse is the cose, the proper plan is to wait for a line of de* f 
mari'atian ; and a eimilar conrse should be adopted when the mortification is , 
mure chronic and in evidently dependent upon tbe presence of a clot iu the prJn- 
cipdl artery of a liuib near the trunk. 



2. CBEtONIC MORTIFICATION. 

Tbi-re is a form of mortification, the very opposite, in many respects, to the ^ 
one just described, and to which, therefore, the term chronic, or dry, may very 
fin^rly be applied. Tbe affection, which may be induced by various caoBcs, is 
cbaractnHzed by the remarkable tardiness of its progress, by the absence of hu- 
midity, and by the great blackness of the skin, which, when the loss of vitality is 
complete, looks very much like a piece of charcoal. ■ 

One of the best types of this variety of mortification ia what is now generally 
knowa M senile gangrene, from the fact that it ia most common in elderly uub- 
jccta. It is the same disease which was so admirably portrayed, for tho first 
time, by Perdvall Pott, of London, under the appellation of mortification of the 
"toea and feet." and which, for this reason, wau formerly known by bis name. 
Ii gvoerally begins npon the inside of one of the email toes as a little bluish or 

CUTfdtf speck, ikot larger, perhaps, than a muatard-seed, which is soon succeeded 
V a rainate vesicle, filled with a serous, ichorous, or sanguinolent fluid, and whichi | 
banting, eiiioses a black surface lieneath, perfectly cold and insensible. Thii I 
ip»>t gradually spreads iu different directions until it involves the whole foot, as 
in fig. S3, as high np, in many instances, as the ankle, or even the middle of the 
k^. althoagh, in general, the patient dies long before it reaches that situation. 
Occasionally, the mortification logins at several t«es simultaneously, or in pretty 
rapid racccssion ; and I have met with several examples iu which it first showed 
iKelf upon the heel ondin- 

«>-p. Dr. Charles Marr. Fig- 32. 

of ScmntoD, has conimu- 
nk«ted to me llic par- 
liculkrs of a «ue in which 
the c!iBi>ai>« was confined 
ID the lower and back 
part of the leg ; and in 
an eHerly female under 
my charge at the Phila- 
delphia Hospiul, in 1»03. 
tbe gsngrenc nerer ex- 
tended beyond the big 
to«. Howfcr this may 
be, Uk part always cx- 
Ubita ft maracteri^tic np- 
; it is perfectJy 




166 TERMINATIONS OF INFLAMMATION. obap.it. 

dry and withered, cold, insensible, odorless, or nearly so, and as black as ditt- 
coal, the limb looking as if it were unnaturally small, as, in fact, it generally it. 
During the progress of the mortification, especially if this is somewhat rapid* 
the skin has occasionally a mottled, purplish aspect^ owing to tiie coagulation of 
the blood in the superficial veins. 

The disease is usually preceded and accompanied by pains in the toes and foot^ 
darting about in different directions, and liable to nocturnal exacerbations, pre- 
yenting sleep, and rapidly undermining the general health. These pains, which 
are of a burning, scalding, or stinging character, are often referred by the patient 
to the effects of gout or rheumatism, particularly if he was formerly subject to 
attacks of that nature ; they steadily increase with the spread of the disease, and 
can be relieved only by the free use of anodynes. The dependent posture com- 
monly aggravates them, but, in a case which I saw not long ago with Dr. Levis, 
of this city, the suffering was immensely augmented whenever the limb was ele* 
vated even for a few moments. The consequence was that the patient, an old 
man of eighty-three, was constantly obliged, during the day as well as the nigfat, 
to let his foot hang down. In some instances, the attendant pain is extremely 
slight. Considerable swelling is sometimes present in the part above the site of 
the mortification ; and cases occur, although rarely, in which the whole extremity 
is very (edematous, exquisitely sore, and of a pale rose color. 

Although in general this form of gangrene is strictly chronic, an instance occa- 
sionally occurs in which it spreads with such rapidity as to entitle it to the term 
acute. The most remarkable case of this kind that I have ever seen, happened 
in a stout, fat female, aged sixty-four, a patient of Dr. Coad, of this city, long 
subject to attacks of gout. The gangrene commenced in the big toe, and in less 
than a fortnight it had spread over the entire foot and lower half of the leg. The 
parts were as black as charcoal, shrivelled, horribly fetid, and excessively painful 

Well-marked constitutional symptoms attend this complaint, usually from the 
very first, and sometimes even before there is any local evidence of its presence. 
They are either of an asthenic type from the beginning, or they soon become so. 
The pulse is feeble and upwards of one hundred and twenty in the minute, quick, 
sharp, and irritable. The tongue is coated with a brownish fur, dry, and more 
or less tremulous ; the appetite is impaired ; the bowels are costive ; the alvine 
evacuations are fetid ; the urine is scanty and high-colored ; the sleep is inte^ 
rupted by pain and frightful dreams; the strength rapidly declines; and the 
patient gradually dies from sheer exhaustion, the period between this event and 
the commencement of the attack varying from six weeks to three or four months. 

This form of gangrene occurs in both sexes, and probably with nearly equal 
frequency, although it was formerly supposed to be more common in men than in 
women. It is observed in all classes of individuals, the rich and the poor, the 
idle and the industrious, the temperate and the dissipated. Nearly all the cases, 
probably about thirty, that have come under my notice occurred among the mid- 
dle and poorer orders of the community. Mr. Pott was of opinion that the dis- 
ease was peculiar to the old, but subsequent experience has shown that it may 
take place at different periods of life ; and within the last fifteen years a numbiar 
of cases have been reported where it occurred in children under ten years of age. 
It has been conjectured that a gouty and rheumatic temperament predisposes to 
the development of the affection, and there are numerous facts upon record which 
would seem to countei^incc such an idea. Again, it has been asserted that par- 
ticular modes of life, as indolence and huge feeding, pow^erfully contribute to its 
production. 

From the form of chronic mortification which we are now considering few 
patients recover. If occasionally one escapes, it only forms an exception to the 
rule. In most instances, the disease proceeds steadily, or, with an occasional 
temporary interruption, to a fatal termination. In a case of senile gangrene, in 
a man, aged sixty-two, recently under my care, the immediate cause of death 
was opisthotonos. Now and then, as when the powers of life are not too much 
exhausted, the morbid action is arrested, and spontaneous amputation takea 
place, followed, after long suffering, by recovery. The event is denoted by the 



CVAP. IT. CHRONIC MOBTIFICATION. 167 

estmhiishment of a line of demarcation, immediately above which the surface 
exhibits a daskv, erysipelatous blush, very different from what usually occurs in 
ordinary gangrene. The sloughing process is generally attended with severe 
pain and the most offensive smell. 

The cawie of senile mortification was not, until recently, at all understood. 
Mr. Cowper, the anatomist, had, it is true, advanced the idea, now become general, 
that it was owing to ossification of the arteries, bat his researches had not been 
condncted upon a sufficiently extensive scale to justify the positive conclusions 
which modem observation has so fully established. The result of my own dis- 
sections is very decidedly in favor of this view. Ossification of the arteries, 
however, is merely a predisposing, not the immediate, cause of the lesion, which 
consists in the formation of fibrinous clots closing up the calibre of the vessels, 
and thus mechanically intercepting the passage of the blood. I have ascertained 
that the principal obstruction occasionally exists at a considerable distance from 
the seat of the disease. Thus, I have found the occlusion limited altogether to 
the femoral artery, the popliteal, or the commencement of the tibial and fibular. 
In most cases, however, it affects also the smaller branches. The concretions 
generally exist in various degrees of development, from recent coagulation of the 
blood to complete organization ; hence, while some may be easily detached, others 
are firmly adherent to the sides of the vessels. 

What the immediate cause of these clot formations is has not been determined. 
It has been alleged that it is owing to the interception of the fibrin of the blood 
by the roughened walls of the arteries consequent upon their calcification ; but 
there can hardly be any doubt that it is due to an ef^sion of plastic matter, the 
result of chronic inflaounation of the serous membrane, thereby favoring the 
adhesion of the blood and its conversion into clots. . 

A very remarkable form of chronic gangrene is sometimes produced by the 
inordinate use of ergot, sparred rye, or secale comutum. The affection, which 
has occasionally prevailed endemically, has hitherto been observed chiefly among 
the inhabitants of France, Germany, and Switzerland, in certain districts of 
which rye bread forms a principal article of diet. When the seasons are very 
wet an unusual quantity of ergot is generated, and this entering largely into the 
composition of the flour has the effect, when used for any length of time, of 
giving rise to mortification in the remote parts of the body. The attention of 
the profession was first directed to the subject in a prominent manner in 1676, 
by Mons. Dodard, a French physician, and since then it has been frequently 
noticed by other writers. For a long time doubts were entertained respecting 
the power of ergot to produce this effect, and in order to solve these Mons. 
Tessier, of Paris, was commissioned, many years ago, by the Royal Academy of 
Medicine to investigate the matter experimentally. For this purpose he selected 
varioas animals, especially pigs, ducks, and turkeys, which he fed exclusively 
upon ergot ; he found that most of them died from the tenth to the twenty-fourth 
day, and that distinct marks of mortification existed in the bodies of all, both 
externally and internally. Since the poisonous effects of this substance have 
become so well understood the disease has almost entirely disappeared, and in 
this country I am not aware that it has ever been noticed in the human subject. 
It is said, however, to have prevailed extensively among the homed cattle of 
Chester County, in this State, in 1819, and in the following year in Orange County, 
Xew York, in consequence, as was supposed, of the free use of the green grass, 
the poa viridis, the seeds of which were affected with ergot. 

The manner in which ergot acts in producing this disastrous effect has not 
been explained. It is very singular that its virulence should explode upon those 
parts of the body which are most remote from the heart, as the feet and legs, and 
the corresponding portions of the upper extremities, along with the nose, chin, 
and ears. I am myself inclined to believe that the primary impression of the 
poison is upon the blood, rendering it abnormally stimulant and plastic ; and the 
secondary upon the inner coat of the arteries, which, becoming inflamed, thereby 
intercepts the liquid, and thus leads to the formation of fibrinous clots. In a 
word, there is reason to believe that mechanical obstruction of the vessels is the 



168 TERMINATIONS OF INFLAMMATION. chap. it. 

direct and immediate cause of the gangrene, and if this idea be correct, we can- 
not fail to discover the closest analogy between this form of the disease and senile 
mortification described in a previous page. It is much to be regretted that 
Dodard, Noel, Bossau, Gassoud, and others, who have left such admirable descrip- 
tions of the external characters of this strange affection, should not have g^Ten 
us any account of its pathological anatomy. 

Mortification from ergotism has been observed at all periods of life ; it is usually 
preceded by discoloration, pain, and burning heat, which, subsiding in the course 
of four or five days, leave the parts cold, dry, hard, insensible, of a uniform 
black color, and free from fetor. It generally begins in the toes, whence it 
gradually extends over the foot and leg, until, in some cases, which, however, 
arc rare, it reaches as high up as the hip. Occasionally it appears simultaneously 
both in the lower and upper extremities, as well as in the nose and ears. Some- 
times the disease is accompanied by considerable swelling and by the most ex- 
cruciating pain, allowing the patient no rest day or night. The constitutional 
symptoms vary, being at one time very slight, at another excessive ; in general, 
however, the patient is tormented with fever, thirst, restlessness, and high delirium. 
Under favorable circumstances ulcerative action is set up, and this, gradually 
progressing, at length eventuates in spontaneous amputation of the sphacelated 
structures. 

Anomalous cases of chronic mortification occasionally occur, so obscure in 
their character as to render it impossible to refer them to any particular division 
of the disease. To this variety belongs the extraordinary instance, published in 
the Philadelphia Medical Examiner, by Dr. Bernard Henry, of this city, of a 
female, aged forty-two, who suffered from gangrene of all the extremities, from 
the effects of which she finally died. She was the mother of nine children, of 
intemperate habits, and formerly affected with syphilis. The malady was pre> 
ceded by stinging and burning pains in the hands and feet, which, together 
with the tip of the nose and the skin of the knees, were gradually transformed 
into black, dry, and shrivelled bodies, the gangrene finally extending beyond 
the middle of the arms and legs. The only lesion revealed on dissection was 
some contraction of the left auriculo-ventricular orifice, which seemed to have 
obstructed the flow of blood into the aorta. The arteries were free from ossifi- 
cation. 

Treatment, — Much diversity still exists among authors respecting the proper 
method of treatment in chronic mortification ; some favoring stimulating measures, 
while others are the w^arm and avowed advocates of depletion, just as if it were 
possible in a disease which exhibits such a protean character to lay down any 
one plan that shall be applicable to all cases. When a writer recommends an 
exclusive system of treatment, and especially when he inculcates the adoption 
of that treatment with extraordinary enthusiasm, tinctured, perhaps, with a sense 
of bitterness which neither the subject nor the occasion demands, his views may 
well be received with some degree of allowance ; and to no surgical topic is this 
remark more justly applicable than to that under consideration. If the reader 
will take the trouble to peruse the literature of the profession upon this subject 
from the time of Mr. Pott down to our own, he cannot fail to be struck with the 
truth of this remark, nor fail to lament the uncertainty of medical doctrine and 
practice. How are we to reconcile such discrepancies ? By supposing that 
different practitioners have had totally different and opposite classes of cases, or 
that the disease varies in different countries and at different seasons, being now 
attended with high excitement, and now with great depression ? Such occur- 
rences are possible, but not probable, unless we conclude that there has been an 
extraordinary concurrence of events, or that the views of these opposite parti- 
sans are founded upon the most limited personal experience. A more plausible 
conjecture is that these notions are incorrect, from having been deduced firom an 
insufficient number of facts, or that they are the offspring of preconceived hypo- ' 
theses. However this may be, it is certain that no one method of treatment is 
applicable to chronic gangrene, although, as a general rule, the stimulant will be 
found to be the most reliable. I have seen cases where, from the robust stale 



CBAP. IT. CHRONIC MORTIFICATION. 169 

of the iodiTidual, and the character of the palse, no doabt could be entertained 
about the propriety of the employment, at least to a moderate extent, of anti- 
phlogistic measures, where, indeed, even the lancet and antimony were admissible ; 
bat I am quite sure that such instances are comparatively few, and that, even in 
them, too much caution cannot be used in their adoption. Nine patients oat of 
ten would be injured by this course. The symptoms are generally of a typhoid 
character from the very beginning of the malady, and not only so, but the dis- 
ea.«e nearly always oecars in old, worn-out sabjects, or in persons who have long 
labored under depression of the nervous, vascular, and muscular powers, and 
who are therefore ill -prepared to undergo such a plan of treatment with impu- 
nity. Tonics and stimulants, judiciously administered, and aided by appropriate 
local measures, constitute the proper means in such cases. Sometimes a *' mas- 
terly inactivity" is more effective than anything else, the surgeon doing little 
more than watching the case, and attending to his patient's diet, bowels, and 
secretions. But, in general, it will be found that a supporting plan of treatment 
is absolutely necessary, to prevent the system from falling into a hopeless state 
of exhaustion. Quinine, carbonate of ammonia, and the tincture of the chloride 
of iron, with wine-whey, or milk punch, and opium, are the articles most to be 
relied upon, and they should be given in such doses as shall bo calculated to 
meet the exigencies of each particular case. 

Locally the best remedies are the dilate tincture of iodine, brushed very tho- 
roaghly twice a day over the whole of the affected part, and the use of the 
bandage, applied with moderate force, and kept constantly wet with a strong 
solution of opium and acetate of lead, Goulard's extract, or hydrochlorate of 
anmoonia. Leeches are usually objectionable, as their bites are sometimes pro- 
vocative of gangrene, and the same remark is applicable to punctures and inci- 
sions. By these means the inflammation of the obstructed vessels may now and 
then be promptly arrested, and the further extension of the mortification pre- 
vented. 

When the sloughing process has commenced, the treatment must be conducted 
upon the same generaJ principles as in the acute form of the malady, only that 
the local applications should, if possible, be still more mild and soothing. The 
most eligible remedies, according to my experience, arc the nitric acid lotion, 
in the proportion of two to six drops of the acid to the ounce of mucilage of 
gum arable, or the opiate cerate, for the ulcerated surface, and cloths constantly 
wet with a solution of chloride of lime for the dead, especially if there be much 
fetor. As the parts become detached they may be removed with the scissors, 
but this must be done with the greatest possible gentleness, as the slightest 
injury inflicted upon the living tissues is sure to be productive of mischief. 

In regard to the question of amputation, it is extremely difficult to offer any 
satisfactory statement. My belief, founded upon considerable experience, is 
that we ought scrupulously to follow the practice long ago laid down by surgeons 
not to interfere until there is a well-marked line of demarcation ; and, indeed, 
not even then unless it is perfectly evident that there is sufficient strength of the 
system to bear the shock of the operation. I have, however, seen several cases 
where amputation was succeeded by the most happy results before nature had 
made any attempt to cast off the slough, and that too under circumstances 
apparently not at all promising as it respected the powers of the constitution. 
Whenever sargical interference is deemed advisable no means should be spared 
to support the patient with tonics and stimulants, as upon their judicious use tho 
chances of his recovery will, in great degree, depend. When the operation is 
performed prematurely, or before the system has sufficiently recovered from the 
exhausted condition consequent upon the gangrenous action, the disease will 
generally reappear within a few days after npon the stump, or death will follow 
from sheer prostration. 

In regard to chronic mortification from the use of ergot, we have no positive 
knowledge to guide us in our treatment There la no remedy, so far as is at 
present Imown, the employment of which exerts the slightest counteracting influ- 
ence upon the deleterious effects of this substance mr Hence the 



170 TERMINATIONS OF INFLAMMATION. ohap. it. 

only proper plan of procedure is to treat all such cases upon the general princi- 
ples just laid down in respect to the management of the ordinary form of chionie 
gangrene. 

SECT. VII. — HOSPITAL GANGRENE. 

Under this name may be described a variety of mortification, or of mortificatioii 
and ulceration, which often commits great ravages among the wonnded in crowded 
hospitals, in camps, and on board of vessels of war. The disease appears to be 
much more common in Europe and in the East than in this coantry, where, 
judging from the silence of the profession respecting it, it is exceedingly infre- 
quent, oven in our larger eleemosynary institutions, while in private practice it 
is almost unheard of During the present war, however, it has been safBdentb^ 
prevalent among our wounded soldiers. I place this affection between mortifi- 
cation and ulceration, as it evidently, in many cases, if not in all, strongly par- 
takes of the nature of both. 

Although it is extremely probable that hospital gang^ne has existed from 
time immemorial, no distinct and satisfactory account of it appeared ontil 1788, 
when an admirable description of it was published in the posthumous works of 
Pouteau, of Lyons, who had himself suffered from a severe attack of it while 
resident pupil of the Hotel Dieu of that city. Soon afterwards attention wis 
directed to it by Dussassoy, whose treatise was rapidly followed by the tracts 
of Moreau, Burdin, Gillespie, Leslie, Blackadder, Brauer, and Boggie, to whose 
joint labors we are mainly indebted for our present knowledge of this curionfl 
affection. 

Various names, more or less expressive of the nature of this disease, have 
been employed to designate it by different authors. Thus, by Ponteau and some 
of the earlier writers upon the subject, it was denominated hospital gang^ne, 
evidently in reference to the frequency of its occurrence in this class of public 
institutions, of which it was at one time the great scourge, both in military and 
civil practice, particularly the former. Subsequently it was described under the 
appellations of contagious gangrene, gangrenous phagedena, putrid degeneration, 
malignant sloughing, or putrid ulcer, camp gangrene, and humid hospital gang^ne. 

Sporadic cases of this variety of gangrene, more or less severe, are occasionally 
met with in all large hospitals and other places crowded with sick and wounded, 
but we no longer hear of that frightful devastation which used to characterize 
its existence in former times. This happy change is no doubt due to the great 
attention which the modern practitioner bestows upon ventilation and cleanliness, 
and the prompt segregation of his patients on the appearance of the malady. 
According to Mr. Macleod, hospital gangrene was not at all common among the 
English during the late war in the Crimea ; it prevailed during the first winter 
in a mild form at Scutari, but it never became either general or severe, altiiough 
the barrack hospital of that city was, during the early occupation of the troops, 
in a very filthy and uncomfortable condition. Whenever any cases broke oat, the 
patients were at once isolated, and sent into wards specially set apart for the 
treatment of the disease. The French, on the other hand, suffered most severely, 
owing, as was supposed, to the injury which they sustained during their removal 
immediately after being wounded to the hospitals on the Bosphorus, and to the 
manner in which they were crowded together in the wards of those institutions. 

Formerly hospital gangrene often prevailed as an endemic, attacking almost 
every one that was brought within its baneful inflnence, and thus causing the most 
horrible mortality. In the Hotel Dieu, at Lyons, in the time of Pouteau, several 
frightful outbreaks of this sort appeared, and such were their ravages that this 
distinguished surgeon was induced to ask the question, whether hospitals were 
not an e?il instead of a blessing. In ItSO, the disease prevailed extensively 
among the inmates of the naval hospital at New York, some of whom had been 
sent thither from the American squadron, then in port on account of stress of 
weather, others from the West Indies. Upwards of two hundred cases occurred, 
and of these many died ; quite a number from the recurrence of grangrene upon 
the stump after they had suffered amputation. In It 81, the malady committed 



^tip. IT. HOSPITAL GANGR£NE. 171 

terrible raTages at the naral hospital on Pigeon Island, St. Lucia. In 1800, it 
prerailed eztenBively on board the Prince of Wales, on her homeward passage 
horn Martinique to England ; the suffering is described as haying been excessive, 
lod it is stated that every little scratch or injury, in whatever manner inflicted, 
jpeedily degenerated into a bad gangrenous ulcer. A short time before this, the 
disease existed in a very severe form at the Cape of Gh>od Hope. Of the hor- 
rible ravages which it occasionally commits at sea, an idea may be formed 
vhea it is stated that sixty bodies were thrown overboard by one vessel in 
thirty-six hours in her passage from the south of France to the Bosphorus. 
At Bilbao, after the battle of Yittoria, the mortality from this source was excessive. 
In the Parisian hospitals, the disease has prevailed, off and on, for many years, 
often sadly interfering with the results of surgical accidents and operations. In 
1847, it appeared in some of the London hospitals, and nearly at the same time 
in some of those at Edinburgh ; in both cities, however, in a mild and transient 
manner. In the Philadelphia Hospital, I have seen cases of the disease, in a 
more or less severe form, every winter for the last five years, chiefly in old worn- 
out persons, the subjects of chronic ulcers of the extremities, accompanied with 
a scorbutic state of the system, brought on apparently by an insufficient supply 
of vegetables and subacid fruits. 

Daring the present war the disease has prevailed more or less extensively in 
many of our military hospitals. It was particularly troublesome, for a time, at 
Annapolis, Washington, Baltimore, New York, Louisville, and Frederick, Mary- 
land, after the engagements at South Mountain and Antietam, iu September, 1862. 
At the latter place, it manifested, as has been asserted by Dr. Alfred North, a 
very decided preference for ulcers of the lower extremities in an advanced state 
of cicatrization ; with a single exception no recent wounds were attacked, although 
numerous operations were performed. In the military hospitals in and around 
this city comparatively few persons suffered from it, and of those most recovered. 
I have adduced these references with a view of showing the occasional epidemic 
tendency of this disease, and the consequent absolute importance of avoiding the 
huddling and crowding together indiscriminately of the sick and wounded in 
large hospitals, camps, and other places, often selected with little judgment, for 
the accommodation of the poor. There can be no doubt whatever that much, 
if not the whole, of the immunity enjoyed by the hospitals, infirmaries, and 
almshouses of this country is due to the vigilance that is exercised in the seques- 
tration of their inmates and the great attention that is paid to the cleanliness and 
ventilation of these establishments ; circumstances which can never fail to exercise 
a powerful prophylactic influence upon this and other diseases whose origin and 
propagation are so closely connected with a vitiated state of the atmosphere and 
a disordered condition of the blood. 

Hospital gang^ne shows itself in one of two ways: either as an original 
affection upon an unbroken surface, or in connection with an open wound, ulcer, 
or abrasion ; more frequcDtly in the latter than in the former. When the tendency 
to the disease is very strong, the slightest scratch, sore, or wound may become 
the means of propagating it, and of producing the most frightful ravages. 
Several instances have been recorded of the most horrible sloughing occasioned 
by the accidental inoculation of the bite of the mosquito. When the disease 
prevails endemically, or even when there is merely some tendency of this kind, 
no operation, however insignificant, can be performed with any certainty that it 
may not be followed by hospital gangrene. The stripes inflicted in flogging 
soldiers have frequently been known to become the seat of the disease in its 
very worst form. Boils, abscesses, sinuses, fistules, and cicatrices generally, 
under such circumstances, share a similar fate. It has been noticed, what is 
certainly very singular, that, when hospital gangrene exists as an endemic, it 
manifests but little disposition to seize upon ulcers of a specific nature, as chan- 
cres, syphilitic buboes, and cancerous sores. In its sporiadic form, on the con- 
trarr, these are the parts which seem to be particularly liable to suffer, the 
d ise'ase often attacking them, apparently, in preference to simple ulcers. 

The distinction, which has been made by some authorities, of this disease into 



172 TEBMINATIONS. OF INFLAKKATION. omap.it. 

sloughing and phagedenic, seems to me to bo improper, since it is evident that 
the two affections are merely different grades of the same disorder, the one 
destroying the tissues in large masses, the other on a small scale, the action bj 
which this is done being strictly identical in both cases. A much more important 
division is that into idiopathic and traumatic, the origin of the former depending 
upon constitutional causes, that of the latter upon external injury. 

If inquiry be made into the causes of this variety of gangrene, it will hardly be 
found to reward our labor. While some regard it strictly as a local affection, others 
consider it as having a constitutional origin ; and in this opinion I am strongly 
inclined to concur, from a careful study of the history of the disease, both from 
what I have seen of it myself, and from the accounts given of it by different 
writers. Possessing many features in common with erysipelas, it is highly 
probable that, like that disease, it owes its origin to a species of blood-poisoning, 
depending upon a foul, infected atmosphere, operating upon a depraved and 
enfeebled constitution. It is very certain that the strong and robust are much 
less liable to suffer from it than those of an opposite state of the system, or who 
have become exhausted by intemperance, disease, exposure, or want of propef 
food ; and it is often easy to determine, beforehand, when a grreat many persons 
are crowded together in the wards of an infected hospital, which will be likely 
to be attacked and which to escape, simply from the differences in their appea^ 
ances. Whether the subjects of hospital gangrene are capable of generating a 
poison which, in its turn, can impart the disease to others, by its operation upon 
the system, is still a mooted point, though an extremely probable one. However 
this may be, the fact that the malady may be communicated by actual contact 
of the secretions of a gangrenous sore with a sore of a healthy character, appears 
to be well established ; at all events, the theory is constantly acted upon in insti- 
tutions where the disease is prevalent, in the care which is taken to prevent 
'sponges and other articles used in cleansing and dressing affected persons, from 
being employed upon healthy ones. A very striking circumstance, bearing 
strongly upon the question of the existence of a distinct poison elaborated during 
the progress of this malady, has been recorded by Sir George Ballingall, in his 
Outlines of Military Surgery. Speaking of this disease as it prevailed in a 
regimental hospital at Feversham, in 1806, he states that, after the endemic had 
been going on for some time, it was discovered that all the ulcers in the estab- 
lishment had been washed with one sponge. A different mode of cleansing the 
sores was immediately adopted, and the consequence was that not a single case 
of the disease appeared afterwards. When to this circumstance is added the 
result of the experiment of Ollivier, who produced the disease in his own person, 
by inserting matter, taken from an ulcer of the very worst description, into the 
arm just below the attachment of the deltoid muscle, it is impossible to withhold 
our belief in the contagious property of traumatic hospital gangrene. The case 
of Blackadder, who suffered severly from a puncture accidentally inflicted upon 
one of his fingers in dissecting the stump of a man dead of this affection, is 
equally strong and convincing. 

A scorbutic state of the system, severe shock, loss of blood, and, in short, all 
depressing influences whatever, probably act as so many predisposing causes of 
this disease, by lowering the powers of the heart and nervous system, and thereby 
favoring the operation of the septic poison, if such a poison really exist. Pro- 
tracted courses of mercury, or exposure to wet and cold during salivation, have 
often been observed to be followed by the disease during its endemic prevalence. 
In private as well as in hospital practice, it is particularly liable to be induced 
in young, unhealthy, scrofulous persons, affected with syphilitic ulcers, and 
weakened by all kinds of privation, especially the effects of cold, and the exces- 
sive use of ardent spirits. In the army and naval service of Europe, it formerly 
often supervened upon severe and exhausting attacks of dysentery, scurvy, and 
typhoid fever. 

The time during which the poison of hospital gangrene lies latent in the sys- 
tem has not been determined. It probably varies in different persona and in dif- 
ferent cases, depending upon the previous state of the general health, and the 



IT. HOSPITAL OANGR£NS. 178 

r mode of the lofection. In most cases it is short, not exceeding thirtj- 
orty-eight hoora before it shows its specific effect. When the infection is 
t, a longer time is probably required for the development of the disease 
heo it is direct, or effected by actual contact of the secretions. 
disease occurs at all periods of life, and probably the only reason why 
Q do not suffer more frequently is that they are so seldom subjected to the 
ce of its exciting causes. Both sexes are obnoxious to it ; and, although • 
show itself at any season of the year, it is most common, as well as most 
t» in hot weather. 

mfmptoms which characterize this affection are partly of a local, partly of a 
itional nature, the order of their priority being not always easily deter- 
When it supervenes upon an ulcer or abrasion, the appearance of the 
Bting affection undergoes at once a series of the most important changes, 
tely modifying its whole aspect The discharge is sensibly diminished, 
tiaps, entirely dried up ; the granulations, if any exist, assume a dark, foul 
inoe, and are rapidly destroyed ; a large quantity of aplastic lymph, of a 
rmyish color, soon covers the bottom of the sore, the edges of which at the 
ime become jagged and everted ; the adjacent parts are of a deep purple or 
ae, mod the seat of numerous vesicles, filled with a sanious or bloody 
the pain is constant and excessive, being sharp, biting, or stinging ; the 
I structures exhale a horrible odor; and swelling is both great and 
ning. Sloughing now takes place, skin, cellular tissue, fascia, and muscle 
rapping off in large, livid, putrescent masses, thoroughly impregnated with 
9t horribly offensive secretions. In the more severe forms of the lesion, 
ages are not limited to the soft parts, but often extend to the bones and 

> the joints ; the affection, perhaps, rapidly travelling up a limb until it is 
tefy destroyed. Long before this crisis has been attained, indeed gene- 
: an early period, glandular swellings are observed in the groin or axilla, 
ling many of the features of pestilential buboes ; they usually involve a 
' of ganglions, and arc always exquisitely tender and painful, thus greatly 
ating the local and constitutional distress. When suppuration occurs, 
however, is not invariably the case, the discharge is generally abundant 
cfaly fetid, and the resulting ulcer speedily exhibits all the characteristics 
Murent sore. 

n the disease appears on an unbroken surface, its advent is announced by 
nation of little vesicles, or blebs, filled with ichorous fluid, and surrounded 
ddish areola ; both gradually extending, the former soon burst, and thus 
I dirty, foul slough, which, dropping off, exposes a filthy looking, exca- 
atvity, incrusted with a thick layer of adherent, grayish, unorganizable 
The parts feel hot and stinging, and there is great swelling, with livid dis- 
ion, of the adjacent surface, and a tendency to rapid extension and destruc- 
e different tissues dying either together or successively, in the same manner 
a the disease is ingrafted upon an ulcer or open sore. 
constitutional symptoms of hospital gangrene are generally well marked, 
•verity being usually in proportion to the violence of the local disturbance. 
latient, prior to the attack, was tolerably strong and robust, they will pro- 
« of a strictly inflammatory nature, but in any event they will soon lose 
»e, and assume the asthenic form, which will become more and more dis- 
( the disease pursues its downward tendency. The pulse will be found to 
mally frequent, quick, and irritable ; the mind is peevish, fretful, and des- 
!l^ ; the tongue is dry, and covered with a brownish fur ; the strength is 
mpaired ; and the pain is so excessive that the patint is completely de- 
both of appetite and sleep. Delirium often sets in at an early period, 
^ one of the most prominent symptoms. 

diagnosis of hospital gangrene is generally not difficult, for there arc few 
B with which it can be confounded. Almost the only affection, indeed, for 
t is in danger of being mistaken is scurvy, but a little attention will usually 

> render the distinction between them very evident. The scorbutic ulcer, 
IS been named by Lynd and other writers, is remarkable for its fungous, 



171 T£RMlNATIONS OF INFLAMKATION. obap.it. 

livid, bloody, and fetid character; the grannlations are of enormous size, yeiy 
soft and sponf^y, growing with great rapidity, and bleeding copioaslj upon the 
slightest touch. The discharge is profuse, and the blood often lies in cakes opiin 
the surface of the sore, from which it is wiped with difficulty ; the pain is trivial, 
and if the granulations are cut away they are speedily reproduced, generally in 
the course of a single night. Ulcers of this kind are nearly always attended bj 
serious disease of the gums, which are fungous and extremely vascular, and by 
hemorrhagic spots in different regions of the body. There is also, as another 
striking diagnostic circumstance, an absence of fever, and, generally, also of 
vesication. In hospital gangrene, on the contrary, there is always grave consti- 
tutional disorder, while the local phenomena arcdenotive of high vascular actioB. 
The ulcer is foul, exquisitely painful, deeply incrustcd with lymph, and surrounded 
by a livid, vesicated surface. The granulating process is speedily arrested, and 
the sloughing extends in every direction. 

The prognosis of this disease varies with many circumstances, a few only of 
which it will be necessary to specify. Thus, it is always, other things being 
equal, more unfavorable when the attack is of an epidemic character than when 
it is sporadic, and in persons who have been exhausted by previous safTering, 
privation, or intemperance, than in such as are young and robust. The extent 
of the disease must also necessarily exert a material influence upon the progress 
of the case, the danger being less when this is slight than when it is considerable, 
and conversely. Serious involvement of the brain, the early occurrence of 
delirium, or the development of secondary disease in some internal organ, as the 
lung or liver, always portends evil, and should induce a guarded prognosii 
Formerly, hospital gangrene was an extremely fatal disease, the mortality being 
often in the proportion of one to three of those attacked. In some instances, 
indeed, nearly one-half perished. Since the pathology of the disorder, however, 
has come to be better understood, comparatively few cases prove fatal. 

Death may be caused by mere exhaustion of the vital powers from the extreme 
violence of the morbid action, or from the occurrence of repeated hemorrhages, 
as wlu^n an important vessel is laid open during the sloughing process. In 
general, the arteries and veins are among the last structures that yield to the 
devastating influence of the disease, and it, therefore, seldom happens that they 
are not protected by a provisional clot ; occasionally, however, nature fails in 
her efforts, and the bleeding may not only be profuse but fatal. Finally, there is 
a class of cases, by no means uncommon, in which, although the suffering is very 
great, death is apparently occasioned by an empoisoned state of the syston, 
induced by purulent infection, or the formation of secondary abscesses. The 
time at which death occurs varies from a few days to several weeks from the com- 
mencement of the attack. 

Treatment, — The treatment of hospital gangrene was, until lately, but little 
understood, and the consequence was that an immense number of persons were 
lost by it. The indiscriminate use of bark and other stimulants, so much in 
vogue among the army and naval surgeons of Europe, especially those of Great 
Britain, even down to the time of the late Mr. Hennen and his colleagues in the 
Peninsular wars, exercised a most destructive influence upon the subjects of this 
disease. No judgment seems to have been employed by these practitioners In 
adapting their remedies to the exigencies of their cases; all were treated alike, 
and the result was an amount of mortality that was often truly appalling. Dr. 
Boggie did much to reform this vicious system, by substituting the use of the 
lancet ; but it is questionable whether he did not err by carrying his measures to 
the opposite extreme. However this may be, it is certain that neither plan ii 
applicable to all cases ; but that the management of each must depend upon ill 
own contingencies. The abstraction of blood can, as a general rule, be reqnind 
only in persons of a comparatively robust constitution, and in the earlier stages 
of the disease ; but even then it should be practised with much caation, lest it 
lead to fatal exhaustion, or so far damage the system as to prevent it fhim shak- 
ing off, without great difficulty, the morbific influence. The disease, it mnst be 
recollected, has an asthenic tendency, often from the very start, especially whn 



CHAP. IT. HOSPITAL GANURBNE. 175 

it is of an endemic character ; and hence any measures calculated to favor this 
tendency must necessarily exercise a pernicious influence. 

Purging and attention to the diet and secretions constitute important elements 
in the treatment, and must on no account be neglected. A goocl dose of calomel 
and rhobarb, or of equal parts of blue mass, jalap, and compound extract of 
colocynth, given so as to induce two A three large, consistent, alvine evacuations, 
will often be more beneficial in arresting the morbid action than almost every- 
thing else. Subsequently the bowels should be constantly maintained in a 
solable condition, without establishing any decided drain upon them, and the 
utmost care should be taken to restore the secretions, which are always so much 
disordered in hospital gangrene. Mercury, as a salivaut, is to be avoided as a 
poison. 

When the system begins to flag, whether from the overwhelming influence of 
the attack, or from the neglect of proper treatment, prompt recourse must be had 
to quinine, iron, wine, brandy, and nutritious broths. The best preparation of 
iron is the tincture of the chloride, given in doses of fifteen to twenty-five drops, 
every three or four hours, in some mucilaginous fluid. Quinine is often extremely 
serviceable, and there are few cases, when this stage has been attained, which 
will not be immensely benefited by brandy, or some other form of alcohol, either 
alone or combined with milk. 

But the great constitutioual remedy in hospital gangrene is opium, either in 
substance, or in the form of morphia. It shouU be given in large doses, gene- 
rally not less than from two to four grains, every six or eight hours, in union 
with a diaphoretic, as ipecacuanha, tartar emetic, or tlie neutral mixture. AVhen 
we reflect upon the excessive pain, irritability, and sleeplessness which so generally 
attend the severer grades of this disease, it is im]>ossibIe to place too high an 
estimate upon the value of anodynes as means not only of insuring comfort to 
the patient, but of arresting the morbid action. 

The diet, especially in the latter stages of the disease, should be highly nutri- 
tious, and as concentrated as possible. The patient's room should be con- 
stantlj ventilated, the bed and Ixnly clothes daily changed, and the cutaneous 
surface frequently 8|>onged with tepid salt water, or weak alkaline solutions. 
The chlorides, bromine, or permanganate of potassa should l>c freely used. When 
the disease manifests an endemic tendency, as when it breaks out on board ship, 
or in the crowded wards of a hospital, the sick should be promptly sequestered, 
and the apartments thoroughly cleansed. 

When the disease is obviously connected with a scorbutic state of the system, 
the lH't*t internal remedies will be potassa, in union with lemon-juice, potatoes, 
wati-r cresses, oranges, onions, tomatoes, and other fresh fruits and vegetables. 

The local treatment should bi^ of the most gentle and soothing characttT. 
Any vesicles that may exist should be promptly opened, and the whole surface 
pencilled over with a weak solution of iodine, followed by the warm or cold 
water-dressing, containing a large supply of acetate of lead and opium, a cloth 
dippc*d in the solution being constantly kept upon the part. If an eschar has 
formed, the adjacent structun^s should be freely rubl>ed with the solid nitrat(> of 
silver, and as soon as the slough has dropped off, the botUim of the sore should 
be thoroaghly mopped \%ith a weak solution of acid nitrate of mercury, nitric 
acid, or perchloride of iron, with a view of changing its action. If the tendency 
to spread is very great, and there is, at the same time, excessive pain with a 
feeling of tension, scarifications and incisions must be practised, in the same 
manner and with the same object as in erysipelas. 

During the present war extensive use has been made, chiefly on the roeoni- 
mendation of Dr. Goldsmith, of pure bromine in the treatment of this affection. 
It is appliefl by means of a glass teat-tube or other suitable instrument, the 
extremity of which is brought in contact with die whole of the diseased sur- 
€m», previously divested of slough, and thoroacfabr dried. The parts should 
then be covered with a yeast, cinchona^ «r port- Itiee. One application 

generally suffices ; if a second be neoeaaaiy, it ^ lade under several 

days. 



176 TERMINATIONS OF INFLAMMATION. ohap.it. 

Another article of great potency, less painful than bromine and altogether 
superior to it, is permanganate of potassa, first employed in the treatment of 
hospital gangrene by Dr. F. Hinkle. Possessing powerful deodorizing, disin- 
fecting, and oxygenating properties, it may be advantageously used both inter- 
nally and externally ; internally, in doses of one to two grains severa) times in 
the twenty-four hours, and externally, as an escharotic, in concentrated solution, 
applied by moans of a camel-hair pencil to the surface of the wound and also 
to the cuticle for some distance around. The parts are first thoroughly cleansed 
with Castile soap and water, and afterwards covered with lint soaked in a weak 
solution of the medicine, the dressing being renewed about every three hours. 
When the wound is deep seated or inaccessible, medication is effected with the 
syringe. The sloughs usually separate in from four to six days, leaving a healthy 
sore which soon heals under simple treatment. The beneficial effects of petman- 
ganatc of potassa, as a remedy in hospital gangrene, are fully established, having 
been tested in several hundred cases of that disease. 

The hot iron has long been a favorite remedy with the French and German 
surgeons in the treatment of this affection, and of its occasional beneficial effects 
there can be no doubt. The application should always embrace the whole of the 
diseased surface. During the sloughing process a port wine poultice and weak 
solutions of nitric acid, chlorinated soda, creasote, and sulphate of copper will 
generally be found extremely valuable in arresting morbid action, and allaying 
fetor. Another useful remedy is pyroligneous acid, diluted with six or eight 
parts of water, and kept constantly upon the affected surface with a cloth. Dead 
structure should be removed with the knife and scissors. Should the mortifica- 
tion stop, amputation must not be thought of until there is a decided line of 
demarcation, with sufficient power in the constitution to bear the shock of the 
operation. During convalescence change of air generally proves an important 

auxiliary to recovery. 

f 

SECT. VIII. — ULCERATION AND ULCERS. 

Ulceration is the molecular death of a part, as mortification is the destruction 
of a part upon a large scale : in a word, it is dissolution in miniature. At least 
three distinct acts are concerned in its production : these are, first, the softening 
of the affected tissues, secondly, their disintegration, and, lastly, their removal, 
as effete and extraneous matter. Antecedently, however, to these acts there is 
another in operation, paving the way for their advent ; this is inflammation, 
which is always an indispensable accompaniment of the process, whatever may 
bo its situation, stage, or degree. It was supposed until lately, chiefly in conse- 
quence of the influence of the writings of Mr. John Hunter, that ulceration 
consisted essentially in the disintegration and absorption of the suffering tex- 
tures ; hence the general use of the phrase " ulcerative absorption." According 
to this doctrine the substance of the affected part, after having been deprived of 
vitality, is taken up by the absorbent vessels, and carried by them into the circu- 
lating mass, to go the rounds of the body, and be finally cast off as excremen- 
titious matter. There are numerous circumstances which, at first sight, would 
S(!em to favor such a view. Thus, large ulcers sometimes form in a very short 
time, and yet it is quite impossible, so far as we can determine by the most care- 
ful examination, to ascertain what has become of the tissues concerned in their 
development. If search be made for them in the discharges they cannot be dis- 
covered, since their quantity, however great, is frequently insufficient to account 
for the loss of solid material. Similar phenomena are witnessed in abscesses 
of the brain, liver, and spleen, where enormous destruction of the proper substance 
of these organs often occurs in consequence of the accumulating pus, without 
our being able to explain what has become of it It might naturally be supposed 
that the lost tissues were contained, in an altered and disintegrated condition, in 
the pus, but that this is not the case is proved by the fact that it is impossible to 
detect their presence by the most careful examination. 

Ulceration manifests a remarkable proneness to invade some stmctures and 



!HAP. IT. ULCERATIOX AND ULCERS. 177 

x> aToid others. Those which are most liable to its inroads are the dermoid 
md maooos tissoes, the cartilages, bones, lymphatic ganglions, tonsils, uterus, 
lungs, and kidneys. The fibrous and serous membranes, the muscles, tendons, 
resaels, ncrres, brain, heart, liver, and spleen, together with the salivary, pros- 
tate, and thyroid glands, seldom suffer in this way. Newly-formed parts, as 
deatrioes mod the aUlus of broken bones, are easily affected by ulceration, espo- 
ciaHy when, from any cause, there is a depraved and impoverished condition of 
the system. It is worthy of remark, both in a pathological and practical sense, 
that this action is more prone to show itself in certain portions of the same 
stnictnre than in others. Of this occurrence an illustration is afforded both in 
the skin and in the mucous membranes. Common ulceration of the skin is by 
hr most frequent in the legs and feet, whether because these parts are in a 
state of habitual congestion, or because they are more exposed to fatigue and 
accident^ is not determined ; but that this is the fact daily observation abundantly 
attests. Ulceration is extremely rare in the oesophagus, but quite common in 
Ae pharynx, tonsils, tongue, cheeks, and lips. The same statement is true of 
nlceration of the stomach and small intestine as compared with ulceration of the 
eokm and rectum. In the genito-urinary division of the mucous system a similar 
lav obtains. Thus, the disease is extremely infrequent in the urethra and bladder 
of the female, but common enough in the vulva, vagina, and uterus. The male, 
oa the contrary, rarely suffers from ulceration in any portion of the genito-urinary 
^iparatos. 

The terms common and specific, as applied to this disease, are sufficiently sig- 
nificaot. By the former is meant an ulceration that is liable to occur in all 
persons, as well as in all parts of the body, as a result of ordinary inflammation. 
The word q>ecific, on the other hand, is employed to denote an ulceration which 
is the product of some specific cause, which runs a peculiar course, and which, 
in its progress, furnishes a specific secretion, capable, by inoculation, of producing 
a nmiJar action. To this category belong syphilitic ulceration and the ulceration 
which follows vaccination and smallpox. The ulceration which attends carci- 
noma is also specific, but the matter it yields is not, so far as we know, capable 
of propagating a similar disease. 

Ulceration varies in its progress, being sometimes very rapid, at other times 
very tardy. The circumstances which determine this result are not always appre- 
ciable, but, in general, they may be considered as depending upon the nature of 
the exciting cause, the amount of the attending inflammation, and, above all, the 
state of the system. When the action is very rapid, an extent of surface may 
be destroyed in a few days which it may perhaps require several months to repair. 
The process often goes on simultaneously at several points in the same organ or 
tissue, and not unfrcquently in structures of an entirely opposite character. 

The causes of ulceration are such as produce inflammation, which, as has 
already been stated, always accompanies the process. They may very properly 
be divided into predisposing and exciting. The former comprise an impover- 
isiied state of the blood, however induced, and, in short, whatever has a tendency 
to impair the powers of the system. Experiments, performed long ago, by Ma- 
gendie and others, have established the fact that the protracted and exclusive 
OM of starch, sugar, and other non-azotized articles of food, will produce ulcera- 
tion of the cornea ; and it is well known that the poorer classes of people who 
are ill fed and sometimes almost starved, are peculiarly subject to this disease 
in the skin and mucous membranes. Ulceration of a severe nature often follows 
opon various kinds of fever, especially typhoid, scarlet, and morbillous, from the 
exhaosting influence which they exert upon the solids and fluids. 

Of the exciting causes of ulceration, nothing need be said, except that they 
may be common or specific, the latter being such as act primarily upon a par- 
ticalar part» as the head of the penis in chancre, or secondarily, in the same 
disease, upon the constitution, in consequence of the absorption of the specific 
poison. Tubercular, scirrhous, encephaloid, and melanotic matter, having under- 
gone a process of softening, always creates ulceration by its pressure upon the 
sd[jaoent tissues, thereby favoring its elimination from the part and system. 

TOL. I. — 12 



178 TERMINATIONS OF INFLAMMATION. cbap.it. 

The inflammation which precedes and accompanies ulceration yaries mudi in 
its degree, as well as in its character. When acute, it is usually marked bj the 
phenomena which ordinarily distinguish it under other circumstances, as discol- 
oration, heat, swelling, pain, and disordered function, and then often spreads 
with great rapidity, laying waste a large amount of tissue in an almost incredibly 
short time. When this is the case, the molecular structures perish, as it were, 
in mass, and not in the slow and gradual manner which characterizes the disease 
when the inflammation is of a more mild and simple grade. It is to this form 
of ulceration that the term phagedenic is commonly applied, from a Greek com- 
pound literally signifying to eat, feed upon, or corrode, the parts around the 
breach made by the morbid action being rapidly disintegrated and cast off, as if 
they had been consumed by fire, their ashes alone being left as the evidence of 
their former existence. When the concomitant inflammation is chronic, the 
ulceration generally advances more tardily, and is also marked by fnilder symp- 
toms ; this rule, however, has many exceptions. 

The pain of ulceration is sometimes peculiar, affording thus valuable diagnostic 
information. Thus, in ulceration of the joints and bones, it is usually heavy 
and aching, as if insects were feeding upon the part ; in rupia, it is hot and 
burning; in scirrhus, sharp and lancinating, or like the pricking of a needle. 
Sometimes, again, there is a complete absence of pain, as in common ulceration 
of the skin, in ulceration of the glands of Peyer in typhoid fever, and in ulcera- 
tion in tubercular disease of the large bowel. As a general rule, it may be 
stated that the pain is more severe in the acute than in the chronic form of the 
disease, and it is then also more steady and persistent. In syphilitic ulceration 
of the bones and skin, the suffering is often of an intermittent character, the 
paroxysm usually coming on at night, and gradually disappearing towards 
morning. Finally, the pain may be of a neuralgic character, although this is 
rare. 

Ulceration is always attended with more or less discharge of matter, the quality 
of which is greatly influenced by the nature of the case. Thus, when the attendant 
inflammation is unusually high, the matter is generally of a sanious, bloody, or 
ichorous character, corrosive and profuse ; a similar fluid is always present in 
ulceration of carcinomatous growths. When the action is less severe, or tending 
to restoration, the discharge is commonly somewhat consistent and of a yellowish 
color, like laudable pus. 

The tendency in ulceration is usually towards the nearest surface, a circnm- 
stance which is often of great service in the evacuation of abscesses and the 
discharge of foreign matter. It would seem is if nature availed herself of the 
operation of this law to economize time, save structure, and prevent pain. With- 
out its aid, abscesses would often, if, indeed, not generally, be emptied in the 
most tedious and circuitous manner, and at the expense of a vast amount of 
suffering, both local and constitutional. An illustration of the beneficial effects 
of this law is afforded in collections of pus in the liver, which, as a general rule, 
discbarge themselves, not through the walls of the abdomen, which are thick, 
muscular, and resistant, but through a contiguous coil of intestine, which is thin, 
proximal, and yielding. In abscess of the lung, the matter usually escapes 
through a neighboring bronchial tube ; when it makes an effort to empty itself 
externally, it either pours the fluid into the pleuritic cavity, thus speedily causing 
fatal inflammation, or it attains its object only after a long and tedious process 
of ulceration, generally accompanied by great pain and hectic irritation. 

When ulceration has continued for some time, it manifests a disposition either 
to remain stationary, to cease altogether, or to continue in a modified form. Its 
conduct, in these various particulars, is greatly influenced by internal and external 
circumstances, as the state of the constitution, the amount of the local inflamma- 
tion, the nature of the exciting cause, and the effects of remedies. In the skin 
of the lower extremities, in syphilitic rupia, in the spongy structure of the bones, 
in the movable joints, and in malignant growths, it often continues for an almost 
indefinite period, being better at one time and worse at another. When it is 
about to cease, the accompanying inflammation gradually subsides, the discharges 



CHiF. !▼. ULCERATION AND ULCERS. 179 

disappear, and, plastic matter being poured ont, granulations are formed, by which 
the breach is finally closed up, the process of cicatrization generally, if not always, 
proceeding from the circumference toward the centre. 

In the treaimerU of ulceration, the great and leading indication is to combat 
the concomitant inflammation, and thus place the part in a condition for the 
efficient development of granulations, as it is through their agency that the lost 
substance is to be repaired. For this purpose the ordinary antiphlogistic appli- 
ances are to be put in requisition and continued until the morbid action has been 
completely arrested, as will be denoted by the subsidence of the pain, heat, swell- 
ing, and redness by which it is usually characterized. When granulations begin 
to form, none but the most mild and soothing measures must be employed, and 
the sore carefully watched to keep it in a healthy condition until it is perfectly 
cicatrized. In specific disease, as chancre and malignant pustule, the most efficient 
treatment, provided the case can be seen in time, before the matter has been 
absorbed into the system, is to cut out the part or destroy it with the actual 
cautery, Vienna paste, or acid nitrate of mercury. 

ULCERS. 

An ulcer is a breach in the continuity of a surface, organ, or tissue, attended 
with inflammation, and a discharge of pus, ichor, or sanies. The disease, which 
is of frequent occurrence, is met with at all periods of life, in both sexes, and in 
all classes of persons, and is often a source of great suffering to the patient, as 
well as of immense trouble and vexation to the surgeon. Its very name carries 
with it an idea of loathsomeness, and it may well be imagined how much this 
feeling is increased when, as so often happens, the sore is the seat of foul and 
offensive discharges, rendering the patient disagreeable both to himself and to all 
around. 

It may confidently be asserted that there is not, in all surgery, a class of mala- 
diej* whose pathology and treatment are less thoroughly understood, by the pro- 
fession generally, than those of ulcers. It is amazing to find what an immense 
amount of confusion still exists upon the subject even among many of the best 
and most experienced authors. In examining the various treatises on surgery, 
in the principal languages of Europe, the reader has little cause to congratulate 
himself upon the progress that has been eflected in this department of the healing 
art. He looks almost in vain for any positive additions to his stock of knowledge 
since the latter part of the last century, when Mr. Benjamin Bell published his 
Treatise on the Theory and Management of Ulcers. The minute divisions and 
subdivisions, the refinements and absurdities, respecting the nature of these 
lesions, are, with little variation, substantially reproduced by most of the pradieal 
writers of the present day. In studying the literature upon the subject, one is 
almost forced to the conclusion that, while every other branch of surgery has 
experienced the benign influence of progress, this one alone has remained unim- 
proved and uncared-for. I am, indeed, ready to admit that the nosography of 
ulcers is much more perfect now than it was formerly ; but who can read their 
classification, as it appears in most of our modern treatises, and not be struck 
with its many absurdities and inconsistencies ? The catalogue is absolutely 
appalling, and it must be apparent to the most superficial observer that it com- 
pn^hends, under different names, diseases which are absolutely and positively 
identical in their nature ; not even constituting, strictly speaking, so many varieties, 
much less distinct species. Sir Astley Cooper, in his Lectures on the Principles 
and Practice of Surgery, describes not less than ten forms of ulcers, under the 
names, respectively, of healthy, languid, inflamed, gangrenous, irritable, sinuous, 
menstrual, varicose, ungual, and cutaneous, the latter including noli me tangere, 
and ulcers with thickened, inverted, and everted edges. A more recent foreign 
author, whose works are extensively circulated in this country, adopts a some- 
what similar arrangement. Thus, he treats, under so many separate heads, of 
the simple purulent or healthy, the weak, scrofulous, cachectic, indolent, irritable, 
inflamed, sloughing, phagedenic, and sloughing-phagedenic ulcer. The sam^ 



180 TERMINATIONS OF INFLAMKATION. CBir. it. 

spirit of classificatioD pervades the works of other writers. Why, then, shonld 
it be deemed strange that the student should take up the inyestigation of the 
subject with doubt and misgiving as to his ability to comprehend it, even in the 
most superficial manner ? No one, however industrious and zealous, can posubly 
unravel the mysteries of divisions so minute, and, it may be added, so atteriy 
meaningless and unphilosophical. It would puzzle the most profound patholo- 
gical anatomist to discriminate between some of these classes of ulcers, as, for 
instance, between the irritable and inflamed, the sloughing and sloughing-phage- 
denic. To describe every sore that appears upon the body as a distinct nicer 
because it happens to possess slight shades of differences, in its external diarac- 
tcrs, would be as absurd as to describe, in a work on anthropology, every human 
being as a separate variety of the race because he happens to be a little unlike 
his neighbor. All inflammatory affections resemble each other, some closely, 
others remotely, but yet always sufficiently so to enable the observer to trace out 
their relations and affinities. The same is strictly true of ulcers ; we never meet 
with two cases which are precisely alike, and yet he who runs may see that they 
exhibit many traits in common, the one with the other ; one may be undermined, 
incrustcd with aplastic matter, and the seat of severe pain, with a foul, sanious 
discharge, and great discoloration, heat, and swelling of the surrounding integu* 
ments ; another may have hard and elevated edges, and a glossy, granulated 
surface, with, perhaps, scarcely any secretion at all, and none of the ordinaiy 
evidences of inflammation ; in a third case the ulcer may be disposed to spread, 
its tendency being essentially destructive ; in another series, by no means ui^ 
common, the sore has thickened and everted edges, with profuse ichorous 
discharge, and an inability to furnish reparative material ; finally, there may be 
a varicose state of the veins of the part, a sinus, disease of the adjacent bone, 
or disorder of the general system, modifying the action of the ulcer, and inter- 
fering with its cure. These are, be sure, contrarieties, but contrarieties which 
are solely dependent upon local and constitutional causes, and which, conse- 
quently, are not entitled to be considered as distinct diseases. We might as 
well say that the varieties of color in ordinary inflammation constituted so many 
reasons for founding new species of morbid action, when it is obvious that, in 
this as in the former case, the circumstance is entirely accidental. The tendency 
of this refinement, of this division and subdivision, is, as above stated, the cause 
why practitioners have so imperfect a knowledge of ulcers, and why every one 
complains of the great difficulties and embarrassments which still environ the 
subject in all its aspects and relations, nt^twithstanding the great advances of 
pathological science. 

Assuming that all ulcers are merely so many forms of inflammation with breach 
of texture and more or less discharge, the most rational classification, it seems 
to me, that can be adopted, is that of ulcers into acute and chronic, according to 
the intensity and rapidity of the morbid action. Such an arrangement certainly 
greatly simplifies the subject and divests it of much of the mystery and per- 
plexity that have hitherto enshrouded it. 

There are two genera of ulcers, the common and the specific, just as there lure 
two genera of inflammations. Common ulcers are such as arc produced by 
ordinary causes, as common inflammations, abrasions, and wounds; specific 
ulcers, on the contrary, owe their origin to the operation of some peculiar .virus, 
as the poison of syphilis, smallpox, glanders, malignant pustule, scirrhus, ence- 
phaloid, tubercle, or melanosis. Although the ensuing remarks arc more particu- 
larly intended to illustrate the various forms of common ulcers, they are also, at 
least, in some degree, applicable to the specific, which, however, will receive 
special attention in their proper place. 

1. ACUTE ULCERS. 

The acute ulcer is distinguished by the rapidity of its progress, and the severity 
of its symptoms, which are those very much of ordinary acute inflammation 
The sore usually begins at a small point of skin, or skin and cellular tissue, flrom 



CHAP. IV. ACUTE ULCERS. 181 

which it speedily spreads in different directions until it often covers a large extent 
of surfkce. In its form it is generally somewhat oval or circular, but it is fre- 
qaently Terj irregolar, and instances are met with in which it is of a serpiginous, 
creeping, or angular shape. When the ulcerative action commences simultaue- 
ouslj at several spots, as occasionally happens, the sore may have a peculiar 
neTe4ike, or worm-eaten appearance, similar to that of the cover of an old book, 
or the bark of a tree. Its surface is red and angry-looking, either uniformly, or 
red at one point, and white at another, owing to a deposit of aplastic matter, 
which occasionally overspreads it completely. When the action is unusually 
severe the bottom of the ulcer generally exhibits a foul, greenish, brownish, or 
blackish appearance, and if, under such circumstances, any plasma is poured out, 
it is immeifUately spoiled or washed away by the discharges, which are always 
thin, sero-sanguinolent, and irritating, possessing none of the properties of 
Uodable pus, snch as is furnished by a granulating wound. In regard to the 
edges of this class of ulcer, they present the greatest possible variety ; in general, 
however, they are thin, rather sharp, and somewhat undermined, or undermined 
at one place, straight at another, and perhaps everted at a third : in some cases 
they are very steep and ragged, notched or serrated. Extending from the sore 
in different directions are occasionally small sinuses or fistulous passages, which 
thos gpreatly complicate its character and protract the cure. The parts immedi- 
ately aronnd the nicer exhibit all the phenomena of high inflammation, being of a 
deep red, livid, or purple color, pretematurally hot, painful, and more or less 
CEdematons, from sero-plastic effusions, and consequently pitting under pressure. 
The laiter symptom is hardly ever entirely absent in any case of acute ulcer, and 
is therefore of great diagnostic value. The oedema often extends over a consider- 
able surface, but is always most conspicuous in the immediate vicinity of the sore. 
The same remark is applicable to the other inflammatory phenomena. 

The pain of the acute ulcer is frequently a prominent and absorbing symptom ; 
it varies not only in degree but likewise in character, being at one time throbbing 
or palsatile, at another sharp or pricking, at another dull, heavy, and gnawing, as 
if insects were feeding upon the part. Its violence is often altogether dispropor- 
tionate to the extent of the morbid action. I have seen cases where, although 
the ulcer was scarcely as large as a twenty-five cent piece, it was so excruciating 
as to deprive the patient of sleep for days and nights together, and bring on rapid 
emaciation and hectic irritation. It may be limited to the sore, but in general it 
is felt over the whole of the inflamed surface, and is usually worse at night and 
in damp states of the atmosphere. Posture also commonly aggravates it, being 
generally more severe when the part hangs down than when it is elevated, although 
occasionally the reverse is true, even when the sore is quite large. 

Along with these phenomena there is generally considerable constitutional de- 
rangement, manifesting itself, not so much commonly in febrile commotion, as in 
an irritable state of the system, and in disorder of the digestive organs. The 
patient feels unwell rather than sick ; his head troubles him ; his appetite is vitia- 
ted, or temporarily arrested ; the tongue is coated, and there is a bad taste in 
the month, especially in the morning ; the bowels are inclined to be constipated ; 
and the urine is scanty and high-colored. When the ulcerative action is rapid 
and extensive, there is frequently more or less fever, with thirst, restlessness, 
loss af sleep, and excitement of the pulse. Disorder of the secretions is generally 
a prominent symptom in these cases, especially of the liver, the uterus, and mu- 
cous follicles. 

An impoverished state of the blood, however induced, habitual intemperance, 
excessive indulgence at table, mental anxiety, exposure to cold, and the various 
eruptive diseases may be enumerated as so many predisposing causes of the acute 
ulcer. Xervous, irritable, and plethoric persons, especially old dram drinkers, 
are its most frequent subjects. Both sexes are liable to it, but men suffer much 
more frequently than women. The malady is rarely met with in the higher circles 
of society, and it is also very uncommon in children. 

The acate ulcer may be a primary affection, or an ulcer, after having been for 
some time in a dormant condition, may suddenly assume the acute character, either 



182 TERMINATIONS OF INFLAKMATION. gbap. it. 

in consequence of local or constitutional causes, or of both combined ; that is, the 
part becomes more or less severely inflamed, and manifests a tendencj to extend 
its ravages. However this may be, the disease often spreads with great rapidity, 
eating away everything with which it comes in contact — skin, cellnlMr tissue, 
fibrous membrane, muscle, and sometimes even bone — and often laying waste in 
a few days an extent of surface which it may take months, aided bj the best skill, 
to repair. When this is the case, the action may be said to be truly phagedenic, 
or to consist in rapid mortification of the molecular structure of the suffering 
part, which is hot, oedematous, fiery red, exquisitely painful, and bathed with 
profuse, fetid discharges. Constitutional disturbance is great, and the tendencj 
is usually decidedly typhoid, especially if .the subject of the disease baa been 
worn out by intemperance and other causes of depression. This form of ulcer is 
very prone to occur upon new and imperfectly organized skin, where it often com- 
mits the most terrible ravages, which, for a time, hardly anything can saccessfullj 
resist. 

Treatment. — The treatment of the acute ulcer must be strictly antiphlogistic, 
modified, of course, by the peculiar exigencies of each particular case. When the 
symptoms arc urgent, as denoted by the severity of the local and constitutional 
disorder, the indication obviously is to take blood from the arm, provided the 
patient is at all plethoric ; or, this not being permissible, at all events to open his 
bowels freely with an active cathartic, containing from five to ten grains of calo- 
mel, and followed up, if necessary, in six or eight hours, by infusion of senna and 
sulphate of magnesia. Recourse is then had to the antimonial and saline mixture 
to subdue vascular action ; while opium is administered in large doses to allay pain 
and induce sleep. The diet must be mild and not too nutritious, and the patient 
must observe the most perfect rest in the recumbent posture. Active purgation 
will be found to be of the greatest value in this form of ulcer ; in fact, it is difficult to 
imagine a case in which it could be entirely dispensed with. To render it promptly 
effective, however, I have long been in the habit of combining with it a certain 
quantity of mercury, either in the form of calomel, or blue mass, with a view of 
making a strong and rapid impression upon the secretions, which, as before 
stated, arc usually notably deranged, and which thus keep up a spreading ten- 
dency in the disease. Of the beneficial effects of anodynes in arresting acute 
ulceration no one, who has not witnessed them, can form any just conception. 
That they exert any direct influence upon the part itself cannot be supposed ; 
but that they produce a most salutary impression by tranquillizing the heart's 
action, and allaying nervous irritability, which is generally so prominent a symp- 
tom in this affection, is indisputable ; hence the remedy should aways be given in 
large and sustained doses from the very commencement of the malady. 

It is not to be inferred from the remarks now made that active depletion is 
suited to all cases of this disease ; on the contrary, we are often obliged to use 
tonics and stimulants at the very beginning of the treatment, and to continue 
their exhibition until we have succeeded in building up the system, so as to enable 
it to oppose a successful barrier to the encroachment of the morbid action. The 
state of the pulse, skin, digestive organs, and muscular system will generally 
serve as a correct guide to the kind of treatment best adapted to meet the exi- 
gencies of this class of cases. Quinine, iron, and milk punch, with opium, or the 
salts of morphia, will usually constitute the most reliable means. 

The local treatment will not differ, in its general principles, from that already 
described as applicable to acute inflammation, except as it respects the modifica- 
tions arising f^om the presence of a broken surface. The part, as a primary and 
essential step, must be placed perfectly at rest in an easy and elevated position, 
to prevent arterial ingress and favor venous return ; it will even be well, in many 
cases, to lay the limb upon an inclined plane, so that the sore shall be higher than 
the rest of the body, and to confine it, if necessary, in this situation by means of 
a light roller, care being taken not to obstruct discharge or to make undue com- 
pression. If the part be filthy from want of cleanliness, or adherent dressings, 
ablution by immersion should precede direct medication. If the morbid action be 
high, the young practitioner might be induced to apply leeches, not to the sore. 



CHAP. IT. AGUT£ ULCERS. 183 

bat in its immediate yicinity ; but such a proceeding is objectionable, for the rea- 
son that the bites of these animals are liable to occasion excessive pain, and some- 
times even an aggravation of the disease. A much better plan is to draw blood 
bv scarification with the lancet, the limb, firmly encircled with a cord a few 
inches below the knee, the while standing in a tub of warm water. From 
six to a dozen vertical incisions, not quite skin deep, are made over the inflamed 
surface around the sore, and the blood is permitted to flow until the patient shows 
signs of approaching syncope, if he be at all plethoric, or, at all events, until the 
engorged vessels have been measurably deprived of their contents, as denoted by 
the comparative pallor of the part. I know of no method so well adapted as this 
to make a prompt and decisive impression upon an acute ulcer ; it is a most po- 
tent alterant, and I rarely omit its employment whenever the case presents the 
slightest urgency. For the sore itself the best remedy is the officinal solution of 
acid nitrate of mercury, diluted with two, three, or four parts of water, accord- 
ing to the foulness of the affected surface. The application should be made 
lightly with a soft sponge or a cloth mop, and may, if necessary, be repeated once 
in the twenty-four hours until there is a manifest improvement in the condition 
of the ulcer, when it should be entirely dispensed with, or used more sparingly, and 
still weaker. As a constant covering for the parts the most suitable one is a light 
emollient cataplasm, sprinkled with morphia, laudanum, or powdered opium, or 
the warm water-dressing, similarly medicated. Fetor is allayed with the chlo- 
rides. In some instances yeast may advantageously be added to the poultice ; 
but in general this may be dispensed with. Under this treatment rapid improve- 
ment may usually be looked for ; indeed, in many cases we have the satisfaction 
to find, within less than thirty-six hours after its commencement, already a de- 
cided change for the better ; the ulceration evinces a disposition to cease, the dis- 
charges assume a more healthy aspect, and the surrounding parts lose their fiery 
red and cedematous character. By persevering in the treatment, in a modified 
form, the sore will soon begin to granulate, and to form new skin along the mar- 
gin of the old, and this point being attained, none but the mildest applications 
will be required. 

Such, in a few words, is an outline of the treatment which, when a choice of 
remedies is allowed, I usually adopt in this disease. But the patient will not 
always submit to scarification, nor is this always proper, owing to the exhausted 
condition of his system. Under such circumstances, our object may often be 
promptly attained by the free application of the dilute tincture of iodine to the 
parts around the sore, while the sore itself is lightly touched with the acid nitrate 
of mercury, as in the former case, or with a strong solution of nitrate of silver, 
or this article in substance, although both are decidedly inferior to the former 
remedy. In some instances I have succeeded in putting a prompt and permanent 
check to the ulcerative action by covering the sore and the inflamed surface with 
a blister, retained until thorough vesication was induced, and then using the 
ordinary dressings Few cases of acute ulcers are able to resist this remedy. 
Its beneficial effects are no doubt due to the drainage which it establishes and 
the consequent change in the action of the capillary vessels. The progress of 
the cure is sometimes embarrassed by dead matter, as shreds of cellular tissue or 
fibrous membrane, the removal of which should receive prompt attention. 

Of creasote, sulphate of copper, acetate of lead, and other remedies so much 
lauded by some practitioners in the treatment of acute ulcers, little need be said. 
These articles undoubtedly possess some merit, and I have occasionally employed 
them with advantage, but as they arc altogether of a subordinate character they 
should never take the place, in urgent cases, of those just mentioned. Acetic 
and nitric acid, the former in the proportion of one drachm, and the latter of 
eight or ten drops, to the ounce of water, are excellent applications, in the milder 
varieties of the affection, allaying fetor and changing the action of the sore so 
as to promote the formation of healthy granulations and laudable discharge. 
Lead water is chiefly serviceable when there is unusual vascular activity in the 
parts around the ulcer. 



184 TEBMINATIOX3 OF INFLAIIMATION. cbap. it. 

2. CHROMO ULCERa 

While it is not always easy to determine when an ulcer becomes chronic, it is 
to be borne in mind, as was previonsly stated, that a chronic ulcer maj, in con- 
sequence of local and constitutional causes, occasionally assnme an acute charM- 
ter. In this respect the present disease does not differ from ordinary inflamnui- 
tion, unattended by breach of teztnre. Thus, an inflammation of the coiijunctiT% 
after having pursued a chronic march, with but little pain and discoloration, 
perhaps suddenly, at the end of several months, breaks out with renewed vigor, 
characterized by all its primitive intensity, and now rapidly urging on the affected 
structures to permanent disorganization, rendered the more prone to this occur- 
rence by their protracted suffering. Ulcers are not onfrequently snlirjected to 
similar hardships ; not once only, but, perhaps, many times dnring their progresi^ 
and thus their career often becomes a most checkered one, defying alike our 
powers of diagnosis and treatment, and constituting at least one of the causes, 
previously adverted to, of the unscientific nomenclature which disfigures this 
branch of surgery. 

When does an ulcer become chronic? or, in other words, what time must 
elapse before it can be said to assume this character 1 To this question it is 
impossible to give anything like a definite reply ; in some instances the disease 
is chronic almost from the beginning ; in others, it becomes so in a few weeks, 
and in others, again, perhaps several months intervene. The term chronic, as 
every one knows, has reference to time, and is employed to designate a class of 
affections which have passed through their acute stages, and which, consequently, 
have been deprived of their primitive characteristics ; their action has been 
modified by treatment, by the operation of time, or by the joint influence of both. 
The inflammation now generally exists in a much milder form ; there is less func- 
tional disturbance, while the constitutional derangement often entirely ceases, and 
the local phenomena of heat, redness, pain, and swelling are materially dimin- 
ished. The part, however, is oppressed, if not overpowered, by effused fluids ; 
its vessels are sluggish, dilated and engorged with dark blood ; nervous sensibility 
is perverted, and the restorative tendency is either much enfeebled or else com- 
pletely at a stand. Ulceration still goes on, and perhaps even serious havoc is 
committed by it, but the action is tardy, and exhibits few, if any, of the pheno- 
mena which originally characterized it It would seem, at first sight, as if it 
were a paradox to say that a disease was chronic from its commencement, and 
yet such is, nevertheless, the fact, rather, however, in reference to its symptoms 
than to the true and legitimate meaning of the word. 

Chronic ulcers often exist for many months and years together ; at one time 
stationary, now receding, now advancing ; in one case exhibiting too much action, 
in another too little, but rarely in a condition to furnish the requisite amount 
and quality of reparative material. Even if granulations occasionally do form, 
they are seldom of a healthy character, or, if they are, it is seldom that they long 
retain it ; on the contrary, they soon languish for the want of proper support, or 
they perish from the violence of the attendant inflammation. These effects may 
be the result purely of local causes or of causes exerting their influence indirectly 
through the constitution ; generally, perhaps, of both. If this statement be 
true, as multiplied observation proves, we cannot fail to deduce from it important 
principles of practice. It plainly suggests the necessity, in every instance, of 
instituting a careful inquiry into the nature of the exciting cause and the condi- 
tion of the system, as well as the state of the part itself. To treat a chronic 
ulcer upon any other plan would be a palpable absurdity ; and yet that this is 
generally the case my experience amply attests. Few practitioners look upon 
this class of diseases in the true light of philosophy ; their ideas of their patho- 
logy are vague and indistinct ; and it is therefore not surprising that they shonld 
find themselves completely baffled in their efforts at curing them. It is for this 
reason that chronic ulcers of the legs have so long been regarded as an oppro- 
brium of surgery, and that so many patients are obliged to carry their malady 
with them to the grave, notwithstanding the numerous attempts that may have 



. IV. CHBONIO ULCEBS. 185 

nude to get rid of it ; all u^Biug from the fact that its tme uatnre was 
r properly anderatood. 

it dtronic nicer is capable of asBnming every possible Tariety of Beat, nam- 
foriB, dxe, color, condition of surface, and complication. Id genera), it is 
1 to occupy the inner sarface of the leg, a few inches above the ankle ; but 
ofteD sitnated higher up, and in rara cases it is placed directly over the Joint 
'. The outer surface of the limb is also liable to suffer, and we occasioDally 

with instances of ulcers existing simultaneonely upon both BidcB. In fact, 
art of the leg is wholly exempt from the disease, unless it be that just below 
JK*. Why this liability should exist to a greater extent at one point than 
•other we are unable to explain. 

^M the diflerence is owing to Fig. 23. 

Eict that the inner surface of 
iob is more liberally supplied 

▼eins, and, consequently, more 
!ct to habitual congestion of the 
and cellular tisane. Such an 
at all events, is not improbable. 
M form of the ulcer is variable, 
f at one time circnlar, now oval, 
then angular, or so irregular as 
itj all attempts at accuracy of 
■iptioD. In some cases, it ex- 
I ronnd the limb in the form of 
It neariy of equal width. In 
it ranges from that of a five- 
piece to that of the palm of the 
, or eren the entire band, the 
■netion of substance being truly 

tfal. In its depth, it rarely .,„„,„„„_,„ .„„„ „,.>.u™ -,iu ^.-ui.,^ 

tea beyond the enbcntaneons uuh. 
lar tissue ; in some cases, bow- 

. it involves the aponeuroses, the muscles, and even the bones and cartilages, 
1 ravages generally imply an unugnal amount of antecedent inflammation, or 
'Cpeatod iuterreution of acute action, although they are often produced by 
iteady progress of the chronic disease itself. 

ithongh the chronic nicer is often solitary, it is not uncommon to meet vrith 
three, or even a larger number, situated either in close proximity with each 
r, or at different, and perhaps rather remote points of the limb. When the 
ber is considerable, their size is ueually proportionately small. 
le color of the ulcer varies from light rose to deep purple, according to the 
laity of the concomitant action and the congested condition of the cutaneous 
llaries. The most common shades of color are the dnsky, brownish, and 
. livid, but it is worthy of note that an ulcer which is of a rosy hue to-day 
be of a deep purple to-morrow, simply from the change in the condition of 
inflammatory action. The parts around the sore are often quite as high- 
-ed as the sore itself; sometimes, indeed, much more so. In general, tJie 
ilormtion, whatever may be its character, is lost by insensible gradations in 
nrronnding healthy hue, not abruptly, as in erysipelas and erythema. 
. regard to the edges of the chronic ulcer, nothing can be more diversified ; 
e, some of the singular distinctions of Home, Astley Cooper, and others who 

followed so closely in each other's footsteps. In general, the edges are 

or callous, elevated, rather broad, and so insensible as to admit of the rudest 
ipnlation ; in some cases, they are thin, ragged, almost serrated, and either 
t«d or inverted, and perhaps exqnisitely sensitive. In another class of coses, 
o means infrequent, they are considerably undermined, or shelving at one 
t and everted at another. In fact there is no end to the diversities presented 
he boundaries of the sore ; hence, all attempts at description must be futile, 
M earfius of the sore is generally more or less irregular, being deeper at OM 




186 TERMINATIONS OF INFLAMMATION. cbap.it. 

part than at another, although, as was before stated, it rarely extends beneath 
the subcntaneons cellnlar tissue. Its real condition usually varies with the 
amount of inflammatory action. When this is considerable, there is often an 
entire absence of granulations, and then the bottom of the sore will generally be 
found to be in a foul, bloody, or phagedenic condition, or incrusted with a stra- 
tum of lymph too feeble to admit of organization; or, finally, granulations, 
sloughy matter, and vitiated plasma may all be present, in varying degrees, upoa 
different parts of the exposed surface. The concomitant discharge is profuse, 
sanious, fetid, and irritating, possessing none of the properties of healthy pns. 
The sore, as well as the surface immediately around, is unusually sensitive, and 
often the seat of severe pain. It is to this form of ulcer that writers usually 
apply the term inflamed, or irritable, from its excess of vascular and nervous 
activity. It is most common in nervous, irritable subjects, and in the habitnally 
intemperate. It is of frequent occurrence. 

When the inflammation is more moderate, granulations will seldom be wholly 
absent, and they may exist even in great abundance, although they may be alto- 
gether unhealthy. When the action is somewhat less, but not too languid, they 
commonly exhibit a pale, reddish, flabby appearance ; their surface is irregular 
or tuberculated, and they are much too large ; in fact, they look as if they had 
been reared in a hot-bed, and been too freely watered. Their reparative power 
is very feeble, and we are often obliged to get rid of them entirely before we can 
effect a cure. This state of granulation constitutes what is vulgarly called 
'' proud flesh," and is often difficult to manage. 

Again, the circulation may be inordinately languid, and then the granulations, 
if any be present, will generally be still larger than in the preceding case, totally 
insensible, and perhaps quite ccdematous, readily pitting under pressure, and, if 
punctured, freely exuding a serous, sanious, or ichorous fluid. Cacoplastic lymph 
is generally interspersed through the granulations, or adherent to the surface of 
the sore, the edges of which are hard and very prominent, so that the raw surface 
appears as if it were much below the level of the surrounding parts, which, how- 
ever, is seldom the case. The accompanying discharge is slight, thin, and sero- 
sanguinolent ; while the adjoining skin is osdematous and of a dusky-brownish 
hue. 

Finally, cases occur where the granulations are very small, or apparently 
stunted in their growth, irregular in shape, of a fiery red color, and so exquisitely 
sensitive as to be a source of great suffering, the ulcer being intolerant of the 
slightest pressure, or manipulation ; the discharge is sanious and irritating, 
although seldom very fetid or profuse ; the edges of the sore are thin, irregular, 
everted, or inverted ; and the surrounding skin is the seat of active inflammation. 

The chronic ulcer is often complicated with other diseases, which tend to 
modify its action, and impede, if not entirely prevent, its restoration. Of these 
affections some arc of a local, others of a general character. The former consist 
mainly in the involvement of the deep-seated structures, as the fibrous membranes, 
tendons, muscles, and bones ; in the formation of sinuses ; in a varicose state 
of the veins ; and in the presence of foreign matter, nn^pr the influence of which 
the ulcer was, perhaps, originally induced. Among the constitutional complica- 
tions, the most common are, disorder of the secretions, especially of the liver 
and alimentary canal, anemia, dyspepsia, plethora, and habitual intemperance in 
eating and drinking. I have never seen what writers have called the menstrual 
ulcer, although it is not to be doubted that great uterine derangement, showing 
itself in deficiency of discharge, might seriously interfere with the healing of a 
sore on the leg, or, indeed, in any other part of the body. 

Treatment. — In the management of chronic ulcers three leading indications 
present themselves ; first, to remove any complications that may exist ; secondly, 
to regulate the inflammatory action ; and, thirdly, to produce healthy granulations. 
Keeping before him these important points, to the attainment of which all his 
energies should be steadily directed, the practitioner cannot fail to settle down 
upon a rational and philosophical plan of treatment, which must, sooner or later, 
be crowned with success. Let him not lose sight of common sense, but proceed 



CHAP. IT. CHRONIC ULCEBS. 187 

preciselj as if the disease were one of ordinary inflammation, modified merely by 
aceidental circnmstances, and he will be Bare to go right. His object should be, 
in every. case, to bring the ulcer into a simple granulating condition, so as to 
give nature an opportunity of beginning and carrying on, without impediment, 
the healing process. 

Ulcers sometimes refuse to heal in consequence of the partial destruction of 
aponenrotic, tendinous, or muscular tissue, or the manner in which the parts are 
compressed by overlying structures : in the former case, the dead substance is 
removed with the knife or scissors : in the latter relief is afforded by adequate 
incisions, after which the malady is treated upon general principles. If necrosed 
bone exist, this must be extracted, while caries must be cut away with the chisel, 
saw. or scalpel 

Varicose veins are to be dealt with according to the rules laid down for the 
management of that disease in a subsequent chapter ; the complication is often a 
serious one, and nothing short of the ligation of the vessels, or their destruction 
with Vienna paste, will answer the purpose. When the malady is compara- 
tively slight, amelioration may be afforded by wearing a laced stocking to give 
oniform support to the limb, and by the free use of spirituous lotions, with the 
occasional application along the track of the enlarged vessels of the dilute tine- 
tnre of iodine. Hemorrhage sometimes attends this complication, from extension 
of the ulceration into a contiguous vein ; I have seen cases where more than a 
quart of blood was thus lost in a few minutes, and two instances have been 
reported to me where the bleeding was so copious as to prove fatal. The proper 
remedy is compression, followed, if need be, by a Vienna paste issue to produce 
permanent obliteration of the vessel at the seat of the ulceration. 

Sinuses are laid open with the director and bistoury, their course being com- 
pletely traced out, as no cure is to be expected so long as any portion remains 
concealed. Reunion of the incision is opposed by the tent and careful dressing. 

Ulcers, consequent upon wounds, are frequently prevented from closing by the 
presence' of foreign matter, as a pellet of paper, a piece of cloth, a ball, nail, or 
fimgment of bone ; when this is the case a careful search is made with the probe, 
and the substance extracted in the usual manner. 

One of the worst complications in chronic ulcers occasionally arises from the 
of the sore being undermined, inverted, uncommonly ragged, or very callous. 
The best procedure is to use the knife, cutting off all that is spoiled, redundant, 
or irreclaimable. Exuberant granulations are dealt with in the same manner, 
excision here being far preferable to escharotics, which are always painful, tedious, 
and uncertain. 

The second object is to reduce the concomitant inflammation so as to enable 
the sore to form healthy granulations, which it cannot possibly do so long as the 
morbid action is either very high or very low. One step towards accomplishing 
this end is the removal of complications, which, indeed, is frequently of itself 
sufficient to effect a cure. When this fails, the rest of the inflammation is often 
readily relieved by the use of the dilute tincture of iodine to the parts imme- 
diately around the ulcer, preceded, when the congestion and discoloration are 
unusually great, by free scarification ; and by touching the sore itself very gently, 
once a day, with the solid nitrate of silver, or, what is better, the acid nitrate of 
mercury, either in its pure state or variously weakened, according to the exigen- 
cies of each particular case. One application of the acid in the twenty-four hours 
will usually suffice, and in many instances the cure will progress more rapidly 
and satisfactorily if it be made less frequently. Other topical remedies may 
often be used with advantage, especially the nitric acid lotion, and w^eak solutions 
of «(nlphate of copper, acetate of lead and zinc, sulphate of zinc, creasote, and 
acetic acid. All these articles, however, are of a subordinate character, and hence 
I seldom have recourse to them. As a constant protection for the parts, nothing 
is more suitable than the elm or linseed cataplasm, which, notwithstanding the 
abuse that has been heaped upon it, is still, in most cases, one of our nicest and 
most reliable remedies. Or, instead of the poultice, the warm water-dressing may 
be used, although this is generally mnch less convenient in private practice, and 



188 TSBUINATIONS OF IN FLAUHATIOV. cbap. 

not any better. When the pain is very great, the application shonld be medicated 
witli solutions of morphia, or morphia may be cautioosly eprinlded diioctly npoi 
the BnrTace of the ulcer. 

During all this time proper attention is to be paid to the atate of the sjiton; 
the bowels arc regularly moved with mild aperients, and care is taken that te 
diet is perfectly mild and not too nutritious. If the general health is mnch im- 
ordered, recourse is had to more active purgation, and ftee use ia made of the 
antimonial and saline mixture, with a fall opiate at night, if there is mach p^ 
or inability to sleep. Bleeding at the arm will be required only in very ple^otfe 
subjects, in urgent caaes. Absolute recumbency is observed, at least nntil the 
morbid action has been measurably subdoed ; and the affected part is placed at 
rest in an easy, elevated position, precisely as in ordinary inflammation. 

If the general health is mnch reduced by protracted suffering, or if the system 
is in an anemic condition, or, finally, if typhoid symptoms are present, stimalanti 
and tonics will be indicated, especially qniniue and iron, with milk punch, and 
untritioua food. 

If the measures now detailed be judiciously employed, the surgeon will eoon 
be able to get the ulcer into a con- 
Fig. 3A. dition for the development of 
healthy granulations, fig. S4, and, 
as soon as this has been brou^t 
about, he will have little else to do 
than to watch the parts, with a 
view to the prevention of over-ac- 
tion. The mildest and moat sooth- 
ing applications will now generally 
suffice, the object being ratLer to 
protect the sarTace of the sore from 
the injurious contact of the atmo- 
sphere, than to promote its welfare 
by medicative agency. Among the 
best of these remedies are the cerates 
of opium, balsam of Peru, oxide of 
zinc, and the nitrate of mercniy, 
the last of which I prefer to dl 
others, on account of its cicatrix 
ing properties. It must, however, 
be employed with care, and in a 
very weak form, as in tJie propor- 
tion of six, eight, or ten gruns to 
the drachm of simple ointment 
The scabbing process may occasionally be expedited by touching the g^ranulatioDB 
very lightly, once a day, along the edge of the sore, for the space of a line, with 
the solid nitrate of silver. 

I consider rest, in the treatment of ulcers, as a matter of paramount import- 
ance whenever it is desirable to effect a rapid cure; I am certain, from much 
observation, that nothing else is at all comparable to it. Nevertheless, instances 
often occur where, either on account of the patient's condition in life, or the 
exhausted state of his health, exercise in the open air is absolutely indispensable ; 
under these circumstances, the part should be as carefully protected as the 
exigencies of the case will admit of, fatigue and protracted dependency being 
especially guarded against. The bandage in particular will usually be found to 
be a powerful adjuvant both to comfort and cure ; but it must be applied equably 
from the distal portion of the limb upwards, and not in folds or creases, otherwise 
it will do infinite barm. It mnst be changed at least once a day, being replaced 
as soon as the extremity has been thoronghly cleansed and the sore properly 
dressed. In hot weather, it may occasionally be kept constantly wet, with good 
effect, with cold water, spirituous lotions, or weak solutions of lead uid opium. 




o th« perlphffr^ lijWArdt t 




CIAP. IT. CHBONIO ULCERS. 189 

Manj practitioners are fond of strapping the sore and the ac^acent parts with 

adhesive plaster cot into strips, yary- 

isg from an inch to an inch and a pj 25. 

quarter in width, and long enough to 

extend abont three-fonrths round the 

fimb, each one being so arranged as 
to overlap that which is below it, and 
drawn so firmlj as to afford uniform 
rapport to the afl^ected surface, as in 
ig. S5. This plan of treatment, 
howcTer, which is known as that of 
Mr. Bajnton, by whom it was first 
•aggestedy has many disadvantages, 
of which one of {he most serious is 
the impossibili^ of watching its ef- 
fects, the sore being too much con- 
cealed from view. The method of 
Mr. Crichett, recently brought under 
the notice of the profession, is„ I 
conceive, still more objectionable ; it 
consists in enveloping the entire foot 

and 1^, for some distance above the Mode or vtnipping of an indolent nlcor. 

nicer, with adhesive plaster, a pro- 
ceeding which, although it may answer very well in the hands of its ingenious 
originator, can hardly fail to prove mischievous in the practice of others less 
adroit and less experienced in the use of the remedy. 

The proper method of dressing ulcers usually receives too little attention, and 
the eonseqaence is that the part often suffers great injury. All rude manipula- 
tion and protracted exposure must be avoided ; the sore should never be wiped, 
or even touched with the finger, and, while the necessary ablutions are going on, 
the limb should be carefully supported over a basin or small tub, the water, which 
mav be cold or tepid, being gently squeezed upon it from a sponge held several 
imies offl The secretions being thus disposed of, the surrounding surface is 
properly dried, and the dressing reapplied. If fetor be present, a little chlori- 
nated soda may be mixed with the water employed in cleansing the sore, as well 
as sprinkled from time to time upon the poultice and bandage. 

When a large extent of integument has been destroyed by the ulceration, or 
when the morbid action has a constant disposition to reappear, as so often hap- 
pens, upon the imperfectly organized cicatrices of old sores, it has been proposed 
to cover the breach by borrowing the requisite amount of tissue from the imme- 
diate neighborhood, as in the more ordinary plastic operations. The plan, which 
has been dignified with the name of elkoplasty, has been warmly advocated by 
Professor Hamilton, in a short article upon the subject published in 1854. The 
same principles of treatment, however, had previously been applied by Dr. John 
Watson, of New York, under the name of mylopoplasty, in a case of syphilitic 
nicer of the forehead, the particulars of which will be found in the American 
Journal of the Medical Sciences for October, 1844. To insure the union of the 
edges of the wound, it is necessary that the part should be quite free from inflam- 
mation, and that the general health should be as nearly as possible at the natural 
standard. The flap should be much larger than the gap in the limb, and should 
be well secured in its new position by the interrupted suture. 

Whatever mode of treatment be employed, it is of paramount importance, as 
it respects the prevention of relapse, that the patient should observe great care 
in regard to his diet and exercise, for a number of weeks after the ulcer has com- 
pletely healed. If he indulge his appetite too soon, neglects his bowels, or 
allows his secretions to become disordered, he can hardly escape a new outbreak 
of the disease, especially if, at the same time, he fatigues his leg much, lets it 
hang down constantly, constricts it improperly with his garter, rubs it with his 
boot, or permits it to become covered with filth. Cleanliness, indeed, cannot be 



190 TERMINATIONS OF INFLAMMATION. chap, i^ 

too rigidly insisted upon as a means of promoting the restoration of health 
action. Tl^e parts should be thoroughly washed at least once a day with soap 
and water, and then sponged with some alcoholic lotion, to reyive and invigorate 
their exhausted powers. 

In inveterate cases, extensively involving the osseoas tissue, greatly impairing 
the general health, and resisting the best efforts of the surgeon for their relieC 
the only resource is amputation, performed through a sound portion of the limb. 
I believe, however, that such a procedure will rarely be demanded in these days 
of conservative surgery ; for, unless the bone is almost entirely destroyed, it will 
be easy, in the majority of instances, to dispose of the diseased structures with 
the knife, gouge, and mallet, or by a resort to resection. 

Finally, the question may be asked, is it always safe and proper to heal old 
ulcers ? Upon this subject, various opinions have been expressed by writers on 
surgery. Those who assert that it is not, assume that a sore of this kind acts, 
when it has existed for a great length of time, as an issue, which serves as a 
safety-jfralve to the system, by ridding it of redundant, if not positively peccant, 
humors. They allege that cases have occasionally been witnessed where cerebral 
apoplexy and other serious diseases have occurred as the direct and speedy con- 
sequence of the drying up of such sores. Those, on the contrary, who espouse 
the opposite side of the question, declare that such attacks are mere accidental 
circumstances, readily explicable by the laws of coincidence ; and such is the 
view which I am myself inclined to adopt I do not believe that medical science 
possesses any well-authenticated facts by which this opinion can be sustained. 
I have often cured ulcers of five, ten, and even fifteen years' standing, constantly 
attended with more or less discharge and irritation, and yet no instance to which 
such an event could justly be ascribed has ever fallen under my notice. Besides, 
the constitutional treatment which is usually necessary in these cases to effect 
relief, is, in itself, almost a guarantee against attacks of grave disease in other 
parts of the body. If, however, such an occurrence should be dreaded, it would 
be easy, while the sore is drying up, to protect the system by a continuance 
of the constitutional remedies, especially a spare diet, and the occasional use of 
a purgative, conjoined with the employment of an issue in a remote part of the 
body, as the arm, chest, or neck. 

SECT. IX. — GRANULATION. 

Granulation is the means by which lost tissues are replaced and wounds healed 
when they refuse to unite by the first intention, or adhesive action. The process 
is one of great interest, whether it be viewed merely as a physiological phenome- 
non, or as an operation employed by the system to restore injured and mutilated 
structures. An intimate knowledge of its nature and habits is therefore of para- 
mount importance to the surgeon. 

It is chiefly upon the external surface of the body that an opportunity is afforded 
of examining the process in question with any degree of satisfaction. In the 
various mucous outlets it is more difficult to watch and to trace it through its 
different stages ; while in the internal organs it either does not occur at all, or is 
observed only as a post-mortem appearance. 

Before granulation can begin, it is necessary that there should be a reduction 
of the inflammation of the part, however it may have been induced ; I do not 
mean to say that all the inflammation must be got rid of as an essential prelimi- 
nary, for I believe that more or less of this action is absolutely necessary to its 
successful operation ; I merely wish to declare that granulation cannot go on so 
long as there is any considerable degree of inflammation ; or, what is the same 
thing, that high vascular excitement and repair are, as a general rule, incompati- 
ble with each other. The balance of action having thus been re-established, the 
breach soon becomes covered with a layer of lymph, which, undergoing organiza- 
tion, is rapidly converted into red, fleshy-looking bodies, technically denominated 
granulations. By a continuance of this action the process of repair steadily pro- 
gresses until the gap is finally filled up and scabbed over. 




tof^Uier by a small qnantity of intermediate substance, the precise nature of whi<^ 
is not nnderstood. ll is usaally of a Horiil color, very vascular, extremely Benat' 
lire, sod of a coDical. rounded, or oval shape, its volume varying from that of t 
(torer-eeed to that of a lar^ shot. Its vesHels, which are remarkably nnmeroui, 
•ra BTideutly oatgrowths from those of the adjacent parte, aud are arrauged, as 
Mwn in fig. 26, in the form of beautiful loopa and arches, doRcly interwoven with 
each nlher. As they are developed with great rapidity, their walls arc at Brat so 
cilremely delicate as to yield under the slightest pressure ; hence there is gene- 
rillr more or lre» bemorrhage whenever anything is rudely brought into contact 
«ith thrm. The veins are very large, tortuous, and convoluted. No nerves an 
demonstrable in this body, but that it receives an abundaiil supply of this kind 
is tbown by the fact that it ia often very sensitive, especially when diseased. The 
rxi«t4nice of lympbalic vessels also is a matter of inference rather than of positiv* 
proof. Observation shows that certain articles, placed in contact with a gmna- 
bUng alccr, will be promplly taken np, and carried into the system, producing t 
■rmilBr effect, nearly in as short a time, as when introduced in the ordinary man- 
ner. Tbna. ra(>r|)hia will readily allay pain and induce sleep ; atropia, dilate the 
Mpfl ; arsenic, irritate and inflame the stomach ; strychnia, convulee the muscles. 
lunoTer, a grauulatiou h a secreting body, a kind of compound gland, capable 
of panring out plasma and providing the elements of pus ; the former for enlarg- 
ing iu own dimensions und multiplying itself, the latter as a means of defence 
from the atmusphvrc and the surgeon's dressings. 

GranotalioDs form with various degrees of facility, depending mainly upon the 
■tractnre of the part and the amount of inflammatory action. Ulcers of the i^kin 
and crllaUr tissue always, other things being equal, furnish them most readily, 
ait well as in most abundance ; a circumstance which is not surprising when we 
rriU'rt apon their extreme vascularity and high nervous endowment. Bone, 
rvtiln)^, tendon, and librons membrane, on the contrary, granulate more slowly, 
and Iietirs ihcir injuries arc always repaired with more difficulty. The same 
rvBsrk applies, but iu a more pointed manner, to scirrhous and other malignant 
olcvra 

Tbeae bodies are sometimes developed eubcutaneously. Paget states that he 
ha* aeen a maus of florid granulations in a case of simple fracture, in which tJie 
a of the boDeH had remoiuetl long ununited, and a similar phenomenon is occa» 
taDy witneKMd in Pott's disease of the spine. 

Is examining a cluster of grannlations, a great difference may generally be ob- 
•er*tfd Iu their character. The deep-seated ones are comparatively Grm. more or 
ham einngntwt, and of a fibro-plastic strnclure, if not actually filamentous. The 
•)ip«rilcial, un tlic contrary, arc in a mdimcutary state, very soft, lacerablCt 



I 
I 



192 TERMINATIONS OF INFLAMMATION. chap. it. 

and extremely vascnlar. At the edges of the sarface, near the janction of the 
new and the old tissaes, they possess the properties of incipient epithelial cells. 

Granulations are liable to disease. This often occurs from causes apparently 
the most insignificant ; depending, perhaps, at one time apon the state of the part, 
at another upon the state of the constitution, or upon both combined, but more 
frequently upon the nature of the dressing, and the indiscretion of the patient 
Hence, the appearance of these bodies usually serves as an index of the concomi* 
tant action, local and general, and affords useful indications of treatoient. The 
most important alterations which they undergo are snch as relate to their sise, 
color, consistence, and sensibility. Healthy granulations are generally small, not 
exceeding the Yolume of a mustard-seed, but cases occur in which they are many 
times larger. Their natural color is a beautiful florid ; when congested or in- 
flamed they assume a livid aspect, while under opposite states they are occasion- 
ally pale, or even blanched. In their consistence these bodies also present much 
diversity, being sometimes very soft and lacerable, and at other times very firm, 
inelastic, and almost callous. Occasionally they have an infiltrated, (sdematous, 
or dropsical appearance, serum escaping freely upon the slightest puncture. Their 
sensibility is usually very feeble, but in nervous, irritable persons they are some* 
times exquisitely painful, particularly if they are much inflamed. In ulcers 
from bums the granulations are always distinguished by their excessive tender- 
ness and by the rapidity of their growth. 

The discharge furnished by these bodies is liable to vary in different cases and 
under different circumstances. When they are in a perfectly normal condition, 
as is indicated by their florid aspect, small size, and steady development, it is 
usually of a thick, cream-like consistence, and of a pale yellowish color, or, in 
other words, of the nature of laudable pus ; if, on the other hand, they are in- 
flamed and irritable, it will generally be thin and sanious, with an inordinate 
quantity of earthy salts ; when the excitement is very high, the matter is usually 
mixed with aplastic lymph ; hard, callous granulations are often free from all dis- 
charge, being apparently incapable of furnishing purulent matter of any kmd. 
In dropsical granulations the fluid is usually serous. 

The management of the granulating process must be conducted upon the same 
general principles as the ulcerative. The leading indication is to favor its develop- 
ment by protecting the raw surface from the atmosphere and from whatever else 
has a tendency to embarrass its progress. The most suitable applications, as a 
general rule, are water-dressings and emollient poultices, employed in such a 
manner as, on the one hand, not to excite exuberant action by their warmth, and, 
on the other, not to repress growth by their refrigerant effect. Rude contact, 
protracted exposure to the air, and irritating applications must be carefully 
avoided. 



SECT. X. — CICATRIZATION. 

Cicatrization is the completion of the granulating process, the last act in the 
operation of repair, the hermetic sealing, as it were, of the breach left by the 
destruction of the tissues of the affected part. If we study this process with 
proper care, we shall find in it much that is calculated to arrest attention and 
elicit admiration at the wonderful resources of the animal economy. 

When cicatrization is about to take place, there must necessarily be a subsi- 
dence of the inflammation of the part, just as in the development of granulations, 
only to a still greater extent. This may be regarded as an essential preliminary. 
The next stop is a deposit of plasma upon the edges of the breach, followed by 
its rapid organization and conversion into epithelial scales, or a thin, bluish, or 
whitish pellicle, which forms a striking contrast with the granulations and adjoin- 
ing skin, indicating the progress of the change. The new substance may always 
be easily detached with the s]K>nge or finger, for as yet its consistence is veiy 
slight. Gradually, however, it becomes more thick and firm, assimilating itsetf 
more and more closely to the pre-existing integument, the place of whidi it is 
intended to supply. The process thus begun continuing, the plastic, orgaoiaable 



ciir. IT. CICATBIZATIOK. 19S 

iim exteads steadily onward until the exposed surface is Gnallj completely covered 
to, the length of time neceBsary for this varying' according to the size aiid shape 
of the breach, the absence or presence of complications, and the state of the 
srglem. Observation has shown that ovoidai nlcers, all other thinffa being equal, 
heal more rapidly than circalar, superficial than deep, common than specific. It 
is also well known that cicatrization is usnally more easily accomplished in the 
npper extremities than in the inferior, and in the ekia and cellular tissue than in 
the other stractares. In the organs, properly so called, it generally takes place 
with dilficolty, and only after a long interval. 

It is a law of ci^trixation that the process shall always begin, as the starting 
point, at the edges of the breach which it is designed to repair, and thcnee pro- 
reed towards the centre. So nniform is this occnrrence that I have eei'u but few 
inatancea to the contrary, notwithstanding the numerous and diversified cases 
whicb bare been thrown in my way. It would seem as if the aid of the pre- 
existing tissaea were necessary in order to enable the new substance to obtain a 
proper foothold. I am aware that a different doctrine has been promulgated by 
some, and there is, no doubt, occasionally an instance where the process proceeds 
in an opposite direction, after having commenced at a central point ; bat if this 
he so. it forma merely an exception to a general law, not the law itstclf. Those 
who assert that this occurrence is rather frequent than otherwise may have 
been deceived by the existence of a small fragment of old tissue, with or without 
integament, which, standing like a little island in the midst of the ulcer, thus 
becomes the nacleua of the new structure. In this event, however, there is 
obrioDsly do new law in force, but simply an application of that already 
described. 

Some time necessarily elapses, after the cicatrization is completed, before the 

new Btnictnre, now called a cicatrice, acquires mach solidity 

and strength. It is only by degrees that it loses its bluish ^g- 27. 

apprarance and assumes the properties of the pre-existing sub- 

stance. Even then it is at best only a very imperfect copy of 

the original, although it is capable of supplying its place and 

of executing the functions which nature has allotted to it. Its 

Tciisets, at first remarkably large and tortuous, gradually 

dwindle doirn to a size approximating them to those in the 

adjacent soaod parts, and, when fully formed, they generally 

tihibit a beautiful retifnrm arrangement, as in fig. 27. The 

Kar always remains tender for a considerable period after its 

formation, and is usually very liable to break, crack, or ulcerate from the slightest 

t»ttses. Its tendency to contract or diminish also continues for a while longer. 

What I have said respecting the imperfect reproduction of skin is equally 

, tppUcable to the other textures. Kew bone comes perhaps nearer to the original 

Hnicture than any other; but even this presents many pecnliarities, and it is 

nrtain that it otlen acquires a degree of hardness and solidity far greater than 

^ IhU of the primitive substance. There are, moreover, some pieces of the skeleton 

1 ■birh. when broken, never unite by osseous matter, but only through the medium 

i' of fbrous tissue, fibro-cartilage or cartilage. Fractures of the patella, the 
oVcTuion, the acromion process of the scapula, and the neck of the tliigh-hone 
^iihia the capsular ligament, are generally, if not always, repaired in tliis way, 
■ Ibr parts not having the power of secreting phosphate aud carbonate of lime, in 
J mnirquence of their imperfect supply of blood and nervous influence, to say 
i »"tbin)r of the difficulty of maintaining the ends of such fractures in contact for 
; ■ nCcient length of time to afford tliera an opportunity of becoming consolidated, 
•'wils^re is never perfectly reproduced after injuries; the new subetitute is 
•'■ITS very thin, hard, and of an unnaturally bluish tint Tendon is renewed 
ntk is the case of sobcataaeoas section ; never when it has been lost by disease. 
VbkIm usually unite through the medium of fibro-cellular substance. In frac- 
^ot the costal cartil^es the consolidation is effected by bone. Bloodvessels 
ud nerves are never regenerated ; the continuity of the former cannot be re- 
f^blixhed after complete division, on account of the retraction of their extremi- 
VOL. I. — 13 




194 TERMINATIONS OF INFLAMMATION. cbap. jt. 

ties ; if a small piece of the latter is excised, the gap is supplied bj fibroos tiarae, 
very different from the pre-existing one, but, nevertheless, often sufficient to tnuu- 
mit the nervous fluid with little or no impairment of its influence. The cerebral, 
pulmonary, hepatic, splenic, salivary, renal, and seminiferous structares are ioca- 
pable of reproduction, the new substitute being always of a cellulo-fibrouB, or 
fibro-cartilaginons nature. Serous, mucous, and fibrous membranes are repaired 
in a similar manner. Thus it will be seen that a tissue, when seriously mutilated, 
is seldom perfectly reproduced, whatever pains may be taken to assist its efforts. 

It is not surprising that a substance so imperfectly organized as a cicatrice 
should be liable to inflammation and its consequences, as well as to some of the 
heterologous formations. Its powers of resistance being naturally feeble, it yields, 
in general, more readily to disease, whether simple or malignant, than the orig^bal 
structures. It is for this reason that inflammation of the substitute-tissue is 
prone to pass into ulceration, and, if the morbid action is at all severe, even into 
mortification. In suppuration, the matter furnished by the part is nearly always 
of a thin, ichorous nature, a development of genuine pus being almost impossible 
under any circumstances. 

When a cicatrice is habitually exposed to pressure, it is very liable to be con- 
verted into a species of corn, not unlike a corn upon a toe, both in its color, 
shape, and consistence. In other cases, again, it may be transformed into a bunion, 
burse, or synovial cyst, as upon the extremity of an old stump, especially after 
amputation of the thigh. A genuine horny growth sometimes occurs upon a 
cicatrice ; and instances are seen, although they are uncommon, in which the new 
tissue, in consequence of the effects of long-continued pressure, undergoes the 
cartilaginous, fibro-cartilaginous, and even the osseous degeneration. 

The most common form of malignant disease liable to show itself in a scar is 
epithelial cancer or lupus ; it may break out upon any part of the body, but is 
most prone to appear upon the face, hands, and feet, parts which are habitually 
exposed, or frequently subjected to pressure and friction. The diseased structure, 
almost of stone-like hardness, and the seat of sharp, pricking, or burning pains, 
soon ulcerates, and pours out a thin, sanious, and fetid fluid, highly irritating to 
the neighboring healthy surface. The edges of the sore are hard, steep, everted, 
or partially undermined, while the bottom is foul and slightly covered with spoiled 
lymph : occasionally the part has a worm-eaten appearance. However this may 
be; the ulcer is always intractable, and, going on steadily from bad to worse, is 
liable to be followed by the most serious consequences. 

Keloid is another form of disease liable to appear upon cicatrices ; this, as will 
be seen elsewhere, is a peculiar fibro-plastic growth, which often forms after bums 
and scalds, and which derives its name from the supposed resemblance which it 
bears, in its configuration, to a crab. 

There are certain cicatrices which are habitually dry, painful, and the seat of 
more or less itching, with a tendency to nlceration and discharge. Old stumps 
of the leg and thigh, imperfectly covered with integument, with the raw sub- 
stance firmly adhering to the ends of the bones, arc remarkably prone to suffer 
in this way, and to be a source of perpetual annoyance. Not unfrequently the 
paia is of a neuralgic character, especially when it is dependent upon tho pre- 
sence of a neuroma, or a bulbous expansion of the nerves. Lastly, cases occur 
in which the pain, whatever may be its character, is materially influenced and 
aggravated by hygrometric conditions of the atmosphere, the part and system 
being conscious of the slightest changes of the weather. 

Finally, cicatrices sometimes manifest a remarkable disposition to contract, 
which often continues long after they have apparently attained their full develop- 
ment. This tendency is nowhere more conspicuous than in bums and scalds, 
where it is occasionally so great as to give rise to tho most horrible deformity. 
Thus, a vicious scar may pinion the arm to the side, pull back the hand upon 
the wrist, and draw down the chin upon the chest. The new tissue, consequent 
upon the loss of substance caused by salivation, generally contracts in such a 
manner as to produce firm adhesion of the jaws, sadly interfering with eating and 
mastication. 



CBAP. T, SOFTENING. 196 

In order to prevent degeneration of a cicatrice, it should bo protected, espe- 
dallj if It be large, for a long time from rude manipulation, pressure, friction, 
and irritating applications If there is any tendency to undue contraction, mea- 
nires should be promptly adopted to counteract it, otherwise it may lead to great 
deformity and impairment of function. A vicious cicatrice may occasionally be 
adrantageously extirpated. 



CHAPTER V. 

TEXTURAL CHANGES. 

Under this head may be described those organic changes which are effected in 
the sobetance of the organs and tissues, as the result either of inflammation or 
of defective nutrition, consequent upon lesion in the circulatory and nervous sys- 
tems. The most important of these alterations of texture are softening, induration, 
transformations, hypertrophy, atrophy, contraction, and fistule. 

8KCT. I. — bOFTENINO. 

Inflammation not unfrequently passes into softening, or what the French patho- 
logists have denominated ramollissement. The event is characterized by a loss 
of cohesion of the affected textures, varying in degree from the slightest change 
of the natural consistence to almost complete pulpifaction. All parts of the body 
are liable to this occurrence, but those which are most apt to suffer are the longs, 
brain, spleen, liver, and heart, together with the mucous membrane of the stomach 
and bowels, the articular cartilages, and the spongy structure of the bones. The 
subcutaneous and inter-muscular areolar tissue is occasionally softened to a great 
extent in rapidly progressive forms of inflammation, particularly in diffuse ery- 
sipelas. The vessels, nerves, muscles, and tendons, the fibrous and serous mem- 
branes, the lymphatic and salivary glands, the kidneys, the thyroid body, utcnis, 
ovaries, testes, and prostate rarely experience this alteration under any circum- 
stances, however violent the attendant action. 

Softening sometimes takes place rapidly, at other times slowly; hence the 
distinction into acute and chronic. In the former case the affected tissues may 
be almost completely deprived of their natural consistence within the space of a 
very few days. Thus, in acute pneumonia the lungs are often so much softened 
at the end of three or four days as to be incapable of resisting the slightest pres- 
sure of the finger. In the brain and spleen the loss of cohesion sometimes pro- 
ceeds even more rapidly than in the lungs. Chronic softening is most common 
in the cerebral substance and in the mucous membrane of the ileum and colon, 
where it is generally a most insidious disease, often involving a largo extent of 
tissue, and yet unaccompanied by any characteristic symptoms. 

The true nature of softening has not been explained. We can hardly, however, 
divest ourselves of the idea that it is not a species of molecular mortification, 
especially in its more advanced stages. Be this as it may, it is unquestionable 
that the loss of cohesion, under such circumstances, is entirely incompatible with 
the exercise of the functions of the part, or its restoration to health. Many of 
its smaller vessels are completely obliterated, while the remainder are so crippled 
and paralyzed as to be scarcely able to propel their contents. Changes not less 
con^lcuous are observable in the proper parencbymaUHis ttructure, which not 
only loses its natural consistence, but also its nwP ' 'ire infiltrated 

with serosity, or serosity, lymph, pus, and bk tore is no 



196 TEXTCBAL CHANGES. chap. t. 

longer distmg^isbable by the aid of the most powerful microscope. If thii is 
not death, or a condition closely approximating to it, what can it be ? In the 
milder forms of mollescence the structure may still retain some vitality, and may, 
consequently, be able, in time, to regain its original characters ; or, what is more 
probable, may be rebuilt by plastic matter, after the manner of other broken-dows 
and mutilated tissues, the first step in the process being the removal of the effete 
substance. 

There is a species of softening which is intimately connected with, if not actu- 
ally dependent upon, obliteration of the vessels of the affected structures, with 
consequent deficiency of blood and impairment of nutrition. It is most fre- 
quently met with in the brain and spinal cord of old persons, and is generally 
supposed, although, perhaps, erroneously, to be of a non-inflammatory character. 
If this opinion were correct, it is not probable that we should find, as we always 
do in this disease, more or less effusion of serum, plasma, and even pus. Wherever 
these fluids are deposited they afford indubitable evidence of incited action ; hence 
it would be absurd to conclude that they could be poured out here without inflam- 
mation. 

This event of inflammation is interesting chiefly in a pathological point of 
view ; for, as it is met with almost exclusively in the internal organs, and presents 
no characteristic symptoms, it is evident that treatment holds out little prospect 
of relief. When the true nature of the lesion is suspected, the proper remedies^ 
in the acute form, will be such as are calculated to reduce inflammatory action 
and to favor the removal of deposits ; in the chronic variety a mildly alterative 
course, with tonics, embracing cod-liver oil, quinine, and iron, is indicated. 

SECT. II. — INDURATION. 

It has already been seen that a deposit of lymph, plasma, or plastic matter is 
common to nearly all inflammations, whatever may be their cause, site, or degree. 
When occurring upon the free surfaces of the organs, it usually presents itself 
in the form of a layer, which, escaping the influence of the absorbents, is ulti- 
mately converted into an analogous tissue, which often remains during the rest 
of the individuaPs life, being subject, in the meanwhile, to all the diseases and 
accidents incident to pre-existing structures. When the deposit takes place in 
the substance of the organs, it fills up their cells, interstices, or molecular spaces, 
and thus increases their consistence, as well as their weight, the matter assuming 
the shape of the cavities in which it is lodged, and being liable, as in the former 
case, either to be absorbed or to become organized, according to the condition of 
the part and the vitality of the morbid product. A similar arrangement occurs 
when plasma is effused into the cellular tissue beneath the skin, among tiie 
muscles, and in other situations. 

Induration is extremely common, and may occur in any organ and tissue of 
the body. It is most frequently met with, however, in the lungs, spleen, liverp 
thyroid gland, testicle, lymphatic ganglions, prostate gland, mamma, ovaries, 
uterus, bones, and subcutaneous cellular structure. 

Age exerts considerable influence upon the production of induration. In the 
great majority of the organs it may take place at any period of life, but in some, 
as in the thyroid gland, for example, it rarely occurs before the fourteenth year, 
while in the genital apparatus it is hardly ever observed until after puberty. 
Induration of the prostate gland, of the vessels, and of the brain and spinal 
cord is an affection of advanced life, as is also induration of the crystalline lens 
and its capsule. 

The degree of induration varies from the slightest alteration of the natural con- 
sistence of the part to the solidity and density of concrete albumen, old cheese, 
fibro-cartilage, cartilage, or 1x)ne. Much, in this respect, will depend upon the 
nature of the affected tissue, and the date of the lesion, or the degree of change 
which the deposit upon which the induration depends may have undergone. 
The color of the affected part may be normal, or variously altered, according to 
the amount of its vascularity and the presence or absence of effused blood. 



CHAP. ▼. TRAXSFOUMATIOXS. 197 

Much dirorpity also exists in regard to its volume, althongli in most cases this 
is considerably augmented, and sometimes even quite enormously, the bulk many 
times exceeding that which is natural to the organ in health. The weight of the 
part, too. is usually increased, and there is commonly some dryness, with a 
marked loss of elasticity. 

The period required for the production of induration ranges from a few hours 
to several days, weeks, or months, depending upon the nature of the exciting 
cause and of the affected structures. In the testicle it often occurs in a very 
marked degree in less than twenty-four hours, and at the end of forty-eight hours 
the organ may be so hanl as to be entirely incompressible. The induration 
aceonipanying the development of tonsillitis, adenitis, furuucle, carbuncle, and 
erysipelas generally occurs with extraordinary rapidity ; and the same thing is 
frequently witness<*d in the cellular tissue around the joints, especially in inflam- 
Dation of a gouty or rheumatic character. In pneumonitis the parenchymatous 
sohtstance of the lungs is often extensively solidified within a few days from the 
commencement of the morbid action. On the other hand, the induration may 
proceed very slowly, as in goitre, in chronic arteritis, hepatitis, and splenitis, and 
in certain affections of the uterus and prostate gland, where months, if not years, 
may elapse before it attains its full development. 

The effect of induration uj)on the tissues in which it occurs is of the most 
prejudicial character, sadly impairing their structure and functions and frequently 
leading to the worst results. Thus, when it affects lK)th testicles it may become 
a cause of impotence ; in the liver it may interfere with the secretion of bile ; and 
in the lung it may produce death by offering a mechanical obstruction to the 
ingress of the air. In the arteries induration is frequently followed by rupture of 
their coats, leading to aneurism ; while in the cellular tissue around the joints it 
always impedes the exercise of the articular surfaces. 

The immediate cause of induration is a deposit of plastic matter into the colls 
of the affected structures, which it thus obliterates while it condenses the adjoining 
substance, and so renders it unfit, either temporarily or permanently, for the proper 
exercise of its functions. The fluid is generally associated with more or lees 
serum, and not unfre<iuently also with pus and even pure blood. When the 
circumstances ander which it is deposited are favorable, it soon becomes organized, 
and mav finallv be converte<l into an analo^^ous tissue, which often retains its 
paraiiitic connection during the remainder of life, although in most cases it ulti- 
mately disappears. 

In the treatment of induration the leading object is to excite the absorbent 
vessels so as to induce them to remove the deposits upon the presence of which 
the lesion depends. It need hardly l>e said that the sooner this is done the better. 
The longer we wait, the greater will be the danger of a permanent change of 
structure, or, when the organ is one of great importance to life, of the death of 
the patient. When the deposit is n^cont, and action still high, our reliance is 
maiuly upon the vigorous employment of antiphlogistics, such as bleeding, purging, 
and diaphoretics, with antimonials, light diet, and perfect rest in the recumbent 
pri^sture. Inflammation having thus been moderated, the induration, already 
greatly reduced by the previous measures, may usually be promptly disposed of 
by alterative doses of mercury, carried, perhaps, to slight ptyalism ; and, when 
the part is accessible, by sorbefacient liniments, embrocations, and ungucmts, aided 
by pressure with the bandage. In the more chronic forms of the affection the 
different preparations of iodine must be brought in play, particularly LugoPs 
folution, Donovan-s liquor, and the various forms of mercury, as the bichloride 
and biniodide ; along with the topical applications just mentioned, if the indura- 
tion be external. Friction and the cold douche will also prove serviceable under 
such circumstances. 

SECT. III. — TBANSFOBMATIONS. 

The human body is in a state of constant mutation, decaj and renoTation, 
coDunendng before birth, and continuing down to the last Mmai ' vdilenoeL 



198 TKXTUBAL CHANGES. chap. t. 

The Wolffian bodies and the gubernacalum of the testicle disappear during intn- 
uterine life ; the thymun gland is gradually effaced during childhood ; the arteriei 
ossify in elderly persons ; and at every period of life vanous states of the system, 
dependent upon disease or accident, arise, in which there is a strong tendency 
to the dc{)osition of oil globules, or the transformation of different organs and 
tissues into fatty matter. 

The most important of these changes, surgically considered, are the ceDular, 
mucous, cutaneous, fibrous, calcareous, and fatty; they are all connected with 
defective vitality, and with atrophy of some, if not all, of the constituent ele* 
meuts of the affected structures. 

The cellular transfonnatioii is met with chiefly in parts that have been rendered 
useless, either from the natural cessation of their functions, or in consequence of 
accidental circumstances. Thus, the thymus gland, which is evidently connected 
with some important office in the fcetus, gradually decays during childhood, being 
converted into shreddy cellular substance, of which hardly a trace remains after 
the thirtieth year. The gubeniaculum undergoes a similar change ; the gall- 
bladder, occluded by biliary concretions, is occasionally completely transformed 
into this tissue ; and the cellular adhesions so often seen between the costal and 
pulmonary pleurse, consequent upon the degeneration of old adventitious mem- 
branes, are familiar to every pathologist. Various ligaments, especially the 
capsular, sometimes degenerate in this way ; the metamorphosis is most mariLed 
in young subjects affected with unreduced dislocations of the hip and shoulder. 

When skin is inverted for any length of time into one of the natural outlets 
of the body, as, for instance, the anal, it gradually undergoes a species of meta- 
morphosis into mucous membrane. The first indication of the change is a soft^ 
ened condition of the cuticle and the disappearance of the hair ; the epidermis 
scaling off, the surface beneath assumes a reddish, velvety aspect, becomes 
extremely vascular, and soon bc^gius to secrete a thin, ropy, whitish fluid, not 
unlike mucus. 

A change from mucous membrane to skin is sometimes observed, although the 
occurrence is uncommon. It is noticed chiefly in prolapse of the rectum, vagina, 
and uterus, the nmcous investment of which, from long exposure to the atmo- 
sphere, becomes dry, rough, and insensible, and is ultimately converted into a 
tissue bearing a more close resemblance to the cutaneous than to the mucous. The 
transformation, however, as in the case of the skin, is at best extremely imperfect, 
and it remains to be shown whether, in either instance, the old structures are so 
completely deprived of their identity as to justify the idea of a genuine transfor- 
mation. 

The fibrous transformation is most commonly met with in those partd of the 
body that have been deprived, either accidentally or otherwise, of their natural 
functions. Thus, in an artery that has been tied for the cure of aneurism or the 
arrest of hemorrhage the portion of the vessel included between the ligature and 
the first large collateral branch is gradually converted into a solid cylinder, which, 
in its turn, is changed into a dense fibrous structure, in which it is impossible to 
discern any trace whatever of the primitive tissues. Ligaments, serous mem- 
brane, and adventitious textures occasionally undergo similar changes. The 
cornea, in the withered and atrophied eye, the victim of destructive inflammation, 
seems, at times, to be almost completely transformed into a substance bearing 
the closest resemblance to the sclerotica, one of the best examples of the fibrous 
tissue. In some of these cases, as in that just mentioned, the change is accom- 
panied by a deposit of oil globules. The whitish opaque bodies, so frequently 
observed in the coats of the spleen, in the placenta, and in the arteries of elderiy 
subjects, are apparently essentially composed of fibrous substance, although in 
their outward characters they strikingly resemble fibro-cartilage. 

The calcareous degeneration is most common in the arteries, but is also occa- 
sionally seen in other parts of tha body, as in fibrous tumors, especially those of 
the uterus, in the articular cartilages, and in the concretions sometimes found in 
the larger joints, particularly that of the knee. In the arteries it generally b^^ 
in the form of little opaque patches, in the cellular substance between the inner 



CHAP. T. TRANdFOBMATIONS. 199 

and middle tunics, which, as they advance in age, assume a fiim, solid consistence, 
and ultimately couTert the vessels into rigid earthy cylinders. The deposit — ^for 
such is its nature rather than a genuine degeneration — was formerly supposed 
to be of an osseous character, but recent researches have shown it to be altogether 
different, both in its chemical and physical properties. In the more matured 
specimens it is essentially composed of carbonate and phosphate of lime, in 
onion with a minute portion of albumen ; in recent cases, on the contrary, the 
animal matter exists in much greater quantity. It differs still further from bone 
in haTing no areolar structure, and in being destitute of vital properties. In 
fibrous tumors of the uterus large calcareous masses, weighing several pounds, 
are occasionally found. 

The/aity degeneration, if not the most common of all, is the most universally 
distributed, since there is hardly any organ or tissue of the body in which, under 
fiiTorable circumstances, it may not occur. Observation has demonstrated that 
it may take place in the lungs, in cartilage, in bone, the placenta, the cornea, and 
the crystalline lens. It is also met with in plastic exudations, tubercles, cancer- 
ous gprowths, and even in pus globules. It has long been known to be of frequent 
occurrence in the muscles, and within the last twenty years its presence has often 
been detected in the coats of the arteries, in connection with the atheromatous 
deposit. Thus it will be perceived that the fatty degeneration may take place 
both in natural and in adventitious formations ; in the hard as well as in the 
soft, in the most humble as well as in the most exalted in point of organization 
and life-power. Of all the various structures, however, which are liable to suffer 
from it, the liver and arteries are probably the most frequently affected. Fatty 
degeueration may occur in the former at any period of life, even in young chil- 
dren, and is a very common consequence of habitual alcoholic stimulation ; in 
the latter, on the contrary, it is usually restricted to elderly subjects. The senile 
arc of the cornea is most common in advanced life, and is supposed by some 
recent observers, amongst others by Mr. Canton, to be almost always coincident 
with fatty degeneration of the heart and other organs. Fatty degeneration of 
the muscles occurs both in the voluntary and involuntary classes, although it is 
br no means so common in the latter as in the former. 

The fat in this degeneration occurs occasionally in a free state, in the form of 
oil globules, cholesterine, and amorphous fragments, and is then essentially a 
deposit occupying the intercellular structure of the tissues. Such a supcraddi- 
tion of fat is often observed in the liver, arteries, brain, and pancreas. On the 
other hand, there is no doubt that the transformation is sometimes real, being the 
pame in principle as the fibrous or calcareous ; that is, the affected tissues are 
broken down, and converted into fatty matter, or, to express the idea more accu- 
rately, replaced by oil. 

An organ that has undergone the fatty degeneration will generally be a few 
shades lighter than in the natural state, and diminished rather than increased in 
consistence, easily torn, greasy to the touch, and of lighter specific gravity than 
in health. The amount of oil which it contains often ranges from one-third to 
one-half of its own weight. 

What is the essential cause of the fatty degeneration ? In some cases it would 
seem to be connected with general hypertrophy of the adipose tissue, and. con- 
sequently, to be owing to a mere redundancy of oily matter dependent upon the 
use of an inordinate quantity of hydro-carburetted food and imperfect assimilative 
power. In the liver of some of the inferior animals the fatty degeneration may 
often be produced at will, simply by subjecting them to rest, and constantly 
crmnming the stomach with food, which, by creating obstruction in the portal 
circle, probably induces congestion and inflammation of the hepatic tissues, which 
thus favor the deposition of oily matter. The fatty transformation of the liver 
of drunkards is doubtless occasioned in a similar manner. In other cases the 
lesion appears to be essentially due to a want of exercise of the affected parts, 
conjoined with deficient nervous supply, as is so often witnessed in the muscles 
of the leg in paralysis of the inferior extremity. Under such circumstances, 
•specially when the case is of long standing, the muscles generally assume a 



200 TEXTL'BAL CHANQK8. CBAp. t. 

pale, yellowish, or brownish aspect, are rcmarkablj soft and flaccid, and* 3rie1id t 
clear oily fluid on pressure, their fibres, however, remaining perfectly distincL 

It is still a mooted question whether the fatty matter, in this transfonnatioii, 
is deposited directly from the blood, or whether it is the product of some chemical 
change in the affected tissues, or in these tissues and other consentaneouB cxodi- 
tions. My own belief is that it is generally, if not invariably, derived from the 
former source ; and my reason for this opinion simply is that the transfonnatioi 
in question, when at all extensive, is nearly always associated with defective vital 
power of the diseased textures, along with impaired assimilative action, and with 
a redundancy of the protein principles of the blood ; circumstances eminently 
propitious to the formation and deposition of fatty matter. Besides, cases have 
recently been observed of fatty degeneration of the heart and other viscera in 
which oil existed in the blood. On the other hand, the researches of Quain, 
Bennett, and others go to prove that the change may be altogether the result of 
a chemical transformation, these pathologists having fonnd that healthy muscnlar 
fibre may bo rendered fatty artificially, simply by digesting it for several weeks in 
water. 

Of the treatment of the fatty transformation it is impossible to offer any satis- 
factory account. The whole subject, in fact, is at present shrouded in mystery. 
When the patient's habits are at fault, they must of course be corrected ; alcoholle 
stimulation must be abandoned, the diet must be changed, and a system of exerdse 
must be instituted, to improve the state of the blood and the assimilative powers. 
Local treatment should not be neglected when the degeneration is snspected to 
be going on externally, as when the muscles of a limb begin to waste in case of 
paralysis, disease, or injury 

SECT. IV. — HYPERTROPHY. 

The word hypertrophy is employed to designate the increased size and weight 
which an organ acquires in consequence of an augmentation of its natntion or 
the deposit of plastic, organizable matter into its interstices. Its use was on* 
ginally restricted to those preternatural enlargements which are so frequently met 
with in the heart and thyroid gland; but modern observation has shown that it is 
applicable to all organs and tissues characterized by an unusual development of 
their substance. 

Hypertrophy may be general or local, and the latter may either occupy an entire 
organ or be limited to particular portions of it, or even to some of its component 
elements. It may exist alone or in association with other lesions, and is liable 
to occur at all periods of life ; sometimes, as in the thymus gland and capillary 
vessels, apparently even before birth. No organ or structure is probably entirely 
exempt from it ; but among those which are most frequently affected may be 
specified the lymphatic ganglions, mamma, thyroid gland, spleen, liver, heart, 
prostate gland, tonsils, bones, vessels, adipose tissue, and skin. The best example 
of hypertrophy of the cutaneous textures is elephantiasis, in which the Increase 
of weight and bulk is sometimes enormous. 

The causes of hypertrophy are, first, inordinate exercise of an organ; secondly, 
mechanical obstruction ; and, thirdly, chronic inflammation. 

The most simple manner, apparently, in which hypertrophy of an organ occurs 
is from an increase of its functional activity. Examples of this variety of the 
affection are found in various textures, particularly the muscles, lungs, and kid- 
neys. The muscles, voluntary and involuntary, are always developed in propor- 
tion to the amount of their exercise. Kept at rest, they soon lose their firmness 
and healthy color, and become comparatively feeble and useless. The blacksmith, 
who constantly plies his hammer, has much larger and stronger arms than the 
dancing-master, who merely employs his legs. The same law obtains with regard 
to the lungs and kidneys. When one of these organs is imperfectly developed, 
compressed by effused fluid, or destroyed by some morbid growth, the other is 
sure to become preternaturally expanded, thereby compensating for the deficiency. 
There are certain viscera which are subject to temporary hypertrophy. Of tlda 



MAF. T. HYPERTROPHY. 201 

lescription are the uterus and mammary gland. During pregnancy and lactation 
iiese organs increase very much in balk, but again diminish soon a^er parturition 
md weaning. 

Hypertrophy may be caused, secondly, by some mechanical impediment inter- 
fering with the due performance of the functions of an organ. This is frequently 
Been in the heart, where, in conseqaence of disease of the valves, preventing the 
easy passage of the blood, the viscus is obliged to undergo increased action, 
and so becomes more or less enlarged. In the muscular fibres of the stomach, a 
similar change is often witnessed from obstruction at the pylorus, and in those 
of the urinary bladder, from stri/jture of the urethra, or hypertrophy of the pros- 
tate gland. 

Hypertrophy from chronic irritation is of frequent occurrence, and is met with 
mder a great variety of circumstances. Some of the best examples of this species 
of hypertrophy are seen in the lymphatic ganglions of the groin from chronic 
farritation of the head of the penis, of the mesentery from ulceration of the ileum, 
of the bronchis from disease of the lungs. Enlargement of the liver and spleen, 
sometimes of enormous size, is unquestionably due to a similar cause. In chronic 
dysentery, not only the mucous and submucous cellular textures become hyper- 
trophied, but the affection often extends to the muscular tunic, which occasionally 
attains an extraordinary degree of development. The follicles and villosities, 
which, in the healthy state, are hardly perceptible to the naked eye, arc also 
rendered extremely prominent, the former being sometimes of the size of a mus- 
tard-seed, while the latter are more than a line in length. A similar development 
is frequently observed in the coats of the urinary bladder, in consequence of chronic 
inflammation. 

Encysted tumors of the skin, mucous membranes, ovaries, and some other 
parts of the body, are evidently mere enlargements of the glands, cysts, and cells 
which naturally exist in these structures from the effects of chronic irritation or 
inflammation. The manner in which some of these growths are formed is easily 
understood. In the skin-follicle, for example, the first step in the development 
of the morbid structure is an obstruction of its orifice, thereby interfering with 
the evacuation of its natural secretion. The next is the change which the secre- 
tion nndergoes from the fluid to the solid state, and the pernicious pressure which 
it exercises upon the wall of the crypt. Thus two sources of irritation are set 
up — altered and retained secretion and constant pressure — under the influence 
of which the little follicle often expands into a tumor of considerable size. The 
nncous tumor is formed in a similar manner. The enormous ovarian masses, so 
often seen in elderly women, are fre<iuently, if not generally, mere enlargements 
of the so-called Graafian vesicles consequent upon chronic disease. 

The color of the affecte<l organ varies much in different cases and under different 
circumstances. In general, it is very much heightened, especially when the 
hypertniphy is wholly phyi*iological ; on the other hand, it is occasionally greatly 
diminished, and instances are often observed where it is apparently quite natural. 
The consistence mav likewise be normal, diminished or increased. These three 
conditions do not, however, occur with equal frequency. An increase of density 
is by far the most common, and is particularly conspicuous in hypertrophy of the 
heart, the mammary gland, the muscular fibres of the stomach and colon, the 
lymphatic ganglions, cellular tissue, bones, liver, spleen, and kidneys. A dimi- 
nution of consistence is extremely rare, and cannot be viewed as a necessary 
consequence of the lesion. 

An increase of weight of the affected organ follows, as a necessary consequence, 
in all cases where the lesion is not conjoined with atrophy. An augmentation 
of volume is by no means constant. Thus, in hypertrophy of the heart and 
bladder, there may be a great development of the muscular fibres, with marked 
dhnination of the size of their cavities. A change of form always arises when 
the hypertrophy is partially circumscribed,, or limited to a particular point, as in 
the bones, skin, heart, bronchial tubes, and bloodvessels. 

Hypertrophy essentially consists in an augmentation of the nutritive function. 
When an organ is in a state of extraordinary activity, its vessels receive more 



202 TEXTUBAL CHANGES. ohap y. 

blood than naturally, and the consequence is that it assumes a deeper color, 
at the same time that its structure is rendered somewhat more dense ; its cells 
are multiplied and augmented in size. It is in this manner that the alteration 
under consideration is brought about In that Tariety of it which results from 
chronic irritation, it is not unlikely thi^t there is often superadded to the alteration 
just mentioned a deposit of new substance in the connecting cellular tissue, thai 
leading to a real change of structure. The effects of hypertrophy on surrouading 
parts will be pointed out in connection with the different organs and textures ^ 
the body. 

In regard to the treatment of hypertrophy, no definite rules can be laid down, 
as it must be regulated, in great degree, by the nature of the exciting cause, 
which should, therefore, always be a prominent object of inquiry. Much benefit 
may, in general, be anticipated from the steady and persistent use of sorbefacienti, 
locally and constitutionally applied, such as iodine, blisters, compression, mercury, 
iodide of potassium, and tartar emetic, aided by purgatives and attention to diet 
In some cases, nothing short of the removal, partial or complete, of the affected 
organ will hold out any prospect of relief. 

SECT. V. — ATROPHY. 

Atrophy is the reverse of hypertrophy, consisting in a wasting of the substance 
of an organ, with a diminution of its w^eight and bulk. Occurring at all periods 
of life and in both sexes, it may affect a whole organ, or it may be limited to a 
part of an organ, or even to some of its constituent elements. 

Remarkable examples of general atrophy are occasionally met with, but SDch 
an occurrence is of no special surgical interest, and does not therefore demand 
any particular notice here. Cases of this kind are sometimes apparently of a 
congenital character ; at other times they are the result of disease, and are either 
curable or otherwise, according to their extent and the nature of their exciting 
causes. 

Local atrophy may be produced by a variety of causes, of which the principal 
are, first, cessation of the natural function of an organ ; secondly, loss of nervous 
influence ; thirdly, deficient supply of blood or nutritive matter ; and, lastly, 
inflammatory irritation. 

It appears to be a law of the animal economy that an organ, when of no 
further use, gradually falls into a state of decay. Of this class of structures are 
the umbilical vesicle and the pupillary membrane of the foetus, the former of which, 
after having subserved the purpose of its formation, disappears at the close of 
the third month, the latter between the seventh and eighth. The kidneys are 
preceded in the embryo by two jelly-like bodies, to which the term WolflSan has 
been applied ; these bodies, which exist not cnly in the mammalia, but likewise 
in birds and amphibia, acquire their greatest bulk alx)ut the middle of utero- 
gestation, after which they gradually diminish by absorption, and at length entirely 
disappear. The guberuaculum, which is visible in the tenth week of embryotic 
life, is a thin membranous process, which guides the testicle to the internal ring, 
and is finally converted into cellular substance. The above are instances of atrophy 
from the cessation of the functions of an organ in the foetus. After birth changes 
not less remarkable are to be observed ; such, for example, as the wasting of the 
thyroid body, the supra-renal capsules, and the thymus gland. From the same 
cause the alveolar processes of the jaws disappear after the removal of the teeth. 
The ovaries shrink after the decline of \he menses ; and, in conformity with a 
similar law, the testicles often diminish remarkably in size in monks, who lead a 
life of celibacy, in strict observance of their vows. 

Atrophy may, secondly, result from a diminution of nervous influence ; a cir- 
cuinstance not surprising when it is recollected how much the action of the 
capillaries is under the control of the cerebro-spinal axis. Whole limbs sometimes 
w^ast(^ from this cause ; in other cases the lesion is m6re limited, and implies a 
very partial disorder of the nerves. It has been obser\'ed that atrophy, when 
caused by disease of the brain, occurs much more slowly than when it is occasioned 



CBAP. ▼• 



ATROPHY. 203 



bjr an affection of the nerres of the part. The reason of this difference is not 
rery obvions. 

This Tarietj of atrophy is yery common in yonng children during dentition, from 
the sndden suspension, partial or complete, of nervons influence, constituting 
a species of local paralysis, which often terminates in complete wasting of the 
affected parts. It is most frequently observed in the lower extremities, sometimes 
in one, at other times in both ; but it also occurs, though much less frequently, 
in the upper extremities, particularly in the deltoid muscle, which is occasionally 
transformed into a pale, flabby, membranous layer, not more than a few lines in 
thickness. 

Remarkable examples of atrophy of the upper extremities occasionally occur 
from pressure of the head of the humeras on the axillary plexus of nerves, thereby 
interrupting the nervous influx. When such an accident takes place in very 
young subjects, and is permitted to remain unrelieved, the growth of the limb, 
if not positively arrested, is imperfectly executed, and the consequence is that not 
only the muscles, but even the bones become singularly stunted in their develop- 
ment, their shafts being very thin, and their prominences unnaturally small and 
indistinct 

It is probable that a mere perversion of the nervous function of an organ is 
capable of producing atrophy. In neuralgia of the testicle, that organ is some- 
times remarkably diminished both in size and consistence, not so much, apparent- 
ly, from an actual loss of nervous influx, as from a change in its character. 
What corroborates this view is the fact that the testicle, while the wasting pro- 
cess is in operation, is often so exquisitely sensitive as to be intolerant of the 
slightest manipulation. 

The effects of a deficient supply of blood in producing atrophy are well known, 
inasmuch as cases of this description are sufficiently frequent to make them an 
object of special interest. When any part is deprived of the usual quantity of 
this fluid, it very soon becomes enfeebled, its substance is rendered pale and 
flabby, and it at last loses the power of action, although every other condition 
for its performance may remain unimpaired. Thus, the testicle wastes after tying 
the spermatic artery ; and, for the same reason, the muscles of the lower extremity 
occasionally shrink after securing the principal vascular trunk of the thigh. 
Atrophy of the heart is sometimes produced by ossification of the coronary ves- 
sels; and a case is recorded in which the spleen, from the obstructed condition of 
its artery, was not larger than a' filbert. In old age, many of the capillaries are . 
obliterated ; and it is not improbable that to this circumstance is owing that dimi- 
nution of the size of the organs which constitutes senile atrophy. To the same 
cause is to be attributed the wasting of the lung and heart, from the accumula- 
tion of fluids in the pleuritic and pericardiac cavities. 

Atrophy attendant upon mere want of exercise is no doubt essentially due to 
deficient nervous and vascular supply, in conformity with a law, mentioned 
under the head of hypertrophy, that the development of an organ is usually in 
proportion to the amount of its use. The wasted and attenuated condition of the 
legs in club-foot and other affections depriving the muscles of their functions, or 
interfering with their proper exercise, is probably owing entirely to this cause, 
as is shown by the fact that, when the disability is removed, the individual 
gradually recovers the use of his limbs, the calves often becoming strong and 
plump, as if there never had been any arrest of growth. Tlic only, or chief, ex- 
ception to this is where the muscles have undergone the fatty degeneration, in 
which case they never regain their original development, but always remain weak 
and puny. 

Atrophy from inflammation is very common. A good example of this species 
of wasting is seen in what occurs in the gall-bladder from the presence of biliary 
concretions, and which is sometimes followed by complete wasting of this organ, 
tta coats being converted into a thin fibrous mass, having hardly any trace of the 
original reservoir. Hepatitis often gives rise to atrophy of the parenchymatous 
structure of the liver, and orchitis, especially when supervening on mumps, is not 
mnfrequently succeeded by impotence. How the lesion, in these and other cases, 



204 TEXTURAL CHANGES. chap. t. 

is produced, is not easily determined. It is probable that the inflammatory d^ 
posits may so choke up the capillary vessels of the parts as to deprive them of 
their customary and necessary supply of nutritive material ; or, if this conjectnn 
be untenable, that the pressure exerted by these effusions causes the absorption 
of some of the anatomical elements of the affected structures, thus reducing tnem, 
as it were, to their primitive condition. 

Atrophied structures are prone to undergo the fiEitty transformation, and it is 
not improbable that this transformation itself occasionally acts as an exciting 
cause of the wasting process. However this may be, it is certain that the two 
lesions are sometimes so intimately associated as to render it impossible to de- 
termine which preceded the other, or what part they played as cause and effect 

The change of color experienced by an atrophied organ is necessarily greatly 
influenced by the natural complexion of the part, but does not possess any special 
surgical interest. The weight of the affected structures is generally considerablj 
diminished, but their bulk of\en remains unaltered, and it is not uncommon to 
meet with cases where it is even greater than natural. 

The treatment of atrophy, occurring in an external or accessible part of the 
body, as a muscle, resolves itself into the use of the warm and cold douche, fric- 
tions, either dry or through the medium of stimulating embrocations, and the 
application of electricity, as described under the head of wasting palsy. The 
general health must be amended, strychnia and tonics being given when there 
is marked evidence of debility. The affected part must 'be gradually and steadily 
exercised, or, as it were, re-educated ; the influence of a strong will frequently 
directed upon it being often of essential service in rousing its latent faculties. 

SECT. VI. — CONTRACTION AND OBLITERATION. 

By the term contraction is meant the diminution of a canal, tube, or passage 
to an extent incompatible with the due performance of its functions. It is 
strictly synonymous with the term stricture, the signification of which is so well 
understood by the surgeon. The lesion is liable to occur in various degrees, from 
the slightest possible change in the size of a canal to the complete obliteration of 
its caliber. 

The chief interest of this subject, surgically considered, relates to the con- 
tractions that occur in the mucous canals, or excretory ducts, as they are called, 
and in the bloodvessels, in both of which the lesion is frequently productive of 
the most disastrous consequences ; attended, in the former, by retention of the 
secretions of these tubes and of the contents of the reservoirs with which they 
communicate, and in the latter by an impediment to the circulation which, in 
one case, may lead to atrophy, and, in another, to softening, ulceration, or gan- 
grene. 

Contractions of the mucous passages, to which the ensuing remarks are more 
particularly designed to apply, are deserving of great attention, both from the 
frequency of the occurrence, and from the great suffering which they so often 
entail u])on those who are the subjects of them. They are met with in nearly 
every mucous outlet of the lx)dy, but are more common in the male urethra and 
in the nasal canal than anywhere else. Doubtless stricture often exists in the 
smaller excretory ducts, as those of the prostate and salivary glands, without our 
knowledge, or without awakening any serious functional disturbance ; however, 
in the larger passages the slightest coarctation is generally a source of more or 
less annoyance, if not of great pain and inconvenience. 

The causes under whose influence contraction takes place are mainly two; 
first, inflammation with plastic deposit, and, secondly, mechanical compreasion. 
Of these the first is by far the more common. 

The inflammation giving rise to this lesion may be either acute or chronic ; in 
the former case generally doing its work rapidly, with bold and well-marked 
symptoms ; in the latter, on the contrary, the injury is often inflicted in a slow 
and stealthy manner, without perhaps exciting any suspicion on the part of the 
patient of what is impending. The plastic matter, the real cause of the contrao- 



CIAP. T. 



CONTRACTION AND OBLITERATION — FISTULE. 206 



/ 



tioD, is generally deposited into the submucous areolar tissue, either exclusively, 
or partly there and partly into the interstices of the mucous membrane itself. 
However this may be, it soon becomes organized, and is ultimately transformed 
into cellolo-fibroas or fibro-cartilaginous tissue, which, gradually contracting upon 
itself and upon the neighboring structures, thus diminishes, in a pro{)ortionato 
degree, the caliber of the tube in which it is situated. It is in this manner that 
all organic atrictores, properly so termed, of the mucous outlets of the body are 
formed. 

The second cause of contraction is of a purely mechanical character, although 
in most cases, if not in all, the lesion is attended with inflammation and plastic 
deposit, secondary, however, in their character. It is thus that stricture of the 
na^ canal may be produced by the pressure of a tumor in the sinus of the upper 
jaw ; of the bronchia, by the pressure of an aortic aneurism ; and of the Fallo- 
pian tobes, the biliary ducts, and ureters, by the pressure of an enlarged viscus 
or morbid growth in their immediate vicinity. The same cause often induces 
constriction and even complete obliteration of the bloodvessels. A tumor, com- 
pressing the aorta, has been known to give rise to permanent closure of that 
vessel as elTectually as if it had been surrounded by a ligature. 

The extent of the contraction varies, both in length and in diameter, in such 
a manner as to render it impossible to specify it in a general manner. In some 
cases, it may not exceed the fraction of a line, while in others it may involve the 
whole length of the affected tube. 

The effects of such a lesion upon the parts concerned are often extremely dis- 
tressing. Thus, in the urethra, the obstruction is attended with difficulty of 
niictnntion ; in the nasal canal, with impediment to the passage of the tears into 
the nose ; and in the oesophagus, with difficulty of deglutition. 

The prognosis is, ordinarily, not at all serious, as the obstruction generally 
admits of relief, except when it has been induced by the compression of some 
iutenial tnmor or an enlarged viscus, when it will almost necessarily be irreme- 
diable. 

The treatment of the inflammatory form of contraction must be conducted 
acf^rding to the general principles laid down in the chapter on lyrophization ; 
by antiph](»gistic remedies in the earlier stages of the disease, and afterwards by 
alterants, rest, light diet, purgatives, leeches, and a regular, systematic course of 
dilatation by means of bougies, either alone or aided by incision, scarification, or 
free division of the affected structures. Great care must be taken, in the employ- 
ment of dilatation, to conduct it in the most gentle and cautious manntT, the 
object Inring to excite the al)sorl)ent vessels, while the capillaries are, if possible, 
kept in a pt*rfectly passive condition. In this way, we get rid, in time, of the 
effused matter, upon the presence of which the constriction essentially depends, 
without provoking any further deposition. 

OECT. VII. — FISTULE. 

A fistule is a narrow track, straight or tortuous, of variable depth, having 
gpnr*rally two distinct orifices, lined by an adventitious membrane, and bathed 
with a thin, gleety fluid, intermixed with the natural contents of the part, organ, 
canal, or cavity affected. The disease, which is always of a consecutive nature, 
occurs ill different regions of the body, and is developed under the influence of 
various causes. 

Although the abnormal tract has usually two openings, one of which is super- 
ficial and the other deep-seated, yet this is by no means constantly the case. 
Hence the distinction of fistules into complete and partial. The terms recent and 
old. often used by writers, refer merely to the duration of the disease. 

The lesion may occur in almost any situation, but originates most frequently 
•bout the anus, perineum, face, groin, and mammary gland. Fistule of the neck, 
thoracic cavity, the biliary apparatus, the stomach, colon, and small bowel, kidney, 
pancreas, and urinary bladder, ia oomparatiTely rare. It takes place in both 



206 TSXTURAL GHANOXS. chap, t. 

sexes and at every period of life ; but children and joung persons snffer mnck 
less frequently than the old and middle-aged. 

The nomenclature of fistule is quite extensive. The names are derived cither 
from the parts in which the abnormal passage is situated, as anal, perinetl, 
broncho-pleural, and recto- vaginal, or from the nature of the discharge, as salivaiy, 
urinary, and stercoraceous. 

Fistules vary much in their extent. The longest tracks occur along the spinal 
column in connection with psoas abscess. In this affection, the matter generallj 
escapes in the groin, just above Poupart's ligament, in the upper part of the thigh, 
or, lastly, in the ileo-lumbar region, the channel which is thus established vary- 
ing in length from six to twelve inches, and being always lined by a well-organ- 
ized, adventitious membrane. Passages of considerable length are sometimes 
met with in the internal organs, as between the kidney and lung, between one 
coil of intestine and another, or between the urinary bladder and the cotaneoiu 
surface. In other situations, on the contrary, the track is remarkably short, being 
hardly two or three lines from the surface, or from the cavity with which it com- 
municates. 

The diameter of these abnormal tracks is also very variable. Sometimes they 
are so small as scarcely to admit the finest bristle ; while at other times they are 
sufficiently capacious to receive a goose-quill or the end of the finger. The 
narrowest tracks usually occur in the lachrymal passages, salivary glands, anas, 
and perineum. It is not often that the fistule is of the same uniform diameter 
throughout ; on the contrary, it is almost always larger at one point than at 
another. 

The external orifice, generally of a rounded or .oval shape, may be so narrow, 
on the one hand, as to be hardly perceptible, or, on the other, so large as to admit 
the end of a probe, a goose-quill, or a finger. It may have sharp and well-defined 
margins ; be surrounded by a soft, spongy, florid rim ; or, be depressed, inverted, 
or infundibuliforni. The number of external orifices varies in different cases, 
from one to as many as six or a dozen ; when it is very considerable, the affected 
surface commonly presents a cribriform appearance. 

The internal orifice may be of the same size as the external, or it may be 
smaller or larger. In its shape it is usually irregularly rounded, and it is 
seldom that it is found multiple, even when the number of external openings is 
considerable. 

Although the direction of the passage may be perfectly straight, yet, in general, 
it is more or less flexuous, serpentine, oblique, or winding. Occasionally it forms 
nearly a right angle with the surface upon which it opens. When several tracks 
exist, they often run together, and open by one common orifice upon the reservoir 
with which they communicate. 

A fistule, in its recent state, is simply a raw surface bathed with purulent 
matter. It is, in fact, an ulcer, an open sore, a solution of continuity, which 
must undergo a process of reparation before it can be justly entitled to its dis- 
tinctive appellation. The track, however, soon becomes smooth, and is speedily 
coated with an adventitious membrane, varying in thickness from a mere film to 
half a line, a line, or even the sixth of an inch. This new layer, at first soft and 
easily detached, gradually augments in density, and is at length inseparably 
united to the parts which it serves to line. Its color, like its consistence, is very 
much influenced by its age, and by the nature of the secretion or excretion which 
passes over it. At an early period it is red, pink, or rose ; in cases of long stand- 
ing, on the contrary, it is either white, gray, or slightly bluish. The free surface 
of the membrane is smooth and polished ; or it is rough, mammillated, or studded 
with villi of various shapes and sizes. The other surface is attached by means 
of short cellular substance to the parts upon which it lies. Bands of lymph 
sometimes extend from one side of the abnormnl channel to the other, very much 
as in the bridle stricture of the urethra ; but this is rare. 

The membrane here described is formed out of the blood-liquor, and is of the 
same nature as the pyogenic membrane of a chronic abscess. Around the anus, 
in the perineum, and in some other regions, it bears no little resemblance to 



CRAP. T. 



FISTULB. 207 



iDocoas tissne, but differs ftom it in having no follicles and no distinct epithelial 
layer. It is liberallj supplied with vessels, nerves, and, probably, also with 
absorbents, is the seat of a constant secretion of gleety or other matter, and is 
liable, like all new textures, to inflammation and its consequences. In ancient 
cases it occasionally acquires a dense, fibrous, or fibro-cartilaginous consistence. 

The nature of the discharge in this disease varies with the situation of the 
abnormal passage. In general, it is thin and gleety, as in chronic gonorrhoea, 
and mingled with the natural secretions or excretions of the reservoir with which 
the fistula communicates. When, however, the lining membrane labors under 
inflammatory irritation, the discharge is either entirely suspended, or it is bloody, 
ponilenty or muco-purulent. 

The parts in which the abnormal track is situated are varioasly affected. In 
some cases they are nearly natural ; but in general they are firm and callous, 
from the effusion and organization of plasma, which, when present in large 
quantity, may completely obliterate the meshes of the connecting cellular tissue. 

Finally, the causes which give rise to fistulcs are either mechanical or vital. 
To the first class belong woands, contusions, and lacerations ; to the second, 
ulceration, gangrene, and abscesses. There is a variety of the affection which 
may be regarded as a remnant of embryotic organization. Its most frequent 
situation is the antero-lateral part of the neck. Like the ordinary fistule, it may 
terminate in a cul-de-sac, or it may have two orifices, of which the external is 
sometimes scarcely visible. The abnormal passage itself is usually very narrow, 
and seldom extends beyond two or three lines in depth. 

The treatment of fistule must be regulated by circumstances. In recent cases, 
before the passage has become lined by an adventitious membrane, a cure will 
sometimes follow the use of stiihulating ii^ections, as a weak solution of nitrate 
of silver, sulphate of copper, tincture of iodine, or acetate of lead, repeated twice 
in the twenty-four hours ; or by touching the parts lightly once a day, or once 
every other day, with solid lunar caustic, or with the end of a probe dipped in 
a solution of acid nitrate of mercury. Strict attention should be paid to clean- 
liness, and the parts should be maintained in a state of absolute rest. It is 
aeklom, however, that a permanent cure can be effected in this way, especially if 
the fistule be of any extent, or situated where it is influenced by the contraction 
of mu;M!uIar fibres, as, for example, when it involves the anus. The best plan, 
in fact, nearly always is not to lose any time in experimenting with these reme- 
dies, but at once to lay open the abnormal passage in its entire length, so as to 
afford the parts an opportunity of healing from the bottom by the granulating 
process, a tent being interposed between the edges to prevent their readhesion. 
Occasionally a seton may be passed through the track, and be retained until it 
ulcerates out. In some forms of fistule, as in the vesico-vaginal and urethral, a 
very delicate operation is generally required in order to effect a cure, consisting 
in paring the margins of the opening and bringing them together by seversd 
points of suture. 

The healing of a fistule is often materially retarded, if not effectually prevented, 
by the presence of a foreign body, as a mass of dead cellular tissue, a loose piece 
of bone, a bullet, or a portion of wadding, or, by the contact of some irritating 
matter, as urine, or feces. The indication, of course, is to remove the extraneous 
t>ab:^iance whatever it may be, and then to mauage the case upon the principles 
ju&t laid dowiL 

Occasionally, again, the difficulty in respect to a cure may depend, at least in 
part, upon deficient tone of the system, or some disorder of the general health. 
The patient, for example, may be anemic from organic disease, intemperance, or 
want of wholesome air and food. Such cases are not uncommon in large cities 
and in the wards of crowded, ill- ventilated hospitals, and readily suggest their 
own treatment 

The prudent practitioner is sometimes sorely perplexed in this disease as to 
the propriety of attempting a radical cure, or whether he should interfere ouiy 
«o far as to palliate the patient's suffering. In general, it will be best to let each 
be governed by its own rules. When the fistule has been of long standing, 



208 CONGENITAL MALFORMATIONS. oiap. ti. 

and has acted all along as a drain upon the system, serving perhaps to counter- 
act some other affection, such as phthisis or a tendency to afxiplezy, no opentioa 
should be practised, since it could hardly fail to provoke mischief. In foct, serioni 
organic disease of any kind is a contra-indication to an operatioD. The only 
exception to this is where the fistule is a cause of excessive local distress, gobi- 
pletely depriving the patient for days of sleep, appetite, and comfort Under 
such circumstances the surgeon could hardly refuse his aid ; bnt before doing 
this, he would be sure to open a now source of counter-irritation, in the fonn ot 
an issue or seton, in some other and more eligible portion of the body, thsi 
establishing a drain at least equal to that which he is about to suppress in order 
to afford temporary mitigation. In ordinary cases there is of course no retsoi 
for dolay ; the operation is promptly performed, and a rapid recovery is reasoft* 
ably anticipated. 



CHAPTER VI. 

CONGENITAL MALFORMATIONS. 

CoNOENTTAL malformations, surgically considered, constitute a subject of the 
deepest interest, both because they are of frequent occurrence, and because they 
generally require an extraordinary amount of knowledge and skill for their 8n^ 
cessful management. Presenting themselves under different forms or characters, 
they exhibit every variety of grade, from the most simple departure from the 
normal standard to the most pitiable and disgusting deformity, well calculated to 
elicit the sympathy and aid of the considerate and humane surgeon. With a viev 
to a more full appreciation of the nature of these malformations, they may con- 
veniently be arranged under the following heads: Ist, deficiency of parts; 2dly, 
redundancy of parts ; 3dly, displacements ; 4thly, occlusions ; 5thly, deviations 
of position ; 6thly, adhesions of contiguous surfaces ; 7thly, vascular tumors. 

1st. The first class, consisting of a deficiency of parts, maybe subdivided into 
two orders ; the one comprehending fissures, or clefts, and the other an entire 
absence of certain structures, as a finger, hand, or ear. 

The most common, and, in a surgical point of view, the most interesting:, 
fissures arc hare-lip, cleft palate, bifid uvula, extrophy of the bladder, epispadias, 
hypospadias, and bifid spine, together with extraordinary patency of the fonti^ 
nelles. Of these malformations some admit of relief by operation, whereas 
others are hopelessly irremediable ; at all events, every attempt hitherto made to 
cure them has either signally failed, or eventually destroyed the patient. The 
operation for hare-lip is of daily occurrence, and, when properly executed, rarely 
disappoints expectation ; besides, if it fail, it admits of repetition. Staphylo- 
raphy has also become a common procedure, which is frequently, if not generally, 
crowned with success. Extrophy of the bladder, consisting in a deficiency of the 
anterior wall of that viscus and of its protrusion at the linea alba, has hitherto 
resisted every means directed for its relief. Epispadias and hjrpospadias are 
difficult of cure ; and a cleft of the vertebra, with protrusion of the envelopes of 
the spinal cord and of the cephalo-spinal liquid, is nearly alwa3r8 a fiatal affectioB. 
The closure of these fissures is effected by paring their edges, and afterwards 
approximating them by suture, ultimate union being accomplished through the 
intervention of plastic matter. The tumor in bifid spine is emptied with the 
trocar, and then injected with some slightly stimulating fluid, with the hope of 
exciting obliterative inflammation. In general, the operation is speedily followed 
by convulsions, coma, and death. 



CHAP. VI, CONGENITAL MALFORMATIONS. 209 

Iq the second order of cases the deficiency consists in the absence of certain 
ftmctares, as a finger, a hand, or even au entire arm. The genital organs suffer 
perhaps more frequently in this way than any other parts of the body. Thus it 
is by no means uncommon to find the vagina absent, or the vagina and uterus, or 
these organs along with the ovaries and Fallopian tubes. Sometimes the testes 
are wanting, or, if present, they exist only in a rudimentary form, perhaps hardly 
equalling the volume of an ordinary bean. The penis, too, may be absent ; or, 
instead of being large and well grown, it may, at the age of puberty, be less 
than that of a child at the eighth or tenth year. 

Sdly. A congenital redundancy of structures is sometimes met with, consisting, 
chiefly, in hypertrophy of the integuments of various regions of the body, or in 
the addition of a supernumerary finger, toe, tooth, or ear. To the same category 
belong the anomalous divisions of certain arteries, as the brachial and femoral, 
high up in their respective limbs. A redundancy of skin and cellular substance 
is most common about the neck, hands, feet, and genital organs, as the prepuce 
and vulva, where the superfluous structures sometin^s occur in large, pendulous 
mass^es. A supernumerary toe, thumb, or finger is no unusual occurrence ; occa- 
sionally each hand and each foot are provided with such an appendage. I have 
been one well-marked example of four ears ; an increase of the naturcd number of 
teeth is not uncommon. In some of these cases the supernumerary organ is buried 
in the alveolar process of the jaw, where I have known it to be productive of such 
an amount of disease as to require a serious operation for its removal. Most of 
these malformations admit of cure by retrenchment with the knife, and the opera- 
tion may generally be safely executed at an early age. 

3<Uy. Congenital dUplacements occur in various parts of the body, but prin- 
cipally in the articulations and in the abdominal viscera. The joints that are 
motit liable to this form of dislocation are the hip, shoulder, and wrist ; but it has 
aliMi. although very seldom, been met with in those of the jaw, clavicle, elbow, 
and knee. The deformity thus produced is often very great, and what aggravates 
the ease is the circumstance that it rarely admits of relief, however skilfully and 
persevcringly it may be treated. The malformation, as will be shown elsewhere, 
probably begins at an early period of foetal life, and goes on gradually increasing 
until it attains an irremediable stage. 

The most common form of displacement of the abdominal viscera occurs in 
what is called congenital hernia, caused by a want of closure of the inguinal 
canal during the descent of the testis. The consequence is that, soon after the 
chihi has begun to breathe, the diaphragm, pressing the bowels against the walls 
of the abdomen, forces them down into the scrotum. The portion of tube thus 
displaced is generally a loop of small intestine, but now and then other organs 
are pushiKl down along with it. The most suitable remedy for such a defect is 
steady compression upon the neck of the hernia by means of a well-adjusted 
tnidS. which generally eventuates in an efi'usion of lymph, and the obliteration of 
the sac of the tumor. 

4thly. Congenital occlusion may occur in any of the mucous outlets of the 
body, but is much more frequent at the anus and genital organs than anywhere 
else. Closure, properly so called, of the anus may be produced by a continuation 
of the integuments across from one buttock to the other ; or it may depend upon the 
existence of a fold of mucous membrane situated just within the anus, an arrange- 
ment not unlike a hymen. In either case, relief may easily be affected by the 
knife, patency being afterwards maintained by the frequent insertion of the finger. 
Tlie prepuiH; is sometimes completely impervious, or if an opening be present, it 
aa?wer:s very imperfectly the purpose of an outlet for the urine. The vagina is 
occasionally imperforate, being closed by what is termed the hymen ; and there 
L» r«*ason to believe that certain forms of sterility are due to occlusion of the 
uterus, or of the Fallopian tubes. 

5t]ily. Congenital deviations of position are infrequent. The most interesting, 
in a surgical point of view, is the deformity of the nasal septum, which is occa- 
sionally so great as to interfere materially with the functions of the nose, one of 
the anterior nares being sometimes completely occluded by the projection of the 

VOL. 1. — U 



210 CONGENITAL MALFORMATIONS. gbap. rt. 

partition towards the corresponding side. A simple operation, consisting in the 
romoval of the incurvated portion of the septnm, geuerallj effectually relieTes the 
difficulty. 

There is occasionally a remarkable congenital incurvation of the penis, dis* 
qualifying the organ for the easy and full discharge of its functions. The defect 
is always associated with hypospadias, and consequent shortening, or imperfect 
development, of the spongy structure of the urethra. An admirable operation for 
the cure of this deformity, devised by my colleague, Professor Pancoast, will be 
described in the chapter on the genital organs. 

Deviation of position is often associated with permanent contraction or shorten- 
ing of the muscles and tendons, as is seen in club-foot, wry-neck, and other 
analogous distortions. This class of lesions is one of great practical interest, 
having opened to the modern practitioner a wide field for the exercise of his in- 
genuity and skill, as well as of his patience. Taken in hand soon after birth, 
they may frequently be promptly remedied by the use of the most simple ap- 
pliances, whereas under opposite circumstances the treatment will generally be 
very tedious, even if aided by the free division of the affected structures. The 
rectification of these malformations forms one of the most interesting chapters 
in the history of subcutaneous surgery, one of the great discoveries of modem 
times. 

6thly. Congenital adhesions are sometimes observed, chiefly betwen the fingers 
and toes ; more rarely between other parts, as the eyelids and the ball of the eye, 
the ear and the scalp. The uniting medium is generally merely a fold of common 
integument, the severance of which often effectually releases the parts firom their 
restraint, and restores them to usefulness. 

'Tthly. I may mention, finally, as another class of congenital affections, those 
peculiar vascular tumors known as nevi^ or mother^ 8 marks ; they occur in differ- 
ent regions of the body, especially the head and face, and constitute an exceed- 
ingly interesting and important form of morbid growth. Their composition is 
variable ; sometimes they are essentially composed of dilated and tortuous capil- 
lary veins, connected by areolar tissue ; at other times they are made up mainly 
of enlarged and diseased capillary arteries ; lastly, there is a third species which 
seems to partake of the character of both the others, the two set« of vessels being 
so intimately blended as to render it impossible to determine which predominates 

These vascular growths, however constituted, almost always begin in the sub- 
stiince of the skin, from which, as they augment in size, thoy gradually extend to 
the cellular tissue beneath ; they are of a soft, spongy consistence, readily receding 
under pressure, and expanding under mental emotion. Their color is variable; 
the venous varieties being usually of a dark purple, and the arterial of a red 
scarlet hue. The latter are of a truly erectile character, and hence they com- 
monly pulsate, heaving and throbbing synchronously with the contraction of the 
left ventricle of the heart. The growth of both varieties is generally steadily 
progressive, and the consequence is that they often acquire a considerable bulk. 

Most of these morbid growths readily admit of cure, especially if timeousty 
begun. This may be effected, 1st, by ligation ; 2dly, by incision ; and, 3dly, by 
escharotics. 

In regard to the causes of these various malformations, it would be entirely 
out of place to inquire into them here. My sole object has been to bring the 
subject briefly before the reader in its practical relations ; any other information 
respecting it may readily be obtained by a reference to the many works specially 
devoted to such discussions. Some of these malformations are doubtless owing 
to an arrest of development, dependent upon a defective organization of the 
germ; others are probably caused by irritation of the nervous centres; while 
others, again, are perhaps due to faulty position of the foetus in 'the uteruB, or 
violence inflicted upon it during gestation. 



11. GENERAL OBSERVATIONS. 211 



CHAPTER VII. 

TUMORS, OR MORBID GROWTHS. 

SECT. I. — GENERAL OBSERVATIONS. 

What is a tumor 1 The best definition that, in ray jud^ent, can be given 
of it is that it is an enlargement of a part, structure, or organ, produced by ab- 
Bonnal deposit. This abnormal deposit may be an entirely new formation, or it 
nay be merely a superaddition to the original one. It may, moreover, be benign 
or malignant ; that is, it may simply incommodate, by its situation, weight, and 
balk, or it may, after a certain period, destroy not only the part in which it ap- 
pears, but also the patient. It may be stated, as a general law, that most of the 
benign tumors, or innocuous growths, are the result merely of some alteration in 
tke fanetion of the primitive tissues ; many, indeed, are nothing but local hyper- 
trophies, or enlargements produced by inflammatory deposits, supemutrition, or 
the retention of some normal secretion. On the other hand, malignant tumors 
are always formed out of new material which is either entirely distinct from the 
aatoral stmctures, or which bears merely a very faint resemblance to them, in its 
physical, chemical, and vital relations. The only exception, perhaps, to this law 
is the hydatie tnmor, which, although it is altogether foreign to the natural or- 
ganisation, is of a non-malignant character. 

The nnmbcr of malignant formations, bo far as is at present known, is com- 
paratively small, while the number of benign is very considerable. Occurring at 
nearly all periods of life, and in nearly all the organs and tissues of the body, 
they possess certain features in common with each other, a circumstance which 
renders it necessary to study them in a general point of view. Such a proceed- 
ing is indispensable to a correct appreciation of the structure, diagnosis, and 
treatment of these affections. The principal topics to be considered, in connec- 
tion with these points, are, first, the physical properties of the morbid growth ; 
secondly, its relations to the surrounding parts ; and, thirdly, its history. 

1st It would be difficult to point out a situation where tumors may not occur. 
With the exception of the tendons, fibrous membranes, cartilages, and blood- 
vessels, they are found in all parts of the body, and it would hardly be proper to 
affirm that even these structures are altogether exempt from them. Asa general 
rule, it may be stated that malignant growths are most common in glandular 
orgrans, as the mamma, liver, and mucous follicles ; in the cellulo-adipose tissue, 
as in the case of melanosis ; or in the peritoneum, stomach, bowel, and bones, as 
in that of colloid. Tubercular deposits occur almost everywhere ; but, surgically 
coDj>(idered, more frequently in the lymphatic ganglions than in any other parts. 
Epithelial cancer has a peculiar predilection for the cutaneous and mucous tex- 
tores at the various outlets of the body. Benign tumors are most common in the 
ckin, cellulo-adipose tissue, nose, uterus, and ovary. Hydalic formations are seen 
chiefly in the liver, breast, testicle, and bones. 

Tumors affect various /orms, depending not merely upon the nature and amount 
of resistance offered to their development, but also, in some degree, upon the 
original shape of the part wherein they originate. A sebaceous tumor is gene- 
rally globular ; a fatty one either flat or pendulous ; a polypoid one pyrifomi, 
conical, or pediculated. Malignant growths are commonly distinguished by the 
irregnlarity of their snrfooe, which is often lobnlated, or marked off into ridges 
and depressions. 



212 TUMOBS, OR MOBBID GROWTHS. chap. Tii. 

In their volume, tumors range, io every possible gradation, from that of a 
millet-seed, as in the little granule on the eyelid, to that of the patient's body, 
as in ovarian cjsis and elephantiasis of the scrotum, those enormous masses which 
are sometimes absolutely more bulky and heavy than the subject in whom they 
are developed. Fatty, fibrous, cartilaginous, and osseous growths occasionally 
acquire a large size, but they are almost the only ones of their class that do. 
Among the heterologous tumors, those which attain the greatest magnitude are 
the encephaloid and colloid ; scirrhous, melanotic, and otber formations of this 
description being usually comparatively small. 

In respect to their consistence, some tumors are soft, some solid, some semi- 
solid. Tumors containing serous fluid, as hygromatous cysts of the neck and 
ovary, are always soft and fluctuating, unless they are overlaid by a lai^ quantity 
of solid substance, when they may partake of the latter character even more 
than of the former. Fibrous, cartilaginous, and osseous tumors are known by their 
great hardness, which equals that of the natural structures. Scirrhas is the most 
firm of the heteroclite formations, its namo being derived from that circumstance. 
Occasionally one portion of a tumor is soft, another hard, and a third, perhaps, 
semi-liquid. Ovarian growths exhibit these varieties of consistence more 
frequently, and in a more perplexing degree, than any other, whether benign or 
malignant. 

The color of a tumor is generally a matter of secondary consideration, as the 
morbid growth is seldom sufficiently exposed to admit of direct inspection, except 
in some of the mucous outlets. In the early stage of all formations of this kind 
that take place beneath the external surface of the body, there is usually an 
absence of discoloration, and it is only when the growth bears too heavily npon 
the integument, pushing it out in every direction, or when it manifests a disposi- 
tion to ulcerate and evacuate its contents, that it causes the skin to be red, livid, 
or purple. In tumors of the nose, uterus, and anus, color often affords us great 
assistance in the discrimination of the case. A gelatinoid polyp can never be 
mistaken for a fibrous one ; for its complexion is always diagnostic of its character. 
It may be assumed, as a general rule, that the lighter a tumor is externally the 
greater is the probability of its being benign, and conversely. 

Mobility is an important quality in a tumor, its amount varying according to 
the nature of the affected organ and the degree of resistance offered by the 8a^ 
rounding parts. Some morbid growths are never movable, others always are, 
whatever may be their age, volume, or situation. A sebaceous tumor never con- 
tracts such firm adhesions as to bo insusceptible of being pushed about ; while an 
exostosis is always inimovubl(> from its very commencement. Most of these 
formations, be their character what it may, unite with the surrounding tissues as 
they augment in age and volume, their pressure exciting inflammation and plastic 
d(^posits, which thus become the bond of connection between the normal and ab- 
normal structures. 

Tumors are endowed with various degrees of sensibility, depending upon the 
peculiarity of their structure and the amount of compression exerted upon them 
by the parts in which they are developed. Most tumors, whether innocuous or 
malignant, are free from pain during their earlier stages ; but, as they increase 
in size, they encroach upon the neighboring tissues in such a manner as to inte^ 
fere with their movements, and thus seriously compress their nerves, whilst the 
latter, in their turn, more or less compress the nerves of the advancing masfli 
Occasionally the pain is characteristic, as, for example, in scirrhus of the mamnurj 
gland. Encysted tumors of the skin are usually entirely free from pain, or, if there 
be any pain, it is the result of accidental circumstances. 

2dly. In regard to the relations which tumors bear to the surrounding structarea, 
several circumstances deserve to be noticed. The first is the manner in which 
they are bound down, or inclosed in their habitation. Every tumor must neceutrily 
have an appropriate residence, but, like a settler in a new country, it is seldoift 
content with the spot originally assigned to it On the contrary, soon lacking rooi^ 
it is sure to encroach upon, fret, and worry the parts around it, which, as alrea47 
seen, are not slow to resent the invasion. Mutual oppression and mutiud dii^ 



CHAP. Til. GENERAL OBSERVATIONS. 218 

comfort arc the irsnlt The healthy structures successfully resist for a while the 
intrar^ion, but gradually they yield before the enlarging mass, which thus often 
couYtrrts the muscles into mere ribbons and the bones into mere shells. Function, 
loo, may be seriously interfered with ; the rannla filling the mouth, the goitre 
compressing the neck, the polyp closing the womb. 

Id the second place, the tumor, as it progresses, is apt, either by the continued 
pressure which it exerts upon the superimposed parts, or by the gradual decay 
of its own structure, to produce ulceration, followed by more or less discharge.- 
This tendency, although most conspicuous in the heteroclite formations, is not 
peculiar to them, but is also witnessed in some of the benign growths, as the 
encysted and adipose. Large vessels are sometimes laid open during the progress 
of the disease, thereby inducing copious hemorrhage. 

Tumors often occasion serious disease in the surrounding lymphatic ganglions. 
This is particularly true of malignant tumors, in some of which it forms a very 
con^icuous, if not unmistakable feature. In cancer of the jaw the ganglions of 
the neck enlarge ; of the breast, the ganglions of the axilla ; and of the testicle, 
the ganglions of the groin ; either by actual extension of the morbid action, or 
from sympathetic irritation. 

Finally, an intimate Hijmpaihy exists between tumors and the constitution, 
operating at one time beneficially, at another, prejudicially. The progress of 
malignant growths is often stayed for months and years, simply by attention to 
the general health ; on the other hand, it is frequently astonishingly hastened by 
disorder of the system, and, in fact, by whatever has a tendency to produce 
derangement of the secretions, especially those of the liver, uterus, and kidneys. 

3dly. The hiMory of the case often furnishes important points of comparison. 
Tumors occur at all periods of lift?, in both sexes, in all classes of society, and in 
all varieties of temperament. Certain forms of malignant disease, however, are 
most common at one period, and others at another. Thus, scirrhus is almost 
peculiar to elderly subjects, while encephaloid is most frequent between the ages 
of twenty and fifty. The scrofulous tumor is most common in childhood and 
adolescence. Benign growths of every description are often observed in early 
life, but the greatest number of cases occur in young adults. 

Rapidity of growth and great bulk imply inordinate vascular activity, and lead 
to a suspicion of malignancy. There is no tumor that attains so great a bulk in 
sio short a time as the encephaloid, and certainly none that is more surely fatal. 
Ovarian cysts, of the non-malignant type, often acquire an astonishing develop- 
ment in a comparatively brief space. Sebaceous, polypoid, osseous, and fatty 
tumors, on the contrary, usually grow slowly, and occasionally enjoy even a period 
of repose. 

Consstitutional involvement may be occasioned by sheer malignancy, or by the 
injurious effocts exerted by the morbid growth upon important structures in its 
neighborhood. In general, rapidity of development, large size, and the early 
formation of adhesions, along with enlargement of the lymphatic ganglions, and 
constitutional disorder, may be regarded as evidences of a malignant tendency. 

Some tumors have a disposition to return after extirpation ; others have not. 
AH malignant grc3wths, without exception, possess this repullulating tendency, 
and hence their removal is rarely, if ever, followed by a permanent cure. Re- 
lapse, however, may also occur when the tumor is perfectly benign, but then it is 
generally dependent upon imperfect extirpation. Thus, an encysted tumor will 
alnios>t be certain to recur if any portion of its sac, however minute, is left behind. 

It is seldom that a tumor disappears spontaneously; nevertheless, such an 
occurrence is possible, and there are several ways in which it may bo effected, as 
by absorption, enucleation, ulceration, and gangrene. The former of these modes 
of cure is the most common ; one of the best examples of it is witnessed in the 
tcrofolons tumor, so frequent in the neck and about the angle of the jaw in 
stnunoos children, from exposure to cold and derangement of the digestive organs. 
Tlie disease essentially consists in an inflammatory enlargement of one or more 
lymphatic ganglions, which, aftier having existed perhaps for years, finally goes 



214 TUMORS, OB MORBID GROWTHS. chap. Tii. 

away without any assignable cause, merely, to all appearance, in conaeqneDce of 
an improved state of the general health, and of a change in the nutrition of tiw 
part. 

Sometimes a tumor becomes enucleated, and drops off, leaving perhaps merely 
its inclosing cyst. It is thus that the fibrous tumor of the uterus is oeeasionilly 
detached ; and a similar accident may happen to an exostosis, particularly if it 
be large and situated upon the skull. In such cases the vascular connectioa 
between the morbid growth and the circumjacent structures is probably, as t 
preliminary step, in a great degree destroyed, so that the tumor, gradually dyiog 
and acting as a foreign body, is at length cast off by the living tissues. 

A cure is occasionally effected by profuse suppuration, or, more correctly 
speaking, by suppuration and ulceration. The kind of tumor most easily inflt- 
cuced in this way is the scrofulous, which is either completely disintegrated and 
broken down, or it is dissected off by ulcerative action, and is finally detached ti 
an effete substance. 

Lastly, gangrene seizing upon a tumor may so interfere with its circulation as 
effectually to destroy its vitality. Such an occurrence, although very rare, may 
take place in a malignant as well as in a benign growth. Some years ago, I 
attended an elderly lady.on account of scirrhus of the mammary gland ; after 
the disease had been going on for upwards of a year, the carcinomatous strac- 
tures were suddenly attacked by gangrene, and in less than a week they dropped 
off in the form of a black slough, leaving in their stead a large excavated cavity. 

SECT. II. — BENIQN TUMORS. 

The benign or non-malignant tumors may be arranged under the following: 
heads : I. Hypertrophic ; 2, vascular ; 3, adipose ; 4, homy ; 5, fibrous ; 6, 
cartilaginous; 7, osseous; 8, calcareous; 9, neuromatous; 10, cystic; 11, hydatic; 
12, polypoid; and 13, myeloid. The latter, however, must, for the present, 
occupy an equivocal position in this arrangement. As for myself, I have very 
little doubt but that it will ultimately be found to be merely a variety of ence- 
phaloid. 

1. HYPERTROPHIC TUMORS. 

I employ the term " hypertrophic" to designate a class of tumors which are 
produc(;d by the gradual enlargement of an organ, in consequence of an increase 
of its nutrition. A good type of this form of tumor occurs in the thyroid body, 
in what is generally known as goitre. This affection, which commonly begins 
very early in life, consists essentially ia an abnormal development- of the com- 
ponent elements of the gland, simply as the result of a preternatural supply of 
blood. What the immediate cause of this increased supply is does not admit of 
easy explanation. It is possible, although problematical, that it may originally 
depend upon inflammatory irritation ; but, even if this be true, it can hardly be 
supposed that this action would continue through a series of twenty, thirty, and 
even fifty years, as we know it often does, from the steady and persistent increase 
of the morbid mass. Whatever, therefore, may set the process in motion most^ 
after a time, cease to exert its influence, while the perverted movement, once 
begun, daily progresses, until the structures affected by it are incapable of fiirther 
change. This idea derives additional support from the fact that goitre, after 
having attained a certain degree of development, often remains stationary for a 
long period, when, perhaps suddenly and without any obvious cause, it again 
commences to grow. If such a tumor be examined in its earlier stages, it will 
be found that, while the tissues are unnaturally red, firm, and distinct, and that, 
while the thyroid arteries which supply them with blood are nnnaturaUy Tohi- 
minous, there is no evidence whatever of plastic deposits justifying the belief 
that inflammation had any agency in the production of these changes. If, at a 
later period in the disease, we find various morbid products, such as the patho- 
logist is accustomed to regard as the consequence of inflammation, it only shows 



CBAP. Til. HYPSBTROPHIC TUMORS. 215 

that thej are the resalt of secondary caascs, developed during the progress of the 
hjpertrophj, which is itself, no doubt, often a source of inflammation to the 
affected tissues. 

Hypertrophy of the prostate gland, generally described as senile enlargement, 
is often produced in a similar way. The same cause usually presides over the 
development of those enormous growths of the mamma which are occasionally 
observed in young females, and in which that organ has been known to acquire 
t bulk many times exceeding the natural one. Congenital enlargement of the 
tongue is another well-marked example of the same mode of formation. 

A chronically enlarged tonsil is clearly a specimen of this form of tumor, only 
that the hypertrophy is usually attended with an inordinate amount of plastic 
deposit. The inflammation, however, after a time, frequently disappears ; but 
not so the enlargement. On the contrary, when it has once been fairly estab- 
lished, it often steadily progresses until the gland has attained an enormous bulk, 
simply from the increased nutrition of its proper tissues, aided by occasional 
sol^qnent attacks of inflammation, to which it is ever afterwards remarkably 
prone. 

The encysted tumor of the skin, the common sebaceous tumor of authors, is 
essentially a hypertrophic formation, awakened by obstruction of the outlet of a 
cataneous follicle, caused either by inflammation or by the impaction of seba- 
ceous matter. The natural secretion being thus retained, presses upon the walls 
of the follicle in every direction, thus inviting a preternatural afflux of blood, 
probably attended, in the first instance, by interstitial deposits, but gradually 
subsiding as the cyst becomes tolerant of the presence of the altered and now 
foreign substance. That this is true does not admit of doubt, especially if we 
reflect upon the fact that this form of tumor often steadily increases for many 
years without any demonstrable evidence of inflammatory irritation. 

To the same category as the above affections belong those chronic lesions of 
the lymphatic ganglions in which there is not only more or less augmentation 
of their volume, but marked induration and alteration of their proper tissues. 
Sometimes a large tumor is formed in this way by a single gland, bat, in general, 
such growths consist of an agglomeration of several bodies of this kind, united 
so as to form a bulky mass, of a nodulated character, and of extraordinary firm- 
ness. 

If we adopt the term which I have here employed to designate these changes, 
we shall be able to dispense altogether with the word " sarcoma," introduced by 
Mr. Abemethy, and so constantly used since his time, in reference to certain 
alterations produced in our organs as a consequence either of simple supcrnutri- 
tion or inflammatory deposits, or both conjoined. Sarcoma literally signifies 
flesh, and is therefore wholly inapplicable, not only to this but also to every 
other form of morbid growth, which never has any resemblance, not even the 
faintest, to flesh. The sarcomatous testicle, for example, as it was formerly 
called, in conformity with the nomenclature of the English surgeon, is merely a 
chronic enlargement of that organ, the result of inflammatory deposits and super- 
natrition of its proper structures. 

The mammary gland not unfrequently enlarges in a similar manner, its sul)- 
stance being indurated and distinctly defined, but not so completely masked as 
to lose all trace of its primitive character. The organ is simply hypertrophied, 
and is therefore capable, under judicious management, of regaining its natural 
properties. 

Much is to be expected from medical treatment in this class of tumors. The 
remedies upon which our chief reliance is to be placed are purgatives and sorbc- 
bcients, with strict attention to the diet Occasionally, valuable aid is derived 
from topical bleeding, especially when there is decided evidence of overaction 
with tendency to plastic effusion from inflammatory accession. The bowels 
having been duly attended to, the best internal remedies are, in the more recent 
ca^es, the milder forms of mercury, and, in the more chronic, the different prepa- 
rations of iodine, of which LugoPs solution and the iodide of potassium are 
entitled to the preference. The object is to change capillary action and to pro- 



216 



TUHOBS, OB SOBBID OBOWTHS. 



mote the absorption of rodnndant matorial, whether the product mere1)r of an^ 
or of perverted nutritioo. The operation of iutomal remedies is genenllj mj 
much increased, under such circumetanceB, by local applications, employed so utB 
excite the lympliatics without irritating the skin. They may coneist of nngaents, 
embrocations, ur liniments, used several times in the twenty-four bonn, tbeb 
beneficial eifucts being aided by rest and other means calculated to fkTor resto- 
ration of structure and function. Blistering occasionally exerts a most pownM 
influence in affording relief. Catting off the supply of blood to the part by 
tying the main artery leading to it has sometimes been succesBfully practiied. 
Excision is performed only as a dernier resort; partinl.aH in the case of ui enlarged 
tonsil, complete, as when the mammary gland or a lymphatic ganglion u involTed. 



2. VASCULAR TUMORS. 

The vasealar tumor, of which a g<K)d idea may be formed by reference to flg. 
28, essentially consists, as the uame implies, of a network uf small bloodveneli, 
connected together by areolar nb- 
1^>»' -S- stance. It is generally met with as a 

congenital affection, its foundation bemg 
laid during foetal life, and it is Dot 
uncommon for it to acquire a consider 
nbtc ))ulk before birth. Most generally, 
ho were r, it is quite diminntiTe whn 
tlie chilli is born, and it often continae* 
80 until some time after, when, perhips 
suddenly, and without any assignable 
cause, it takes a new start, growmg 
with remarkable rapidity. The ordi- 
nary Bites of the vascular tumor ire 
the head, face, and mucous membranes, 
especially that of the rectum, where it 
often presents itself in the form of whit 
is called an internal pile. Their color 
ranges from a deep rofc to scarlet or 
puqile. They are of a soft, apoagy 
c(tni«istcnce, and vary in size flx>m that 
of a mustard seed to that of a fceliJ 
head. 

The vascular tumor exhibits consid* 
erablevorietyofstrncture; being some- 
times essentially composed of veini^ 
sometimes of arteries, and sometimes, again, of l>otli arteries and veins together, 
so equally balanced, in nuiuber and calilier, as to render it difficult to determine 
which predominate. When the tumor is of an arterial character it generallj 
pulsates synchronously with the left ventridi; of the heart, and constitutes a real 
erectile growth, similar to that of the cavernous Imdy of the penis. As these 
formations will claim special attention in the chapter on the diseases of the Ta» 
cular system, no farther notice of them will here be necessary. 




3, FATTT TUMORS. 

The fatty tnmor is quite common. It may arise in any part of the body, with 
the exception, perhaps, of the palm of the hand, tlie Bole of the foot, fingers, and 
toes. It is seen, however, more frequently about the back, shoulder, and arm, 
than in any other regions. The upper eyelid is also a common seat of it, Som^ 
times, but more rarely, it occurs in the orbit of tlie eye, the walls of the abdomen, 
]M!rineum, labium, and nnderncath and even in the substance of the tongue. 
Large masses of this kind occasionally form in the internal cavities of the bod;, 
as in the omentum and mesentery, and around the kidneys. 



FATTY TUaOBS. 



21T 



The naroher of futtj tumors varies, in different caseB, fr6m one to sevei 
hamired- lii general, they ari; solitary, or, nt must, there are only two or three;-' 
■wtopring different regions of the l>ody, or grouped more or less closely together. 1 
la k medical gentleman, aged thirty-eight, who some years ago attended my leo- I 
lonn, I counted upwards of two hundred, from the volume of a siuall pea np tO' { 
tiut of a large marble. They all had a doughy, inelastic feel, and most of tJien | 
irero of a globular shape ; u few were sliglitly flattened, or compressed. They- 1 
<nn sItnUed priDcipally on the forearms, tho inside of the thighs, the loins, aMo- 
men. and pectoral museles, the latter of which were literally covered with them, 
NuDi! existed ud the head, neck, and upper part of the back. The general health 
*wi f^MMl. and the tnmorn had i>een first observed about sixteen years previously. 
Knriag two severe attacks of acute disease, accompanied with great emaciation, 
many nf Ihein entirely disappeared. To satisfy myself of the true nature of these 
inmora, I was permitted to remove one, about the size of a filbert, which proved 
to be composed entirely of fatty matter. 

In their volnme, these growths vary from that of a small pea to that of an 
adult head. Sometimes, indeed, tlicy are much larger, measuring many indies 1 

diameter, and projecting a great 



l'T< 



Fig. 29. 



dutance beyond the surface. 
feasor Lcidy, in 1)459, presented to 
me a lectioo of a fatty tnmor n hich 
wcifHwd Dpwards ofseventy pounds , 
It bad been removed, after death, 
fnio) the abdomen of an elderlv per- 
BMi, and contained large masses of 
b.my waiter. Pr. Bray, of Evan»- 
rille, Indiana, some years ago ex 
Itrpatcd one which weighed ntarly 
fiuir [founds. The patient made a 
good rw-'overy. 

In their shape, fatty tumors are 
gnurrally somewhat globular with 
al<ibalat«d snrface, as seen in hg 29, 
fmm a specimen in my collection , 
aathey aagraent in volume, however, 
tfaM' ar« liable to become elongated, 
and to osmmo a pyriform, gourd 
I3u^, or pedlculatml configuration 
The*e changes, no doubt, depend 
npuu Uieir weight, by which ihi y 
art gradually dragged out of thtir 
original shape, as well as position. 
For tlw same reason tliey sometimes 
shift their »eat, descending from the 

paini wherw they originally appeared to one below it, perhaps, several inches 
Thus, a fatty tumor developed in the groin, has been known, in time, 
down between the scrotum and the thigh. Thia migratory tendency, 
ia intcrceting as a matter of diagnosis, is most common in those parts 
biidy which are abundantly supplied with loose cellular substance, and in 
nues in which the tumor has a large bnlk and a pediculated attachment. 

Fatty Inmors are always invested with a capsule, by which they are connected 
with ifae Burrounding structures, and through which they obtain their vessels, 
" abaorlwnts. This covering is not a new formation, produced by 
inflammatory action, but the result simply of a condensation of the circumjacent 
rrilalai' suliatanoe ; hence it varies very much in its appearance in different eases 
■B<1 in different clreumstanecH. In tho early stage of the affection, and espe- 
dally when the tumor is diminutive, it ia, in general, very thin, soft, elastic, and 
traaniarRnt ; but In cases of long standing and lai^ size, it is always more or 
ka* deR»e, firm, resisting, and of a fibro- cellular, or distinctly fibrous textnro. 




I 



218 TUU0B3, OB UOBBID QBUWTBS. CK&r. tii. 

Ittt tbickncBg rangce between a mcro film and a layer ttt t, line or more in dqnh. 
Kxttirual pressure, particularly if long continned, and the preasnre also of ou 
part of the tumor upon another part, no doubt exert an important influence upw 
the anatomical character of this invcatiture, serving to adapt it to th« varying 
circa nis tan ces of tlie shape and bulk of the morbid growtli. The adkefiion d 
tb<! capsule to the ukin is eometimvs reniarkablf close, requiring great care ia 
Beparating it. 

Attached to the inner surface of this covering arc numerone processes, vfaicb, 
di]ipiiig into the interior of the morbid growth, separate it into IoImb, lobulo, 
and graiiuleti, until the componeut tissues are resolved into their ultimate ele- 
ments. These proi-cNscs arc usually very delicate ; but occasionally, aa whea 
there is a liypertrophous condition of the fibro-cellular substance, they are Tecj 
dense and tough, forming distinct bauds, of a whitish or grayish color, bctwen 
the different structures. 

When the fatty tuinor contains an unusual quantity of fibrona matter, aa when 
its capsule and intersecting processes are very thick and dense, it constitutn 
that form of morbid growth to which Milller, Uokitansky, Uluge, and other 
Uennnn histologists have applied the terms mixed lipoma, stcatoaia, and lirda- 
ccous tumor. The name fibro-fatty would Ix; more appropriate, although the 
distinction is of no practical value. 

Fatty tumors do not recuive much blood, at least not as a general rule ; henre 
they seldom blued a great deal when they are extirpated. It is only when they 
arc of lai^o size, or when they grow very rapidly, that they are likely to be very 
vascular. The capsule and its processes serve to conduct the TesHcls into tha 
interior of the morbid mass, and to direct, as it weie, 
the distribution of their branches and ramificationiL 
As the tumor is always free from pain, and tolennt 
of the Tudust manipulation, it may be concluded that 
it does not receive many nerves. Its absorbent ves- 
sels are also few in number. It may, furthermeit, 
be inferred that, inasmuch as the general health is 
usually unimpaired throughout the whole progress 
of the affection, however long it may continue, it 
does not possess any important sj-mpaihetic relatiooa 
with the general economy. 

The minute structure of this form of tumor is well 
displayed in fig. BO. It is made up of cells, eiactl; 
uiiiui«iirui:tnr«iir«riitriuinor. Similar to thosc of natural fat, interspersed through 
areolar tissue, as seen in the larger drawing; the 
small figure a represents isolated cells, showing thn crytitalline nucleus of nw^ 
garic acid. Various other substances, of an adventitious character, generally 
])rc3cnt themselves upon the field of the microscope, in the form of molecules, 
granules, and globules, especially in old fatty growths. It is upon these accideuUl 
occurrenL-cs that, as stated above, some pathologists have attempted to foDDd 
certain subdivisions of the fatly tumor, which, while they ore of doubtful histolo- 
gical propriety, are altogether destitute of practical value. 

Fatty growths are most common in the sulwutaneous cellular tissue, but thej 
are not confined to this substance ; for in many cases they send prolongatiuns 
around the muscles, tendons, fascisa, vessels, and other structures. Thus a htxj 
tumor of the neck has been known to extend deeply between the trachea and 
(Esophagus, to dip in between the carotid artery and jugnlar vein, or to pass 
down behind the sternum and clavicle into the chest. A fatty growth of the 
wall of the alxlomen is sometimes prolonged into the cavity of that namo; and, 
on the other hand, such a tumor occasionally begins in the subperitoneal cellular 
tissue, and ultimately descends through the inguinal canal, or some abnormal 
outlet, down into the scrotum, thus simulating hernia of the groin. It must be 
obvious that all such arrangements, which, however, are fortunately rare, must 
greatly embarrass both our diagnosis and oar attempts to remove the morbid 




CMAP. Til. KATTY TCMORS. 219 

Fatty tumors are soft, doupliv, and pemi-elastic ; properties wliich, m general, 
enal»le the sargron readily to distiiiguiBh them from other morbid growths. 
Their l>oundarie8 arc usually welklefined, especially when they are superficial or 
pedi<-a]ated. iSonietimefl, however, they are inseiisilily lost in the surronndiug 
parts, being spread out beneath the skin, and sending processes among the mus- 
c!e<, or their fasciculi. In many ca^a they have an irregular, lobuhited surface; 
while In other cases, and perhaps in the majority, they are ])erfi?ctly smooth and 
anifnrm. There is no enlargement of the subeutantMms veins, no disease of the 
ski II. no pain, and no tenderness on pressure. The ])rogress of the tumor is, in 
fact, quite indolent ; the only inconvenience which the patient experiences being 
rausf-d by its weight and bulk. The general health is usually perfect. These 
circumstances, with a careful consideration of the historv of the case, will com- 
monly serve to distinguish fatty tumors from other morbid growths, whether benign 
or malignant in their character. 

Fatty tumors are liable to inflammation, suppuration, ulceration, and gangrene. 
The«e events, however, are very infrequent, and are usually induced by mechanical 
pn^s.^un*. by caustic applications, and by inefficient nourishment, in consequence 
of a loss of their vascular and nervous sujqily from the pendulous or overgrown 
chararttT of the morbid mass. In a tumor of this kind, about the volume of an 
orangt'. which I removed many years ago from the top of the left shoulder of a 
girl of f ighteen, the ulcer had a remarkably foul, unhealthy aspect, with thin, 
everted edge.* ; the pain was at times quite severe, and the discharge was of a 
sanions nature, intermixed with globules of fat. Various attempts had been 
made, but without success, to heal it up, and no cause could be assigned for its 
fMrmation. The general health had 1x*en a good deal impaired, and for some time 
past there had been irregularity of the menstrual function. The ulcer was included 
in the incisions, and a speedy recovery was the result. 

When the fatty tumor Ix^comes inflamed, it may suppurate, the pus occurring 
either as an infiltration or as a distinct abscess. Occasionally it serves as a nidus 
for the fleposit of osseous matttT, as in the case already mentiimed. 

Again, such tumors now and then undergo a sort of fil)rous or cartilaginous 
dt^reneration, not uniformly, but at certain points of their extent. Nodules, 
varying in size from a hazel-nut to a pullrt*s i^pf:, nmy thus bi* fornuKl, having a 
finii. characteristic consistence, more or less movable, aud contrasting .singularly 
with the other structures. Finally, they occasionally contain cysts filleil with 
vari'ius kinds of substances, as oily, serous, or gelatinous. The walls of the 
cysts may be very thin and transjmrcnt, or thick, opaque, and perhaps even 
partially calcified. 

It is not easy to determine how fatty tumors are develojied. The difliculty 
which surrounds the subj<*ct is not ch'ared up by assuming that they are merely 
h^^wrtrt^phies of the natural adipose tissue. This is doubtless the fact ; but W(> 
cannot explain why such an occurrence should taktt place at one point rather 
than at another, or why, indcfd, it should happen at all. The exciting cause of 
the morbid growth has sometimes been traced to (external injury, as a blow, con- 
tusion, or steady mechanical compression ; but in the generality of cases no rea- 
bnn whatever can be assigned for its production. 

B«jth s<*xes arc liable to this formation, but in whnt proportion has not been 
laoertained. It is most common in young adults and middle-aged persons. 

The medical treatment of this class of morbid growths is most unsatisfactory ; 
for there is no remedy of which we have any knowledge that is capable of arrest- 
ing its progress, or causing its removal. If the reverse is occasionally the case, 
It serves only as an exception to the rule, and nothing else. The instance of 
Mr. Brodie. in which he succeeded in dispersing a large mass of fat from a man's 
chin and neck, by the free and persistent use of the solution of potassa, may be 
regarded as a remarkable example of good luck. He Ci)mmenced with half 
i drachm of the fluid three times a day, and gradually increased the dose to a 
drachm. At the end of a month there was a sensible diminution in the volume 
of the tumor, which steadily continued as long as the medicine was persevered 
in. Some time afterwards Mr. Brodie sabatitated the tincture of iodine, which 



220 



TUUORS, OR UORBID GROWTHS. 



ha<l just then eomo into nsc, but the tumor again increased. Finding this to bt 
the case, the alkali was resumed and cnntinued, off an on, nntil the masi TO 
almost entiri'lj' alisnrljrdv Alto^thcr, the man took an cDormoua quantity of tbe 
nxirlicine. I oni not awnrc that the eamo happy effects have been realised fron 
thta remi'dy by other practitionem. 

Alt Wal applications arc equally unavailing. This is true alike of stead; ud 
BTMteniatic compression, of mercurial and other innnctions, and of Motions with 
stimulatinjr liniments and embrocations. The absorbent vcsselfl in these tnmon 
are few and feeble, and this is ]iroba.bly the rooson why all remedies of this 
description are bo utterly valuelenfl as curative agents. 

The manner of excising such tumors is generally sufficiently simple. Any 
diseased skin that may exist should be removed along with the morbid mass, 
which should be enacleated by » 



Fig. 31, 



rapid dissection, care being takes 
that not a particle of the deposit Ii 
left behind ; otherwise reprodnction 
may take place. When the tumor 
is snperGcial the operation is easily 
performed and soon over; but when 
it is deep-seated, or when it sends 
processes among the surrounding 
structures, it may be one of great 
difficulty and perplexity, reqniriag 
the most consummate skill for iti 
successful execution, and the mort 
thorongh knowledge of the anslo- 
my of the parts. For the reasons 
already mentioned, the operation 
iH sometimes nearly bloodless. I 
have, indeed, seldom found it neceft- 
sary to apply more than two or 
throe ligatures, what«v«r may have 
been the volume of the tumor. 

4. HOR.Nr TUU0B8. 

The skin is occasionally the sest 
of a very curious growth, known u 
the horn-like excrescence, from its 
resemblance to the horn of ths 
eheep and goat. A more appro- 
priate name would be the homy 
tumor. It is met with principally 
in those parts of the body wnich 
abound in sebaceous follicles, at 
the face and forehead. In scven^- 
one cases collected by Tilleneave, 
KiirurcicreiimiMeruwinKrronitheKitp. the tumor in tweuty-six was seated 

on the scalp, in five on the nose, Id 
two on the cheek, in one on the lower jaw, in four on the chest, in four on the 
back, in three on the anus and penis, in four on the buttocks, in twelve on the 
thigh, in two on the knee, in two on the ham, in one on the leg, and in three on 
the foot. In the cases that have come under my own observation, it was seated 
on the lower lip, the car, and the chin ; others have met with it on the scrotnm 
and hand. It appears to occur with nearly equal frequency in both sexes, tod it 
occasionally begins at a very early period of life, although in the great majority 
of iuHtnnces it does not come on until after the age of forty. In two cases I hsra 
seen small but well-marked growths of this kind in children under ten yean of 
age. Several such excrescences are sometimes observed in the same p 





ci«r. Til. HOBXV TUMORS. 221 

The size, shape, color, and consistence of the homy tumor arc subject to nmch 
direniity. depeuding op its &qe, and other circumstances. A Icngtli of from three 
to six inches by half an inch to an inch in diameter, as in fig. 31, is by no means 
nncommon. In the British Museum there is said to be a growth of this dcscrip- 
tiun, eleTea inches in length by two and a half in circumference ; and examples 
of a dtill more remarkable nature have been reported by authors. In that curious 
book. An Essay for the Recording of llluijtrious ProTidenct^s, by Increase Mather, 
are briefly mentioned the particulars of the case of a "man that has an horn 
growiufr ont of one comer of his mouth, Just like that of a sheep ; from which 
he haa cut seventeen inches, and is forced to keep it tyed by a string to his car, 
ta prevent its growing up to his eye." 

The ahape of these excrescences is usually conical, lieing lat^r at their adiic- 
RBt than at tJieir free extremity, which is always somewhat tapering, and their 
diRCtion is either spiral, twisted, or bent, so as, in the main, to bear a striking 
m«mbluice to that of the horn of a sheep. In a case recorded in the New York 
iledicml Repository for ltl20, an enonnous growth of this kind, 
mekriuring fourteen inches in circumference at its shaft, is Fig. 32. 

stated to hare consisted of three branches. Ttie surfac-e is 
generally marked by rough circular rings, indicative of the 
eoccessive steps of their development. Now and then it is 
imbricated, knobbed, or covtircd with small pearl-colored 
scales. In color they vary from a dingy yellow to a dark 
grarijib, brown, or black, according to tlicir age, and the 
amoout of their exposure. They are more or less flexible, 
and of a firm, fib ru- cartilaginous consistence. Their internal 
arraugemcnt, as seen on a section, is longitudinally lamcllatcd, 
as in fig. 3J. 

When bnmcd, these excrescences exhale a characteristic 
animal odor. They arc chiefly composed of albumen, in union 
wiih a small qaantity of mucus, phosphate of lime, and chloride 
of sodium, with a trace of lactate of soda. On the addition 
of acetic acid, numerous epidermic scales become apparent, 
with all the characteristic pro|>ertics of Buch struc-tures. Under the microscope, 
the minute texture of these growths exhibits epithelial cells, which, according to 
£rti.-mu.s Wilson, are of a flattened shape, closely condensed, and, here and there, 
fibrous in their arrangement. They arc somewhat larger than those of the epi- 
dermis, and possess nuclei, for the most part of an oval shat>e, their long diameter 
measuring ^^b^- ^^^ short n,^'gg of an inch. The average size of the flattened 
cell:- is aJMiut five times greater llian that of the nuclei. 

Iluiiian bonis are generally, if not invariably, connected with the sebaceous fol- 
licleii, in which they probably take their rise. Their deTeloi«nent is frequently 
directly traceable to the effcrts of chronic inflammation, or external injury, as a 
l«m, wound, or contusion. When first observed, llicy are qnitc soft, scmi-truris- 
parent, and invc9ie<l by a distinct cyst, which, extending over tlicir base, is gradu- 
ally and inseusibly lost upon their trunk. Very soon, however, they hccumu 
hard, and, assuming a darker hue, thus acquire the real properties of thq horny 
tiuoe as it exists in the inferior animals. Their growth is always very slow, 
from three to five years olap.fing before they attain any considerable bulk. 

Althongh these cxcrescenceB sometimes drop off spontaneously, a cure rnivly. 
if ever, follows such an event ; for, as the matrix remains, it soon becomes the 
ftaning-point of a new growth, which, pursuing the same course as its predecessor, 
■ay, iu time, acquire a similar, or even a greater, bulk. The projter remi'dy is 
extirpation, performed in such a manner as to include the whole of the epigcnic 
CTil in two elliptical incisions, the edges of which aru afterwards carerully ap- 
proxioiated by suture and adhesive strips. It has lieen suggested that wc might 
get rid of these bodies by softening and dissolving them with alkalies and wutor- 
drea«ing8 ; and then, after they have dropped off, prevent their reproduction 
by touching the matral cyst tn6\j and npmtedlf with nitrate of silver, with n 
new of preTeating the tendency to afaaoniMl nlMbnMtinL Buch a procedure, 



222 TUMORS, OR MORBID GROWTHS. cbaf. Tii. 

however, besides being tedioas, must be very nncertain, and is, I imagine, alt<h 
gethor more disfignring in the eud than excision. 

«5. FIBROUS TUMORS. 

The fibrous tumor owes its name to the peculiarity of its stractare, which 
i^troiigly resembles the fibrous tissue in the normal state. One of the best speri- 
niens of this variety of morbid growth is to be found in the uterus of eldeiij 
females, where it sometimes attains a weight and magnitude equal to those of the 
lK)dy of the patient. It also occurs in liie cellular tissue, both subcutaneous and 
intermuscular, in the testicle, the ovary, and other parts of the body. My cabinet 
contains a large fiiirous tumor, weighing nearly five pounds, which I removed from 
the interior of the ifcrotum of a young man of twenty-five, but which had no con- 
nection whatever with the testicle. A remarkable fibrous tumor is sometimet 
seen growing pendulously from the lobo of the oar. Keloid formations of the 
skin obviously belong to the present class of morbid products, although thej 
usually contain an inordinate quantity of plastic material. Fibrous growths 
occasionally occur in the interior of the joints, especially the elbow and knee, in 
the latter of which they sumetimos attain the volume of a pulletV egg. The dnn 
mater, periosteum, and fibrous envelopes of the muscles are all liable to their for- 
mation, although the occurrence is unusual. Finally, fibrous tumors are often 
met with in the neck, either just beneath the skin or deep among the musdes and 
lymphatic ganglions. In 1862, I removed from a female, ag^'d forty-three, a 
small nodule of this kind from the site of the lachrymal sac, which it had almost 
completely obliterated by its pressure. 

The present growth is not peculiar to any period of life. The greatest number 
of cases, perhaps, occur in young adults. In the uterus and ovary it is most 
common in elderly subjects. In a few instances I have found it to be congenital, 
and I have also met with it in several members of the same family. 

The fibrous tumor, although of slow growth, may, in time, acquire an enormom 
bulk, as is exemplified in the immense masses which are occasionally found in the 
neck, the uterus, and other parts of the body. It feels heavy and incompressible, 
is globular, ovoidal, or pyriform in shape, and has generally a smooth, even su^ 
face, although not unfrequently it is remarkably lobulated, or marked by nume^ 
ous elevations and depressions. In the uterus and the joints it is often attached 
by a narrow neck, but almost everywhere else it is in immediate contact, on all sides, 
with the structures in which it is developed, its adhesions being effected by cellnlo- 
fibrous tissue. Generally solitary, it occasionally occurs in considerable nnmben, 
more particularly in the uterus, which is sometimes completely crammed with it 

The structure of this tumor is characteristic. As its name indicates, it is com- 
posed of fibrous matter, the filaments of which cross each other in every con- 
ceivable manner, forming thus an intricate network, which the most careful dis- 
section fails to unravel. These filaments are of variable size and shape, and are 
so intimately compacted together as to constitute a dense, finn, inelastic substance, 
so characteristic of this kind of product. It is only in rare cases that their pas- 
sage across each other leaves, any interspaces for the lodgment of fluid or solid 
matter. They are. of a grayish or pale drab color after maceration, but in their 
natural state they are rosaceous, reddish, or even purple, their complexion de- 
pending upon the amount of blood they contain. Occasionally they have a sil- 
very, glistening appearance. 

The fibrous tumor has seldom any distinct capsule ; the tissues around it are, 
it is true, usually a good deal condensed and thickened, but the covering thas 
derived is altogether adventitious and secondary, forming none of the essential 
elements of its growth. Few vessels can be traced into its substance, and 
these are rarely of any considerable size ; a circumstance the more surprising 
when it is recollected what immense bulk it sometimes acquires. No reliable 
chemical examination has yet been made of this variety of tumor, but it is pro- 
bable that it consists essentially of gelatine, as this substance is largely furnished 
by protracted boiling. Under the microscope it exhibits nucleated mUs, some* 



I 

1 



FIBROUS TUU0R9. 



223 




ime» in gmt DDmbera, of an ov&I, rounded, or elongated form, which are alw&^s 
endered very conspicaaus if the part be prcviouely treated with acetic acid, as 
n fi)f. 33, from a drawing of one of my specimens by Dr. Packard. 

Growths of this kind sometimes contain colloid matter, lodged in distinct cells 
ad possessing the ordinary physical 
ad microscopical characters. Its 
nwDce probably serves to give ad- 
itiooAl impalse to the development 
f the tnmor, which often increases 
rith great rapidity, and thus soon 
equirei a lai^ bulk. 

The fibrous tumor seldom takes on 
lalignaat action, although it is not 
leapable of iL Its general tendency 
t gradually to increase, to impair 
uction, and ultimately to wear not 
fe by itn secondary effects. The 
Ider fonnations of this kind nearly 
■ways contain adventitious deposits, 
tpedally the calcareous, which often 
xhtA in considerable quantity. The 
artilagiaous is also not uncommon. 
kMaetimea large cavities, containing 

enaitT, pus, and other SUbBtances, Mir-nwonlal thuratur- ..r ■ lll,r..Q. lumat Irom (ha 

re found in them. Tht^ir progress inLuiiixiUirrngioii.— iTSduiucun. 

I naually painless, ezc<?pt when tliey 

ampre»>s important parts, the inconvenience which they occasion being dependent 

lainly upon their weight and bulk. 

There is a form of fibrous timmr to wliich the term fibro-plaslie has been 
pplied, as denotivc of its pecuiir comjiosition. It is, in fai;t. however, montly a 
Dodification of the one just described, with a predominance of the plastic element, 
ir, at all events, a very conspicuous amount of it. It is met with chiefly in 
citaJD pendnloDB growths of the ear, in elephantiasis, and in certain formations 
if the skin, especially in keloid. It \i uli^o found in the subcutaneous and inter- 
inMular cellular tissue of the neck, trunk, and extremities. When cut, it grates 
lader the knife, and the surface exhibits a ]mlc yellowish, greenish, or bluish 
rliatcDing baa is -substance, intersected by whitish, opaque filaments. Thi:se Rla- 
aents, which, by their interlacements, form the stroma of this variety of tumor, 
ire generally disposed in wave-like lines, but in many specimens tbey are very 
rregnlar, and seem to observe no definite arrangement. The matter which 
Kcupics the cells of the stroma is very succulent, being pervaded by a peculiar 
laid, of a yellowish oily appearance, which gives the mass an infiltrated, anasar- 
cas condition. 

The fibro-plastic tumor essentially consists of plastic matter, its development 
leing' effected from nucleated blastema, in the same manner as in ordinary lymph- 
frowlb. It occurs princi]ially in young and middle-aged subjects, and is usually 
Bore rapid in its march than the purely Gbrous formation, into which it sometimes 
lartially degenerates, the plastic material being supplanted by the fibrous. 

The Gbrous tumor, as already stated, sometimes takes on malignant action, its 
issues serving as a nidus for the deposition of carcinomatous mutter. It is im- 
masible to determine what are the circumstances which predisposcto, or inflnence, 
loch an occurrence ; but there can be no doubt that it is governed by the same 
aw8 as those which preside over the development of cancer in the primitive 
tractures generally, and that the change does not consist in a degeneration, 
mperiy BO termed, of the fibrous substance, but of an entirely new formation. 

^e rerurring fibroid tumor, as it is termed, is probably often originally of a 
Malignant nature, but does not show its real character nntil it is called into play 
bj some disturbing agency, either local or constitution al, or, perhaps, both. At 
^ cvenia, this morbid growth f^queutly remuns for a long time in a suto of 



22ri TUMORS, OR MORBID OROWTHS. cbap. rii. 

latency, when, it may be all of a sudden, it assumes an extraordinary degree uf 
activity, and soon exhibits the worst malignant tendencies. Caaaal inspectiui 
of tlio fil)roid tumor might lead to the supposition that it was of a fatty natim, 
so closely do its external properties resemble those of the adipose tissue ; bat % 
careful examination with the microscope soon dispels this illusion, and detrij 
proves that it is essentially composed of the fibrous element, with, now and tbeo, 
a small quantity of oily or fatty matter. Its texture is sometimes remarkably 
lobulated, soft, and even brittle, the slightest traction separating it into nmneroiu 
fragments ; it often sends ouc small processes, which, extending far among the 
surrounding structures, are apt to be left behind during extirpation, unless grot 
care is used in tracing them out. In its color it varies from white to drab; 
grayish, bluish, or pale yellowish. A very common site of this tumor is the 
superior maxillary sinus ; it is also not unfrequently seen upon the face, especially 
at the side of the nose, taking its rise, apparently, in the periosteum of the upper 
jaw. 

The diagnosis of the fibrous tumor must mainly be deduced ftom its history 
and its cou.si&tence. Its development, as a general rule, is tardy, there being i 
marked difiference, in this respect, between it and the carcinomatous formatioiu, 
even, indeed, the scirrhous. Usually beginning in a little hard nodule, or lump, 
several years commonly elapse before it attains any considerable bulk, especially 
when it is developed among the external tissues ; its progress is comparatively 
painless, the chief inconvenience occasioned by it being of a mechanical nature. 
The tumor feels hard, firm, and inelu^stic ; it is more dense than encephaloid, hot 
not as solid and dense as scirrhous. Its consistence is usually uniform ; not hard 
at one point, and soft at another, but of the same character throughout Its 
surface, too, is commonly smooth ; and there is nearly always, unless the grofrth 
is very large, an absence of enlargement of the subcutaneous veins. In its earlier 
stages it is somewhat movable, except when it springs from the periosteum ; by 
degrees, however, it contracts adhesions, and thus becomes firmly fixed in its 
position. 

The fibrous tumor is rarely, in any of its fonns, amenable to local or coDsti- 
tutional means. Wiien it is favorably situated, pressure, steadily and systemati- 
cally ])ursued, may sometimes be serviceable ; but it is so seldom that this is the 
case that hardly any calculations of a curative character are to be based upon it 
In the early st^ge of the development, before any great firmness and density of 
structure have been attained, a mild course of mercury may be tried, its consti- 
tationul impression being persistt^ntly yet most gently maintained for sevenl 
successive months, or alternated witii that of iodide of potassium, also an sf^ent 
of some consequence in the softer forms of fibrous growths, although rarely of 
any benefit in those of maturer development. But tlie surest remedy, when the 
tumor is accessible, is excision, performed early and efficiently, by dissection and 
enucleation. Hemorrhage is usually slight, and recurrence not probable, unless, 
as sometimes happens, the morbid mass has become the nidus of carcinomatoos 
deposit. As this cannot always be certainly predicted, the prognosis should not 
be too sanguine. The fibro-plastic growth, known as the keloid tumor, netriy 
always returns after removal, however thoroughly eflfected. . 

6. CARTILAGINOUS TUMORS. 

The cartilaginous tumor, to which Miiller has applied the term enchondromi, 
holds, histologically speaking, a position intermediate between the fibrous and 
osseous, being harder than the former and softer than the latter. Occurring in 
various parts of the body, as the ovary, testicle, mamma, and the parotid region, 
as well as in the subcutaneous and intermuscular cellular substance, it is most 
frequently found in connection with the skeleton, its most common Bites being 
the metacarpal bones and the phalanges of the fingers. I have seen large and 
numerous growths of this kind form simultaneously upon both hands and feet, 
causing hideous defonnity and almost complete loss of function of the affected 
parts. Although it occasionally takes place in elderly subjects, it is by far most 



CAKTir.AQIXOL'S TUMORS. 



225 



etg. M. 



^^H^A 



It in joung peraoDB, especially such as are of a weak, rickety coDstitntiou ; 
often associated with a remarkably 
1 state of the body. The annexed 
fig. 34, from a Hpecimen in my pos- 
, coareya a good idea of the external 
:ers of a cartila^iious tamor aa it 
id apon one of the fingers, 
enonnonii size which an cnchondronia 
aKtimen attain ie welt illustrated in a 
bich csnie under my ohscrration lost 
in a yonng men twenty-sin years of 
rbe tumor, which occupied the ri|;ht 
er, had appeared aUiut ttix years pre- 
and iaTulved the scapula, humerus, 
ride, forming an imniciiiic mass, of very irregular outline, exce^jsively bard, 
re inches in circn inference at the base, and weighing, as was ascertained 
H. J. Bigclow afYer death, tliirty^one pounds. 

Btractnre of this variety of tumor is subject to great diversity; hence it 
y fonnd to Ik oF a uniformly cartilaginous character, but, in most cases, 
nance ie intermixed with fibrous and fibro-plastic matter, if not also with 
T leaa of osseous, or calcareous, especially when the growth is of ioug 
g; not uufrequently it contains large cysts filled with various kinds of 
ices, either solid or fluid. To the hand it gcnurallj imparts the liensation 
)n«l firmness and solidity; it ia destitute of elasticity, is generally dis- 
circumscribed, and is nearly always strongly adherent to the tissues from 
It springs. Its surface, which is sometimes smooth, ie commonly lobulated, 
led by irregular prominences and depressions. No pain usually exists, 
uBering in present, it is owing rather to the pressare which the tumor 
upon the neighlioring parts than to any disorder of its own sensibility, 
narily the consistence of this tumor ranges from that of the vitreous 
or solid albumen, to that of cartilage, 
it sections of it often exhibiting, as 
tted, different degrees of firmness. In 
. the nia:<.s is easily cut with the knife, 
imiDeut sometimes causing a creaking 
Ii id uf a whitish, grayish, or bluish 
and is characterized by a peculiar 
(mmgement. Under the microscope 
;nt« numerous cells, as in lig. 35, uf 
I or rounded shape, from the j^^ to 
an inch in diameter, loosely iml>eddcd 
intercellular hyaline substance, and 
iog each one or more nuclei and 
i. Id the older growths, some of the 
ire filled with oil granules, while others, ogoin, arc marked by projections 
to those of ca^ttl)^l;e in process of ossification. 

listry has shown that this tumor is mainly composed of chondrinc, a pecn- 
n of gelatine, in union with phosphate of lime. The animal matter is 
extracted by boiling, and differs from ordinary gelatine chiefly in being 
ated by some of the salts of lead, alum, and iron. 

cartilaginou.s tumor is sometimes enveloped by a distinct cyst, composed 
lenied cellular substance ; at other times, it is entirely destitute of such a 
g. especially when it originates in the interior of the organs. Its vascu- 
t often very great, a circumstance which readily explains the astonishing 
'' which occasionally marks its growth, coses having been observed in 
ID the course of a few months, it attained the siie of an adult's head, or 
the patient's chest. Such an occurrence, however, is eztnmelr uncom- 
itr, in general, the progress of the eartilaginons tninor !■ ■ twdfa 

h it may, in time, actjaire an exiraordinaiy toUub 
vut. I. — 15 



F%. 35. 







nuclei and nucleoli are shrivelled. 



226 TUMORS, OR MORBID GROWTHS. chap. tii. 

The eartilaginoafl gro^^h is generally painless and indolent, causing Htde or 
no inconvenience, save what results from its weight and pressure ; Bometimei» 
however, it inflames and ulcerates, and in this way a large cavity is occasionally 
formed, attended with copious discharge and excessive constitutional disturbance, 
ra))idly followed by hectic fever. Portions of it sometimes, as already stated, 
undergo various transfonnations, as the cystic, fatty, and calcareous. It is also 
probable that it may occasionally become the seat of carcinoma, resembling, in 
this respect, some of the other benign formations. 

The only remedy for this tumor is early and efficient extirpation. The opera- 
tion, however, is not always successful, for now and then repullulation occarB, 
either causing death, or demanding further surgical interference. When the 
new growth is closely connected with Ijone, amputation will generally be re- 
quired. 

1. OSSEOUS TUMORS. 

Osseous tumors, usually known by the name of exostoses, are mostly found in 
connection with the sktOeton, especially the skull and thigh-bone, presenting 
themselves in various forms and sizes, from that of a pea up to that of a fcet^ 
head ; hard and compact, like the normal lione, whicli they closely resemble in 
structure and com])Osition ; slow and painless in their progress ; never degenen^ 
ting into malignant disease ; unamenable to ordinary medication ; and requiring 
removal only when they seriously interfere with the exercise of important func- 
tions. The exciting causes of this class of tumors are not well understood; 
occasionally their development may be traced directly to external injury, but in 
general no reoson whatever can be assigned for it. Commencing usually upon 
the outer surface of the bone, beneath the periosteum, their foundation is some* 
times laid in the i)eriosteum itself, the connection with the primitive bone being, 
periiaps, onginally of a cartilaginous character. The osseous tumor is most 
common in persons after the meridian of life, and occasionally occurs in larjre 
numbers, d(>pending ai)parently upon the existence of a real exostotic diathesis. 
A remarkably hard, ivory-like exostosis is sometimes found upon the skull. 

8. CALCAREOUS TUMORS. 

The calcareous tumor is very uncommon, and is generally the result of a de- 
generation of a lymjihatic ganglion, nearly always one of the neck, in the vicinity 
of tiie lower jaw. The ghmd having perhaps been for a long time enlarged and 
indurated, usually from a de])08it of tubercular matter, gradually diminishes in 
size, and is fmally transformed into a hard, firm substance, resembling baked 
earth. It has none of the properties of genuine bone, and consists almost en- 
tirely of carbonate and phosphate of line, cementiMi together by a minute quantity 
of animal matter. It is usually of small size, of a spherical form, and surrounded 
by an imperfect capsule. As it is not amenable to absorption, the proper remedy 
is excision, performed whenever it is found that the little tumor is in the way of 
comfort, or good looks. 

Calcareous deposits are sometimes found in other structures, as fibrous tumorB 
of the uterus, the vaginal tunic of the testicle, the bronchial lymphatic glandSt 
and the ])u1monary tissues ; but as they do not interest the surgeon they may wc^ 
be passed over here. 

9. NEUROMATOUS TUMORS. 

The nerves of animal life, especially the radial, ulnar, median, tibial, ai 
peroneal, are subject to two forms of tumors, or morbid developments, know 
respectively, as the neuromatous growth and the painful tubercle, although th< 
structural differences are not always very well defined. The latter of the^^ 
affections, incidentally noticed by Petit, Cheselden, and other observers, was fir^^ 
accurately described by Mr. William Wood, of p]ngland. in 1812. The neurC^ 
matous tumor, properly so denominated, has been particularly studied and 



Keubomatoi's ttmobs. 



29 rl 



'tJD««ted bj- Mr, Robert W. Smith, of Dublic, who publishi'd a splendid monograph J 
OQ ih(f eabject in l84!f. 

The ueuroiuatoua tumor may he solitary, or there may he a considerable num- 
ber, Tarying iu size from that of a pea to that of an ahiiond, au egg, or even nn ■ 
tduli bead. It is solid to the touch, tirm, inelastic, and or an oblong, ovoidal, or 1 
tm-^lnrly ccuipressed form. When email, it has generally a distinct cyst, of a J 
R-llnlo-fibroas structure, filled with a transparent jelly-like substance, and de- 1 
n-lopnl within the neurilemma of the affected nervo, the Blaments of which are | 
Bfparated from each other, and spread out over the surface of the tumor. 
CH»e9 ijf lon^ standing, or when the tumor has acquired an unusual bulk, the mor< \ 
bid moss is remarkably dense, white, or nearly bo, homogeneous, and deetitnte oi I 
a •■yst. properly so called. 

The ttenromatoas tumor occurs in both sexea, and at various periods ol life, 
though it is most common in males and in middle age. Its progress jg usually 
■low, and it seldom attains any great volume. The exciting causes are generally 
Tery obscure, hut in some casus it is plainly traceable to the effects of external 
injury, as a wound, blow, or bruise. Occasionally it follows upon amputation, 
ihe nerves of tlie stump becoming enlarged and bulbous. The pain which at- 
tends this disease is very variable, both in degree and character. In most cases 
It is neuralgic, exceedingly severe, sharp, darting, pungent, or stinging, and ha- 
bte to periodical exacerbations, dependent apparently upon atmospheric vicissi- . 
taiiri, and disorder of the digestive functions. The slightest pressure, frietiooi | 
or Biaoipulation increases the auQering, which, then, not unfreqnently amounts to I 
grvat agony. The parts beyond the tumor, especially those supplied by thq t 
affiectc'l nerve, are cold, numb, and almost powerless. The pain is sometiraea I 
Bm«d in the neighborhood of the tumor rather than in the tumi>r itself; and I 
ixrft«ionally again, though rarely, there is an entire absence of local distress. | 
The general health may remain good, but in the great miyority of instances it ia 1 
more nr less impaired ; and the system, constantly tortured by the e 
fcring, is gradually reduced to 
the utmost prostration. Fig. 36. 

The accompanying sketch, 
fig. 36. affords an excclleut 
illustmtioD of the anatomical 
characters of a neuromatous 
tntnor of tbe leg, situated 
■long thv course uf the pero- 
Deal nerve. It had existed 
for n>-ar)y tw»-nty years, dnr- 
iog thr last three of wliicli it 
bad b^en exquisitely lender 
and painful. The extirjiation 
na effected by Dr. Dalton 
•mJ Dr. Hoffman, of Ohio, 
who were kind enough to send 
BK the specimen. The ope- 
ratioa was followed b; stongh- 
lag of the fourth and fifth toes, 

X large iguantity of fibrous 

Bentera into the compo- 
r the neuromatous tu- 
mingo. stroma inter- s„„„, ,,. „„„„.„„ „„„„,, „,„, ,k, „„„ ,„.„^,„.„d 
with grannies and (,„„, i, 

pnomadet. as seen in fig. 37. 

The only effectual treatment is excision. Aa long, however, as the tumor is 
Bsinleaa, or causes no inconvenience by its size or situation, the best plan is to 
IM ItaloQC:. Wh(^ the reverse is the case it is our duty to extirpate il. The 
l>p«rKtlaa it niaally iioile simple, and devoid of danger, ' In general, an attempt 
tboiiM b« madti to enucleate the tumor, by pushing aside the nervous filaments 

i 




228 TUM0B9, OR MORBID GROWTHS. caip. t:[. 

which are Epread out over ils fnirTace, and which may thus occasionallj b« pn- 
Hcrved fvoin barm. When tliis is impracticable, from the manner in which the 
parts are fused together, the morbid idm 
Fig. 37. should be exposed by a free incision, tai 

lifted out of itH bed by dividing the tt- 
fected nerve immediately above and he- 
low, over a grooved director. The Ion 
of motion, occasioDcd by this proceeding;, 
even when it involves a compantiTelj 
large nerve, is usually restored in a ttrj 
short time. Indeed, the chief incoD> 
venicnce to which it gives rise is a bcd- 
eotion of coldness in the distal part of 
the limb, which may, however, remuD 
for rears. Amputation has been resorttd 
to for the cure of this complaint ; hnt it 
is difficult to conceive of a case where h 
would really be necessary, 

HlersHinplotrDetDnDriinenraiiiiitaiulamnr. Tlie painful BubcutaneOUS lubercle,ig. 

38, ir! generally situated, as the duuc 
implies, just beneath tho skin, in the areolar tissue, where it is usually connected 
with one or more very dclicnte nervous filaments, slightly enlarged and nl^ 
rounded by ccllnlo-fibrous, fibrouB, or fibro-cartilaginous matter, freely inte^ 
spcraed with corpuscles, as seen in fig. 39. On being cut out, it looks very mack 




Fg 38 



Fig 39 




like a small ma a of adipose sui>stance Fiw vessels can be drscemed in it f* 
is alwavs remurkablv email seldom exceeding the volume of a pea very mova-" 
ble ; Lxquiiitdy tender to the touih and the seat of frequent pam o^en of ^ 
neuralgic character and subject to con tant exacerbations fiom the most trifling 
causes It is aid to be mo t common in the loner extremities hut this does ootf 
accord with my experience most of the cases that have come undir my obeerra 
tiuii having occurred in the arm forearm and shoulder 

The painful tuberUe is generally single or if multiple more than two or three 
rarely e^ist in th same person It oc urs in both sexes bnt much more flre- 
quenth in women than in men the reverse being the case in regard to the nea 
romatous tumor Its development is usually tardv and several years often 
elapse before it becomes very tender and painful. ^\ omen of a nervous, hysteri- 
cal temperament appear to be most prone to its occnrrencc. Daring its develop- 
ment it always involves the skin. 

The situation of this tumor just beneath the skin, or in the skin uid areolar 



AF. Til. EXCYSTED TUMOKS. 229 

sue, the abitence of discoloration of the surface, the peculiar character of the 
in, the IntoleraDce of manipulation, and the history of the case, will generally 
Bice to determine the diagnosis. 

The only remedy for this affection is free excision, including a small portion 
the rarroanding healthy integument. The disease never returns at the cicatrice, 
Jioagh it may oecur afterwards in other parts of the body. 

10. ENCYSTED TUMORS. 

The class of encysted tumors is a large and important one ; for it comprises 
ite a number of morbid products, which, whether they be viewed with reference 
the frequency of their occurrence, or the extraordinary bulk they are capable 
attaining, deserves more than ordinary attention. Their contents, which are 
a singularly diversified character, may be either solid, semi-solid, or liquid. 
leir stroctnre is sometimes very simple; at other times extremely complex. 
enc% the division of encysted tumors into simple and compound. In regard to 
eir origin, some are of new formation, but many, if not most, are merely so 
mj alterations effected in the primitive structures ; in fact, merely so many 
pertrophies. Occurring in nearly every organ and tissue of the body, they arc 
oticularly liable to arise in the skin and mucous membranes, the glandular 
gans, as the breast, testicle, liver, and thyroid body, in the ovaries, and in the 
bcntaneoas cellular substance. While no period of life is exempt from them, 
ey are most common between the ages of twenty and forty-five, especially in 
Bualc^, who are also more subject to them than males, and in whom they occa- 
>nally attain an enormous volume. 

In respect to their structure, some of these tumors are of the most simple 
laractcr possible, consisting merely of a thin cyst, sac, or capsule, occupied by 
e natural secretion of the part, more or less altered by its protracted retention. 
u excellent type of this variety of morbid product is afforded by the sebaceous 
.mor, which is, in reality, nothing more than a sebaceous follicle of the skin, in 
state of hypertrophy from the occlusion of its orifice, and the consequent reten- 
[>n of the sebaceous matter. The immediate cause of the obstruction is inflam- 
ation, prodncing adhesion of the opposite edges of the outlet of the follicle, 
id thus constituting the first link in the chain of morbid action. The second is 
le retention of the normal secretion of the follicle, which, being tightly pent up, 
adergnes important changes, both in its physical and chemical properties, lead- 
ig to irritation, and sometimes even to inflammation of the sac, wliich, gradually 
ilarging before the accumulating and burdensome mass, at length forms a tumor 
erhaps as large as a medium-sized orange. The little encysted tumor which is 
»inetimes fonnd upon the lower lip and upon the vulva arises in a similar man- 
tr. The probability is that ranula owes its origin to a like cause. Certain 
iCTs^ted tumors beneath the skin, containing senim, blood, or solid matter, are 
rodnced by the occlusion of one of the cells of the cellular tissue, the walls of 
le affected cavity forming a characteristic cyst. Obstruction of a lactifcrons 
net has been known to produce the encysted milk tumor of the breast. In all 
lese instances, as well as in many others that might be adduced, we perceive 
lat the mode of formation is extremely simple, obstruction of the natural outlet 
f the part, and the retention of its proper secretion being the exciting cause of 
le disease. 

Sometimes the cysts which form the distinguishing feature of this variety of 
lorbid product are an entirely new growth, and then it is not always easy to 
qilain their origin. The cysts which are found in cystic sarcoma of the testicle 
are been supposed to owe their development to obstruction of the seminiferons 
ibes, but such a mode of explanation is hardly tenable. In the different cases 
I which I have had an opportunity of examining these tumors, I have been led 
> conclude that their origin was altogether foreign to the canalicular substance 
f the organ. It is certain that hundreds, and sometimes thousands, of cysts are 
mned in the testicle long after its seminal tubes are apparently oomnlatelT an- 
ihilated, as is proved by the large size which snch tunuM^ 



230 TUMORS, OR MORBID GROWTHS. chap. tii. 

the total absence of the primitive structures. The more plausible conjecture is 
that the development is effected in the plastic matter which accompaDies the 
morbid action, in the same manner that cells are formed in the original tissues. 
The cysts found in osteo-sarcomatous formations of the lower jaw hare probablj 
a similar origin. 

The contents of this form of encysted tumor must necessarily vary, as may be 
gathered from what precedes, according to the structure and functions of the 
affected part. Thus, in the mamma the tumor contains milk, in ranula saliva, 
and in a sebaceous formation sebaceous matter ; altered, in every instance, in its 
physical and chemical properties, by the action of the inclosing cyst The cyst 
itself is always solitary, and generally composed of a single layer, its external 
surface, which is rough and flocculent, being more or less firmly adlierent to the 
surrounding tissues, while the internal one is usually smooth, shining, or glossy, 
without septa, and in immediate but loose contact with the proper contents of the 
tumor. It is usually of a cellulo-fibrous stnicture, and varies in thickness from 
the merest film up to that of a stratum several lines in depth. In cases of long 
standing it is occasionally partially converted into a substance resembling fibro* 
cartilage, cartilage, bone, or earthy matter. 

A cyst is said to be muUiloculary compound or proliferous, when it consists 
of a numljer of compartments, cells, or cavities, or, to use a familiar expressioi, 
rooms, or chambers. This arrangement is brought about by the existence of 
membranous processes attached to the inner surface of the parent cjst, firom 
which they branch out so as to intersect each other in different directions. It 
might be very easily imitated by sewing pieces of linen across a common bag, 
separating the main cavity into a number of small ones. The chambers some- 
times communicate with each other ; at other times they are perfectly closed. 
Their products are frequently remarkably dissimilar ; thus one may contain a 
serous fluid, another a jelly-like substance, another blood, and a fourth, perhi^M, 
a solid material. Hair, teeth, and bones are occasionally found in them, espe- 
cially when they occur in the ovary. In general, the older the cyst is the more 
likely will it be to contain some outre substance. The walls of these sacs are 
commonly very thick, and of a dense fibrous structure, with a tendency to the 
fibro-cartilaginous degeneration. The septa, or internal partitions, are of a similar 
character. Numerous vessels occur in them, thus enabling us to explain the 
rapid growth and large bulk which these tumors occasionally attain. 

In the older varieties of proliferous cysts, the inner surface of the thick lami- 
nated wall is sometimes profusely studded with secondary vesicles, either isolated 
or clustered together in warty-looking, lobulated, or cauliflower-like excrescences, 
filled with serous fluid. They are evidently derived from cell-germs in the parent 
walls, and, in the more complex forms of the disease, often acquire so large a 
size as to constitute the chief bulk of the morbid growth. Exogenous vesicles, 
or external outgrowths, are comparatively rare, and never very numerous, the 
tendency to endogenous generation evidently, as a general rule, predominating. 

The most common situation of the proliferous tumor is the ovary ; it is also 
found in the mammary gland, thyroid body, testicle, and cellular tissue. It is of 
irregular shape, and often grows with great rapidity. 

Encvsted tumors are seldom benefited bv constitutional medication ; indeed* 
apparently never, except in so far as it may have a tendency to improve th^ 
general health, and thus retard their development. Their contents do not seem to 
be amenable to the action of the absorbents. When they are situated superficially 
and are of small size, they are sometimes retarded, though seldom cured, by eom-^ 
pression, aided by sorbefacient applications, particularly the dilute tincture of iodine. 
A more certain plan is to break the cysts or incise them subcutaneously, so that, 
their contents having escaped into the surrounding cellular substance, their walls 
may collapse, and ultimately unite by adhesive inflammation. When the tumor, 
however, is deep-seated, iodine injections may sometimes be advantageously 
employed, the operation being performed in the same manner as in hydrocele of 
the vaginal tunic of the testicle. A seton, too, is an eligible procedure. When 
the cysts are large or numerous, and, above all, when the primitive textnres are, 



rilATlC TL'M0B3. . 

In frrent measure, if not entirely, aoniliilated, the only coarfe likely to suceeett is 
II uf the entire maes. earc being [aken not to leave (be slighlest reuuiant, 
Sot fear of regirotlutrtion. Too mutb stress cannot be laid upon thid ii^uuelioti- 
For w»nt of ttiie precaution, J have known a patient to be obliged to submit to 
not Ic-ss ttiDH three distinet operatious for tfae cure of a tumor originally not larger 
IB pigeon's cf^. aud which ought to have tjcen eflectually removed at one 
A secreting surface, hardly the size of a pin's hcui, is lurge enough to 
wo disease. The reuiuval may sometimes be effected by enucleation ; at 
9. and more generally, a minute dissection is necessary. The proceeding 
1 be at all bloody, uiile.-<s the tumor is sealed among very vascular paru>, 
B knife ia carried tuu far unay from the encysted tnoss. h 



II. HYDATIC TtlMORa, ^ 

Under this head I propose to describe a form of morbid growth, CBsentially 
ile|Mi»deDt upon the development of a cyst, inclosing an entozoon, vesicular worai, 
i>r parasite, denominated a hydatid. It is, aa will be perceived, altogeilier 
different from the other varieties of cystic tumors, and therefore requires separate 
cNQsideratiou. The term liydatid is a generic one, including several species o^J 
TesucuUr worms, of whidi the most important, surgically considered, is tbo a 
pluUocyst. 

This hydatid most commonly infests the liver, ovary, and uterus, but is alaj 
met with, although very rarely, in the mamma, testicle, bones, and serous c 
tie*. My cabinet convairis a beautiful specimen whicli I removed from the deltoill 
iBuacle. Varying in volume Iwtweeu a muiitard seed and a small orange, it t^ 
of ■ globular figure, of a whitish, semi-opaque appearance, aud composed of ^ 
vraiclr, or bladder, ^llcd witli tjuroun fluid, and surrounded by a ccllulo-fibronl 
eapMile, which thus isolates, 

ami protects it from the cir- Fi|{. 40. 

au^iacent structures. Jt is 
Dsaally gregarious, numliers of 
tfaam inhabiting a common 
<^rst, Ba been in fig. 4U ; some- 
Ubms, buwever, there \» only a 
Mlitarjr one, which is tlicn cuui- 
Booljr proportionately large. 
The contents of the animal are 
of a civar limpid churucier, n-- 
tnarkahly ratine to lli>' tai-ie, 
but fl«iililute of odor, and 

klUbility. The inclosing 

ll fibrous, or cellulu-librouB, 

par less vascular, anil pos- 
dof considerable strength. 
It IS ariilenlly a kind of ad- 
TentitioHi^ membrane fonued 
umvf {tlastic matter. Between H/dnid. iocIumJ iu 4c^niniui, 'j.l I 

' 'KQ^ ""1 *''*^ parasite there 

inly a soft, pulpy, dirty-looking substance, the precise nature and object 
are nut known. In consequence of its endogenous minle of generation, 
ydatid sunietimee contains several smaller, one within another, like so 

f pilKtiuxes.' 
Altboufch tlie hydatid itself consists of two distinct layers, it is generally so 
mak aail delicate as to break under its own weight when removed from its 
ioulMdng cyxt, fhrinking into a soft, pulpy mass, not unlike the white of a hard- 
boiied «pg, both to appearance aud chemical composition. To the inner surface 
of Uko paramtff arc attached numerous little bodies, as in fig. 41, hardly as large 
ma a !TMB of eand, of a spherical shape, and of a grayisli color, each consisting 
of a deJicats cyat, fiUed with echlnococcl These animals, which derive thw 




I 
1 



2S2 TL'MORR, OR MORBID GROWTHS. en* P. Tit. 

origin and Bupport from the hydatid, soon separate tbemaeWee, DcqairiDg lliw i 
sort of independent existence, great nurabers bciog often seen floatiog alMnl ii 
the parent liquor when they are yet hardly the two-hundredth part of an iadi ii 
diameter. 

Each ccbinocoecuB consists of a body aiid a bead, the latter being encirded bf 
a row of teeth. The l>ody, composed of solid, granular matter, has a cari ' 
speckled appcaratict', owiug to the presence of numeroaa ovoid bodies i 



Fig 41 Fig. 42. 





beneath its outer coat. The teolh are BpinouB, Rharp, hook-like, and perfeeflj 
characteristic. They arc. not easily decomposed, and are, therefore, c^iAle <rf 
affording important diagnostic information. The various appearances here de- 
scribed arc well illustrated in fig. 42. 

Hydatids are usually short-lived, rarely lasting beyond a few years. Variois 
causes may destroy thera. Tims, some perish from suppuration, some from ([sn- 
greue, i^omu from the gradual drying up of their contents, and not a few fron 
the pressure of their young. Under such circumstances, the inclosing cyst fs 
often remarkably thickened, and even partially transForraed into fibrous mattsr. 
I have seen cases where it hod put on the Bpiiearonce of the interior of an aneo- 
riamal sac. Great mischief eventually arises from their preticnee, especially during 
their decay, nature of^en failing to eliminate them, and thus permitting them to 
excite violent irritation. A hydatid of the liver will occasionally induce fattl 
peritonitis, and the hardest structures, the osseous not excepted, are not alwiyi 
capable of withstanding its progress. A case has been reported of a paraiitc 
of this kind having perforated the scapula. In the lungs acephnlocysts sonietimei 
find their way into the hrondiial lubes, from which they are afterwards geded 
by expectoration. 

There are no signs by which the existence of this parasite can be diagnosticated. 
Its presence in the discharges is the only reliable evidence of the kiud. Some 
years ago I removed a small tumor from the arm, which had the character of ad 
ordinary encysted formation, but which was unexpectedly found to contain aix 
acephalocyst, the animal rolling out upon the floor before I had extirpated 1b« 
inclosing capsule. Mo treatment, except excision, is of any avail in this affec- 
tion, and that, of course, is only admissible when the tumor is situated in ai»- 
external and accessible part of the body. 

12. POLYPOID TtTMORB. 

There are certain growths, long known to pathologists and practitioners, to 
which the term polyp, polypus, or polypoid has been applied, apparently from some 
fancied resemblance which they bear to the form of the auimaJ described under 
that name by naturalists. They are found exclusively iu the mucous cavities of 
the body, where they often attain a large bulk, and become a source of serious 
mischief Occurring at all periods of life, they are particularly common in 
middle-aged and elderly subjects, and present themselves in several varieties of 
form, differing essentially from each other in tlieir structure and habits, if not also 
in their mode of origin. 

The situations in which these growths arc most commonly met with are the 
nose and uterus ; they arc also sufficiently frequent in the ear, the maxiliiLry 



Clip. Til. POLYPOID TTMORS. 233 

siDQi, the vagina, and the rectum. In the larvnx and throat they are rare, but 

Bot, perhaps, as much so as is commonly supposed. They are fzrenerally solitary, 

bet occasionally considerable numbers occur in the same subject and even in the 

nine canty. Their volume varies from that of a small pea up to that of an adult's 

heiiL depending upon the nature of the tumor, the locality which it occupies, and 

the imount of resistance offered to its extension. Their shape, which is usually 

Biteriillj inflnenced by that of the cavity in which they are developed, is conical, 

pyrifomi. or globular, their attachment being generally effected by a narrow foot- 

w«ik. root, or pedicle. Most of these growths belong to the class of benign 

'fnictnres, and hence the inconvenience which they occasion is chiefly of a fuiic- 

^'OQal character. 

Poiyp*>id tumors may conveniently be arranged under four heads, which, judging 

from personal observation, comprise all the known and generally recognized 

Varieties, without including any of the subordinate divisions made by certain 

Authors, and which are altogether dependent upon accideivtal circumstances. 

These are the gelatinoid, fibrous, granular, and vascular, which possess features 

^Qfficiently distinctive to entitle them to separate notice. 

The platinoid polyp, the most common of all this class of morbid growths, 

i^rely occurs in any other situation than the nose ; it is, however, occasionally 

oilserved in the ear, larynx, vagina, and certain portions of the alimentary tube. 

As its name implies, it is of a jelly-like appearance, very much like an oyster, 

Soft, spongy, and generally of an irregularly pyriform shape, with a narrow 

pedicle, sometimes nearly an inch in length. Occurring either singly or in clusters, 

it often completely closes the cavity in which it grows, although it rarely acquires 

Qach Iralk; is destitute of sensibility ; readily breaks under pressure; and is 

remarkably hygrometric, expanding in wet weather, and shrinking in dry. When 

pricked, a thin yellowish and slightly coagulable fluid exudes, which under the 

microscope shows nucleated cells lying in a transparent blastema. The growth 

consists essentially of cellular substance supported by mucous membrane — a 

reflection from that of the part to which it is attached — and is nourished by a few 

straggrling vessels, which are often of considerable length and thickness. When 

extirpated it is remarkably apt to be reproduced. 

The JUfrous polyp owes its name to the peculiarity of its structure, which is 
of a dense firm character, the fibres interlacing with each other in every ])ossible 
manner. In the recent state it is of a reddish, purple, or livid hu(^, but after 
maceration for a short time it exhibits a pale grayish aspect, and then displays 
its characteristic fibrous arrangement to great advantage. ' It is usually exceed- 
inirW tongb, hard, and incompressible, offering great resistance to the knife, which 
emits a creaking noise as it is drawn through its substance. Although it has 
seemingly very f^w vessels, its removal is frequently attended with copious hemor- 
rhage, both arterial and venous. As it is nearly always solitary, it generally 
arrows quite rapidly, often attaining a large bulk in a short time, and is usually 
attached by a broad base, not by a narrow pedicle, as is the case with the gelati- 
Eioid polyp. The most common habitations of this growth are the uterus, nose, 
Atid maxillary sinus. When extirpated, it has a tendency to recur; and cases 
».re not wanting in which it manifests a malignant disposition. 

The granular polyp, found chiefly in the uterus and nasnl fossa, is, on the 

-wliole, very uncommon, and seldom attains any great bulk. It is of a ])ale rose- 

c-o^lor. grayish, or whitish ; of a soft, fragile consistence ; globular, ovoidal, or 

cronical in shape : and from the size of a currant to that of a grape, its connection 

l.F«iiig usually effected by a long slender pedicle. Its structure is granular, homo- 

lcr*"i»eoo8, and inelastic, looking, when cut, somewhat like a macerat(?d salivary 

firlaiMl. and containing a small qimntity of serous fluid. It has few vessels, grows 

fe^Iovly, and is easily detached, sometimes reappearing after extirpation. 

The raacular polyp, occurring mostly in the ear, nose, uterus and rectum, is 

of i florid color, soft and spongy in its consistence, and usually attached by a 

^•rrow base. A section of it displays a cellular structure pervaded by numerous 

'''wsels. none of which, however, are of much volume, but still sufficiently large to 

P>wJice eopioas hemorrhage when accidentally opened. The tumor, in fact, pos' 



234 TUMORS, OR MORBID GROWTHS. cbap. tii. 

Besses many of the properties of the erectile tissue. NotwithstandiDg this, it 
seldom attains much bulk, and is generally slow in its progress, with UtUe dis- 
position to recurrence after removal. 

We are hardly sufficiently familiar with the structure and functions of poljpoid 
tumors to enable us to explain their origin. The probability is that most, if not 
all, take their rise in a species of hypertrophy of the tissues with which they are 
connected and from which they grow. Thus, the granular polyp apparently 
always begins in the mucous follicles of the part, which, as it expands, iuFeiglea 
other structures, which thus serve to impart to it its distinctive featnrea In the 
vascular variety, the vascular element predominates, in the gelatinoid, the cellalsr, 
in the hard, the fibrous. Whoever has examined a fibrous polyp of the ntemi 
must have been struck with its firm adhesions to that organ, and the perfect 
identification of its substance with that of the parenchymatous structure. Dr, 
Da Costa informs me that he has often found, in addition to fibrous tissue, mai- 
cular fibres and fibre-cells in this species of wom1>growth, rendering it thns 
highly probable that the fibrous polyp of this viscus is merely a species of hype^ 
trophy of its proper substance. In the nasal fossa it is probable that this font 
of tumor always originates in the periosteum ; at any rate, such a conclusion is 
plausible when it is recollected that it is usually attached by a very broad base 
either to the floor or not unlikely to the septum of the nose. 

These morbid growths are liable to various transformations, especially the 
fibrous, fibro-cartilaginous, cartilaginous and osseous ; a circumstance which hss 
induced some writers to make these changes the bases of so many additionsl 
divisions of these morbid products. They are, however, altogether accidents], 
and are seldom found except in cases of long standing. A more serious occu^ 
rence is the supervention of carcinomatous disease, if we concede the possibility 
that a structure, originally benign, may, during its march, take on malignant 
action. Without altogether denying such an occurrence, it must, to say the 
least, be extremely rare, and it would perhaps be more rational to conclude, in 
the absence of positive facts, that the tumor in most cases was primitively of s 
cancerous character, than that it became so during its progress. The fibrous 
polyp is more liable to this kind of degeneration or assumption than any other. 

All polypoid tumors act obstructingly, closing the cavities in which they are 
developed, and thus interfering with the exercise of their functions. As they 
augment in size, they encroach upon the surrounding structures, pressing them 
out of shape, and causing more or loss serious deformity. In this way, more- 
over, they may be productive of severe pain and great increase of the natanl 
discharge of the part. In the nose and uterus they often give rise to serious 
hemorrhage. 

The period of life at which these bodies appear varies according to circum- 
stances. In the uterus they are most common in elderly females ; in the nose, 
in young adult.s ; in the rectum, in children ; in the larynx, in advanced life. 

No medical treatment of which we have any knowledge is of any avail as & 
means of getting rid of these tumors. Sorbefacients, whether employed exter- 
nally or internally, or both, are utterly useless. The only reliable remedy i* 
extirpation, which, if properly executed, rarely fails to aflbrd at least temporarji 
if not permanent relief. In performing the operation it is important to effect 
complete clearance, since, if the least germ of the morbid product be left, repi^-f 
lulation will almost be inevitable. As it is, even with the best possible care, ^^ 
is very difficult, especially in the gelatinoid variety of the afl^ection, to prev^*^ 
this occurrence. The methods of operation are torsion, ligation, and excisio "* 
of which the first should generally be preferred, as the least likely to cause s*-^ 
fering and hemorrhage. These procedures will be described in connection wi "^ 
polypoid tumors of different parts of the body. 

13. MYELOID TUMORS. 

The name of this tumor, which literally signifies marrow-like, was given to 
by Mr. Paget, although its structure had previously been described by Leber 



:. EXCISION OF BKNION TUMORS. 285 

«n noticed In different parts of the body, bat in particular in or upon 
niAnimar3r gland, uterus, cerebral membranes, the subcutaneous cellular 
d in the ejelids and conjunctiva, occurring in various sized masses, 
of a rounded, or ovoidal shape, and of a consistence varying from that 
or suet to that of fibro-plastic tissue. The cut surface has a smooth, 
shining appearance, with blotches of a dark crimson, brownish, pink, 
a hae, either uniformly, or in various degrees of combination, all these 
g sometimes commingled. Much stress is laid upon these colors by 
sts as diagnostic characters of myeloid tumors, affording, as they do, 
ready external means of discrimination between them and other analo- 
lations. 
Biderable quantity of fibrous, cellulo-fibrous, or fibro-plastic matter, 

enters into the morbid growth, in the form of whitish, grayish, or yel- 
aments, scattered about irregularly, and frequently so arranged as to 
small cells, filled with serum, sanguinolent fluid, or pure blood. Some- 
ge cysts occur, similar to those which we find in tumors of the thyroid 
d occupied by similar liquids. In the more recent specimens a section 
ss generally ftimishes, on pressure, a small quantity of a thin yellowish 
^ether different from cancer-juice. When the disease is developed in 
llous tissue of the bones, in which its occurrence is more frequent than 

else, the tumor disparts the compact layers, forming a kind of cyst-like 
I, In which the new matter is. lodged, and which, under such circum- 
Iten contains a largQ amount of osseous substance, soft, cellulatcd, of a 
r pale yellowish tint, and easily recognized by sight and touch. 
inute structure of the myeloid tumor essentially consists of cells, nuclei, 
soli, imbedded in a finely granular matrix, and interspersed with fila- 
fibro-cellular tissue. More or less fatty substance is frequently present, 
itroma is usually very vascular ; a circumstance which readily explains 
ity of its development. Of the cells, as described by Paget, some are 
d of an oval, lanceolate, angular, or elongated figure, their contents 
ttly dotted with single nuclei and nucleoli ; others are round, oval, or 
led, measuring from ^^jf to mV?r ^^ ^^ ^'^^^^ ^^ diameter, and occupied 
early a dozen nueleolated nuclei. Intermingled with these corpuscles 
luclei, of various forms and sizes, giving evidence of having escaped 
older cells. 

p^eloid tumor is generally rapid in its growth, occurs in both sexes and 
it periods of life, but more commonly in the young and middle-aged 
16 old, and is capable of attaining a considerable bulk. From its ten- 
ie8trf>y effectually the structures in which it is developed, and from the 
I frequently displays a malignant tendency, recurring after extirpation, 
ately causing death, I am strongly inclined to believe that it is gene- 
»ly a modified form of encephaloid, fibrous, or fibro-plastic growth, 
d tumors furnish no diagnostic signs. They generally grow more rapidly 
other class of tumors, except the encephaloid, but their real nature can 
positively determined until after their removal. Of their treatment, or 
lice of remedies in checking or arresting their progress, we are equally 
When connected with the bones of the extremities, nothing short of 
m holds out any prospect of relief, and even this is commonly very un- 

If excision be determined upon, the knife should be freely carridd 
he sound tissues, so as to guard as much as possible against relapse. 



EXCISION OF BENIGN TUMORS. 

above account of benign tumors may be appended, by way of practical 
i few remarks respecting the proper method of removing these morbid 
vith a knife. 

tcrference should, as a general rule, be avoided when the tumor is sta- 
»r nearly so, painless, and not inconvenient by its size or situation. 



236 TUMORS, OR MORBID GROWTHS. cbap. rii. 

2dly. If an operation 1)6 determined upon, the system shonld always be snb- 
jectod to a certain degree of preliminary treatment, even when the tumor is com- 
paratively small, experience having shown that extirpation is often followed bj 
erysipelas. 

3dly. While the object should be to effect the most thorough removal, ciw 
should be taken not to interfere unneccessarily with the surrounding tissues, but 
to respect them as much as possible by keeping the knife in close contact with 
the morbid growth. 

4thly. If the tumor be of unusual bulk, it will generally be necessary to remove 
a portion of its tegumental covering, making, for this purpose, an elliptical inH- 
sion ; otherwise all the skin should be retained, due allowance being always made 
for its astonishing contractile powers. If this precaution be neglected, there mtj 
1)0 a deficiency of flap when the surgeon comes to approximate the edges of the 
wound. 

5thly. Diseased Integument should always be removed along with the morbid 
growth. 

Gthly. In general, extirpation may be effected by a single incision carried acrms 
the centre of the tumor, either vertically, or in a curvilinear direction. It is only 
when, as already stated, the morbid growth is very large, that an elliptical inci- 
sion will be required. 

7thly. Care should be taken, in making the incisions, to give them such a direc^ 
tion as shall favor drainage, or prevent bagging. Hence, one of the extremities 
should always correspond with the most dependent. portion of the tumor. 

8th ly. By keeping the knife in close contact with the tumor, it may sometimes 
be promptly and effectually enucleated with the hand, finger, or scalpel. Another 
advantage resulting from the observance of this precaution will be the avoidance 
of hemorrhage. 

9thly. AVhen the mass is very large, pendulous, and vascular, as in those eno^ 
mous growths constituting what is called elephantiasis of the scrotum, the bleed- 
ing may be essentially diminished by elevating the tumor and pressing the blood 
out of its veins immediately prior to the operation. 

lOthly. Any large arteries that may be divided shonld either be compressed bj 
an assistant until the extir|)ation is completed, or they should immediately he tied, 
loss of blood being carefully guarded against in all proceedings of this kind 
When the surgeon is operating alone, or when he has no good assistants, the 
bleeding may bo temporarily checked with the serrofine, fig. 43, a kind of wire 
forceps, or the contrivance depicted in fig. 44. Those instruments hold on hj 
their own elasticity, and will be found of great service in extensive and tediow 
dissections, especially when it is necessary to cut the same artery several times. 

Fig. 43. Fig. 44. 



•itn 




c o^ 



Serreflue. Small forcepii for temporerilj checking h«moniiftgf> 

llthly. When all oozing of blood has ceased, the edges of the wound are bcc]^ 
rately approximated by suture and adhesive strips, aided, if necessary, by a li^^^ 
compress and bandage, to keep the flaps in close contact with the raw surfi^^ 
beneath, as the object is to secure union by the first intention. 

12thly. The part is to be kept perfectly at rest until the wound has healed; m- ^ 
the case is treated in every respect upon ordinary antiphlogistic principles. -^ 
general, the dressings should not be disturbed before the end of the third dt^^ 
especially if the absence of fetor and discharge indicates favorable progress. 

SECT. ni. — MALIGNANT TUMORS. 

Under the term malignant are comprised certain morbid products which ht""**^ 
the effect, within a variable period after their formation, of destroyinff not onm- 



riiip. Til. MALIGNANT TUMORS. 237 

the tissues in which they are deposited, bat also the life of the patient. The 
ptthological anatomist usually describes them under the name of the hetcrolo- 
goQS, heteroclitc, or heteromorphous products, in reference to their want of simi- 
Jirity to the natural structures, but the prefix malignant is justly applicable to 
them, on account of their destructive disposition. The formations which are 
usually embraced under the present head are scirrbus, encephaloid, colloid, melan- 
osis, and cancroid, the latter having only been lately added to the list as a dis- 
tinct affection. From this catalogue tubercle is usually excluded, although it is 
bv far the most common as well as the most destructive of all the heteromor- 
phous developments, especially when it occurs in the lungs and serous membranes. 
Id the extenial parts of the lK)dy, however, it is less so, and hence, perhaps, the 
reason why surgical writers generally exclude it from this position. It would 
greatly simplify the study of these affections if the tenn " cancer," by which some 
of them continue to be designated, were altogether discarded from surgical nom- 
enclature. This expression, introduced in the infancy of the science, is entirely 
figurative, and, therefore, calculated to mislead the mind of the inquirer. 

Of the extensive prevalence of cancerous disease some idea may be formed 
when it is stated that, in five years, namely, from 1838 to 1842, inclusive, 11,662 
persons died of it in England alone, independently of the cases wliich happened 
in London. Of these cases, 8,746 occurred among women, and 2,916 among 
men, or in the ratio almost of three to one. This difference is due to the extra- 
ordinary frequency of carcinoma of the uterus and mamma, particularly the former, 
which suffers nearly as often as all the other organs together. 

Those various morbid formations, although they differ widely in many of their 
characters, possess certain features in common with each other, which may be 
briefly enumerated before we proceed to speak of them individually. 

1st! They are all deficient in plastic material, while they contain an unusual 
amount of albuminous substance, or the protein principles of the blood. The 
eonsequcncc is that they are less organizable than the ordinary lymph-products, 
and also less capable of maintaining a long existence in the parts among which 
they are deposited. 

illy. Under the microscope they are found to consist of two parts, a fibrous 
stroma, and granules or cells, which bear to each other the relation of contain- 
ing and contained parts. The former is either of new formation, or it is com- 
posi«d of pre-existing tissue, in an altered state. The cells often contain nuclei 
aud nucleoli, and possess, in many cases, an astonishing multiplying faculty ; a 
circumstance which adds greatly to the rapidity and malignancy of the morbid 
gpiwth. 

3«lly. They occur in nearly all the organs and tissues of the body, in both sexes, 
at all peritHls of life, in all temperaments, and in persons of all occupations, often 
existintr simultaneously in a number of localities. They frequently disphiy a 
marked hereditary tendency, forming at or soon after birth, and also a disposition 
to appear in several members of the same family. 

4tbly. They present themselves under different varieties of form ; generally 
as a distinct, circumscribed tumor, but very frequently also as a stratum, or 
intiltration. 

biYiW. They are all deposited, as a secretion, in a fluid form, but soon assume 
a cunerete character, which, after a time, they again, in part, lose, as their tend- 
ency is to liecome disintegrated, and to work their way to the surface, by the 
induction of nk-eration in the surrounding tissues. The resulting sore, incapable 
of forming healthy granulations, remains open and intractable, either for an 
indefiuite ])eriod. or until the patient perishes from the effects of the local and 
cun>titutional irritation. 

tiihly. They arc all of constitutional origin, or connected with a contaminated 
siAUr iif the bliMKl and solid.s, a perfectly healthy individual being incapable of 
their attack, which giMierally takes place without any assignable cause. Owing 
^» This cireumstance, they always manifest a tendency to reappear after extirpa- 
tivin. iMthcr at the original site, or at some other point. 

Tihly. Their progress is generally rapid, most of them causing death in from 



238 TUMORS, OR llORBIU QB0WTE3. cbaf. tii. 

nine to eighteen monthR from tbcir coiDmeDCfment. As tbey advance, especially 
when ulccratiiin is about to bcf?in, thej involve the neighboring lymphatic gu- 
glions, transmitting to thcni, throag-h the af^cncy of the absorbents, Borne of tbes 
own material, or exciting similar disease by ftympathetic irritation. 

tSlhly. They all, with the exception, perhaps, of colloid, ultimately giive rise to 
cteeondary eancerous formations in the akin and subcutaneous cellular tissue, ud 
aiiiu ill the scrouit luenibranes and soiuc of the internal viscera. 

The so-called cancer-cutls have been, and still are, a prolific source of dispnti- 
tion. ^'Iiilc Ihcre are some who altogether deny their existence, as a distinct 
anil spccilic entity, most patholiigri^ts sftne in the opioion that they are pecnliu 
to this class of morbid growth.^, and they, therefore, do not hesitate to aseignto 
them an important histological and diagnostic rank. Without attempting (o 
decide a question of such frrave importance, for which our knowledge is perii^ 
still too imperfect, it may confidently be assumed that all carcinomatouB fbnu- 
tions aro intitnalely connected with, if not directly dependent upon, the presenct 
of ci-lls, of a mure or lesi« complex gtructurc, which thus inflnence their devdof^ 
ineiit, and serve to impart to them their distinctive features. Whether thete 
eelb aro new cells, or merely cells which naturally exist in all organs and tissue^ 
ill n state of disease, alteration, or dc^noratiun, time alone can determine: 

The accompanyirig sketches, from IJcal and Dniitt, will serve to conveya good 
idea, iu a gencruf point of view, of the nature of these cells, and of their dup» 
sitiou iu the fibrons stroma, or basemeut-structure, above alluded to. 



Fig. 45. 



Fig. 48. 




Fig. 4.') represents rella in the earlier stages of carcinoma, with nuclei at a, 
magnified 2U0 dianitlei's. In fig. 46, the cells, termed mother-cells, are older 
and larger, or, in other woi-ds, further advanced in their development. Fig. 41 
exhibits the cells as they lie in th^ 



Fig. 47. 




fibrous stnuiia ; at a, some of the 
celU are loaded with fat, and otben 
with melanotic pigment, unmisrtta- 
ble evidences of increasing age ind 
gradual decay. 

In its shape tbo cancer-cell ii 
pretty regnlarly Gphcrieal, and (boat 



the - 



, of , 



inch in diameter, 



with an oval, eccentric nucleus, eita- 
atcd in its interior, and genenl^ 
occupied by one or more nucW- 
These arrangements may be rendered particularly distinct if the matter nnilet 
examination Iw treated with acetic acid, which makes the cell pole and trn* 
parent, and brings out the nucleus in bold relief. In some varieties of carcinoiUi 
the cell frc(|uetitly exhiltits n candntv configuration. 

The occnrrcnce of ulceration in cancer is a direct consequence of the chang" 
wrought by age and disease in the cancer-cells. As the morbid growth p^ 
grenses, the cells Ijccome opaque, irregular, flattened or compressed, and in™" 
trated with oil and different kinds of pigmenlarj' suljstanecs. They undergOi'* 
fact, changes very similar to thusc which are witnessed in lymph or pUama. ** 



II. 



sciKKuus. 239 



ft] rule, it may be stated that the largest and most perfect cells are found 
los or hard cancer, especially in those of slow growth. The more imper- 
is are seen in encephaloid and other rapidlj developing forms of the 



1. SCIRRHUS. 

enn scirrhns is employed to designate a morbid product which is more 
id firm than any of tho natural tissues, excepting tendon, cartilage, and 
Hence it is often called hard cancer, an expression applied to it in the 
of the science, from some fancied resemblance which it was supp>osed to 
the claws of that animal. It is to be regretted, as already stated, that 
t altogether discanlod from surg^ical nomenclature, as its retention is 
dd only to add confusion to a subject unfortunately, in itself, sufficiently 

>Gcnrrence of scirrhns is as frequent as its character is malignant and 
ing. It is observed at various periods of life, but rarely until after 
ige. The youngest subject in which I have ever seen the disease was a 
child three months old, whose case has been reported by Dr. S. W. 
D the North American Medico- Chirurgical Review for May, 1857. It 
d itself in the liver, which was otherwise perfectly healthy, in the form 
f tal>erc]es. which were of a firm, almost fibro-cartilaginous consistence, 
ibited under the microscope all the characteristics of genuine scirrhus. 
; of the skin is also occasionally observed at a comparatively early period; 
ywhere else it is rare until after the age of forty, when it Ix^comes suffi- 
rommon. The jwriod of its greatest frequency is from the forty-fifth to 
-fifth vear. 

les are more liable to scirrhus than males, but in what precise proportion 
been ascertained. The influence of temperament, habit, and occupation 
• production of the disease also remains undetermined. It is generally 
1 that persons of a dark bilious temperament are particularly subject to 
bis is doubtful. 

exciting causes of scirrhus are not at all understood. In general, the 
irises spontaneously, and makes perhaps considerable progress before 
>icion is aroused as to its true character. Occasionally, though seldom, 
iopment is manifestly due to the influence of some external injury, as a 
II, or bruise. 

in organs and tissues are more prone to scirrhus than others. Thus, 
J called the glandular viscera, as the liver, manmia, and uterus, are par- 
liable to suflTer, though the testicle, which belongs to the same class, is 
ly exempt from it. The stomach, anus, rectum, and colon are often 
in both sexes. Scirrhus was formerly supposed to be very common in 
.ud penis, but recent researches tend to show that the aff*ection, once so 
I, is nothing but epithelial cancer, a milder form of malignant structure. 
r this, however, is reiilly so, future observation must decide. Meanwhile, 
itively certain that cancroid disease is often much more rapidly fatal than 
I. The bones, muscles, tendons, ligaments, aponeuroses, vessels, nerves, 
glands, brain, lungs, spleen, and urinary organs are nearly entirely exempt 
s heterologous formation. 

the other heteromorphous products, the scirrhous may appear under 
varieties of form, as the tulxToid. stratiform, and infiltrated, of which 
ifl the one, surgically speaking, of the greatest interest. The other two 
iefly in the internal organs, particularly the oesophagus, stomach, colon, 
tarn, the submucous cellular tissue of which they often so completely 
n as not to leave a vestige of the original structure ; at the same time 
?y encroach very seriously, if not fatally, upon the calilx^r of the tube. 
€ted part is dense and crisp, cutting almost like fibro-cartilage, and has 
ellowish or grayish appearance, with white fibrinous intersections. The 
m Turiety is occasionally met with in the skin and subserous cellular tissue. 



240 TUMOIfci, OR MOK15II) GROWTHS. chap. Til. 

V>ut the occurrence is uncommon. Scirrhus of the uterus generally presents itself 
as un infiltration. 

The best example of the tuberoid variety occurs in the mamma and lirer; it 
is also sometimes seen upon the serous membranes and in the skin, or in theskia 
and subcutaneous cellular tissue, in the form of little nodules, often not Iirgw 
than a current, a pea, or a filbert. Sometimes the tumor consists of one rin^ 
ma.ss, as in the liver, but more generally it is made up of several, which together 
may form a growth as large as an orange, or even a fist, hard, dense, inelastic, 
and almost ineompressibli', grating under the knife, of variable shape, bot gene- 
rally globular or ovoidal, movable, and deeply inlaid in the tissues among whid 
it is situated. These tissues occasionally afford the tumor an imperfect capsule, 
but in general there is no such investment, the hetcroclite matter being often 
spread out in the most irregular and grotesque manner, like the claws of tk 
animal from which the disease has derived its generic name. The fibrous inte^ 
sections which pervade the interior of the morbid mass are tho remains of tbe 
normal tissues, variously changed by the disease. Tiiey are generally of a dense, 
finn consistence, and of a grayish, bluish, or rosaceous color, thus strikingly con- 
trasting with the abnormal deposit. It is questionable whether the fibrous bands, 
as they are commonly called, are ever entirely of new formation. In the mam- 
mary gland they generally consist of imprisoned lactiferous tubes. 

A section of a scirrhous tumor, especially in its more matured stages, exhibiU 
a whitish, homogeneous as])ect, and yields, upon being scraped, a peculiar fluid, 
sometimes of a whitish creamy aspect, but more generally of a pale grajidi, 
turbid appearance, not unlike thick gruel, and known as the cancer-juice. It is 
slightly unctuous to the touch, readily mixes with water, and often contains a 
considerable quantity of free oil. It exists very sparingly in recent specimens, 
and is evidently caused by tlie softening and disintegration of the hcteromorphoBi 
mass, preparatory to ulceration. Much stress is usually laid upon it as a sign 
of malignancy. 

Scirrhus has a very feel)lo circulation, its vessels being remarkably small, and 
probably wholly derived fnmi the surrounding parts. Of their precise arrange- 
ment, however, wo have no d<'finitc idea. The paucity of vessels affords % 
satisfactory clue to the slow growth and comparatively small size of the morbid 
product, and a reason, also, why there is so seldom any considerable hemoniiage 
after ulceration has set in. No nerves have been demonstrated in its substance, 
but their free distribution is inferred from the sharp, lancinating pain which 
forms so characteristic a symptom of the disease. I^ymphatics also exist, as is 
}>roved by the fact that if arsenic be applied to a scirrhous ulcer, it is often ab- 
sorbed into the system, producing similar effects as when taken directly into the 
stomach. 

Pathologists have laid much stress upon the existence of certain subdivisions 
of scirrhous tumors, as the mammary, pancreatic, lardaceous, and reticular, as if 
the appearances which these expressions are intended to designate were not 
purely accidental, depending upon the character and amount of pre-existing 
tissue, the age and mode of aggregation of the hetcroclite matter, and, above all, 
the state of the patient's general health. I must object the more strenuously to 
the use of these terms, because they hav(^ a tendency only to complicate the sub- 
ject and create confusion. I am sure that, with all my opportunities for observa- 
tion, I have never seen a scirrhous tumor to which the word mammary or pan- 
creatic could be applied with any degree of propriety ; and it is equally certain 
that the lardaceous and reticular varieties, as thev have been termed, althoagb 
they may sometimes present a faint resemblance to the substances after which they 
have been named, must be exceedingly rare. 

Chemically examined, scirrhus is found to consist largely of albumen and fa^^J 
matter, the two together forming more than one-half of the entire mass. In • 
specimen of scirrhus of the utenis, analyzed by Hecht, the fatty substance 
amounted to fifty per cent. The quantity of fibrin is always very small. G^j*" 
tine is said to be occasionally present, but this is questionable. In an examination 



rmp. VM. BCIBBHI'S. 241 

by F07, Dpwudi of thirty per cent of earthy salts exiated, fully one-half of this 
quantity being in the form of Bnbphosphato of lime. 

The facts which chemietry has revealed in regard to the compoeition of scirrhus 
are ralaable, as showing that this substance is formed of materials very much 
of a nou-plastic character, and consequeutly incapable of resisting, for any 
length of time, the inflnencfl of SDrroonding agents. It is reasonable to suppose 
that its compositioQ is not alike ia all cases, but that it is greatly influenced 
by the site and age of the morbid product, and, therefore, that it varies not only 
in <Uiremit stages of the malady, but also in different portions of the same spe- 
cimeo. 

The atructure of scirrhus cansists of two parts, a fibrous network, and a soft 
gnnular matter. The former is made up of filaments, of a whitish or grayish 
color, which, intersecting each other in every 
nmceiTablc direction, form meshes, of variable P's- ^■ 

shape and size, for the lodgment of the grano- 
lar element. These filaments, which are welt 

shown in dg. 48, are of a fibrous texture and ->d^j^i@^^^)>' *#^ 

generally consist, not of new matter, but men ly *£wl7*^>?«^^^'^;^ 

of pre-existing tissue, condensed and altered '^ f^ ' 

by the heteroclite deposit. Their appearanco ' 

is occasionally very distinct in recent specimens V 

of acirrhus, especially of tlio liver and mamma ^c^ , ^ >- -iV 

but ordinarily it is necessary to scrape away the /• — *^'' " -tjx y 
grannlar matter before they can be brought mto x 

fall relief. 

The essential element of scirrhus, contamed siraui or Hirrhiu. 

in the meshes of the fibrous structure, consists 

mainly of cells and free nuclei, lying in a transparent and slightly ganutar matrix. 
The cclU vary mach iu shape; some being round, some oval, and others, again, 
caudate, angular, pyriform, or nearly lanceotalc. Multiformity, in foct, is one of 
their characteristic features. In siEe they range from the ^l^ to the y^^ of an 
inch in diameter, moat of them being large and well defined, especially in the more 
matured specimens of the disease. They iiavo each a delicate, but distinct wall, 
and generally inclose one or more nuclei. 

The nuclei are, for the most part, of an oval shape, or nearly round, and often, 
in turn, inclose well-marked nucleoli. They arc very constant in their appearance, 
even more so than the cells themselves, almost 
transparent, well defined, not easily decom- 
poiied, and abost the ^ ^pi '^^ ^'^ ^^^^ ii ^beir 
long diameter. Sometimes the nuclei escape 
from their cells, and scatter themselves through 
Ihe uniting substance as if in search of new 
homes. Finally, crystals, granules, oil-drops, 
and old, degenerated cells are often found in 
tbc same specimen under the field of the mi- 
croscope. The various forms of cell-formation 
are well shown in fig. 19, from a drawing by 
Dr. Ua Costa. 

The proffress of this disease is geoerally 
DKtre slow than that of the other hctcromor- 
phoud deposits, both as it respects its tendency 

to ak-eratioD and the destruction of life. It is seldom that a scirrhous tumor of 
the breast becomes an open sore under twelve, fifteen, or eighteen months ; not 
nafrequently, indeed, several years elapse before it takes on this kind of action. 
In l><oT, I had at my Clinic an elderly lady, formerly a patient of Sir Astlcy 
Coo|>er, in whom the disease had existed for more than twenty years before any 
dijpusilion to ulceration became apparent. Several other cases, somewhat less 
in their duration, have been under my observation. In general, however, the 
tendfury to ulceration shows itaelf witlun the second year, commencing usually 

VOL. 1. — 16 




242 TUM0R3, OB MORBID QROWTHS. ghap. tii. 

in a superficial portion of the tnmor, Bonietimes at one, and at other times at 
several points, the process being preceded and accompanied bj more or less dis- 
coloration of the surface, and by the adhesion of the skin to the subjacent partSb 
The color is always dark, purple, or livid, the vessels immediately concerned in 
its production being enlarged and deeply congested, frequently presenting sa 
appc^arancc as if they were inlaid in the cutaneous tissnes. The part at lengtli 
giving way, an unsightly ulcer is exposed, having hard, steep, and ronnded edges^ 
and a foul-looking bottom, generally incrustcd with spoiled lymph. The discharge 
is always sanious, ichorous, or sanguinolent, more or less fetid, irritating, and 
often remarkably profnse. It tarnishes silver, imparts a green color to syrap of 
vioh^ts, and, on admixture with sulphuric acid, evolves a peculiar gas, having 
many of the properties of sulphuretted hydrogen. No granulations ever fom 
upon such an ulcer ; hence it never heals, the plastic matter which it secretes being 
devitalized as soon as it is deposited. There are, of course, exceptions to this 
rule ; but they are very uncommon, and I have met with very few. Sometimes 
the scirrhous ulcer has a remarkably excavated appearance, as if it had been dug 
out with a punch. The parts immediately around the ulcer are always very 
tender, discolored, and (edematous. 

Another tendency of the scirrhous tumor is to contract adhesions to the stmo- 
tures among which it is situated. This disposition, which often manifests itself 
at a comparatively early period, is always very conspicuous in the latter stages 
of the malady. The immediate cause of the adhesions is an effusion of ordinary 
plastic matter; but in some cases, especially in such as are of long standing and 
of unusual size, they are owing, at least in part, to the heteromorphous deposit 
itself, which, under such circumstances, often breaks through its original bounda- 
ries into the skin, cellulo-odipose tissue, muscles, glands, and even bones, involv- 
ing all in one common ma^ss. 

A tumor of this kind, however, not only affects the parts with which it lies in 
immediate contact, but it often extends its influence to others farther off. The 
structures that are most liable to suffer.in this way are the lymphatic ganglions, 
which often take on the same kind of action, becoming enlarged and indurated, 
and exhibiting, on division, precisely the same appearances as the original tumor. 
Sometimes, again, parts still more remote become involved in the morbid action. 
Thus, in scirrhus of the mamma there is often not only great contamination of the 
axillary lymphatic ganglions, but serious swelling of the corresponding arm, 
evidently from an extension of the primitive affection. 

Thus the tendency of this disease is to spread and to contaminate the su^ 
rounding structures, making itself deei)ly felt not only at home but abroad ; not 
merely locally but constitutionally. In exceptional cases, the morbid influence 
is closely circumscribed, limiting itself, perhaps for years, to the spot in which it 
originally appeared ; even then, however, it eventually breaks through its barriers, 
and spreads among the adjoining tissues. Finally, after having inhabited the 
part for a time, nature occasionally makes an effort at extrusion, the tumor being 
invaded by gangrene, and at length detached as a slough. Such an occurrence, 
however, is extremly rare. One instance of it only have I seen. The patient 
was an elderly lady, fat, and otherwise healthy, who had had a medium-sized 
scirrhous tumor in one of the mammary glands for several years. Suddenly, 
without any assignable cause, inflammation set in, and in a few weeks the whole 
mass was lifted from its bed as neatly as if the operation had been performed 
with the knife. Some time afterwards the disease broke out in the axillary ly^" 
phatic ganglions, and made rapid strides towards a fatal termination. 

The Hijmptoms of scirrhus necessarily resolve themselves into local and c^^' 
stitutional. The former can only be satisfactorily studied as they appear iii J^ 
external tumor, such, for example, as that which involves the mamma. In tak. ^^\ 
hold of such a tumor we are struck with its extraordinary hardness and dcnsi*: J* 
it feels firm, incompressible, and inelastic. If it be of recent origin, it will 



found to be perfectly circumscribed and movable, the examiner being able to gr^^ 
it with the fingers, and to push it about beneath the skin ; at a later period, hc» '^. 
ever, it contracts adhesions to the surrounding parts, and thus becomes fira> • 



COAP. rfi. EXCEPITALOID. 243 

fixed in its situation. The morbid product may display itself as a solitary tumor, 
or seTeral little lumps may appear simultaneously or successively, and, gradually 
coalescing, a mass of considerable size may thus be formed. 

The pain of seirrhns is peculiar. It is sharp and lancinating, darting through 
the parts like an electric spark, or causing a sensation as if needles were thrust 
into them. It makes its appearance at an early date, gradually increasing in 
eeTcrity, and becoming at length a source of intense suffering. It may be steady 
and I persistent, but more generally it is intermittent. It is always aggravated 
by damp states of the atmosphere, and by whatever has a tendency to impair 
the general health. In some cases we find it to be of a neuralgic character; 
and. then, instead of being limited to the morbid mass, it often shoots about in 
different directions among the neighboring structures. During the latter stages 
of the disease it is generally so constant and violent as to deprive the patient 
of sleep and appetite, thus rapidly urging on the fatal issue. 

As the disease advances, the skin is gradually tied down to the morbid mass, 
and f^oon l>ec«>mes hard and livid, its vessels being at the same time very much 
enlarged and congested. Eventually erosive action sets in, and thus a steep exca- 
vated ulcer is established, the seat of a foul, ichorous discharge, and incapable of 
fr>rmin!r healthy granulations, of furnishing laudable pus, or of undergoing repair. 
The tnmor is now firmly adherent to the surrounding structures, and there is 
generally, though m>t invariably, lymphatic involvement. The ulcer sometimes 
bleed:*, but seldom beyond a few drachms, or, at most, a few ounces. The flow 
may be purely capillary, or it may proceed from a tolerably large vessel, arterial 
or venous, laid open by the morbid action, and unable to retract in consequence 
of the c«>ndensation of the circumjacent tissues. 

Scirrhus, in its earlier stages, produces little or no constitutional disturbance. 
It is strictly a local affection, annoying and fretting the parts directly involved 
in it. but not awakening any general sympathies. A little mental disquietude, 
the rersult of the conscion.sness that there is a suspicious tumor or lump, is the 
only thing that excites attention. By and by, however, the health begins to 
fail ; the appetite is impaired ; the sleep is interrupted by the severity and fre- 
qnenrv of the pain ; the secretions arc sadly disordered ; the bowels arc irregular; 
the as«imilative functions suffer ; occasional attacks of fever take place ; the 
it*sh and strength gradually decline ; the spirits are depressed ; and life is beset 
on every side by the treacherous and unrelenting enemy. During the latter 
EtajBr(*s of the malady, sometimes even before there is any serious lymphatic 
involvement, the countenance assuniert a peculiar sallow, cadaverous expression, 
Fft denotive of the cancerous cachexy ; diarrhoea and sweats set in ; the limbs 
Iwrcome anasarcous; and at length the patient dies utterly exhausted, being 
literally ]>ricked, frett«*d, and stung to death by the disease. 

During the progress of this malady scirrhuus deposits often appear in other 
parts i*f the body ; the blood is thin and colorless ; and the solids arc pale, flabby, 
and wasted. Even the bones often experience important changes, I'specially 
tht»se «»f the extremities, which are sometimes rendered so fragile as to give way 
from the slightest cause. Many years ago I had under my charge, on account 
of scirrhus of the manmia, an old lady of seventy-three, who broke her right 
femur a few days before she died, simply by turning round in bed. 

2. ENCEPUALOID. 

Encephaloid has various synonymes, of whi(!h the most common are soft cancer, 
me^lulliiry sarc<-»ma, cerebriform cancer, and fungus hematodes. Mr. John Hums, 
of (.fla!?gow, who was the first to describe it, gave it the name of spongoid inflam- 
mation. All these various appellations have refenmce either to the appearance, 
consiiitence, or structure of the morbid ])roduct, and are, therefore, more or less 
appropriate. That of encephaloid, however, is, on the whole, the least objec- 
tionable, and is the only one that ought to be retained. There is a form of the 
disease, to which attention was first called by Mr. Hey. of Leeds, under the 
name of fungus hematodes, which I shall designate as the hematoid variety, and 



244 



TUMORS, OR MORBID GROWTHS. 



CHAP. Til. 



which, in my judgment, is the only one that deserves separate consideratioiL 
The terms solauoid, napiform, and reticulated, devised by some of the French 
and German pathologists, to specify particular states of encephaloid, onght to be 
discarded from the nomenclature of the disease, as they are calcnJated only to 
load to confusion by keeping up a refinement which does not exist in nature. 

Of the causes of this affection nothing definite is known. In general, it comes 
on spontaneously. Now and then, however, it is directly traceable to the effecU 
of external injury, as I have seen in a number of instances. 

The disease is more common in the mamma, eye, testicle, utems, liver, lym* 
pliatic ganglions, periosteum and bones, than anywhere else. With the exception, 
however, of the muscles, tendons, nerves, cartilages, ligaments, and aponenrosei) 
there is no part of the body in which it has not been observed. Occasionally it 
takes place, either simultaneously or successively, in a considerable number of 
structures, resembling, in this respect, the other heteromorphous prodncts, and 
constituting a genuine encephaloid diathesis. It appears in both sexes, and tt 
all periods of lif^, from early infancy to old age, but the greatest number of easel 
occur between the twentieth and fiftieth year. The subjoined table, constmcted 
for me by Dr. Cassot, shows the age in ninety-one cases. 



Years. 
1 to 3 
3 " 7 
7 " 14 
14 " 21 
21 " 30 



No. of CAMS. 


Yemrs. 


8 


30 to 40 


4 


40 »* 50 


5 


50 " 60 


9 


60 " 70 


20 


70 " 75 



Ko. of 



14 
18 

7 
4 
2 



The localization of encephaloid is materially influenced by the age of the 
patient. Thus, in the mamma the disease is almost peculiar to middle age; in 
the testicle, to young adults ; in the eye, to childhood. Of the relative frequency 
of the disease in the two sexes, we have no reliable data. In the eases analyied 
by Dr. Cassot, there was a predominance of males, and in my own practice I 
have certainly seen it oftener in men than in women ; but this may have been a 
mere coincidence. 

The chemical composition of encephaloid, as determined by the analysis of 
Foy, probably the most accurate that has yet been made, shows the greatest 
possible resemblance to that of scirrhus by the same chemist. In order to enaUe 
the reader to compare the results of his examinations I shall subjoin his two 
tables in parallel columns : — 





ENCRPIIALOID. 


1 


Albnmpn .... 


47.00 


White fatty matter 
Rod fatty matter . 
Osmazome 




7.50 
6.35 . 
4.00 


Fibrin .... 




6.50 i 


Water . . . , 




8.00 


Oxide of iron 




1.35 


Sabphosphate of lime 

Soda . 




6.30 , 
2.75 


Carbonates of • 


Lime 




4.00 i 


Hydroohlorates 


Maguenia 
, C Potassa . 
^^?Soda . , 


1.00 
2.70 
2.00 


Tartrate of Boda . • • . 


0.35 




100.00 



8CIBRUDS. 

Albiimttn 

White fatty matter 

Red fatty matter . 

Fibrin . 

Water . 

Oxide of iron 

Subphosphate of lime 

iSoda 
Lime 
Mafirnesia 

Hydrochlorates of i ^^^ 

Tartrate of soda . 



42.00 
500 
3.^ 
5.85 
5.00 
1.65 

16.60 
5.(0 
6.60 
085 
4.10 
3.25 
0.8S 

100.1*0 



It will thus be perceived that the chief differences in the composition of the 
two substances consist in the presence of osmazome in encephaloid, in the lesser 
quantity of earthy salts, and the greater quantity of albumen. The fibrin oecani 
in nearly equal proportions. The analyses make no mention of gelatine, which 
has been asserted by certain chemists to exist in both substances, especially la 



SNCEPHA.LOID. 



245 



the more recent apeciineiis. Doubtless tlie composition of cncephaloid is greatly 
infloenced by tbe age and site of the deposit, the 
general health of the patient, the condition of 
the blood, and eren by different portions of the 

Encephsloid consists of a stroma and corpns- 
dea, closely resembling tbose of scirrhna. Tbe 
stroma, or basis-structure, exbibited in fig. 50, 
from Rokitansky, is made up of a fibrous snb- 
stanee, not equally well developed in every 
^Mcimen, bot in general sufficiently distinct to 
admit of easy recognition. Tbe firmer varieties 
■raally contain two kinds of fibres, botb hollow, 
bat one is opaque and granular, tbe otber byalinc 
sad studded with cells and nuclei. The other 
element, the essentially canceroas substance, 
eonaists of corpuscles, of a rounded, ovoidal, or 
caudate shape, exactly similar to those of scir- 
rfaus. only that tbe latter arrangement is com- 
monly more distinctly marked. Nearly all in- 
clude large, oval nuclei, and not a few also 
nncleoli. Besides these two substances, most 
specimens contain pigment matter, granules, and 
oil globuled. The various forms of cancer cor- 
puscles are well displayed in fig. 51. Tbe cau- 
dale bodies are particularly distinct str™. of rD«pii>ii»d 

In regard to its arrangement, cncephaloid 
iDktter presents itself under three varietien of form, as a tumor, a stratum, and 
■s infiltration, the first being the most common, and, sorgically considered, the 
only one of any particular interest. It varies in volume from that of a pea to 
that of an adnlt'a head, its shape being generally somewhat ovoidal. and its surface 
more or less lobulated, as in fig. 51, from a specimen in my cabinet. Its con- 
Iguration. however, is always greatly influenced by the amount of pressure 
exerted upon it by the parts in which it is situated, and hence it is occasionally 
TCiy mnch flattened, or irrcgalarly compressed. When seated in the estenial 
ttmctures, as in the subcutaueous and intcrmuscnlar cellular tissue, over the 
bones, in the mammary gland, and in the lymphatic ganglions, it has generally a 
nell-marked cyst, of a grayish, whitish, or rosaceous appearance, and of con- 

Flg. SI. 





thBrulen ot encephilolil. 



^'vible GnnnesB and thickness, which thus serves to define its limits and to 
'**'ilt it from the original textures. Extending fh>in the inner Bof&ca of this 



246 



TCMOBS, OB UOBBID OBOWTHS. 



Fig. 52. 




envelope are nanieroDS processes, which, pasRing throagh the interior of tin 
discam^d mass, intersect each other in vsrions directions, aad thus form cells, cmri- 
tics, or lodges, for the accommodation of the new matter, precisely as in acirrhus, 
only that they arc generally larger and mora 
fnlly developed. The encephaloid matter, freed 
firom its stroma, or fibrous element, is of a soft, 
jelly-like consistence, very much like that of 
the fffital hrain, viscid to the touch, of a whit- 
ish or slightly reddish tint, miscibte with water, 
of a peculiar sperm-like odor, and readily 
coQgalablc by heat, alcohol, and acids, thai 
showing its protein character. 

A section of an encephaloid tumor presents, in 
most coses. Dot a little variety of form, or diver- 
sity of appearance and consistence. Thns, one 
part may be soft, and white, like brain, anothn 
perhaps feel, look, and cut like fibro-cartilag^ 
while a third may be composed essentially of a 
rcddisbsemi-concrete substance, bcaringa strik- 
ing resemblance to the contents of an old aaeo- 
risni. Most of these differences are due to tbt 
age of the tomor, and the changes experienced 
by the included primitive tissues ; but the latter 
are so distinct and peculiar as to entitle thtn 
to be considered almost as a separate fbnw- 
tion. It is to this morbid prod net that, as wil 
before stated, the term kematoid ought to In 
applied, as expressive of its blood-like Bt^l^ 
ture. It lookit, in fact, more like a nuu of 
frmly coagulated and semi -organized blood thou any other substance to which it 
can be compared. Occasionally a more solid substance is mixed up with tlic 
liematoid, as the fibrous, or fibro-cartilagiuous, and when this is the case it 
generally creaks under the kuife, cutting a good deal like a raw turnip, or tb* 
rind of bacon. I have found this form of tumor most commonly in the niamiu, 
liver, testicle, and lymphatic ganglions, the latter of which, when thus affected, 
occasionally exhibit a singularly areolar structure, a section bearing a cIom le- 
semblance to the surfacu of a sponge, the cells being occupied by the bematoid 
matter. 

Encephaloid sometimes, although rarely, occurs as an infiltration, chiefly in 
the lungs, liver, uterus, and lymphatic ganglions, the proper structure of wMeh 
it subverts and ultimately completely effaces, forming a dense, solid mass, of ^ 
pink, grayish, or ash color, grating under the knife, inelastic, and almost incom- 
pressible. The Ptratiform variety is also uncommon. It is seen chiefly in the 
submucous cellular tissue of the stimiacb and rectum, and beneath the pleura bi^^ 
peritoneum, in small, thin, whitish patches, from the diameter of a dime to tW 
ofadollor. _ 

Encephaloid, licing an extremely vascular structure, is endowed with a Y*^^ 
degree of vitality, growing generally with great rapidity, and often attainin^i^ 
most extraordinary bulk within a few months from its first appearance. 
vessels are unusually large, and are probably derived from the pre-existing tiss^iT 
although eases occur where the circumstances arc such as to lead to the be— - 
that they are now and then crcateii, at least in part, by the heteroclite mal^^ 
itself. If such a conclusion be admissible, as I thinii it is, it follows that en ^ 
pbaloid has occasionally, like plastic lymph, a double circulation, one peculiar"^* 
itself, and the other common to it and the tissues with which it lies in contu** 
Be this as it may, the vessels arc generally remarkably voluminous, thus strikin^p. 
contrasting will) those of scirrhus, at the same time that they afford a ready ^^ 
planatioii of the differences in the rapidity and size of the two formations. Thr ' 
walls also are unusually brittle, and hence they are liable to give way under t.^ 



Til. 



KXCEPIIALOID. 247 



rifling causes, prodacing those apoplectic depots which we so often see in 
nterior, and those frightfal hemorrhages which occasionally attend their 
t>ndition. 

the lymphatics of enccphaloid very little is known. Schrocder Van der 
njected vessels of this kind in two specimens of medullary cancer of the 
;h and liver. Lymphatics doubtless usually exist in large numbers, other- 
i woold be difficult to account for the facility with which morphia and other 
s, implied to encephaloid ulcers, find their way into the general system. 
3 are also probably freely distributed through the morbid mass, although it 
[ignlar fact that this disease is commonly much less painful than scirrhus. 
;ason, however, is not the paucity of nerves in the one, but the manner in 
they are compressed in the other, the structure of encephaloid being so 
softer than that of scirrhus as to admit of much greater comfort to its 

• 

3 not onnsoal for encephaloid tumors to contain serous cysts, as well as 
idveutitious products, thus complicating their structure, and occasionally 
ug a doubt over their diagnosis. In general, the cysts are small; but I 
ct an instance where a cavity of this kind contained fully a pint of serum, its 
laving a peculiar honey-combed appearance. Apoplectic depots, as already 
, are most common in the hematoid variety of encephaloid growths. 
» seldom that an encephaloid tumor, after having once taken a fair start, 
IS even temporarily stationary ; on the contrary, its tendency is to proceed, 
J and regularly, in its work of disorganization, until it destroys life either 
lorrhage or by irritation, the period at which this takes place varying, on 
irage, from nine to twelve months. Death sometimes occurs in an almost 
ibly short period. I remember the case of a youth of eighteen, a patient 
fessor Post, in the New York Hospital, who had a large encephaloid tumor 
he scapula, measuring a foot in its greatest diameter, from which he died 
I than eight weeks from its first appearance. On the other hand, a patient 
>nally lives a long time. Some years ago, I attended a gentleman, aged 
wo, who has been laboring under encephaloid of the antrum for more than 
ears. Great softness of texture, bulk, and rapidity of growth are the cir- 
inces which particularly predispose to an early unfavorable issue. 
period at which the encephaloid tumor becomes an open ulcer is indefinite ; 
mes it takes place within a few months, at other times not under a year, or 
' and a half, although this is uncommon. The immediate cause of the 
Lion may be the pressure of the morbid mass upon the skin, the formation 
abscess, or the occurrence of a slough. However this may be, the sore is 
I characteristic. Its edges are thin, undonnincd, jagged, or irregular, and 
torn, which is sometimes of considerable depth, has a foul, bloody, fungous 
ranee. In some instances it is covered with numerous excrescences, or 
fungous granulations, giving it a peculiar cauliflower-like aspect. The 
mmed lately around are of a deep red, livid, or purple color. The discharge 
ally profuse, and of a sanious, bloody, or sanguinolent character, pure, 
dc pus being rarely, if ever, met with. Copious hemorrhage occasionally 
place, especially in the hematoid variety of the disease, and by its frequent 
:ion often rapidly undermines the general health, urging on the fatal crisis, 
ccurrence is particularly common in encephaloid of the eye, uterus, and 
a. Of the many cas(»s that I have seen of the encephaloid ulcer, not one 
ealed even temporarily. Intractability is one of its distinguishing features. 
aphatic involvement often occurs at an early stage of the disease, some- 
indeed, long before ulceration sets in ; at other times, however, it does not 
lace until the tumor has opened. The general law is that the more rapid 
owth is the earlier will there be disease in the neighboring ganglions, and 
raely. The constitutional cachexy is always well marked in the more ad- 
1 stages of the affection, and the patient^s doom is often depicted in legible 
lers upon his countenance several months before it is finally sealed in death, 
encephaloid tumor is distinguished by its comparative softness, by the 
ty of its growth, by its great bulk, and by its lobulated surface. The pain 

COOLER MEDIOAL li^i; 



248 TUMORS, OR MORBID GROWTHS. chap. vii. 

is generally slight, at least until the occarrence of ulceration ; and there is neiilj 
always considerable, sometimes, indeed, enormous, enlargement of the subcoti- 
neous veins. In its earlier stages, the tumor is movable, as in scirrhns, butui^ 
advances it contracts adhesions, and at length becomes permanently fixed. 

3. EPITHEUOMA. 

• 

There is a class of affections which were formerly known under the name of 
scirrhus, from their supposed identity with that disease, but which modem n- 
search, it is supposed, has shown to be so different from it as to entitle them to be 
regarded as separate formations. They comprise the various forms of maligmit 
disease of the cutaneous and mucous tissues, more particularly carcinoma of the 
lip, gums, tongue, face, anus, and penis. Tliey are not, however, limited to 
these parts ; for they sometimes invade the deeper structures, as the bonei, 
muscles, lymphatic ganglions, liver and lungs, although their occurrence here 
is very infrequent. The names by which these formations are now genenDj 
designated are epithelioma, cancroid, and epithelial cancer, which, as thej are 
sufficiently expressive of their true character, may all be appropriately used tf 
fancy may dictate. 

Epithelioma is more common in men than in women, the latter being more 
liable to scirrhus. In the male the lip and penis are most frequently attacked. 
What is called chimney sweeper's cancer is merely a form of epithelial disease 
of the scrotum. Lupus, the noli me taiicfere of the older writers, is nothing bat 
cancroid of the skin of the face, an affection sufficiently common in both sexes, 
and often committing the most frightful ravages. In whatever form it may 
appear, it seldom shows itself before the age of thirty-five or forty, and usoally 
occurs only in one part of the body, its origin being apparently much less con- 
nected with the constitution than that of the other varieties of carcinoma. 

The causes of this disease arc not well understood. Sometimes it is directly 
traceable to external injury, as long-continued pressure. Thus, Dr. Da Gostfr 
has mentioned to me the case of a shoemaker, where it was clearly attributable 
to the effects of a small l)oard worn habitually upon the abdomen while the matt 
was working at his trade. In 18G3, a man, aged fifty-nine, consulted me on 
account of a cancer of the lip and cheek, induced by a wound received five months 
previously from the prong of a fork in eating. Epithelioma of the lip is often 
charged, though perhaps incorrectly, to the irritation produced by the pipe in 
smoking. Chimney sweeper's cancer is generally supposed to be occasioned by 
the lodgment of soot in the folds of the scrotum. Sometimes the disease origin- 
ates in a wart or cicatrice. p]pithelioma of the penis, until lately regarded as 
true cancer, has been very commonly referred to the irritation arising from want 
of cleanliness due to the exi.stence of a long and tight prepuce. A sharp tooth, 
constantly brought in contact with the tongue, may, it is believed, serve as an 
exciting cause of epithelioma of that organ. Cases have been collected which 
tend to prove that the disease occasionally manifests a hereditary predisposition. 
Dr. Foster, of Terre Coupee, Indiana, has communicated to me the particulars 
of three cases whi<th occurred in three members of the same family, two having 
died from epithelioma of the face, and one from epithelioma of the foot. 

Cancroid generally begins as a tubercle, crack, or wart-like excrescence, hard 
to the touch, movable, and somewhat tender on pressure. As the disease 
advances the part extends in different directions, and becomes more defined in 
its character. By and by ulceration sets in, sometimes almost simultaneonsly 
at several points, the exposed surface having a foul, unhealthy, fungating appear 
ance, with irregular granulated edges, and a hard, rough base. The discharge 
is generally abundant, and of a thin, sanious, acrid description, often eroding the 
skin in the neighborhood. The ulcer is intractable, manifesting no disposition to 
heal, or, if granulations form, they speedily degenerate and lose their vitality, 
their recuperative powers being too feeble to carry on the work of repair. Once 
begun, the disintegrating action never stops^ and hence its ravages are often most 




frijrhiful. a*. for example, in the case from which tho adjoining: cnt. fig. SS, i ^ 

(ufiinj. when' ilie ilieeaBe Bnceesslvely involved, skia, iimacle, bone, cartilage, aud ( 

ilinm* luviiiltrano, sparing nothing thai 

I'll it) itfl way. The pain attending the F'S- ^^' 

ain-ngf- is of & sharp, darling, or pricking 

iifllure, and often extends through the sur- 
manding parts. Hemorrhage occasionally 
(wcwB, chiefly in the rnngating form nl epi- 
tbrJiii nicer, and may he sufficiently cepious 
to cause Eerious dvbitity, eftpecially when a 
pcMt* large artery or Fein is laid open. 

During the progross of the disease, lym- 
pluUic involvement occurs ; eometimee early, 
but gcniTally not nntil after the lapse of 
eigrkt, lw«jve, or fifteen months. Thus, in 
eiiiUwIiuma of tbe lip the ganglions of the 
jaw bevoiue enlarged, and in that of the penia 
tlic gaagliunfi of the gruiu. The cunBtitn- 
tioD*) xuffuriug is also severe, but usually nut 
oo early as in ordiuarv carcinonia, although 
BltUB»l«i7 not less fat^. 

" "'i«tiaJ cancer grates nnder the knife, i 

ore or less vascular, aixl of a radiating structure. It has no stroma like 
or eocephaloid, but is confusedly inlaid in the involved textnrca. In the 
penia, it generally contains well-marked papiltie, of varying size and 
•one being single, others united, which, however, are altogether adventi- 
tMH, or tfaey occur only in epithelioma of the mucous or muco-cutaneous surfaces. 
Ila iiitimat« structure coneit^ts mainly of cells not unlike those of pavement 
epblicliam. only that they are latter. The cells vary considerably in their shape, 
•oiBe bving rounded, some oval, and some fusiform, angular, or elongated. The 
older «ne« are eomctimeii flattened, shrivelled, or curled up, as if. partially do- 
priTcd of vitality, tbey were about to become i-Q'ete. They usually contain one 
or two email nuclei, and either lie In superimposed lavert^, united by fibrous 

luUtCT, or they are inclosed in peculiar cyats, which arc ebnost charactLTistic of ^ 

Fig. H. Fr«. 55. 




ind forms a firm, whitish or grayish 




t Eufljr 



ftb itM of morbid prodnds. These appearances are well seen in fig. 54, from 
*fawingbT Dr. Pa OoMa. Sometimes these cells and nuclei are unusually 
lup utd distinct, strongly resembling those of true carcinoma. Mixed up with 
■i* eella of epithelioma, especially if the disease has made some progress, ar« 
(Ml Bombrnt of five uuelei, and granules, and sometimes, also, of crystals of 
♦•"•aiwine, pigment cells, and blood corpuscles. The papillec, previously 
I'wW iij, consist of loose Gbruus tissue and bloodvessels very densely coated 
*tth bypFR of epithelial cells and free nuclei. Fig. 55 represents oike taken 
''MB a cancer of tbe Up. 



» I 

i 



250 TUMORS, OR MORBID GROWTHS. cbai.tii.. 

Epithelial cancer is generally comparatively tardy in its growth. In a ciM. 
of cancer of the tongue, reported by Dr. Da Costa, twenty-two years elajised 
from the appearance of the disease to the time of its removal by opention. 
Cancer of the lip often lasts a number of years before it terminates &tal]|f, 
though this is not its ordinary tendency, most persons dying in from eigfatea 
months to two y(>urs. I have seen cases of lupus of the faco continue tha 
ravages for nine, fifteen, and twenty years before the disease finally caused dettL 
Under such circumstances, the ulceration occasionally for a time suspendB iU 
action, and then resumes it, perhaps now with increased vigor. 

Although 1 have, in conformity with the custom of the day, described this 
disease under the name of epithelioma, my conviction is, from a careful study of 
the subject, that it is merely a form of scirrhus or hard cancer, modified in its 
character by the nature of the structures in w^hich it occurs. 

4. COLLOID. 

Since the attention of pathologists has been more closely directed to this 2S» 
tion, it has been found to be a good deal more frequent than was formerly imir 
gined ; nevertheless, compared with some of the other heterologous formatiunSi 
it is sufficiently rare. The name bv which it is usually known has reference to 
the peculiar jelly-like appearance of one of its principal constituents, and u 
therefore quite appropriate. It has also been described under the terms gelatini- 
form, alveolar, cystic, and gum cancer. 

The favorite seats of this morbid product arc the omentum, stomach, rectno, 
ovary, lower jaw, subcutaneous cellular tissue, and the bones of the extremities 
The testicle, mamma, uterus, and lymphatic ganglions arc also occasionallj itr 
tacked by it. It has never, I believe, been seen in the eye and its appendages 
It sometimes coexists with encephaloid and melanosis. 

Although it may occur simultaneously in a considerable number of organs, it 
manifests less tendency to general diffusion than any of the other heterologous 
fonnations, exce})t the epithelial. It takes place in both sexes, and at all periods 
of life after puberty, but is most common b(jtween thirty-five and fifty. In two 
instances of enormous colloid tumors of the omentum, observed by myself, the 
patients were, resj)ectively, forty and forty-nine. In a case which I noticed in 
the body of the sphenoid bone, beneath the dura mater, the age was thirty-nine. 
Lebert and Bickersteth refer to examples witnessed in early childhood. 

Colloid occurs under two varieties of form, as a tumor, and as an infiltration. 
The latter is most common in the alimentary canal, particularly the stomach and 
rectum ; the former, in the glandular organs, the peritoneum and omentum, ovary, 
cellular tissue, and bones. In the bones it is most frequent in those affections 
known under the vague names of osteo-sarcoma and spina ventosa, which are 
sometimes almost exclusively composed of this substance. In the infiltrated 
variety of colloid, the new matter occupies the meshes of the cellular substance, 
forming cysts, from the size of a mustard-seed to that of a hazel-nut, which are 
filled with the characteristic jelly-like matter, and which, as they increase in 
volume and number, so completely subvert the primitive structures as ultimatelj 
to leave no trace of them. 

In the other variety of colloid, the heteroclite matter occurs in the form of a 
distinct tumor, from the volume of a marble to that of an adult head, of a globular, 
rounded, or irregular shape, and of a finn, dense consistence. In the peritoneal 
cavity, I have seen, on two occasions, enormous tumors of this kind, one of which 
was supposed, by estimate, to weigh not less than twenty-five pounds. It ex- 
tended from tiie pelvis to the diaphragm, surrounded the colon and part of the 
stomach, and almost comj)letely concealed the abdominal viscera ; its length being 
nearly one foot, its breadth upwards of eight inches, and its thickness from two 
and a half to three inches. The patient, aged forty-nine, had been laboring under 
the disease for four years. In the other case, that of a gentleman of forty, the 
tumor occupied the same situation, and was also of extraortlinary extent. Wb^n 
the disease was first noticed, eight months before he died, the morbid mass was 



rti. COLLOID. 251 

' of iMTge size, rorming an immense protuberance, which bore upon the 
f tfae AbdomeB in every direction, without causing the slightest iDconveni- 
iTe what resiJted from its bulk. 

BDTbce of the colloid tumor is generally rough, knobby, or distinctly 
ed, according to the volumo and arrangement of the component cysts. 
inally it bears a strong rcHcmblancc to the exterior of a pudding stone, 
life, as it passes through it, makes a creaking noiae ; it contains very little 
f labstance, and the investing cyst is usually very thin. In the larger 
, vessels of considerable size may be seen running over the surface, and ' 
tting the walls of the principal cysts, withoot, however, passing through 
OQtents. 

old consists of two component elements, a stroma, and the peculiar jelly- 
ttter from which the deposit derives its distinctive features. The former 
EtiTODs character, and is arranged in such a manner as to form cells, locali, 
ities, from the size of a pin head up to that of a small marble, rounded, 
1, or angular; communicating with each other, and lined by a thin, delicate, 
■rent membrane, which, excepting that it is not a shut sac, closely resem- 
e aerons tissne. The stroma is of 

irmatioD, and generally possesses Fig. C6. Fig. 57. 

imness and density ; it creaks under 
ifr, and is of a dull, whitish, gray- 
pale jellowish color. Thcc.vi'lirorm 
ire gf colloid is easily recognized, 
w remarkable that, once seen, it 
rer be forgotten. It is wuli illos- 
in the annexed cots from a prepa- 
in my collection ; fig. 56 showing 
cnial arrangemeut, and lig. 51 the 
>!. 

fibroDS matter of colloid is almost 
te of tree celiulur substance. It 

i, howeviT, an abundant supply of vessels, as I hare satisfied myself by 
OD, and OS is evinced also Ity the rapid development of the morbid growth, 
! great bulk which it occasionally attains. In one case in particular I had 
nity in tracing several large, str^gling arteries into a tumor of this kind, 
I that it had a very active circulation. The manner, however, in which 
nilar system of the morliiil [iroduct is arranged is not determined ; nor is 
tained whether it i^ of new formation, or derived solely from the surruund- 
incladed healthy structures*. Of the character of its nerves and absorbents, 
equally nninforine^l. 

ither element of colloid is an nnorganizablo product, of a whitish, greenish, 
wish color, and of tlie consistence of urdiniiry jelly, whence the name by 
he disease is usually known. In the oldt-r cells the matter is sometimes 
u moist cheeiw, or the white of a hard-boiled egg, opaque, and of a white 
vyellowii^h hue, interspersed with minute dark points. Somclimes, again, 
lUes currant jelly, half disifolved glue, or a solution of gum shellac. 
;r this may Ije, it never adheres to the walls of the cells, and is, therefore, 
nucleated, or pressed out. Whi'u ])erfect clearance has been etfected of 
s of a mass of colloid, tlic fibrous structnre exhibits very much the 
nee of a piece of sponge, the nivcolur arrangement lieiug then particularly 
louB, hundreds of cells being often visible upon a surface less than an inch 
ater. 

mgli the soft matter of colloid looks so much like jelly, chemical analysis 
wn that it is entirely destitute of this substance, its principal ronstiliients 
bumen, casein, and osnmzone, in varying proportions. Destructive analysis 
led, in the 100 parts, 4iJ.09 of carbon, T.47 of hydrogen, 37.44 of oxygen, 
J of nitrogen. 

r the microscope colloid appears as a homogeneoBS ssbitaac«, with now 
1 a slightly granular arrangement, or large irregalar nlaf— Lobert, wh« 




252 TUMORS, OR MORBID GROWTHS. crap. tm. 

has carefully examined its minute structure, finds it to be composed of nocleatid 
and compound cells with large laminated spaces. The nucleated cells, the f^ 
called colloid cor])uscles, are either free in the colloid matter, or inclosed in Iirge 
brood-cells, slightly transparent, granular, of irregular shape, and from the ^^ 
to the -gji^jf of an inch in diameter. Some have small nuclei, others have nune. 
The coni])ound, brood or mother cells are arranged in clusters, and are sometimei 
remarkably numerous. They are round, oval, or tubular, very pale, and from 
the 7^7 to the -^Ijf of an inch in diameter: some have a lamellar surface, and 
many inclose a granular nucleus. Cancer cells, similar to those of scirrhus and 
eiicephaloid, are occa^^ionally seen in both the nucleated and compound cells, but 
not as necessary constituents, inasmuch as in some specimens they are entirelj 
absent In addition to these structures, large laminated spaces exist, from the 
^'^ to the -f^^ of an inch in diameter, usually oval and grouped, nearly transpip 
rent, and interspersed with elongated nuclei, small nucleated cells and brood oelk 
It is worthy of notice that corpuscles, very similar to those of colloid, sometimei 
occur in gelatinoid infiltrations of the spleen, heart, aud thymus. The stromi 
of colloid is essentially composed of fibrin. 

It is impossible, in the existing state of our knowledge, to determine the 
precise nature of colloid, or to assign to it its proper position in the scale of the 
heterologous formations. It is certainly destitute of many of the properties of 
carcinomatous disease, and yet its career, so far as I have had occasion to watch 
it, is not the less positively fatal, especially when it occurs in the internal orgaai 
In the osseous stnictures, it may occasionally be removed without relapse, and 
the same thing may probably be true in regard to colloid in some other sitoationi; 
but upon this subject we are in need of further light. It has less disposition to 
ulcerate, and to contaminate the surrounding lymphatic ganglions, than the other 
heterologous formations. 

5. MELANOSIS. 

Melanosis, sometimes called black cancer, occurs most commonly in the cellolo- 
adipose tissue beneath the skin, in the folds of the mesentery and omentum, around 
the kidneys, in the mediastinal cavities, the lymphatic ganglions, the eye, liver, 
lungs, and parotid glands. It is also met with, though more rarely, in the senxu 
and fibrous membranes, the bones, ovaries, heart, pancreas, and spleen. Occarring 
usually alone, it occasionally coexists with some of the other heterologous de- 
posits, especially the scirrhous and enccphaloid, and may attack quite a conside^ 
able number of organs either simultaneously or successively. It takes place ia 
both sexes, and at all periods of life, but is most frequent between the thirtietk 
and sixtieth year. 

Now and then a distinct melanotic diathesis prevails, as in a remarkable case 
which came under my observation in 1855, in a man, aged fifty-eight years, who^ 
after a confinement of nearly twelve months, finally died in a state of eztreBi 
exhaustion, the prominent symptoms having been harassing cough, occasioail 
discharges of blood from the bowels, irritability of the bladder, frequency of the 
pulse, and copious night-sweats. Melanotic tubercles existed in the sobcntaneons 
cellular tissue in various regions, the lymphatic ganglions of the groin, axiltai 
and bronchia, the omentum and peritoneum, stomach, large and small bowehi 
pancreas, liver and gall-bladder, kidneys and supra-renal capsules, urinary bladder, 
prostate gland, seminal vesicles, lungs and pleura, heart, and thyroid body. The 
spleen and large vessels were sound. The brain, bones, and muscles were not 
examined. A singular feature in the case was the existence of numerona while 
and grayish tubercles in the midst of the black, showing that the former were in 
a nascent condition, having not yet undergone the melanotic transformation. 

Melanotic matter is deposited in several varieties of form, of which the tuberoM 
is the most common. It occurs in small masses, of a rounded, ovoidal, or irregvlar 
shape, with or without a cyst, and from the size of a pin-head to thftt of a walnot 
Of a dull sooty, brownish, or black color, they are generally invested by a distinct 
capsule, formed ont of the cellular tissue in their immediate vicinity, which thna 




tti. ' iiELAN'osia. 253 

M wpante uid protect them. Fibrous bands generally intcrse<^t their 
, and veBsels are often seon ramifying over their surface, nonu uf them, 
r, dipping into the proper melanotic matter. It is by the uuiun of sETeruI 
I smaller maases that large tumors are sometimes formed, reaching, uow 
m, the Tolume of a fist or even of a f<Etal head. Oases occur in which 
Iter presents itself in small points, or in irregular patches, generally beneath 
sons membrane. Finally, it is sometimes found in a licjuid form. 
iBotic matter, in a pure state, is of a sooty black, dark brown, or dull 
color, and varies in consistence from the fluidity of ink to that of fibro- 
^. lU chemical constituents are albu- 
bria, and a dark, highly carbonized sub- Pig- BB. 

Mt unlike the crnor of the blood, with 
at quantity of iron, soda, magneeia, 
ad potassa. It is opaque, without odor 
tc, and miscible with water and alcohol ; 
Jts a characteristic stain to linen, resists 
NsitioQ, and emits, when burned, &a cm- 
Mtic smell. 

er the microscope it is seen to consist 
vat network, inclosing numerous meshes, 
■re filled with free, unadberent pigment 
f a pale yellowish, dark, or dark brown 
id of a rounded, oval, or irregular figure ; 
re of great delicacy, and are occupied 
nd grauules, a few of the larger or 
BM Bometimes containing a nucleus with its nucleolus. These appesr- 
n well represented in fig. 58. Pigment cells are not present in all cases, 
lir granules arc occasionally observable in other structures, both healthy 
irfoid, as in the lung pigment and the elements of carcinomatous growths, 
pred^e nature of melanosis is undetermined. I am, however, inclined to 
that it is merely a modification of encepUaloid, the chief difference con- 
io the superadditioQ of black pigment. What corroborates this view is 
Kors partaking of the character of both these formations, occasionally 
, either in the same, or in dilTeretit parts of the body ; and also that they 
■imilar histological elements. 

le cftuses of this deposit nothing is known. It is always effused in a 
orm, and is wholly unurganizable, receiving neither vessels nor nerves; 
these are freely distributed through its librous stroma. It has been sup- 
hat black cancer might he communicated by inoculation, or immediate 

hut experiments upon the inferior animals hove refuted this eonjecture. 

baring remained stationary for an indefinite period, this matter manifests 
jtion to disintegration, the SDftening process generally beginning at some 
al point, and thence gradually cctcnding to the skin, which, giving way, 

the establishment uf a foul, nou-granutating, unhealthy ulcer, which no 
I cure. The discharge is generally of a sanious character, mixed with 
nlored by the hcteroclite sei.retion. Its progress is usually more tardy 
tt of Bcirrhus and encephaloid, except when it exists simultaneously in a 
amber uf organs, as iu the case above described, where it terminated 
a a little over a year. The general health often suffers long before 
re action sets in, the patient becoming thin, haggard, and salluw. 
ig thus described each malignant tumor separately, I shall, in the next 
Ter aome remarks on the origin of this class of atTections, their diagnosis, 
tment 

Ori^n of Carcinoma. — It has been supposed that all malignant dis- 
e occaaionally uf a purely local character, having their origin in cqukcs 
Independent of the general system ; or, what amounts to the same thing, 
f ma,j be developed under the influence of local iiyury. But such an 

it Memi to me, is hardly tenable ; at all erraits, it admiU of great doubt 

sodi ■ iMoh rail; ever follows ndi • mw i ** >lalr ooold not, one 



254 TUMORS, OB MORBID GROWTHS. ohap. tii. 

would suppose, unless there )8 a predisposition, a readiness, as it were, on tiie 
part of the system, to generate cancer cells, or to take on malignant action ; eln 
why is it that extenial violence, as a blow or braise, so seldom gives rise to ibk 
horrible and unmanageable complaint? Why, in other words, is it that a bknr 
will produce cancer in one person and not in another ; or, still farther, why wiD 
one individual suffer and a thousand escape ? 

Cancer of the lip has often been attributed to the irritation prodaced by the 
hot and filthy stem of the earthen pipe in smoking. But it may well be asked 
whether the use of the pipe and the occurrence of this frightful disease should not 
be viewed rather in the light of a coincidence than in that of cause and effectf 
Bo this as it may, it is unqui^stionable that thousands of persons smoke and yet 
never suffer from cancer of the lip. So in regard to many of the other drcom- 
stnncos alleged to be capable of inducing malignant disease, as grief, mentil 
anxiety, loss of rest, unwholesome food, and disorder of the menstrual fonctioB, 
which are so often accused of provoking carcinoma in the mamma and uteroa 
Unlesi^, therefore, a predisposition exists in the system to the development of 
these affections, it admits of groat doubt whether it is possible for any local ini- 
tation to originate them. It is far more probable that they take their rise in the 
blood, Imt how, or in what particular element of this fluid, we are of coam 
totally ignorant. It has l>een asserted that cancer cells have been detected in 
th(i blood, but if this has been the fact it is certain that they were not formed 
there, but that they were simply introduced through the agency of the vcMeb 
during the ])rogrc6s of carcinomatous disease. To arrive at any other condadoB 
would be absurd. 

Can a tumor of an innocent, benign, or non-cancerous character, in its progrefl^ 
become malignant ? in other words, is such a growth capable of what has been 
termed the carcinomatous degeneration ? It secerns to mo that it is not difficult 
to give a correct answer to this question. If the term '^ degeneration" is re- 
stricted to its true and legitimate signification we must reply in the negative, for 
no tumor, whatever be its structure, can, by a mere conversion or transformatioii, 
pass into a malignant condition. Siich a change can be effected only under the 
influence of a vital process, involving the development and actual existence of the 
cancer cell ; and I cannot, for my own part, see any good reason why a new 
growth, tumor, or deposit should be more exempt from such a disease thu i 
primitive, original, or pre-existing tissue, whatever be its structure. Nay, in- 
de(*d, may it not be supposed that the more feebly a part is organized, the more 
])rone will it be to takc^ on such a process ? That this change does sometimei 
occur, mav be inferred from the circumstance that tumors, believed to be eance^ 
ous, but which cannot be positively proved to be so, occasionally remain in • 
state of latency for ten, fifteen, twenty, and even thirty years, and then suddenly 
manifest a malignant and destructive action, generally followed by the worst con- 
sequences. 

It would be of great practical utility if we knew the origin of cancer, or if we 
were acquainted with the causes, local and constitutional, under the influence of 
which malignant diseases, properly so called, are developed. But upon thisnlH 
ject we are, unfortunately, entirely ignorant, nor is it likely that our inqoiriei 
concerning it will lead to a satisfactory solution of a question which has occupied 
so much attention. 

Carcinoma is sometimes hereditary ; not, however, so frequently as ia gene- 
rally supposed. Besides, it should be remembered that there is a difference, and 
that a very wide one, between the transmissibility of this disease from the parent 
to the offspring, and its coexistence, or successive development, in diflTerent mem- 
bers of the same family. The latter occurrence, although also very infrequent, 
is much more common than the former, of which my own experience has supplid 
. me with only a few exam])les. Lately, I saw^ a lady with a well-marked cancer 
of the mammary gland, whose mother and maternal aunt had died of the same 
disease. In the summer of 1850, I prescribed for an aged female with a cancer 
of the lip, whose mother had perish(>d from cancer of the breast, and the fcther 
from cancer of the tongue. But the most remarkable and instructive instance oi 



fHAP. Til. DIAGNOSIS. 255 

this kind, probably, upon record, is that related by Dr. Warren, in his work on 
Tnmors. A man died of cancer of the lip ; his son had a similar disease in the 
brea^st, from which, after having undergone an operation at the age of sixty, he 
finally lost his life. Two of his sisters had cancer of the mammary gland ; they 
were operated upon, bat oltimately died from a relapse of the malady. A 
daughter of one of the ladies had a cancer of the breast, which was removed at 
an early period ; she recovered, but perished some years after from disease of 
the uterus. A daughter of the gentleman had a cancer of the breast, and there 
was reason to believe that other members of the family were affected by the same 
mmlady. 

A case, almost equally remarkable, of this hereditary tendency to cancer, has 
been communicate to me by Dr. J. M. Warren. In this instance, a man who 
died of cancer of the penis, lost his father, grandfather, and great-grandfather 
from the same disease. 

More frequently, as has already been stated, the disease occurs, either simulta- 
■eously or successively, in several members of the same family. My own prac- 
tice has afforded me a number of instances of this kind, and there is not a writer 
on carcinoma that does not narrate examples of it. In one remarkable case, 
four out of six members of one family have died of the disease ; one from cancer 
of the uterus ; another from cancer of the mammary gland ; a third from a malig- 
nant polyp of the nose ; and the fourth from carcinoma of the thoracic viscera. 
Professor Gibson gives an instance of cancer of the breast in fonr sisters. 

Diagnosis. — Epithelial cancer is usually sufficiently easy of recognition. Its 
situation at the junction of the skin and mucous membranes, or upon either of 
these structures ; its origin in a crack, fissure, or wart-like excrescence ; its extra- 
ordinary firmness, the part feeling like a mass of fibro-cartilage ; its slow growth ; 
its small size ; and the absence, for a long time, of severe pain and constitutional 
taint ; are features that cannot be mistaken. 

The only characteristic sign of melanosis is the peculiarity of the color of the 
tumor ; hence, when it is situated superficially, as when it occupies the skin, eye, 
parotid gland, or lymphatic ganglions, it is quite impossible to mistake the nature 
of the disease. 

Colloid tumors are liable to be confounded with fibrous and enchondromatous 
formations ; but a careful consideration of the history of the case, and a thorough 
examination of the morbid mass will generally serve to clear up any doubt that 
Bay arise in regard to the diagnosis. Colloid growths are usually situated in the 
peritoneal cavity, in the ovary, or in the bones ; they are slow in their progress, 
nnooth or rough on the surface, of uniform consistence throughout, and free from 

fiin. their bulk being usually enormous, and the general health greatly disordered. 
ibrous tumors advance slowly, seldom attain a great bulk, and do not usually 
•eriously undermine the constitution. The enchondromatous growth is harder 
and less elastic than the colloid ; its progress is rather rapid, and its outlines are 
alwars well defined, which is seldom the case with alveolar cancer. 

Almost the only disease with which encephaloid is liable to be confounded is 
Bcirrhus, and it will therefore be necessary to point out their differential diagnosis. 
For this purpose I give the subjoined table of the characteristics of the two 
affections. 

B5CBPHAL0ID. I BTIRRHrfl. 

I 

L Tb«tai]ior If »oft and elastic, not uniformly, , 1. Uniformly hard and inehistio, feeling like 
bat mor« so at some points than at others. a marble beneath the skin. 

2. It grows rapidly and soon acquires a large ' 2. Growth is slow, and bulk comparatively 
balk, perhaps ultimately attaining the vol- ' small ; the tumor rarely, even in the worst 
vme of an adult*s heail. > cases, exceeding the volume of a double fint. 

I. Th« pain i^ ittiffht, and erratic, nntil ulcera- 3. The pain begins early, is distinctly local- 
tkm bf^ins, when it Itecomes more severe i ized, and is of a sharp, darting, burning, 
AO'l fixmi. or lancinating character. 

L Th«*n» is always marked enlargement of 4. In scirrlmi* these vessels retain their na- 
ihu sabcutaueooB veins. i tural siie, or are only slightly enlarged. 



256 TUMORS, OR MORBID GROWTHS. chap. vti. 

BXCBPUALOID. | 8C1BBHIT8. 

ft. The nicer ia foul and fnngons, with thin, 5. The ulcer is incrosted with spoiled IjBfib 
undermined, and livid edges, and is sub- | and has steep, abrupt edges, looking aiif 



Jeot to frequent and copious hemorrhage. 



6. There is generally earlj lymphatic involve- 
ment. 

7. Occurs at all periods of life. 

8. Is mo9t frequent in the eye, testicle, mam- 
ma, lymphatic ganglions, bones, skin, and 
cellular tissue. 

9. The disease usually terminates fatally in j 9. Seldom sooner than eighteen monthi 
from nine to twelve months. 1 two years 



it had been scooped out of the part ; bM- 
ing little, and seldom. 

6. Usually not until late, w Just betet d- 
ceratiou is about to occur. 

7. Seldom before the age of forty-five. 

8. Never occurs in the eye and tiwude, nL 
rarely in the bones, skin, and lymphititf 
ganglions. 



It is not improbable that an encephaloid tumor might be confonnded wifh^ 
chronic abscess, or an aneurism, especially when it is so situated as to receive n 
impulse from a neighboring artery. The very mention of the possibility of nd 
an occurrence will be sufficient to put the practitioner upon his guard, and sem 
to point out to him the absolute necessity of the most profound caution in evoj 
case of a suspicious character. 

It has been proposed, in cases of doubt, to solve the difficulty by means of til 
exploring needle, or, rather, of an instrument so constructed as to admit of As 
removal of a portion of the morbid growth just sufficient to answer the purpoKl 
of a microscopic examination. I must confess, however, that I have a greit 
aversion to all such procedures, believing that they generally proTC prejudicial to 
the part, by provoking an increase of the morbid deposit, the puncture, DDkH 
very small, serving as a new centre of action. I have witnessed in at least two 
instances great harm from the operation, and have, therefore, of late years nm- 
formly discountenanced it, except when the tumor is seated in an extremitXi n 
as to admit, if found to be cancerous, of prompt removal by amputation. 

The microscope is certainly not infallible as a means of diagnosis. It is often 
a valuable auxiliary, but nothing more. The practical surgeon must indeed be 
dull who cannot, as a general rule, determine the character of a morbid growth 
before he attempts its removal. The merest tyro in the profession has no diM- 
culty in discriminating between a gelatinoid and a fibrous polyp of the noso, ft 
scirrhous and an encephaloid tumor of the breast, or a common hypertrophied gin- 
glion of the neck and a malignant growth of the same part. Every new growth, 
whether benign or malignant, has its peculiar features, not less than every piv- 
existing one. I believe that, with proper care, and a reasonable knowledge of 
morbid structure, such as every cultivated surgeon ought to possess, it is, ia 
genera], as easy to determine the difference between a malignant and a non- 
malignant tumor as it is to determine the difference between a muscle and ft 
tendon. In making these remarks I have no desire to underrate microscopical 
researches ; on the contrary, I only wish to state that they have not, in my jodf* 
ment, effected all the good that has been claimed for them, especially in tlus 
particular department of pathology and practice, and that, therefore, their resohs 
should be received with some degree of allowance. In fact, the whole sabject 
of morbid growths, benign and malignant, should be revised and re-examined. 
When there is so much dispute as there confessedly is at present respecting the 
real nature of the cancer-cell, or, whether indeed there is such a cell at all, it well 
becomes the practitioner to look with some distnist upon many of the alleged 
discoveries of the microscope. Besides, he should not lose sight of the value of 
his unassisted senses, nor cease to cultivate them in the highest possible degree. 

After a malignant disease has made considerable progress, so as to impreM 
itself upon the constitution, the diagnosis, however obscure it may have been in 
the early stages of the affection, is no longer doubtful. The worn and haggard 
features, the sallow complexion, and the emaciated and exsanguine conditi<m of 
the system, are characters which it is impossible to mistake. The countenaace 
bears the impress of the disease, looking as if had been stamped with the seal 
of malignancy. 



CHAP. Tir 



TREATMENT. 2o7 



TREATMENT. 



The treatment of the yarions forms of malignant growths may very properly 
be discussed under one general head, since they are evidently all governed by the 
same laws, both as it respects their origin, progress, tendency, and termination. 
All internal remedies, of whatever kind and character, have proved nnavailing 
in arresting their march, or in modifying them in such a manner as to render the 
surroanding structures tolerant of their presence. The vaunted specific of the 
empiric, and the enchanted draught of the honest but misguided enthusiast, have 
alike failed in performing a solitary cure ; and the science of the nineteenth cen- 
tury must confess, with shame and confusion, its utter inability to offer even any 
rational suggestions for the relief of this class of affections. But, although this 
is the case, yet it by no means follows that the subjects of these complaints may 
not be benefited by general and local treatment, if its application be directed by 
eommon sense and sound judgment Every practitioner of experience knows 
how much ordinary local diseases are influenced by constitutional measures ; and 
if this be true of these lesions, how much more true must it be of the malignant, 
in the production of which both the solids and fluids play such an important part. 
The attention of the surgeon should be particularly directed to the patient's diet, 
bowels, and secretions, and to the avoidance of all sources of local irritation, cal- 
culated to favor the morbid growth, and hasten the fatal issue. 

The diei should, in general, be of a bland and unirritant character, but at the 
■ame time sufficiently nutritions to preserve a sound condition of the blood, and 
maintain the tone of the muscular system. All condiments, coffee, strong tea, 
pastry, hot bread, and the coarser kinds of vegetables and meats should be ab- 
stained fix>m. Eggs, fish, oysters, and the white kinds of meat may be mode- 
rately used once a day, but not oftcner, unless there is some special reason for it, 
founded upon the state of the general health. Frequently a purely farinaceous 
and milk diet is found to answer better than any other, the patient not only thriving 
under it, but the disease being apparently kept in check by it. 

The boweU should be maintained in a soluble condition, but all active purga- 
tion must be carefully avoided. The most suitable aperient, when a tendency to 
constipation exists, is a blue pill, with one grain of ipccacuonha, or equal parts 
of blue mass and jalap, at bedtime, followed, if necessary, 1)y a Seidlitz powder 
in the morning. If gastro-intestinal irritation arise, the blue mass may be 
advantageously replaced by a small portion of calomel. In this way, while the 
bowels are maintained in a tolerably free state, the secretions are also duly pre- 
•erred ; a matter of no little moment in the treatment of all malignant diseases 
without exception, especially when they are attended with marked constitutional 
disturbance. 

Siifep is procured and pain allayed by anodynes, the constipating effects of 
which are counteracted by the conjoined use of hyoscyamus, ipecacuanha, or tartar 
emetic, in suitable doses. When the suffering is of a neuralgic character, the 
anodynes may be combined with arsenic or arsenic and strychnia. 

If marked debility exists, recourse must be had to tonics, as quinine and iron, 
a nutritious diet and the use of brandy, wine, ale, or porter. Night-sweats are 
best controlled by aromatic sulphuric acid. 

Great care should be taken to keep the affected part perfectly at rest, and free 
from pressure and excitement. If it be the breast or testicle that is diseased, 
tlie organ must be well suspended, the dress worn loose, and all manipulation 
stodionsly abstained from. If the surface is tender, hot, and swollen, or cedema- 
tous. some mildly astringent and anodyne lotion will be of service, or the part 
may be painted several times a day with a weak solution of iodine. When the 
local inflammation is unusually severe, as is evinced by the discoloration and 
pain, nothing, according to my observation, will afford such prompt and decided 
relief as the application of from four to six leeches, unless it be a small blister, 
ke[>t on ontil there is pretty free vesication. Some cases are greatly benefited 
by the use of an opium, belladonna, or cicuta plaster, renewed every ten or twelve 
days. All caustic applications are to be careflilly avoided, inasmuch as they can 

▼ OL. I. — 17 



258 TUMORS, OB MORBID GROWTHS. chip. Tii. 

never tlo any good, but may do a great deal of harm by establishing sores wluch 
it will afterwards be impossible to heal. 

When ulceration arises, the resulting sore must be kept constantly detn bj 
frequent ablutions ; while the excessive fetor which so generally attends mu^ 
be allayed by the free use of the chlorides. The best dressing will be an emol- 
lient poultice, particularly that made of powdered elm bark, sprinkled, if then 
is much pain, with a little morphia, pulverized opium, or laudanum. If the 
ulcer is very sensitive, it should occasionally be touched, very lightly, with the 
solid nitrate of silver, or kept constantly covered with the dilute ointment of 
the nitrate of mercury. When the discharge is very profuse, sanious, and 
offensive, a lotion composed of two to four drops of nitric acid to the ount^c of 
mucilage of gum arabic will ho found exceedingly beneficial in diminishing its 
quantity and changing its character. 

The aifected glands in the neigh l)orhoo<l of the diseased organ often require 
attention, especially when they are very painful and bulky. The remedies should 
be of an anodyne and antiphlogistic character, especially leeches, iodine, and 
saturnine lotions. 

The treatment of carcinomatous diseases by compression was introduced to 
the notice of the profession early in the present century by Sir Charles Bell, and 
after having been alternately eulogized and condemned, has at length fallen into 
merited disrepute. Some years ago Mr. Arnott, of London, made an attempt to 
revive this mode of treatment, especially in cancer of the mammary gland, by 
the invention of a cup-sha])ed apparatus furnished with an elastic air-cushion, in 
order to apply the pressure in a more gentle and etiuablc manner. The sugges- 
tion, emanating from so eminent an authority, attracted much attention at the 
time, and led to numerous trials, both in Europe and in this country, but with 
results so discouraging as to have caused its entire abandonment. 

In regard to extirpation^ all experience hus proved that it cannot be relied 
upon as a means of permanent cure. The only benefit which it can confer is 
temporary r(?lief for a few months, or, at most, for a year or two ; and this is 
true no matter in how masterly and thorough a manner the operation nmy be 
executed. Ilence not a few surgeons of the present day have expressed them- 
selves as altogether averse to such a procedure, believing that it will only serve, 
in tho great majority of instances, to hurry on the case to a fatal crisis. My 
own conviction is that interference with the knife is, as a general rule, only pro- 
ductive of harm, and that the patient will live quite as long without as with it, 
and, on the whole, in a state of greater comfort. Nevertheless, there are cases, 
although it is difficult to define their character, where an operation is occa- 
sionally followed by highly beneficial results, not only ameliorating pain, hat 
apparently preventing an extension of the disease, and relieving the mind of 
the terrible anxiety which is so sure to attend the more severe forms of car- 
cinoma. The cases that have done 1)est in my own hands, after operation, 
were females with scirrhous breasts, which, after having been long in a qaies- 
cent state, at length assumed a threatening ulcerative tendency, or which had 
actually, in a slight degree, yielded to this process. 

Epithelial cancer is less liable to recur after extiri)ation than scirrhus, once|iha- 
loid, or melanosis. Removed in its earlier stages, there is occasionally a strong 
probability that there will be either no relapse at all, or only after a considerable 
period. One reason probably of this is the fact that the disease is commonly 
more localized than the ordinary forms of carcinoma. 

General Rules for conducting Excision of Malignant Diseases. — When exci- 
sion is determined upon, it is a matter of paramount importance that it should 
be performed in the most thorough and complete nmnner, in order that the parts 
nmy be ett'ectually protected from relapse. The slightest atom of the new issne, 
the most minute cancer cell, nay, possibly, the smallest particle of cancer-juice, 
may, if left behind, endanger a reproduction of the malady. 

1st. To accomplish this object, it is necessary that the incisions should be 
carried through the healthy tissues some distance from the morbid deposit. If 
any part has escaped the knife in the first instance, it should be traced out imme- 



Ci&p. Til. TREATMENT. 269 

£ttelT after the extirpation of the main mass, and be excised with the most 
teropuloas exactuesa Free use should be made, in this stage of the operation, 
rftbe sponge and finger; of the former, for clearing away the blood, of the 
litter, for ascertaining the consistence of the surface of the wound. The sight 
akme should nerer be tmsted, inasmuch as it is a great deal more deceptive than 
the Koaid of touch. Not a particle of the least suspicious substance should bo 
left behind. Skin, muscle, glands, vessels, nerves, and bone should all be sacri- 
Ittd, if necessary to the success of the operation. Nay, the very atmosphere of 
tk disease should be destroyed ; and, with this view, the surgeon should always 
iBDore a considerable amount of healthy substance. 

Mlf. The operator should endeavor to preserve as much of the common integ- 
VDent as possible, in order to afford a complete covering to the surface of the 
wound. This rule is one of such great importance that it should never be 
deptrted from. Another precept, of nearly equal consequence, but one which is 
Bot generally sufficiently insisted upon, is to preserve as large a quantity as 
pnetictble of the subcutaneous ccllulo-adipose tissue, with a view of maintaining, 
mimpaired, the circulation of the skin. Whenever this is much interrupted, as 
ft fiece^sarily must 1>e by a very close dissection, there is additional danger of a 
. ipeedy return of the abnormal action, and also greater risk of erysipelas imme- 
dbte^ after the operation. 

3dly. When only a portion of aji organ is involved by the heteromorphous 
Hitter, the rule is to remove, not a part, but the whole of it. Thus, in cancer 
of the mammary gland, the practice invariably is to extirpate the entire organ, 
hoverer small a part may be implicated. When the disease is seated in an 
eztRmity, especially the distal portion, the proper operation is amputation, not 
excision. 

4thly. The utmost care must be taken to guard against hemorrhage, even when 
the patient is tolerably plethoric, especially if the operation is a severe one. 
Lett and fat subjects generally bear the loss of blood badly. A copious hemor- 
rhage, besides seriously endangering adhesive action, is often followed by erysipelas, 
ind I am strongly inclined to believe that it occasionally predisposes to early 
relipse. 

5thly. The whole of the wound left by the operation should, if possible, be 
hetkd by the first intention. For this purpose, the parts should be thoroughly 
•pproximated, not only at their edges, but also over the surface of the wound, 
that there may be no cavities or pouches for the lodgment of matter, but that the 
restorative process may proceed in the most rapid and uniform manner. The 
■ort suitable dressings are a light compress and bandage, aided by long, narrow 
•dhesive strips. Sutures are objectionable, because the tract made by them 
oecasionally serves as a point of departure for new deposits, thereby promoting 
jeiapse. They cannot, however, always be dispensed with, especially when there 
is a scarcity of integument. 

6thly. When the skin is defective, it is sometimes practicable to borrow the 
ftqaisite amount from the surrounding parts; an operation first suggested, I 
Meve, by Martinet, who imagined that we could thereby generally, if not always, 
fffectoally prevent a return of the disease. He thought we might thus change 
^functions of the parts in such a maimer as to restore their healthy nutrition, 
^ so counteract the tendency to the reproduction of cancer. 

I have had recourse to this procedure in a number of instances, in diff'ermt 
ffpona of the IxKly, especially in epithelial cancer of the lips and eyelids ; but 
*o Hone with any permanent or even protracted Ix'nefit. For a time the trans- 
ported parts retained their healthy character; but at the end of a few months 
^l^^y gradually became hard and rigid, and soon thereafter exhibited all the evi- 
^'^Oces of carcinomatous disease. 

. *thly. When a sufficiency of integument cannot be obtained, and the w<)und 
** obliged to heal by the granulating process, it is worthy of consideration whether 
**** whole of the raw surface should not be effectually touched with the nitrate 
^ ^'Irer, or the acid nitrate of mercury, so as to form a superficial eschar. The 
P's^ctice certainly derives support from the beneficial influence which is s«k\d 



260 TUMORS, OR MORBID GROWTHS. giap. fiu 

occasionally to follow the treatment of cancer by cauterization^ so often emplojci 
by empirics, as well as by sdme scientific practitioners. 

Finally, considerable diversity of opinion has existed among surgeons u to 
the time when the operation should be undertaken with the best prospect of ulti- 
mate success. The preponderance of sentiment, however, has always been it 
favor of early interference, on the ground that the longer the disease is permittid 
to remain, the greater, all other things being equal, will be the risk of contami- 
nation. The advocates of this measure, indeed, never countenance a resoft 
to the knife when there is positive evidence that the disease has invaded tbe 
adjacent parts, or the system at large. Some, it is true, employ it with a view 
of prolonging life, or alleviating suffering, but never with the hope of effecting i 
radical cure. 

Treatment after Operation. — The treatment after removal of the affected 
structures must be conducted upon general principles. No effort shoold be 
spared to insure union by the first intention. When the patient has recovered 
from the immediate effects of the operation, he should be put upon a genenl 
course of treatment intended to maintain his health as near as possible at the 
normal standard. Above all, strict and constant attention should be bestowed 
upon the diet. 

Of the propriety and importance of attention to the patient's diet, after exciaioa, 
no one can entertain any doubt. The force of this remark will appear the mow 
evident when it is recollected that the progress of cancer has occasionally beet 
stayed for months and even years, by a regular and persistent system of starvatkM, 
barely allowing a sufficient (quantity of food, of the most bland and unirritaBt 
character, to maintain the due play of the vital functions, without too g^reat % 
reduction of the heart's action. 

The kind of diet is, doubtless, a matter of no little moment Meats, sonpik 
and the coarser varieties of vegetables should generally be proscribed, on accoul 
of their heating and indigestible character. For the same reason, condiment!; 
wine, spirits, coffee, and fermented liquors are to be eschewed. Among the 
more suitable articles may be mentioned stale bread, toast, and soda biscnit, 
hominy, rice, sweet and Irish potatoes, mush, maccaroni, baked apples, figs, and 
ripe fruits. Not only should the food be perfectly simple and easy of digestioa, 
but it should be well masticated, and taken in such quantity at each meal as net 
to crowd and oppress the stomach. As drinks, the best articles are water, milk* 
and weak tea. 

Of late years an almost exclusive milk diet has been used in several remarkable 
cases after this operation, with effects so encouraging as to deserve farther tritL 
The facts published upon this subject by Dr. Pierce, Dr. Bowditch, and sercfal 
others, are exceedingly interesting and instructive, and should receive attentiTi 
consideration. 

As there are no remedies which will eradicate the cancerous poison from the 
system before the operation, so are there none which will prevent its rcprodactloB 
after. Of the numerous articles that have been employed for this purpose there 
is not one that can be viewed in the light of a specific, or as a counteragent to 
the morbid action. 

Some of the older surgeons, and, indeed, quite a number also of the modem, 
strongly insist upon the establishment of a kind of perpetual drain in the neigb- 
borhood of the original disease, as a means of preventing relapse after extirpation. 
The principal measures that have been suggested for this purpose are the issw 
and seton ; modes of treatment with which I have no experience. 

Should relapse ensue, and the patient become debilitated, recourse mast be 
had to supporting measures, as quinine, iron, brandy, and nutritious food, aided 
by gentle exercise in the open air. Pain must be allayed by the free use of 
anodynes, and night-sweats by elixir of vitriol, or oxide of zinc, giv