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LEEDS UNIVERSITY LIBRARY Special Collections
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30106
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599
SERIES
OF
LECTURES
ON THE MOST
APPROVED PRINCIPLES AND PRACTICE
MODERN SURGERY;
PRINCIPALLY DERIVED FROM THE LECTURES DELIVERED
BY ASTLEY COOPER, ESQ. F.R.S. &c. &c. &c.
AT THE . •
UNITED HOSPITALS OF GUY AND ST. THOMAS,
AND IN WHICH WILL BE FOUND
SOME OF THE OPINIONS OF THE MOST CELEBRATED SURGEONS, FROM THE TIME OF HUNTER, TO THE PRESENT MOMENT:
INTERSPERSED WITH NUMEROUS CASES.
BY
CHARLES WILLIAMS JONES.
SECOND EDITION.
BY CHARLES MINGAY SYDER,
SURGEON. —
ItonUon:
PRINTED FOR SAMUEL HIGHLEY, 174, FLEET STREET; AND OTRIDGE AND RACKHAM, 39, STRAND.
TO
ASTLEY COOPER, ESQ. F.R.S.
<$fC. fyc.
SIR,
Much as I regret the appearance of the First Edition of this Work in the Name of “ Charles Williams Jones,” formerly a Pupil of your’s, it i3 particularly gratifying to have this opportunity afforded me, of doing justice to ’your professional exertions", by publicly acknowledging that the original ideas of this Series were derived from your Lectures on Sur- gery, as delivered at the United Hospitals of Guy and St. Thomas.
With the most unfeigned respect for your talents, and the sincerest wish that the Profession may long, very long, possess so valuable a Member,
I HAVE THE HONOUR TO SUBSCRIBE MYSELF,
YOUR MOST OBEDIENT
▲NO
VERY HUMBLE SERVANT,
CHARLES MINGAY SYDER
London, June, 18#1.
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TO THE
STUDENTS ATTENDING THE LECTURES,
IN THIS
METROPOLIS.
GENTLEMEN,
It has been my wish, for the last four years, to see a Work of this description published. It is presented to you in the familiar form of Lectures : and I trust and believe it will be found, to contain as concise and faithful a view of the most improved Prac- tice of Surgery, as any Work extant.
I can only assure you, it has been to me a very arduous undertaking : that it may prove as useful to you as a Guide and Director, as my Friends have had the presumption to anticipate, will be ex- tremely gratifying ; and amply compensate me for the great length of time devoted exclusively to this pursuit.
I am, Gentlemen,
With great respect,
•\
Your very obedient Servant,
THE AUTHOR
London , September , 1818.
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LECTURE I.
I shall commence the series with a few preliminary remarks, which will render more intelligible the subjects hereafter to be discussed. The natural temperature of the blood, circu- lating in the body, is 98 degrees of Fahrenheit’s thermometer ; the pulsations of the heart in a state of health from 60 to 84 degrees in a minute, the medium is 72, which may be con- sidered the natural standard The pulsations, with respect to respiration, may be considered nearly as 4 to 1, or rather 7 pul- sations of the heart to 2 respirations in the adult : in children the pulse is much more frequent, in old age less so ; and the smaller in proportion the animal is, the more frequent is the circulation: in children the pulse is very quick*. In the brute creation, as for instance, the horse, we cannot distinguish above 32 or 37 in a minute; in the dog 130. The pulse becomes much accelerated in fevers, from 72 it has risen to 120, 130, 150 and even 160 in a minute, even so quick that it could not be ascertained, and beyond 200 it would be impossible to count it;
* According to Heberdenand Blumenbach, in infants at birth, the pulse is 140 ; first year 124 ; second 110; third and fourth 96 ; seventh 86; at puberty 80 ; manhood, or 21 years old 75 ; sixty years of age 60.
2
LECTURE I.
the lowest pulse ever known was from 18 or 14 to 28 pulsations, observed by Dr. Cholmley and Mr. Stocker. There are many variations in the pulse denoting the state of the circulation; the action of the heart may be diminished, increased, or changed ; as a stronger or weaker pulse than natural, a contracted one, a harder or softer, and sometimes irregular or intermittent. A temperature from 60° to 64” admits with ease and safety every exertion necessary either to our subsistence or pleasure, hence it may be termed temperate. The higher degrees up to 70° are called rearm, and all above that hot. In the inferior range a few degrees below' 60° is termed cool, and all below, cold.
The arteries are divided into three orders, the sanguineous, seriferous, and lymphatics, each set conveying the different de- scription of fluids from whence their names are taken: from the minuteness of the vessels this cannot easily be demonstrated, although it is so evident to our senses, as we find parts of the body that only transmit lymph. This is found to be the case in the minute ramifications of arteries called exhalants, and from which that transparent fluid lubricating the cavity of the thorax, abdo- men, &c.is derived, and also the insensible perspiration.
The blood is an uniform homogeneous fluid ; in three or four minutes after it escapes it begins to coagulate, and a spontane- ous separation takes place, into serum and crassamentum.
The crassamentum is found again to be composed of red particles and coagulable lymph, and this can be very easily demonstrated. —
The lymph is of a size-like appearance, and becomes evident from the red particles subsiding from it.
The blood is then composed of 3 parts, serum, the lightest, coagulable lymph, or fibrin, next, and the cr’uror, qt red par- ticles, which are the heaviest of all. ^Professor Blumenbach -^calculates that the quantity of blood in the body is about 120 ounces troy; and allowing his assumption to be correct, that two ounces is expelled from the left ventricle at each con- traction, and the pulsations 75 in a minute, it follows that 12|lbs. of blood will circulate through the heart every minute, being I more than the w'hole quantity contained in the body, and the whole of the blood thus passes through the
lecture I.
3
heart 75 times in each hour. The system is soon affected when a vessel or orifice is large, and the animal expires from sudden exhaustion; while, if blood were drawn from a small vessel or orifice, the vessels would be able to accommo- date themselves gradually to the loss, and we see in bleeding at the nose, the piles, &c. the blood escapes for days successively, and the quantity lost will be extremely great, and this with- out danger, while the same quantity drawn suddenly from a large vessel or orifice w'ould prove fatal. Mr. Boyle found the specific gravity of blood to water to be as 1041 to 1000, that is, rather less than one-twentieth heavier than water : Dr. Jurin 1054 to 1000, being rather more. Water at 32° is con- gealed into ice; even quicksilver becomes solid at a certain tem- perature.
The blood coagulates without diminution of tempera- ture ; if received into a vessel at 96° or 98° equal to its heat, it coagulates equally quick ; at 40° it does so later than at 9S° ; at 100° sooner than at 40°; if stirred continually, it still does so as well. Rest or air was thought to be the cause; but it coagulates when not exposed to either. Mr. Hewson laid the jugular vein of a rabbit bare, and applied two ligatures, at some distance between which a quantity of blood was included: it was left alone 2| hours, when, on examination, only -§- of the fluid was coagulated. It coagulates when in a bladder or gold-beater’s skin. Rest does not produce it ; air facilitates it. Eight minutes is commonly the time it takes to coagulate : — What a wise provision of nature ! When blood escapes in violent hemorrhages, the mouths of the vessels become plugged up by the coagulation, and the bleeding prevented ; hence in uterine hemorrhage, or indeed, in any other kind of excessive bleeding, nothing can be more favour- able than syncope or fainting, which facilitates, or rather gives an opportunity for this formation. By no means permit or use stimuli in any shape in these cases, as they occasion in- creased action, which would remove the coagula from the mouths of the bleeding vessels, and the hemorrhage would be renew- ed ; rather let your patient be kept cool, and perfectly quiet. Common and neutral salts prevent its speedy coagulation. Coagula are found in many parts of the body ; in aneurismal
B 2
4r
LECTURE I.
tumours coagulable lymph is effused in large quantities, and this appears to be gradually forming strata, having a lamellated ap- pearance, resembling the layers of an onion. I shall enter more fully on the nature aud properties of coagulable lymph as I proceed in the series: it will be here only necessary further to observe, that it is abundantly deposited under inflammation, and when there is no outlet it becomes organized, and occasionally it is seen to unite the pericardium to the heart, the pleura to the lungs, &c. ; and where there is an outlet it peels off as in the bronchia, and is coughed up, when persons suppose they have brought up part of the lungs. The late Dr. Cheston, of Gloucester, had a fine specimen of it. In dysentery and in- flammation of the urinary bladder, such large portions have come away as would very much surprise an ignorant spectator.
The sizy buffy coat in inflammation of an important organ seems to proceed from the action of the vessels themselves, ac- cording to Mr. Hewson : they perform their office with great force, and the appearance is to be attributed to this strong action, as in pneumonia, &c. This is observable in pregnant women, and as nourishment is to be provided for the foetus, it only in- dicates increased action, not disease. In proportion as the animal is'Strong, so is coagulation slow, while in the weak and faint, as we see in patients greatly reduced, previous to amputation, it coagulates while on the stump immediately after the operation r so, when the blood is sizy, it does not coagulate so soon ; it takes half an hour, and sometimes 2, 4, 6, and even 24 hours before this happens, when great inflammation exists : this has been seen in acute rheumatism. Suppose in pneumonia I take 16 ouuces of blood away in 4 cups ; in the first the blood will be very sizy, in the second and third not much so, and in the fourth not at all. Again, if you draw blood in another person to the same quantity in a similar way, in the first there shall be no size or buffy coat, the second and third shall be very sizy, and the fourth shall be as the first. Some people have great fear of having this simple operation performed, and fear produces a diminution in the action of the heart; hence the latter is to be attributed to this cause; first, when the puncture is made, and at last when the circulation becomes weak. A gentleman had
LECTURE J.
5
an affection of the chest, and blood-letting being the only relief, he was bled so often as hardly to tinge or stain a white cloth ; it is therefore apparent the red particles are slower in being formed than the other component parts of the blood, and also that they do not circulate in the minute parts of the body.
i shall digress a little on the effects of stimuli and seda- tives. Whatever increases the strength and frequency of action has been called a stimulus ; whatever diminishes it, a se- dative. A stimulus increases the momentum of the pulse; a sedative diminishes it: whatever would alter the pulse to hard or intermittent, may be called an irritant.
Stimulants are said to be either common or specific; com- mon are what increase every part of the circulation, as wine, &c., but the greater number are specific, that is, they have a peculiar effect on some particular part; such a stimulus is seen in mercury, in squills, and in cantharides; so also in purgative medicines, as aloes, &c. &c. Some medicines stimulate the arteries alone, and some the absorbents, and those that produce this effect on the latter generally have a contrary one on the former, as digitalis. Arsenic was injected into the jugular vein of a dog, which died in twenty minutes from inflam- mation of the stomach; so also of muriate of mercury, as wKl be detailed when treating of poisons.
The effect of stimuli depends on the constitution; hence the immense variety in different applications of medicines. All -stimulants are found to lose their effect by repetition ; this is illustrated by wine and opium. The utmost stimulating effect of opium is to raise the pulse 15 strokes in a minute, that of wine 50, and this without an adequate sedative effect, whereas the sedative operation of opium is considerable.
Sedatives-: these diminish the force and frequency of action; some obviously in the first instance act as a stimulus, as opium ; the sedative effects of this and wine bear no proportion ; the operation of some sedatives is a direct effect on the nerves ; this is demonstrated by injections of opium to the heart or brain; the same of belladonna to the eye; one grain applied, causes such a dilatation of the iris, as totally to disappear ; so of lead applied to the muscles, of the eye, one or a few grains
6
LECTURE t.
applied causes paralysis; it has no stimulant effect; neither has digitalis.
The effects of heat on the body are universally stimulant. The natural temperature of the blood, as 1 have previously observed, is 98° of Fahrenheit’s thermometer in the human body. A person was put into a vapour bath, heated to 202°, it raised the pulse to 120. In another, whose pulse was 75, it rose to 164. A third person’s pulse, exposed to the same degree of heat, rose only to 145. Dr. Fordyce went into a vapour bath of 120° ; his pulse rose to 145 : going into a dry heat of 254°, he supported it much better. The effect of heat in a warm climate produces quicker growth, and premature old age; the inhabitants arrive at puberty at 11 and 12, and seldom live to 60. In more temperate climates, this does not happen till from 18 to 21, and life is prolonged from 70 to even an hundred years and upwards. The effect of heat on the pulse is to produce a quicker and fuller action ; the ex- ternal veins dilate, and are seen apparently distended in the warm bath, which always produces perspiration, and is a geueral stimulus ; it has great power in exciting the absorbent vessels, and in weakening the body. In twenty minutes this powrer extends to the production of syncope : in jive minutes it only- increases the general tone of the vessels. The hot bath, from 105 to 110 degrees, is productive of uncommon benefit in some scrophulous cases. Violent heat causes blisters to arise ; a more violent still, excoriation and detachment of the cuticle ; still greater, death of the part and mortification : and of these three stages of burns, the second is the most dangerous, as I shall explain hereafter, on burns and scalds.
The patient dies of excessive irritation when the cuticle is removed extensively, in a few hours. Heat when applied to the body, generally with moisture, as in a poultice, relieves, by exciting perspiration of the part, and unloading the capillary vessels ; with the same view, fomentations are used : and to excite the absorbent vessels, dry heat by friction or otherwise, tends to the same effect.
Of Cold : its effects are very interesting; though it does diminish, yet sometimes it increases the action of the heat.
LECTURE I.
7
Of its sedative effects: I made this experiment while in Edinburgh, which had been done often before; my pulse being 8,5, J exposed myself to 18 degrees of Fahrenheit’s ; my pulse became in one hour 76, in two hours 65, then followed sleepi- ness ; its ultimate effect is a sleep, and more remotely, death. In this circumstance, the body is robbed of its heat faster than the organs of respiration can supply it, and when the heat be- comes lost, the circulation ceases. Cold, when partially or particularly applied, causes a difference in the heat^ the ears and nose, from excessive cold, mortify and drop off, as was very fatally exemplified in Napoleon’s campaign at Moscow. The living part of the body may be frozen, and yet restored to life, as has been proved by experiments made on frogs ; being completely frozen during a severe winter, they w-ere put on a table before a fire : on the return of warmth, their sensibility returned; they soon began to move, and presently one jumped off. In a case of strangulated hernia, Mr. Cline and Mr. Sharpe applied powdered ice for upwards of forty hours ; the consequence was, the part was frozen white and hard, heat restored life to the part, but being too suddenly applied, ulti- mately caused sloughing. Though cold in general diminishes the frequency of the pulse, yet if applied suddenly, it increases it. A man having a pulse of 80, by plunging into the cold bath, it rose to 120; another person by doing the same, whose pulse was 90, had it raised to 135. I have repealed the experiment, that of trying the effect of a partial application of cold, by plunging my arm in snow; my pulse, from beating slowly, be- came very quick. By the addition of ice to water, lowering it to 33 degrees, my pulse being 81, was raised to 121 ; at another time, being 87 to 139- It seems to me to depend on the suddenness of the plunge and the irritability of the person; as this effect ol cold is irritating, the pulse, though increased, is a contracted one, and thready. I am not aware that the tonic effects of cold have ever been satisfactorily explained. A de- bilitated person shall have a quick pulse but weak, with heat too on the skin ; the effect of cold is to bring down the pulse to its natural standard, and take off the excessive heat ; and it is in this way the cold bath does good in weakly habits, .and in
s
LECTURE I.
typhoid patients. It produces a slower and fuller pulse; it does not agree with a plethoric habit, as it causes head-ache, from a determination of blood to the brain. Ice is used as an external application in hernia, and has been strongly recom- mended by Sir James Earle in burns with the best effect; but I must refer you to the subject itself : do not use it if the cuticle be removed ; it has been most strongly objected to. Artificial ice may be made with equal parts of nitre and sal ammoniac mixed. Cold is applied occasionally by means of evaporation ; aether is the best to a warm surface, and has relieved in a few hours, as on the temples in severe attacks of the head-ache, &c. Cold applications are had recourse to for removing inflammation, in some cases with good effect. The liquor, acet. plumb, dil. c. spir. viu. rec. is an excellent applica- tion ; it has this double effect, that of cold, and the sedative effect of the lead ; and is very effectual in removing inflamma- tion : few clothes should be put over inflamed limbs. That cold poultices retard the formation of matter, and warm en- courage it, must be considered only ideal ; heat is so quickly imparled from the body, that unless it is repeated every ten minutes, nearly the same effect is produced from both.
It is deemed expedient that a short digression on Constitu- tional Irritation should still precede the subject of Inflamma- tion, which most authors have immediately commenced their works with.
Irritation is a subject on the knowledge and compre- hension of which our surgical treatment will depend y by it is meant an unnatural stimulus. If a stimulus be natural to the body, as in taking food, the irritation is confined to one part. Irritation may be either considered local or general; the effects are produced by the nervous influence, as when a nerve is wounded, it communicates the injury to remote parts.
' There is an universal connexion of one part of the body with another, but more particularly so in some parts than in others ; and this is denominated sympathy ,y by which is meant one part being affected in consequence of injury done to another at a distance from it; although sufficiently obvious, yet this prin- ciple is doubted by some. It must happen by the general
LECTURE T.
9
communication of the nervous agency ; the most common and natural is the sympathy of the uterus and breasts. Coughing is an act of sympathy, the effect of irritation in the larynx; sneezing is an act of the same kind. Other instances might be adduced ; but my object now will be to treat of diseased sym- pathy, which is of two kinds.
The one is called the sensation ; the other is termed the action of the part Examples of the Jirst kind: When an obtuse pain is felt in the loins, from a diseased testicle. In inflammation or disease of the hip joint, pain is felt through the whole course of the sciatic nerve, from the knee to the foot; and this often proves a source of mistake to the surgeon, when consulted by a person who complains of pain in the knee. The leg should be examined up to the hip joint, to ascertain if it pro- ceed from sympathy. The length of the limb is apparently increased. A stone in the bladder causes pain in the extremity of the penis. A disease of the prostate gland, causes pain at the basis of the sacrum, and not unfrequently in both thighs. A disease of the stomach will produce pain in the left shoulder. A disease of the liver a sympathetic affection in the right shoulder. A diseased testicle pain in the loins. An affection of the mesenteric glands of the rectum produces an itching at the nose. Examples of the second kind , or sympathetic diseased action. Diseases in the urethra very frequently produce in- flammation of the testicles, sometimes of one, at other times of both.
The glands in the groin are often affected with sympathetic bubo, in consequence of gonorrhoeal inflammation, which disappears as soon as the cause subsides or is removed. Hiccup and convulsive action oi the diaphragm is a symptom of a mor- tification. But of all organs to which these effects are produced, none are more frequently affected than the stomach. For in- stance, if a blow be received on the head, causing injury to the brain, vomiting is the first and almost constant symptom. V omiling is produced when the testes are injured, or the intestines . hurt, wounded, or strangulated ; if will often arise from the mere introduction of a bougie, when it is attended with faint- ness ; or from a gall stone passing the biliary duct; or calculi
10
LECTURE I.
passing through the ureters into the urinary bladder, 8cc. An obtuse pain in any part may occasion vomiting; but an injury to the stomach itself will be attended with fatal effects. A man walking through Fleet-street quarrelled with a woman ; another female came up, and gave him a blow on the region of the stomach, which caused almost instantaneous death. Upon dissection, to trace the cause of his expiring so suddenly, no disease could be perceived. A man belonging to the India House, while lifting a weight, which he was almost incapable of doing, was accidentally struck by another while in the act of extension, and he fell down; no life was perceived in him, and attempts to restore animation were ineffectual ; on being opened, there was hardly any appearance deviating from the natural, except a small part opposite to where he received the blow, which appeared red. When the stomach receives a blow suddenly, the diaphragm becomes incapable of respiration ; and when inspiration is thus impeded, nature cannot perforin her functions, and death is the result. Some substances intro- duced into the stomach, such as oysters, muscles, &c. will by a sympathy between it and the skin, produce eruptions on the skin. It is by irritation, that corrosive sublimate and arsenic cause effects on the stomach which cure cutaneous affections. Fainting is caused by local irritation, respiration being for the moment suspended. A violent shivering once or twice in twenty-four hours, is often the result of a stricture in the urethra, and is best relieved by opium. Shivering is also caused by the formation of matter, and occasionally by the introduction of a bougie. Paralysis of the lower extremities sometimes occurs in children from irritation in the bowels, and it sometimes pro- ceeds from teething, which will also occasion in them convul- sions. A rash may be brought out on the skin by teething, and by costiveness, in apparently healthy children. A sup- pression of urine has followed the amputation of a limb ; and the practitioner is sometimes obliged to desist in the extir- pation of the female breast, from the sickness caused by it. Scalds, burns, &c. though occasioning slight local injury, are frequently followed by bad effects. Compound fractures also are often attended with but slight local effects ; but in the morning 2
LECTURE I.
11
succeeding die accident, great constitutional injury will be evinced, which has been known to mislead the physician, who conceived them to be typhoid. Irritation in the stomach is followed by loss of appetite, vomiting, &c.; the bow’els being at first costive, but generally concluding with diarrhoea; the secre- tion of bile is lessened, consequently the faices are of a bad un- healthy colour. Vegetable poisons, such as tobacco, introduced into the intestines, produce great relaxation, debility, syncope, &c. Pressure on the brain will stop the motion of the heart to a great degree; but on the cause being removed, it again re-acts. The symptoms of constitutional irritation are pains in the head, back, and loins; the pulse being quick, hard, and generally full, next contracted and thready: when the irri- tation is great, irregular, and often intermittent, tongue fur- red ; if the irritation be slight, white ; if considerable, yellow' ; if so great as to terminate in mortification, brown, the stomach rejecting its contents, bowels costive, urine high coloured, and when the irritation is ceasing, it deposits a sediment. The effect on the skin is generally cold chills, succeeded by heat and profuse sweating: if slight, once in twenty-four hours; if great, twice, and so on. The symptoms produced by contused wounds, from their effects causing considerable irritation, are often mistaken for fever. The first effects of the accident are pain in the head, back, and loins, tongue white and furred; afterwards brown, and in proportion to its quick- ness in becoming brown, the violence of the irritation is to be estimated ; the mouth dry, appetite lost, and sometimes sick- ness ensues ; costiveness, which if the irritation be of any con- tinuance, changes into purging ; pulse preternaturally hard, though not full ; the arteries not dilating ; when the irritation becomes more violent, the pulse becomes irregular and inter- rupted, (intermission of pulse in old people not to be considered dangerous of itself, without other concurring symptoms) and sometimes there is a sensation of jerking; respiration quick and laborious; urine discharged in small quantity and highly co- loured; the skin dry, and the patient restless; delirium and siibsultus tendinum often succeed.
The degree of irritation depends on four principal circum-
12
LECTURE I.
stances: on the size of the wound; on the part injured; on the ease with which it can be restored ; and on the constitution of the patient.
The violence of the symptoms in a great measure depends (when the parts are not vitally important) on the irritability or susceptibility of the constitution, and as the latter will be able to resist the influence of irritation, so will it be regulated, for a slight injury occasions violent effects in some persons, while in others thev are trifling.
Case. A man who lived intemperately, was bled by the late Mr. Saunders, two days after he was taken ill ; on the 5th the arm was inflamed above and below the elbow, and pus was discharged from the wound; his pulse was 120, with delirium. Opium was used both internally and externally, combined with other medicines ; on the 6th day his pulse was. 110; on the 7th he was purged, and Ins delirium became less violent; a poultice of bread and water was applied to the arm with opium; the 8th day the pulse was 120, the edges of the wound covered with a brown substance, and having a fleshy feel ; the arm dis- charged a bloody serum; and on the 9th, notwithstanding every assistance that art could devise, he died. On dissection, the skin was found mortified round the arm, the cellular mem- brane inflamed and suppurated, but the vein which had been opened was uninjured.
Case. An instance contrary to this, of considerable injury without fatal effects, was seen in the person of a brewer’s ser- vant, who w-as run over by a dray ; his elbow joint was opened, the bones fractured, and the artery separated from the bone. As he would not consent to an operation, although strongly advised to do so, the wound was closed, it soon healed, and he recovered.
To relieve constitutional irritation, when excessive, or arising from the injury of any vital organ: 1st, take away blood, in proportion to the strength and plethoric disposition of your patient.
2dly. Restore the secretions of the liver, kidnies, skin, and intestines.
In children give calomel and autimonials, for nineteen dis-
TjECTURE I.
13
eases in twenty in them are inflammatory, and this is the best
medicine to restore perspiration, 8cc.; bathe the feet in warm water : by these means you take off the momentum of the blood, and give a healthy action to the secreting organs.
[n adults, it will be better to give calomel at night and sa- line purges the following morning.
Sdly. Lessen the nervous irritability by opium, combined
with some sudorific.
And, 4thly, Guide your patient’s diet and regimen.
The influence of some passions of the mind, as grief, anger, fear,&c. are evident to us all ; and their influence, on diseases, being increased, must be observed with peculiar care and attention by the practitioner. Their effects are almost incre- dible. Grief disturbs the stomach, and is a depressing passion : it lowers the pulse, and particularly affects those organs whose actions are languid, such as the liver, frequently producing in it obstructions and disease. Anger has an irritating effect, quickens the pulse, but renders it thready: it retards the cure of disease in general, of inflammation in particular, rendering ulcers ill-conditioned and sloughy. Fear augments the quantity of urine, and has the most extraordinary effect of all ; from it diseases, not otherwise attended with immediate danger, prove fatal. Instances of this might be enumerated in fractures of the leg, cancers of the breast, stone in the bladder, in which patients have died from excess of fear alone; it is a most de- pressing passion, and lowers the pulse till it altogether ceases. The passions being a part of the mind, and of the animal func- tions, powerfully affect the organic or vital functions under disease.
LECTURE II.
ON INFLAMMATION.
When inflammation occurs externally, it is denoted by four marks or signs ; these are reduess on the part, pain, swelling, and increased heat. It is defined by Mr. Hunter to be a process occasioning, in a given time, and from one immediate cause, the following local effects, viz. pain, swelling, and redness.
The redness is owing to a great quantity of the red globules being determined to the part, and distending the vessels which before admitted only the transparent particles. This is often remarkable in the tunica conjunctiva of the eye.
The swelling in a tumour, proceeds from the dilatation of the vessels from the effusion of coagulable lymph into the in- terstices of the cellular substance.
The cause of pain is supposed to arise from the distention of the blood vessels of the nerves, and thus making pressure on them. A part inflamed is infinitely more susceptible of pain than the same part when in a state of health. An encysted tumour has been removed from a lady with scarcely any pain being expressed, while the mere opening of an abscess, where the integuments were inflamed, has caused apparent tortures ; therefore it would at all times be desirable in amputation to cut, if possible, above all inflammation, for if a cut be made into an inflamed part, independent of the excruciating pain given, the stump will scarcely ever do so well.
LECTURE II.
15
This is remarkable in hydrocele; when uninflamed, the injec- tion produces a slight adhesive inflammation ; but if it were pre- viously inflamed, the case would be altered; and if precisely the same injection were made use of, the inflammation would ex- tend to the suppurative process.
The heat of inflamed parts has been and remains a matter of question. Hunter denied the existence of it, and made several experiments to support his arguments. He introduced a thermometer into the rectum of a dog, and found it stood at 101 ; he then injected a solution of muriate of mercury, by which a violent inflammation was produced; on applying the thermometer, there was no increase of heat.
He likewise introduced it into the vagina of an ass: it was then 100; on producing inflammation, it fell to 99; after a short time it rose again to 100, but there was not any further increase.
These experiments, however ingenious they may be thought, are by no means satisfactory. On the surface of the body increased heat is found to arise from inflammation : a blister raises the thermometer to 94, while the parts around are only 90.
That increased heat really exists externally is now univer- sally admitted: Hunter has allowed that the temporary
enlargement of the diameters of vessels always happens, when- ever there is any process going on requiring an extraordinary supply of blood. He also states that the colouring matter of the blood, the red particles, is its heaviest part, and does even acquire an increase in bulk in inflammation. Now in inflam- mation, the vessels of the part are certainly enlarged, they allow the red particles to circulate through them, which before in a natural and healthy state, contained only the transparent ; this combined with the increased velocity of the circulation, will be sufficient to account reasonably for the excess of animal heat by the greater portion of caloric which is given oft', causing the variation in the temperature, and hence it approximates nearer to the heat of the blood, according to the extent and violence of the inflammation.
Inflammation has four results or terminations :
1(5
LECTURE II.
1st. Adhesion, from coagulable lymph being thrown out in the cells, and the parts becoming glued together, or incasing the extraneous substance, which was the original source of mischief, and all the symptoms existing gradually disappear- ing. This process, or stage, by some is termed adhesive in- flammation, by others, resolution, and is the most favourable of each.
2dly. Suppuration, or a secretion of matter in the centre : from the continuance of the inflammation, the action of the blood vessels becomes changed, and pus is formed.
3dly. Ulceration, which eventually, by continued pressure, excites absorption of the surrounding parts, thereby allow- ing the escape of the extraneous body; this is termed ulcera- tive or absorbent inflammation.
4thly. Mortification or gangrene, in which process the parts losing their vitality become dead, and separate from the living, by the suppurative process taking place for their removal.
Inflammation produces different effects in different parts of the body. In the skin it generally extends a considerable way ; besides the cuticle is raised, as in blisters, containing under- neath serum, and very seldom producing pus; this is called the Erysipelatous Inflammation. In this affection there is generally constitutional irritation, subsequent to its origin, accompanied by shivering, acceleration of the pulse, depression of spirits, prostration of strength, &c. &c. According to Mr. Hunter, this is a cutaneous inflammation, which now and then spreads over a considerable extent of surface very rapidly, without extending generally to the cellular membrane under- neath.
It differs from local or common inflammation, which is of a deep red, by being of a scarlet colour, tinged with yellow, being also more diffused, and not so elevated or circumscribed, dis- appearing in one situation and attacking another, the colour of the cuticle having a glossy smooth appearance ; it is accom- panied with a burning itching pain in the part; frequently ending in resolution, but seldom in suppuration.
Inflammation of the arteries also is very extensive, even
LECTURE IT.
17
going to the heart itself. This has been frequently ob- served in patients who have died from constitutional irritation, after an operation, where a ligature has been made on an artery.
Case. A man in St. Thomas’s Hospital, after the operation before mentioned, had a violent inflammation in the artery, which ran on to suppuration. The symptoms attending it were, first, a sense of cold, with rigidity of the joints similar to rheumatism; delirium came on; pulse 130. After death, the inflammation was discovered running along the internal coat of the artery as far as the heart itself. The cure in such cases must consist in venesection and other evacuating remedies. The inflammation is always found to be in the inner coat only.
In the veins its progress is slower than in the arteries ; and when it reaches the valves, these generally adhere, and glueing the sides of the veins together, often prevent any further ex- tension of the mischief ; but if this fortunate result be not effected, abscesses form in the veins from the continuance of the inflammation, and pus mixed with blood has been seen in the heart.
In the absorbents inflammation may be distinguished by red lines under the skin, feeling like cords, and frequently termi- nating at the first absorbent gland.
Inflammation of the membranes of large cavities is very ex- tensive, beginning at a point and rapidly spreading, and if recoveries take place it is from adhesion ; as the pleura to the lungs, the pericardium to the heart, and the peritoneum to the intestines, &c. 8tc.
In inflammation of the bones, the pain is obtuse and scarcely to be borne, the constitution suffering more irritation than from the most acute pain.
Case. A woman had her leg amputated below the knee ; an inflammation took place in the bone, which caused such an excess of the most excruciating pain, as induced her to submit readily to a second amputation above the knee for Us removal. When it continues in bones, its effects are ex-
c
18
LECTURE II.
ostosis, in consequence of cartilaginous and bony matter being effused.
In the muscles it produces spasms, as in fractures ; the pa- tients are restless for two or three nights, from the effects caused in the inflamed muscles.
Tendons, when inflamed, slough to a great extent, and the reason of this seems to be, the weaker part or action of the living powers in them being diminished; thus, if an abscess form in the finger, and the tendon becomes exposed, it will slough through the whole extent of the abscess.
The nerves are very rarely inflamed ; when it happens, the pain is constant and violently severe, increased on the least motion, and may be known by the tremor of the muscles be- low it.
Inflammation in glands, if general, stops their functions, but if partial their functions continue. In the affection of the liver no bile is secreted.
In the viscera it affects their different functions ; thus, in the stomach, there is a violent pain and vomiting, constipation, tremor, and ultimately hiccup. In inflammation of the viscera, the pulse is generally quick and small ; this has deterred many surgeons from venesection in these complaints ; but without it, in my opinion, there will be but a very little chance of saving the patient’s life; but it must not be done sparingly, unless in very feeble and debilitated habits ; we generally find the pulse rise in proportion to the extent of the bleeding.
We should likewise make use of local applications ; such as cupping, leeches, blisters, &c. The warm bath is highly use- ful also.
In inflammation of the lungs, there is great difficulty in breathing, pain in the side and head, pulse slow, labouring, and full. On dissection, we generally observe the cellular sub- stance distended with grumous blood, and a serous fluid and coagulable lymph in the cavity of the thorax.
In inflammation of the heart, the pulse is peculiar, feeling double its natural diameter, and very hard ; if it be on the in- ternal surface of the pericardium, the pulse is fluttering.
LECTURE II.
19
In inflammation of the brain, there is great pain in the head, redness of the eyes, delirium, pulse full and hard, and an ex- traordinary pulsation observable in the carotid arteries, which you should always take notice of. Here arteriotomy, or open- ing the jugular vein, gives relief sooner than bleeding in the arm.
f
e £
O'
20
LECTURE III.
INFLAMMATION CONTINUED.
Inflammation is divided into two kinds, the common and the specific.
By the first is meant that before described, as regularly pro- ducing adhesion, &c. &c.
In the specific the action of the vessels is peculiarly changed, and the effects different.
In the common kind, the action is only increased.
In the specific, it is changed.
The common , is called the healthy inflammation, being the means which nature makes use of for the restoration of lost parts. As for example, an artery is divided ; here, without in- flammation, death must inevitably ensue : ligatures might be applied, but these would be thrown off and separated in from 10 to 14 days ; but when this happens, nature makes the neces- sary provision, inflammation ensues, the internal coats of the vessel throw out or deposit coagulable lymph, and its sides be- come glued together and the same effect takes place in every part of the body.
LECTURE III.
*21
5f the constitution be bad, the inflammation is slow, and it is called chronic: thus, when the coats of the eye are divided in the operation for cataract, if healthy, the wound unites in two or three days ; if unhealthy, it frequently runs on for a month, or many weeks, being kept up by local and general debility, and the habit of body of the patient.
Specific inflammation is of two lands :
The first arises from the peculiarity of the constitution, by the simple change of the action of vessels.
The second, is from the effects of poison.
Of the first kind is gout, which is an inflammatory action in the joints and tendons, and an earthy or chalky matter is se- creted. This depends on the peculiarity of the person’s con- stitution, which causes that particular and peculiar action of the vessels, which in common inflammation would produce pus. Cancer is another of a similar kind, produce^, owing to some peculiarity in the constitution which we are ignorant of, and is generally most frequent about the cessation of the menses in women. A blow, however, may so disorganize the structure of parts, as to produce it in some constitutions, which shows that it does not depend upon any specific poison, but is the result of a peculiar action, throwing out a cartilaginous sub- stance, instead of coagulable lymph, and sometimes a por- tion of earthy matter in it : it likewise exists often in the uterus. Fungus hematodes is also the effect of a peculiar action of the vessels; it begins by a small blue tumour, which after a short time bursts, and a soft fungus grows rapidly, the lymph effused is soft and pulpy, and the vessels shooting into it grow luxuriantly, having no resistance opposed to them ; but cancer grows slowly, the substance effused being hard, and with difficulty penetrable.
Specific inflammation, as the result of poison, is by no means unfrequent; as the venereal, small-pox, cow-pock, rubeola, scarlatina, and hooping-cough: the matter produced in these is of a specific kind, and capable of communicating a similar disease. Thus, in chancre, the ulcerative process is pe- culiar, true pus being rarely if ever secreted ; it is a thiu acrid
22
LECTURE III.
sanious fluid : indeed, when true pus is discharged, it is a mark that the disease is overcome, and the part is returning to a healthy and natural state. The edges of a chancre are very different from those of a common wound, being thicker and particularly jagged, and easily distinguished at first sight ; in this case, the process of inflammation is not performed.
Scrophulous inflammation comes nearest to the common ; but in this case the ulcerative process is slow, and the matter composed of curds and serum, with the edges of the wound turned to each other. It is generally the result of an original debility, and thinness of the coats of the arteries and ab- sorbents*
We must attend carefully to the varieties of inflammation, and thus vary the remedies, and study to endeavour to allay the predisposing causes, &c.
When inflammation is spontaneous (if ever so) it is the effect of a singular or peculiar weakness, and if once set up extends rapidly. We are, however, to distinguish carefully between the various kinds of debility.
There is one species which arises from stimuli, as any con- siderable evacuations, and these are the very subjects we would choose to perform operations on.
There is another species of debility, arising in consequence of excess of excitement, that is, broken down by intemperance; these last will never do well under operations, and most gene- rally die, either from compound fractures or other causes.
In debility arising from fevers, the parts of the body pressed upon inflame and slough occasionally to a great extent. Blis- ters have been seen often, in cases ot scarlatina and measles, to extend to gangrene : and in children, the same effects are produced now and then from excoriation, arising from their urine. When the parts become gangrenous, calomel and lime water, forming the black wash, is a very beneficial application, exhibiting Penman bark internally, and allowing a generous diet, seldom fail to restore the parts to a healthy appearance.
The original cause of inflammation seems to be, any part of the body put into an unnatural posture or state, when an effort is made in a surrounding part to rectity it, which causes iti-
lecture iii-
23
flammation; thus, if *ny part be divided, inflammation is ex- cited in the neighbouring parts, and the wound becomes hea ed and if any extraneous substance be by any means introduced into the body, an inflammatory action becomes excited, the re- sult of which is, suppuration, by which process the offending substance is expelled. Inflammation arising without any evi- dent cause, is the effect of distention of the vessels of the part ; thus cold suddenly applied after heat, produces inflammation of a deep seated kind. Rheumatism, and sometimes an effusion of coagulable lymph, or an abscess, which is often extensive, will form, if there be constitutional debility. External violence from mechanical or chemical means, application of irritating substances, &c. are common causes of inflammation. Ihere can be however but one general cause of inflammation, that is, parts put into an unnatural state.
The proximate cause of inflammation is a matter of dispute. Dr. Cullen’s doctrine of spasm of the extreme vessels, is con- sidered not at all conclusive. Boerhaave’s opinion of an ob- struction in the smaller vessels from the thickness and lentor of the blood, is disapproved of. He admits the vessels are di- lated, and allows the mischievous red globules to enter, which he conceived produced permanent constriction. If you examine transparent parts with a good microscope, and to do this, take the web of a frog’s foot, you will find that it apparently con- tains no red blood ; but if you excite inflammation by pricking it with a sharp instrument, in a few minutes you will see red par- ticles of blood enter into the vessels, at some little distance from the part injured ; they are pushed forward by little aud little, till they approach the ramification of the veins, which they immediately enter, and become directly conspicuous, though before they were merely visible : but they are now distended by the vessels behind propelling the blood forcibly into them.
There does not appear to be any evident action in the vessels in the part itself, on the blood which they receive ; they dilate and open to receive it, but the action would appear to be in the surrounding parts — a kind of sympathetic action ; and if this bfe an important fact, it extends to the sensorium and heart
<24
LECTURE III.
itself, and causes the constitution to sympathize in severe injuries.
I cannot give you a better idea of this, than by showing you what happens in the eye, when any offending matter gets into the tunica conjunctiva, the lachrymal gland immediately sympa- thizes, and a flow of tears rushes over the eye to expel the offending substance ; did this run through tubes, it would be exactly similar to what takes place in inflammation. The action of the neighbouring vessels is increased, and the blood rushes to the injured part : this increased action you may ob- serve in a whitlow on the finger ; if you feel the artery in the finger, you will find it much increased in its action from that of the corresponding fingers; and sometimes this increased action extends throughout the whole limb.
How a spasm in the extreme arteries, supporting an increased action in their course, as Cullen remarks, can be considered as the proximate cause of inflammation in all cases not arising from the application of direct stimuli, must be argued on this principle : that when glandular structures are inflamed, they cease to secrete as usual ; but this is only when they are gene- rally, not partially inflamed ; as in the latter case their secretions become augmented rather than diminished.
Hunter says, inflammation is to be considered merely as a disturbed state of parts, requiring a new salutary action to re- instate them in their original position : it ought, strictly speak- ing, not to be deemed a disease, but as a salutary operation. Again, he says, it is to be considered as an increased action of the vessels of the part, an increase or distention beyond their original size and diameter; it is not a relaxation but merely temporary dilatation, and a necessary operation perform- ed by nature.
To lender this intricate subject as intelligible as can be, it will be necessary to enumerate a few of the preceding remarks.
We are not to consider arteries as tubes formed merely on mechanical principles, to' transmit a certain fluid : their mus- cularity, their elasticity and vital powers being so well known, Plight to induce us to give them more important offices ; and
LECTURE III.
25
whatever theory may be hereafter introduced, this ought to be borne in mind ; they are temporarily and visibly enlarged in an inflamed part, and that an increase in the circulation of the part is also manifest. How many go thus far and halt, per- fectly satisfied ; but I should imagine, that let the cause of in- flammation be what it may, the first and primary cause of all, must be on the organs of sensation — the nerves of the part; and hence I should say, that the ultimate proximate cause of inflammation, as far as it can be traced, would be, that the sen- sibility of the part affected becomes increased, that it would appear, if I may be allowed to express myself, as if first sus- ceptible of the injury, and from the intimate connexion of the nerves with each other, they call on their immediate neighbours for assistance; that the command they possess over the circula- tion, produces a willing compliance, and if the damage sustained be great, is transmitted to the sensorium : nature, ever on the alert, sets about the re-establishment. Hence, if the part be easily repaired, the constitution suffers no interruption in its accustomed functions ; but if the part be of vital importance, or the person of an extremely irritable habit, the general frame suffers in proportion to the violence of the injury. When the cause is removed, the nerves gradually resume their wonted powers, the arteries their natural diameters, the circulation its healthy standard, and the integuments their usual temperature : jri fact, the tout ensemble, their respective healthy avocations.
ON THE TREATMENT OF INFLAMMATION.
Inflammation being a local affection, in most cases, it will give way to local measures, such as the application of leeches, cupping, &c. &c. ; but when any vital organ is the seat of it, the constitution thereby suffering and the life being endangered, we must not rely upon local means alone.
In inflammation of the lungs, when difficulty of breathing comes on, and the person’s constitution is rather delicate, the taking away a small quantity of blood will be attended with more advantage, than where the contrary plan is followed :
26
JjECTURE in.
about five or six ounces will commonly answer, and this may be repeated according to the urgency of the symptoms.
Syncope is considered a favourable circumstance in venesec- tion, as proving that the evacuation has acted powerfully on the system. It has been the practice, and 1 think too very properly, where we have evident marks of high inflammatory action prevailing, of making a large orifice in the vein ; two reasons seem to guide this determination, the one, that it will take oft the determination of the blood to whatever vital organ is affected, much quicker than if the orifice were small ; the other, by no means an immaterial one, that the circulation be- comes so sensibly affected, as to induce syncope; the earlier it is practised, and the more suddenly the evacuation the better.
There is an evident advantage in. drawing blood as near as possible to the seat of inflammation : for instance, if there be high action going on in the brain, opening the temporal artery, or jugular vein, should be had recourse to for this reason, that the impetuosity of the blood to the part is much diminished in consequence of the neighbouring vessels being considerably lessened in their diameter, and the great distention taken off.
The indications necessary to be observed in repeating blood- letting are, when the blood drawn is sizy, the pulse still remain- ing hard and above the natural standard ; but there is one ob- jection to the former inference, namely, in pregnant women, and also in some irritable constitutions, in whom, when blood is drawn, there is generally a siziness observable. — It also de- pends upon a quantity of serum in the blood evacuated : if there be a larger quantity or portion, with respect to the constituent parts, than usual, it will be improper to repeat the operation.
A pulse from 76 to 100, with tenseness in the artery, indi- cates bleeding ; but from 100 to 120 not so, as it rather indicates debility, though in the inflammatory state of some important organs, the pulse is often thus ; and therefore to relieve any urgent symptoms, it will be proper to have recourse to blood- letting, especially when we find (which is often the case) the pulse gets much fuller after a small quantity has been drawn : but if, on the contrary, we observe the patient’s pulse weakened in the pulsatory motion ; (a more certain sign, however, is when
*
2
LECTURE III.
27
the blood is taken away by cupping, and the pulse at the time, instead of being slower and fuller, becomes rather quickened) then we are immediately to desist. When any secreting sur- faces are the subject of inflammation, and more particularly those of joints, it will be our aim to prevent its extending to the suppurative process ; here we must use local and general bleeding, though it should occasion debility in the system.
Purcinsr is considered one of the most effectual remedies in inflammation, for three reasons, the first is, by discharging the faeces, and taking off the irritation produced in the intestinal canal ; secondly, by restoring the secretions of the alimentary tube : and lastly, by deriving blood from the surfaces inflamed to the intestines.
For children, calomel with rhubarb to be given every fourth night, if the disease be acute ; but if not, every sixth night, as mercury, given too often, may be attended with bad effects. For adults, calomel with cathartic extract, in proportion of a grain and a half of the former, and five grains of the latter, has been considered as very beneficial when given at proper intervals, that is, repeated according to the acuteness of the disease ; but if it should not be found sufficiently active as a purgative, it will be better to give, the following morning, the magnesite sulphas, or oleum ricini. It is very necessary to be particularly careful in exhibiting the mercurial, especially in scrophulous cases, and in venereal ones combined with the latter affection, when the complaint will be more aggravated than relieved. One of the principal practitioners in town employs mild purgatives of the saline kind — Glauber’s, Epsom, or Rochelle salts. Drastic purgatives are to be avoided, of whatever kind, as they produce very considerable irritation in the constitution.
Another mode of lessening inflammatory action is by per- spiration, by winch the edges of the crassamentum being drawn towards each other, and forming a kind of cup, drains the sys* tern of its redundancy, and drives the blood to the surface of the body. Reciprocal affections also take place in the kidneys, by an increase of the urinary discharges. The hot bath is often attended with considerable benefit, and there are other remedies to be given according to circumstances, such as large
28
LECTURE III.
quantities of diluent drinks, bladders of warm water applied to the extremities, and lastly antimonials ; they relieve the oppres- sive dryness of the skin, and tend to lessen the increased action of the affected part.
The remedies just mentioned are intended for acute inflam- mation. Chronic inflammation requires somewhat of a different treatment ; when an organ has laboured long under an inflam- mation, so as to threaten its entire derangement or dissolu- tion, the hydrarg. muriat. with or without the Peruvian bark, ac- cording as circumstances may direct, which may or may not favour the exhibition of the latter medicine, has been found beneficial and serviceable to a great degree.
Case. — A striking instance of this is recollected, which occurred in Guy’s hospital, in the case of a woman who had a chronic inflammation of the eyes, to such an extent as to have produced an opacity of the cornea: the common remedies wrere persisted in, but in vain ; when, after taking the above medi- cine, the opacity of the cornea began gradually to diminish, and in a few days the inflammation subsided. The mercurial, in this instance, was combined w ith a decoction of sarsaparilla.
In tabes mesenterica, chronic affections, and in scrophula, it answers very well, provided it does not act on the system as ft mercurial.
Some of the remedies for topical inflammation have been be- fore alluded to, as cupping, leeches, &c. ; but it will be necessary to observe, that there are other remedies equally proper; these are cold applications, which are of an astringent or sedative nature, and which, by abstracting heat, lessen the action of the blood vessels, and act as powerful agents on the nervous system ; but there are certain limitations to be observed with respect to their use; it w'ould be highly improper to have re- course to them too frequently, or in too violent a degree, as instances have been known, when so applied, they have pro- duced the worst consequences, by freezing the parts, and con- sequently effecting a morbid action, owing to a lax and torpid circulation. Mr. Samuel Sharp has related a case of this kind, when, from ice being applied to the groin in a strangulated hernia, such a morbid state was induced a* to occasion the
LECTURE III.
29
whole of the scrotum to slough off ; but this may be prevented, in similar cases, by enclosing the ice in a bladder.
Evaporating means have been resorted to, on account of their action in extracting heat from the body, by effecting a con- tinual evaporation from the part inflamed, for which purpose the spir. vin. rect. ^j., liquor, acet. plumb, dilut. vel aq. puia? ?v. ft. lotio. have been recommended. There are other lotions which act in a very different manner, by being immediate agents on the nerves, thereby diminishing their energy ; but these are apt to occasion mischief when too powerful, or long persevered in : as for instance in a case of ophthalmia, where preparations of lead, (liquor, acet. plumb.) were used for some time, and produced paralysis of the eyes. Another case is recollected, when the same preparation was once used through mistake un- diluted, in a case of hernia humoralis, where it occasioned a mortification of the scrotum ; thus clearly proving that these kind of sedatives act immediately on the parts themselves, and are of no advantage in deep-seated inflammations.
Heat combined with moisture, namely, flannels wrung out of warm water, or the pediluvium, answers well, by producing perspiration, unloading the excretory ducts, and thereby free- in«- the system of its redundancy : it is on these principles that oiled silk and soap cerate act.
If inflammation should not be got rid of and subdued by the methods mentioned, then, as has been before said, it will be proper to have recourse again to leeches, cupping, and scari- fications : the latter are found of great service in inflammation of the scrotum, done by means of a lancet.
In inflammatory affections of any of the internal viscera, blisters maybe used to induce a counter- action ; liniment, arn- mon. 3j. antimon. tartar, ^ij. well rubbed in is very serviceable ; this liniment brings out eruptions very similar to the variolous.
In joints diseased with scrophula, or indurations remaining in them, the result of an inflammatory action, these latter men- tioned remedies are particularly useful, and more so when as- sisted by internal medicines, such as calomel given every fourth night, &c. ; if the enlargement should not yield, and the joints are stiff, friction must then be used, and persevered in for a
30
LECTURE III.
length of time; but the use of it is improper when* there is in- flammation existing.
It is by friction Mr. Grosvenor, of Oxford, has acquired so much celebrity ; thus, one hand is rubbed up, and the other down the limb at the same time ; and continued for half an hour or longer every day.
The above are the principal remedies for local and constitu- tional inflammation, and are to be employed with judgment according to the existing circumstances ; as it is impossible to lay down rules in a particular way, they must be general ones, and the surgeon must avail himself of those most appli- cable to the case of his patient: lastly, it may be proper to observe, that in most instances, rest and support will prove advantageous, the antiphlogistic regimen must be observed, and attention paid to the patient’s diet ; avoiding those causes that would agitate or disturb him, 8tc.
SI
LECTURE IV.
*
ON ADHESIVE AND SUPPURATIVE INFLAM- MATION.
Inflammation has the effect of changing the blood into three parts, serum, crassamentum, and coagulable lymph, which is different from that in a state of health.
If you put a portion of blood, just drawn, into rectified spirits of wine, you will perceive it harden on the surface ; but it does not harden on the under part, which is composed of red par- ticles, and which are easily separated. The buffy appearance is not only found when the system is affected, or if blood be drawn from an inflamed part, but it will have this appearance, though there be no constitutional affection present, as has already been remarked.
In consequence of coagulable lymph becoming attenuated, it is capable, in inflammation, of being poured out from ex- treme vessels, and inflammation is then taking place when this lymph is effused for the purpose of glueing parts together : we are all of us aware, that if a piece of lint be laid over a wound after this process has taken place, it will so adhere as only to be separated by violence.
Such surfaces as take on this kind of inflammation, are the peritoneum, pleura, &c. &c. and immediately on the com- mencement, the adhesive process takes place, coagulable lymph is effused, and connects the membranes to their attaching surfaces.
S2
LECTURE IV.
The cellular membrane is very liable to this species of in- flammation. On cutting into a tumour, when the process has commenced, you will certainly find a mass of coagulable lymph by attending closely to the appearances, for when first effused it is yellow, and has the consistence of jelly : observe the appearances under the cuticle, raised by a blister ; when effused it takes on a peculiar arrangement; on its first appear- ance you will discover its vascularity, and the parts in contact with its surface begin to shoot out vessels, they become more and more elongated, until they at last shoot entirely into its substance ; hence then it is evident that coagulable lymph ov. "r. its vascularity to neighbouring vessels.
The uses of this lymph are several ; in the first place, it serves to confine pus in the cavity of an abscess: an abscess is capable of producing great destruction, if not prevented by the effusion of this lymph. One case may be related : — it wras that of a man much debilitated, who had a tumour on the neck, which, forming an abscess, extended even to the loins, whereas had coagulable lymph been effused, this great exten- sion w'ould have been avoided; the patients, in these cases, are to be considered in imminent danger, though not at first generally so.
The second use it serves, is in dividing a cavity into several parts, so that if inflammation come on in any one part, and pus form, by this process taking place, and glueing the sides of this cavity together, the inflammation is prevented from spreading farther.
Thirdly, in case of any extraneous body, such as, for ex- ample, a musket or pistol ball being received into any part of the body, this lymph, by forming a cyst, encases this extrane- ous body, and the parts around it are not stimulated to do any further injury ; and cases where extraneous substances have so remained in the body for a length of time, without any very manifest inconvenience, will be detailed in the course of these lectures.
Fourthly, to unite parts together which have been divided, and which is considered as the most essential of its uses. A very wrong opinion has prevailed, that extravasation of blood
LECTURE IV.
S3
produces what is called the first intention, which is now evi- dent can only be answered by coagulable lymph ; for example, in the operation for the hare-lip, it has been invariably ob- served that the less the loss of blood the better.
For the accomplishment of the union of parts, it is abso- lutely necessary that inflammation should first come on, and during its early progress the lymph is thrown out, which an- swers every purpose required.
There are two modes of union, the one already mentioned, namely, adhesion, the other by granulations ; if there be any ex- ception to this, it is where the haemorrhage is stopped by a coa- gulum or clot of blood ; but here ultimately the union is effect- ed by the medium of lymph, which causes an adhesion of the clot to the inside and orifice of the artery, and to the surround- ing parts ; and, in bad habits, the increase or recurrence of haemorrhage is from a deficiency of this action, and after the ligature operates, the ends not being glued together, nor the clot of blood to the sides of the artery, it is carried aw'ay by the force of the blood.
No operation, not even the simplest, could be effected with safety, without the adhesive process ; for after the operation of venesection, if it were not for this mode of union, the vein would inflame, and the inflammation extending along its coats, through the valves, even to the heart itself, would necessarily prove fatal. Many other cases could be mentioned illustrative of this subject, such as tapping in ascites, and in the ope- ration for strangulated hernia, where, if the peritoneum and intestines did not adhere, death would be the result ; amputa- tions might also be alluded to ; and with respect to this latter operation, there is one question I would wish to put to you, that is, why is it found so necessary to save" so much of -the skin or integuments ? to this it may be answered, that it is for the purpose of glueing or connecting it with the ends of the muscles: and from thence proceeds the necessity of cleaning the stump of any foreign body, tending to prevent that desired process, and perhaps it may not be amiss to mention a circum- stance which occasionally happens to unskilful practitioners ; the impropriety of removing the dressings a few days after
D
34
LECTURE IV.
the operation has taken place is here alluded to, in order to see how the limb appears, but it must be evident to every thinking man, this is extremely wrong, as it tends precisely to destroy that mode which nature has intended for the restoration of the parts. Tt is only warranted in those cases where, from the ex- cess of pain the patient complains of in the amputated part, you have reason to suspect there is matter confined, and even in such a case it would be preferable, merely to slip through the adhesive plaster, in order to give vent to the confined matter, without removing all the dressings.
The same adhesive process takes place in the hard as well as in the soft parts of the body, the bones for instance, only that in them, a gelatine is secreted, and in the soft parts lymph is deposited to cover the edges of the fractured bones, either simple or compound: with the exception that, in the latter ac- cident, this process is hindered from being completed by the formation of pus and granulations.
One more proof in favour of the adhesive process will be adduced, namely, in the improved method for the radical cure of hydrocele, for which we are indebted to Sir James Earle ; by the effect of an injection, inflammation is produced, and the sides of the vaginal tunic are glued together, so that the whole cavity or bag previously existing, becomes obliterated ; we here see that even disease can be cured by the beautiful and admira- ble process of nature, in itself very simple, which shews the wisdom of our great Creator in a striking degree.
ON SUPPURATIVE INFLAMMATION.
When inflammation passes the limits of adhesion pus is formed, the symptoms are, the parts affected become more prominent, the tumour being harder on its sides- than 111 its ceutie, attend- ed with a throbbing pain, and a suffused rednessover its sur- face ; this redness generally denotes inflammation in the cellu- lar membrane beneath ; a fluctuation is generally perceptible in its centre, which becomes the most elevated part, and appears whitish and' soft to the feel. ri he constitution now, in its turn,
LECTURE IV.
35
is affected, the patient is seized with shiveriugs, which are more or less violent, according to a combination of cncumstances, the pam, before acute, becomes of a dull kind. These are the general symptoms, but there will be always some little variety, according to the depth it is lodged.
Although Hunter remarks no suppuration ever takes place without being preceded by inflammation, and no pus is ever formed but in consequence of it, yet there are some particular structures which arrive to the formation of pus, without pre- vious adhesive inflammation ; in mucous membranes, for ex- ample, where, on any stimulus being applied, immediately pus begins to form. We may observe this in the urethra, when a bougie has been introduced, in an irritable habit of body.
Also in the trachea and in the lachrymal duct; and this is a very wise provision of nature, for if those parts took on the ad- hesive instead of the suppurative process, in most cases it would be. attended with fatal effects.
In croup, lymph is produced instead of pus; and fistula lachrymalis is a consequence of an obstruction in the ductus ad nasum.
If we are asked why mucous surfaces pour out pus, and vaporous surfaces, coagulable lymph, it may be auswered, that the extreme vessels in exhalant surfaces are more minute, and will not readily admit pus through them, although they allow of coagulable lymph ; whereas, in mucous surfaces, the vessels are larger, and pus readily finds its way.
When suppurative inflammation takes place in a wound, it is always preceded by the adhesive process. Granu- lation is a mode of union where the adhesive process fails ; for instance, if a part be wounded by any sharp in- strument, and lymph is not thrown out sufficiently for its union, then suppuration commences, and the wound is healed by granulation*
36
LECTURE IV.
OF THE NATURE OF MATTER AND ITS MODE OF FORMATION’,
If we attentively examine the nature of pus, we shall find it composed o( serum and white particles similar in form to the led globules of the blood; the usual mode of discovering the diffeience between pus and mucus is by art, and it has been found that pus cannot be coagulated by the gastric juice, and this was attempted from its being thought to have some simi- larity to milk; the fluid part of pus can be made to coagulate in a solution of sal ammoniac, and this effect cannot be pro- duced on any other secretion or animal fluid. Hunter also remarks, that pus is constituted, as I have already stated, of serum and white globules, and is more or less healthy in proportion as the white globules predominate.
The specific gravity of pus and blood are nearly similar ; it must consequently be much heavier than water, in which fluid it sinks, and occasions an uniformly troubled whitish tinge, while mucus floats and communicates to the water something: in the resemblance of stringy or fibrous portions floating in it. Pus has a sweetish taste, which is remarkable, as well as its smell.
It was supposed, till of late years, that pus was formed by the destruction of solids; but this opinion is now very generally exploded: we have several striking examples to the contrary, as in the urethra, where its membranes are rather thickened than otherwise by it ; in this case formerly it w as contended that the matter discharged in gonorrhoea must be caused by an ulcer in the internal passage. The lachrymal duct also, and many similar structures, such as the peritoneum, pleura, and pericardium ; which are always found considerably thickened after the formation of matter. Ur. Hunter first noticed that the dissolution of parts of the body wras not essential to the formation of pus : a subject died of empyema, and in the dis- section, this fact became apparent; the matter, although the quantity w'as very considerable, appeared to be formed from the fluids, and not the solids, as no breach of continuity, or dissolution of structure could be observable.
LECTURE IV.
37
The formation of pus is from the neighbouring vessels, and will be proved by this experiment: — -After a sufficient quantity of fluid is raised under the cuticle, by the application of a blister, remove the latter, make an opening in the cuticle, and apply a bit of glass to the secreted fluid, and you will find it, after remaining a short time, similar in appearance to pus, directly proving that it is produced from the mouths of the vessels, and not from the solids.
Pure pus has not the power of irritating the surfaces in con- tact, being quite a bland fluid : but this is only so when it is in an healthy state, and unchanged ; for as soon as any irritating cause has acted on it, or the vessels rather that secrete it, so as to excite a total change in regard to its texture, then the surfaces no longer secrete a mild bland fluid, but what is already effused becomes ichorous, exciting irritation in the adjacent parts ; such is the case in bones when exposed, where true pus is seldom or ever formed, of which doctrine we have a simple, but sufficiently illustrative example, in the instance of a nail growing into the skin, the parts become irritated, and instead of secreting pus, are discharging an ichorous matter ; as soon as true pus is formed on any sore, inflammation immediately ceases; this latter process is absolutely required for the pro- duction of the former, but of no longer utility when formed: for if inflammation continue, or is resumed, it prevents any further secretion. On a part being irritated by any poisonous matter, it directly becomes inflamed, and in it a poison similar to that which was applied, is produced, and if this morbid matter be introduced into the system by absorption, so as to affect the constitution generally, it then brings on fever by its iiritation, and generates similar poison throughout the system at large.
We have examples of this in syphilis, small-pox, &c. &c. ; in these cases the constitution takes on a particular action, which is continued as long as the cause is applied.
I he uses of suppuration are twofold, and are important; 1st. by its covering granulations, and keeping them in a moist state, otherwise no sore could be possibly healed ; for if a sore be exposed to the action of the atmosphere, it soon becomes
S8
LECTURE IV.
incrusted, and under which matter is confined, which keeps the granulations perfectly moist, so that nature here performs her part without the aid of surgery ; the second use it has, is by its pressure on parts so as to cause them to be absorbed, and by that means rid the body of extraneous substances ; in this it acts similar to ulcerated parts.
Of ULCERATION.
Ulceration is the absorption of any natural formed parts or solids of the body, but differing from simple absorption in this, that the latter takes up minute substances in contact with the vessels. Ulceration is commonly accompanied by matter, but this is not essential to it, as it often occurs without. It is the result of two circumstances : —
Inflammation, with pressure : but inflammatory action is not of itself the immediate cause of it, but only when attended with pressure.
In aneurism of the aorta, where no matter is formed, the parts in contact with the aneurismal sac, such as parts of the ribs, and the sternum, will become absorbed merely by the mechanical pressure of the sac, producing increased action in the absorbent vessels of those parts ; in fungous tumours of the dura mater, the bone will be absorbed without any collection of matter.
j. Ulceration has a tendency to the surface more generally than to the internal parts of the body, as is seen in cases of dis- eased thigh-bou|s ; or it may be better illustrated in those cases of matter foaL'ing behind the sternum, close to the pleura, where, instbaa of ulcerating that membrane, it absorbs the
* • v _
sternum. A' case of this kind occurred in Guy’s Hospital, during my attendance. In the formation of matter also in the abdominal muscles, instead of forcing its way into the viscera, it most commonly finds an outlet on the surface of the body.
The same thing is seen happening also with respect to bdnes, where matter makes its way to that part of the bone
LECTURE, IV.
39
most exposed; these examples shew the admirable wisdom of the Divine Architect, for, were it otherwise, the consequences would be generally prejudicial; and which is accounted for by Hunter thus : although a tumour makes equal pressure in every direction around, it will make its way externally, because in- terstitial absorption only happens in that direction. Slight pressure from without, Hunter remarks, will even produce a thickening of parts, and hence he infers, there even appears to be a corresponding backwardness to admit disease: both these facts are shewn in the case of fistula lachrymalis, for though the collected matter is nearest the cavity of the nose, still it makes its way externally, and the Schneiderian membrane becomes thickened, so as to prove a barrier against its progress inwardly. He gives five causes for ulcerative absorption, pres- sure, irritation of stimulating substances, weakness, inutility of parts, and death of them. It takes place readier in the cellular and adipose substance, than in muscular, tendinous, ligamen- tous, and nervous substances, or blood-vessels. A cicatrix, or newly-formed skin, is sooner acted on, than the originally formed cutis; thus, if an inflammation take place in a patient’s leg, that had been previously affected with ulceration, the ulcer will break out much sooner than if the disease had not existed prior to this last inflammation.
The progress of ulceration takes place much quicker than that of restoration, as parts may be so affected as to be de- stroyed in two or three days, which for their restoration would require twice as many weeks.
Ulceration, although a diseased process, yet is not without its advantages to the body and animal economy, by discharging- extraneous bodies from the system; as for instance, a ball; a ligature upon an artery is disengaged in the |me manner; sloughing parts are also similarly removed ; parts'-having weak circulating or living powers, are readily acted upon by ab- sorption, and we more frequently see ulcers in the legs than in other situations.
When the body has been long accustomed to the discharge of matter, it is absolutely necessary in stopping this, to sub- stitute other evacuations in its room, or the change will produce
40
LECTURE IV.
apoplexy, or a peripneumonia ; these consequences are seen on healing old ulcers of the legs. Surgeons were formerly in the habit of making issues in other places, hut purgatives perse- vered in for some lime are now deemed preferable, and suffi- cient for every purpose.
OF ABSCESSES.
An abscess means a collection of matter in a cyst. In cel- lular textures, prior to the formation of matter, coagulable lymph is effused, forming a kind of wall or cyst, by means of which the further increase of the disease is prevented and arrested. In the middle of this wall you will observe a parti- tion and a small quantity of matter, which is poured into the coagulable lymph, so that by its pressure it produces the ab- sorption of parts. This process goes on in a regular manner, and matter is still secreted, and the process of absorption con- tinues as long as matter is poured out, till at last, with the assistance of the pressure, the whole is taken up.
The dangers attending abscesses are several. The 1st is, when they are very large and present a vast extent of surface. 2dly. When seated in an organ essential to life, the brain or heart for instance, where the lodgment of a very small quantity of matter would prove fatal ; but other organs, such as the lungs and the liver, although very important, do not appear to sympathize with the constitution so much ; abscesses in them will be suffered to exist to a great extent. Sdly. When not seated in parts important to life, yet by their pressure on any essential organs, render the case very different. Matter, for example, seated behind the pharynx, so as to press on the trachea, will destroy life. There is one case on record, how- ever, of this kind, which ended favourably, free vent having been given to tire confined matter, by an opening into the sac, which relieved the patient from the most imminent danger. 4thly. When matter begins from a bone extending to the surface of the body; and this is the great cause why lumbar abscesses are attended with danger, as bones require to
LECTURE IV.
41
exfoliate before granulation, so that from the length of time induced by this process, which is very tedious, patients seldom recover.
TREATMENT OF ABSCESSES.
When an abscess is formed accidentally, poultices and fo- mentations are all that is requisite. 13ut in a constitution ' much worn down by debility, and m indolent abscesses, it would be proper to have recourse to stimulating remedies, in order to excite the system to action, and giving also at the same time tonics with a generous diet.
In opening abscesses, the lancet is the best instrument, and is much preferable to the using of caustic ; but after having made an opening, should the abscess not discharge freely, then introduce a probe (the point of which being dipped in nitrous acid) into the orifice. If the abscess be very extensive, the best method after an opening has been made, is to apply around it a roller, only taking care to leave an opening suffi- ciently large to give vent to the matter; by this plan the sides will generally unite.
It is necessary to be thoroughly acquainted- with the time necessary for opening an abscess, as a great deal depends on it. There are some that require an early opening ; those, namely, that are situated under the fascia or ligamentary ex- pansion and thickened cutis, the palm of the hand and sole of the foot; and the opening made into them should be very free, as there is no risk in so doing, and it prevents their unnecessary extension.
Abscesses also near bones should be prematurely opened, and those that are near organs important to the functions of the animal economy, such as are under the pericranium, in the eye, the thorax, and abdomen, and also in joints, require this plan. Hunter says, generally a collection of matter should be allowed to break of itself: but it is now considered bad practice to allow an abscess to do so, although the confinement of its con- tents can do no injury ; an opening should therefore be made
42
LECTURE IV.
when there is a conical tapering to a certain point, with evident fluctuation, indicating where nature would, if left to herself, fix upon for the precise spot ; but it must not be understood that a premature opening is recommended, except in selected cases.
ON HECTIC FEVER.
It is found (but this depends more or less on the irritability of the patient’s constitution), that the system is affected with hectic fever to a considerable degree, according to the extent of the abscess, which comes on sometimes twice a day. Till of late years an opinion prevailed, (and it is even now main- tained by some) that hectic fever was caused by absorption of matter; but this opinion is certainly wrong. In proof of this assumption, it is found that hectic fever prevails where there has been no formation of matter.
Case. — An instance of this is recollected which occurred some time since in this city ; where a girl was admitted into an hospital for an affection of her knee, accompanied with pain, yet no appearance could be perceived of any collection of matter. Hectic fever came on twice a day, and so reduced her constitution, that amputation was resolved on, conceiving there might be matter formed internally, which could not before be detected. But on examination, the limb was discovered to have nothing of this sort : the only appearance of disease was in the epiphises of the os femoris, which were much inflamed.
This case distinctly set the question at rest, and proved that hectic fever is capable of existing without absorption of matter. Since that time many other proofs might be adduced, that hectic fever often exists previous to the formation of matter. A small ulcer in the lungs may bring on hectic symptoms, while a very large one in the leg will produce no such effect : these are certain and incontrovertible evidences of what has been advanced. The hectic fever is simply this : it arises from sympathy induced on the system by the irritation of some part or parts ; or in other w’ords, it is that general disordered
2
LECTURE IV.
43
state, the immediate effect of irritation. There are three stages of it, the cold, the hot, and the sweating fits ; the patient is alternately seized with chilliness, which is succeeded by flushes of heat and copious perspirations ; the pulse is small but frequent, with an unnatural moisture of the skin, indicative of debility; urine pale, and rather copious, depositing a sedi- ment ; tongue dry and parched ; with indigestion, vomiting, and diarrhoea.
This fever, as has been previously remarked, depends on local irritation : we must first diminish or remove the cause before it can be expected to cease ; do that, and it ultimately will vanish. Hunter says, when an incurable disease in an ex- tremity is removed by amputation (such as a scrophulous affec- tion of the joints where- the suppurative process has been tediously prolonged) the hectic fever immediately begins to abate. “ I have known,” says John Hunter, “ a hectic pulse at 120, sink to 90 in a few hours, upon the removal of the cause. I have known persons sleep soundly the first night without any opiate, who had not slept tolerably for weeks be- fore. I have known cold sweats stop immediately, as well as those called colliquative. I have known a purging stop as suddenly on the removal of the hectic cause, and the urine drop its sediment.”
The practice in these cases is plain enough : but where our patients are reduced to the lowest state of debility by some in- curable local disease, as in lumbar and psoas abscesses, &c. 8tc. this plan cannot be pursued ; we must therefore endeavour to support the person’s strength, and invigorate his vital powers, both by the aid of medicine and diet, by the most powerful tonics on the one hand, as bark, acids, &c. &c. and by nourish- ing and nutritious food on the other, combined with cordials and aromatics. Sleep may be procured and pain alleviated by narcotics, as opium, cicuta, &c.
Resuming the subject of abscesses, we are not to be sur- prised to find inflammation come on in a few days after an
44
LECTURE IV.
abscess has been apened, as this is commonly the case. It was generally believed that the admission of air was the cause of it; but this we are certain is incorrect; and to prove it, these experiments were made some time since ; a trocar was passed through the skin of a dog, and then inflated with air, yet no appearance of inflammation followed; openings were also made into the chest and abdomen of the same animal, and with the like lesult. Also it is found, that if the lungs are wounded by any sharp instrument, the air immediately escapes from the bronchial cells into the cellular membrane, puffing it up, as was the case in the experiments made on the dog; and yet after the air has been absorbed, no traces of inflammation could be discovered. The cause of it then is truly this ; the dividing of the vessels, which, exciting irritation, produces a change in the parts so acted on. Fomentations and poultices may be continued after an opening has been made, until the granula- tions nearly fill up the cavity, when the more simple the dress- ings are the better.
ON UNION BY GRANULATION.
Granulations are those substances which arise from wounded cr other injured surfaces, as in suppurating wounds or surfaces of ulcers. Their formation is after this manner; when au abscess is opened, coagulable lymph is deposited, which lines the internal surface of the abscess ; after a few hours this lymph becomes vascular ; and after the expiration of five or six days (but this depends on the age, constitution, Sec.) the whole surface lining the abscess is found to become highly so ; the vessels open on the external part of the coagulable lymph, and their termination is in its middle, or internal surface; from the orifices of these vessels, after a little time has elapsed, is deposited another layer of lymph, and thus layer after layer are successively formed, till at last the whole cavity of the abscess is filled up.
The difference existing between this mode of union and by adhesion is this : that in the latter the vessels do not shoot forth
LECTUKE IV.
45
from their orifices ; and in the former the vessels throw out pus at the same time that coagulable lymph is effused.
Granulations are entirely new substances formed from se- creted matter ; they are extremely vascular, from the various arteries passing in radiated forms on their surfaces 5 and it is principally owing to this circumstance that they appear so red, which is their colour when healthy ; when livid, or of a pale red, it denotes the languid circulation in the part, and they are considered by no means of a healthy disposition. Their sur- faces are generally approaching to a point, and termed convex, and the smaller and more numerous such points are, the more health they indicate.
With respect to absorbents, few can be discovered in their new structure, so that fresh formed granulations have bad ab- sorbent surfaces. But this is not the case with old sores or ulcers, which readily take up any mercurial preparation that may be applied.
On looking at granulations, they appear tender and endowed with great sensibility ; this is the case, indeed, with regard to the skin, but it is not so in the other parts of the body ; the bones for example; where if granulations form after exfoliation has taken place, we find little if any sensibility adherent in them.
To illustrate this, suppose a blow has been received, or a wound inflicted on some part of the cranium, and the in- teguments do not unite by the adhesive process, consequently this method by granulation ensues ; but previous to this, a thin plate of bone is exfoliated. On touching the granula- tions, there will be no pain excited ; and cases have been known where it has not created the least uneasiness, even by pressure.
The want of sensibility also is applicable to tendons and fascia, except when inflammation is present, which alters the case very materially.
There remains one very important observation to be made on the subject ; w hich is, that granulations applied to each other will readily unite; this is certainly very useful to be
46
LECTURE TV.
known, and is of great service to the practitioner. After amputation, it the adhesive process should not succeed, by bringing the granulations on one side to those of the other side of the skin, they may be made readily to unite ; but one caution is here necessary to be observed, namely, that care should be taken that the union thus effected is not partial, as here a sinus would be formed extremely trouble- some to get rid of.
OF CICATRIZATION.
When granulations arise even with the surface of the sur- rounding parts, or a little above them, then the process of cicatrization commences, which effects a covering over the whole extent of the sore ; or in other words, skin is formed which spreads over the entire surface of it; this process depends in a great measure upon the inosculations of the granulations which form on the edges of the skin. There is a gradual and uniform contraction from the sides to the centre of a wound during the healing of it; the progress of the granulations is from the sides , not the centre of a wound ; and thus, if it be a con- cave one, this fact is indisputable, as the skin becomes puckered or drawn inwardly to a centrical point. In a transverse wound the edges recede by their natural elasticity, but during the heal- ing process they are again approximated, from the contraction of the granulations ; and hence it is, that as they contract, the skin becomes gradually elongated, till the progress of cicatriza- tion is complete. As soon as a sore begins to cicatrize, the surrounding skin becomes smooth, and has that whitish cast so frequently observed, with a similar coloured substance, which Hunter conjectured to be the new forming cuticle. It would appear that new skin is derived mostly from elongations of the old ; but this is not always the case, as new skin is seen formed in detached portions in the centre of some sores, quite uncon- nected with the surrounding skin. Now whether this is a new surface formed by the granulations, or a change that they
LECTURE IV.
47
undergo, remains to be ascertained. New formed cutis is less yielding, less elastic and moveable, also thinner and more ten- der than the original, although in course of time it recovers more flexibility, is less attached, and becomes firmer aud more dense ; it has a smooth general surface, without the indenta- tions of the original, and the living principle is less active, as it is sooner absorbed than the old.
The cicatrix forms an entirely new cuticle over the sore, and which is very expeditiously done ; but not quite so soon with respect to the rete mucosum, as instances have shown with regard to negroes. In the filling up of the parts, it is the general opinion, that the substance restored is similar to that which was lost : this is certainly true as respecting most parts of the body ; it is known very well that skin can be re-produced. The cellular membrane also generally acquires its original texture, though at first it is somewhat condensed. Tendons are also readily re-produced ; their production seldom takes longer than a fortnight or three weeks ; but there are some objections, however, to be advanced against this opinion above quoted.
The muscles are not properly reproduced (and here I am aware that I differ from most writers) but it has been care- fully observed the mode of union in them after a wound had been inflicted, and a complete union taken place, was different ; on examining their structure, it has always been found that the connecting substance was tendinous and not muscular.
The ribs also, if their cartilages are wounded, do not unite again by their original structure, but by bone. But a gentle- man very eminent in practice, has discovered, that this is not the case as far as regards young subjects, in whom cartilage is commonly produced.
Skin, newly formed, has a redder and more florid aspect than an original formed cutis ; the reason is, on account of the full distention of the vessels, so that a cicatrix that is large at first, afterwards lessens, in consequence of the vessels becoming greatly diminished in their diameter.
48
LECTURE IV.
There is one circumstance to be kept in view in the forma- tion of skin: — a wound which is long and narrow will sooner unite than one that has a circular form ; the reason here is obvious ; every cicatrix is healed from the vessels of the edges, so that a long one must be united much sooner than a circular one, on account of the vessels in the latter having a further ex- tent to pass to the centre.
4
49
LECTURE V.
ON ULCERS.
An ulcer is a granulated surface secreting pus : when healthy the granulations have a florid appearance, and the skin forming the edge of the sore is approximating to the surface of the sore : here granulations are no impediment to its restoration. Every wound must become an ulcer, which does not unite by adhesion. Healthy ulcers secrete pus which is white and thick, and not adhering to the surface.
The only treatment required is, first to apply lint to the surface, which will come off after a few days, and when re- moved, granulations will be discovered under it, and a quan- tity of pus will be also secreted at the same time, and deposited on the surface of the sore. Poultices must then be applied, as they materially assist the rising of the granulations by their gentle stimulus, and are of greater utility than simple dressings of any ointment. In a few days more they rise as high as the edges of the skin ; then lint must be applied,5 and some unctu- ous substance on the edges, the simpler the better, as that composed only of wax and oil; but be careful the lint does not touch the edges, as it would greatly impede the healing of the parts, by preventing the shooting of granulations to the skin. A formation of a scab from the evaporation going on, on the sur- face, will be best prevented by the poultice'. This is the treat- ment required when an ulcer is in an healthy state.
E •>
50
LECTURE V.
IMPEDIMENTS TO THE HEALING PROCESS,
Mr. Home on the healthy ulcer, tells us, that some super- ficial ones will not be so disposed to heal when kept moist and unexposed to the atmosphere, as when they become dry and covered with a scab ; and it will also be proper here to remark, in his work on this subject, that he discountenances the employ- ment of poultices. The subject will now be resumed.
The 1st impediment is, when granulations arise above the edges of the skin, and are too luxuriant, forming what is com- monly called fungus flesh ; here bandages are proper, and even a thin sheet of lead applied will be found useful : but if this plan do not arrest their further progress, it will be necessary to have recourse to caustic applications, as the lunar caustic, which should only be applied round the edges ; any further extension of the caustic is unnecessary ; afterwards cover the part with dry lint.
The 2d obstacle to healing is, when the granulations are too languid, and have a glossy aspect : the coagulable lymph de- posited is not rendered vascular, which gives them that semi- transparent appearance ; it marks a languid constitution, and want of energy in the vascular system, so that the action it greater than the person is able to support ; these granulations grow with greater rapidity than in the healthy ulcer ; they are larger* and do not possess that firmness in texture. It will be here necessary to improve the constitution by tonics, such a's bark and .steel, and allow a generous diet. Stimulating ointments will be required to rouse the parts to action, and the best will be found to be the red nitrate of quicksilver, from 5 to 10 grs, mixed with an ounce of lard : vitriolic lotions may also be used t two grains of the ainci sulphas to an ounce of water, of the diluted nitric acid, in the proportidi of two drops to an ounce of water ; a tight roller should also be applied, as in- creasing the vigour of the circulation, and also giving due sup- port, and is effectual in producing a determination of blood to the parts ; and Mr. Home here very justly remarks that ulcers
LECTURE V.
51
which heal while the patient is walking about, are not so apt to recur as those which heal while at perfect rest.
3dly, An inflamed state of the parts, which will prove an impediment to the healing process: — here poultices and fo- mentations may be recommended, rest should be enjoined, and the bowels kept open.
4thlv, Irritable ulcers, according to Mr. Home, are thus designated: “The margin of the surrounding skin being jagged, and terminating in an edge, which is sharp and undermined, the bottom being made up of concavities of different sizes, with no distinct appearance of granulations, but a whitish spongy sub- stance covered with a thin ichorous discharge ; the surface readily bleeds, and is painful. Ulcers which occur on the malleolus externus, on the ligament of the patella, and the anterior surfaces of the tibia, are generally of this kind ;” aud Mr. Home conceives that the periosteum is the seat of this ulcer.
The treatment most generally pursued consists in the appli- cation of steam, or vapour from warm water, or with a small quantity of vinegar or spirits added to it; fomentations of poppy heads, of hemlock, or of opium, are very serviceable; a decoction of the poppy heads, and of the recent hemlock dried, if it can be procured, are to be employed. A striking instance of die good effects of dried hemlock made into a decoction, in these irritable ulcers, the author saw in the person of an in- valided officer of rank in the country. The hemlock was col- lected in the summer, and carefully dried, and the old veteran did not feel satisfied unless he had an ample stock regularly in the house by him. It is but fair to remark, this occasionally failed in procuring him accustomed relief, and then he was obliged to have recourse to a watery solution of opium. A decoction of wormwood or camomile is recommended by Mr. Home. Poultices made of marshmallows, or linseed, are useful ; but that so frequently used iu town, the carrot poultice, seems to agree as well as either; but it is sometimes preferred to mix linseed with it, iu the proportion of one part of the latter to five of the former : a change in the applications will he very advantageous in some cases ; and the principle of this occurrence
E 2
52
LECTURE V.
is compared with that by which change of air, even to a less salubrious one, often improves the health. It is advisable that a heavy poultice should not lie on the ulcer, but the ulcer rather on it. Mr. Home remarks on this subject, that carbon pow- dered has been found useful. Ointments are not proper ap- plications ; and when warmth has been found hurtful, cream has proved very serviceable ; bandages are of course to be avoided.
5th, Indolent ulcers are the very reverse of those previously alluded to; u the edges of the surrounding skin are thick, pro- minent, smooth, and rounded ; the surface of the granulations is smooth and glossy; the pus is thin and watery, being im- perfectly formed, and coagulable lymph in flakes appear blended together. The lymph consists of flakes which cannot be easily separated from the surface of the ulcer : the bottom of the ulcer forms quite a level, or nearly so ; and Mr. Home re- marks, the general aspect conveys an idea that a portion of the skin and parts underneath, has been for some time removed, without the exposed surface having begun any new action to fill up the cavity.”
The principal part of the ulcers which are seen in the hos- pitals are of this kind, although in appearance they vary some- what from the above characteristic. A healthy, weak, or irritable ulcer, unless healed in a certain time, degenerates into an indolent one, although we see some few exceptions, as there are irritable ulcers which never change their nature. In- dolent sores, form unhealthy granulations, which become again suddenly absorbed, and this event is promoted by changes in the weather, anxiety, fatigue, &c.
Treatment.
Mr. Abernethy has remarked, that, generally speaking, who- ever could apply a roller or a bandage the most perfectly and securely around a limb, would cure these ulcers the best; and the profession is under singular obligations to Mr. Thomas Baynton, of Bristol, for the very excellent treatise which he has published on this disease, which further elucidates the subject. The treatment consists in strapping the wound with adhesive
LECTURE V.
53
plaster, and applying a bandage from the foot to the knee (if the ulcers are situated, as we so often find them, between the knee and ancle) to give due support to the circulation. Adhesive plaster is to be applied round the limb, covering the sore both above and below ; this is to be so done as to ap- proximate the sides of the ulcer as near as possible: soft compresses are to be then laid on, and afterwards a roller applied. The excess of inflammation is to be moderated by keeping the bandages moist with spring water ; or a very diluted solution of the acetate of lead, if considerable water gene- rally will be found sufficient ; and then there is no necessity to confine the patient ; he may use moderate exercise. It may be proper in some cases to apply poultices at the com- mencement, till the granulations arise to some height; then stimulating them with a solution of lunar caustic, or the nitrous acid diluted, giving due support to the circulation, by means of a roller applied to the same extent as before alluded to ; but the preceding plan is always preferable, and will be found more universally successful.
An indolent ulcer is sometimes attended with a varicose state of the vena saphena, and this is found more troublesome to heal than the preceding, and is more likely to recur afterwards. Compression, by means of a common roller, is the most approved mode of treating this state, extending from the foot to the knee, and an horizontal posture. Mr. Home states cases where this has failed ; and has practised an operation, that of securing the vein as it passes over the knee joint; he does not divide, but merely tye the vessel : but this plan has but few advocates, if any, at this moment, on account of the very serious effects that have been known to result from its adoption.
6th. When a sore is sloughy, and has a black aspect, it is another impediment to the healing process. The treatment in this case is simple ; use a strong solution of nitrous acid, from 50 to 60 drops to two pints of water. Poultices of stale beer, or wine lees, or w'hat is known as crop of beer, which is the remains in the cask after the clear beer has been drawn off, mixed with oatmeal, will be very proper: and in some cases, a table spoonful of yeast added will be an improvement to restore it to a healthy surface.
54
LECTURE V.
7th. In consequence of sinuses : the mode of treatment, when they are deeply seated is, to inject the hydr. muriat. in the proportion of 2 grs. to 3 j. of aquae: it should be used thus strong to excite inflammation, and produce adhesion of the sides. Tinctura Iyttae has been also used to bring on the same effect. A caustic bougie may be also introduced. If the sinuses have two openings, it will be best to make an incision between them both, and to introduce proper applications. A sinus in the rectum (fistula in ano) is not to be cured in this way, and rarely by injection. The reason is, that on the motion or contraction of the gut, the sides of the sinus separate; here a cut must be made through the rectum, the whole length of the sinus.
8th. The next obstacle opposed to the healing of ulcers is, a suppression of the menstrual discharge; when this happens, it is seldom found an ulcer will be at all disposed to heal, and will continue in this state so long as the cause remains. In cases of this nature it is necessary to give stimulants, to excite them to an healthy action, and the best medicine to answer this purpose is Dr. Griffith’s mixture, composed of myrrh, steel, zinc, &c. and to the sore the best application will be mercurial oiutment, or the liq. calcis : but these local applications w ill avail little, without we are successful at the same time in restoring the natural vigour of the constitution. Indurations are often observed in those who have obstructed menses in their lower extre- mities.
9th. Sores are very subject to a fungus state, the effect of ex- traneous bodies irritating the granulations, commonly attended with bloody serum instead of pus, being of an offensive nature. Nails growing into the skin often produce fungus, by the great irritation they cause ; it was usually the custom to destroy this excrescence by means of caustic ; but the treatment is evidently improper, as the fungus was always found to grow again ; which is not surprising, as long as the cause existed, namely, the irritation produced by the nail, which ought to be cut out in the following manner: put the foot or hand into warm water; suffer it to remain for some time, then scrape the nail through with a piece of glass, put a piece of lint under it, for the.
LECTURE V.
55
purpose of raising it, which being done, cut it off. There is another method, which is, to pass a pair of scissars about one- eighth of an inch in length under it, so as to slit it up; but this . latter mode, although quicker, is attended with a great deal of pain. Sores of this description, although apparently so trifling, have been seen to produce such a disordered state of the parts, as to cause the necessity of dissecting into the skin, and also the gland which secretes the nail ; but previous to this it will be better to try the liq. calcis, or ung. hydrarg. nitr.
10th. Sores often occur in the lower extremities from dis- eased viscera, and are generally accompanied with anasarca;— here it i6 proper to attend to the state of the viscera, as no cure will take place before they are restored to their proper func- tions. When attended with anasarca, calomel united with squills, and about half a grain of gamboge, will be found very efficacious; also the cathartic extract; at the same time giving digitalis with the bark, twice a day, as tonics are highly proper at the time evacuants are employed. Bandages are here to be applied.
1 1th. Sores are also found in the lower extremities, with dis- quamation of the cuticle, and skin abraded; under the cuticle is found a small quantity of serum, owing to a lax circulation of the parts. There are two remedies proper for this disease : the liq. calcis, with hydr. muriat, in the proportion of one grain of the latter to an ounce of the former ; dip linen in this wash and lay it upon the sore, over which apply a piece of oil silk, which prevents the linen from being too suddenly dried; upon the oil silk apply a roller, which should extend over all the limb. It the parts are irritated with the above wash, apply the nitrate of mercury united with lard.
12th. There are other impediments to healing, such as a white and callous state of the edges of the sores ; in this case apply the ung. hydrarg. and if this should not succeed, it will then be uselul to scarify the edges with a lancet. Blistering ointments have also their uses as stimulants. When the edges turn inwards, it lias been observed that this state is a general attendant on scrophulous sores; apply this wash to the ulcers . twice a day— argent. uitrat. 3ss. liq. calcis 3j. M. and after-
56
LECTURE V.
wards the liq. calcis alone, as a constant lotion, at the same time strengthen the habit with tonics. It is generally the mark of cancerous sores when the edges turn outwards. Sometimes we observe a species of sores not very common, which are attended with a great deal of pain, and yet little or no inflam- mation present; these are best treated by the diluted nitrous acid, giving at the same time the decoction of sarsaparilla, ap- plying the adhesive strapping on Mr. Baynton’s plan, so as gently to stimulate them to produce granulations, and also to cause the skin to elongate over the sore by the cicatrizing process. This variety may come with much propriety under the general designation of indolent ulcers. The plan adopted in most hospitals in town in indolent dicers, is to foment and poultice at first, and after granulations have formed, to apply the adhe- sive plaster, roller, &c. as already stated.
Ulcers, with a specific action, will be noticed elsewhere in the course of this work, such as scrophulous, venereal, can- cerous, &c. &c. &c.
ON GANGRENE, OR MORTIFICATION.
By gangrene or mortification is meant the death or loss of any particular parts of the body of their vital principle, while the others are perfectly sound. Authors give a distinct defini- tion to the term gangrene and mortification ; but this is of very little practical utility. By gangrene they mean to designate that stage commencing with the loss of the vital energy of the part, till it becomes quite insensible, cold, and of a dark dis- colouration : when they apply the other term mortification. It is the result of two states or conditions of parts : 1st. of high inflammation ; secondly of cold. When oi the former, the parts are red and painful, and on a sudden the patient becomes easier, the redness disappears, and vesication succeeds, the skin becomes insensible, and of a dry brown livid colour; within these vesications there is contained a bloody serum; the pulse is quick, small, and intermitting; shiverings, followed by cold perspirations, come on ; diarrhoea, often delirium and hiccup :
LECTURE V.
57
the patient’s spirits become dejected, and his countenance assumes a wild cadaverous look.
A different state ensues when the mortification arises from cold ; the parts are at first benumbed, and on the exposure to heat are afflicted with redness and pain ; the parts are de- stroyed not by a constant, but by a weakly and frequent in- flammation. One species of inflammation has been seen where there is a medium between high inflammatory action and ex- cessive cold, and wherein the patient feels but little pain; this was first noticed by Percival Pott, Surgeon of Bartholomew’s Hospital. It most frequently happens to men of a gouty diathesis, who have enjoyed themselves in their youth, and are considerably advanced in life ; it commences at the extremities of the toes, and gradually advances to the foot, ankle, and now and then to the leg, unpreceded by any visible inflammation; there are instances adduced by Mr. Pott, where it has occa- sioned very little pain ; in others, during the night, they suffer greatly from the toes to the ankle. The cuticle becomes sepa- rated on the spot where it begins, and a darkish red appearance becomes apparent underneath ; its progress is mostly slow, but when it becomes unusually accelerated, the patient suffers in proportion. It is by no means confined alone to the male sex, or those in years, but when it attacks youth, it is rapid in its progress, and may, with propriety, be referred to exposure to cold. A remarkable case the author saw in Mary Jenkins, aged 1 3, brought on from losing her way in the snow. ' The five toes, to the second phalanx of each, mortified and sloughed ; she lost her voice and recollection, which was not restored under a week from the time she was discovered ; she ultimately did well.
Some parts mortify sooner than others ; in the extremities for instance, awing to a due want of circulation, and a proper degree of warmth necessary for the maintenance of that vigour in the parts. The difference of heat in the calf of the leg and foot has been known to be so much, that the former exceeded the temperature of the latter by 20 degrees of the thermometer. A very curious process takes place in the removal of dead parts, and is as follows Around the dead substance, in about two
58
LECTURE V.
days, there is observable a white prominent line ; this appear- ance is owing to a raised cuticle, under which there is serum : if you look 24 hours hence, attentively, the skin under this line will be absorbed ; this process passes very soon through the skin, a chasm becomes formed between the dead and the living parts by the absorption of the latter; the process continues ex- tending, till at length all are taken up except the bone. The process of absorption, in these cases, will be found to be much favoured by the application of nitrous acid: the inside of a bone will require two or three years to exfoliate; this is to be attributed to a languidness in the constitution.
In mortification, when the parts are separated by nature, a very curious and important circumstance occurs, which is, that the arteries, though completely eaten through, discharge no blood, and this is prevented by coagulation in the large arteries, to some little distance from the seat of the mor- tification.
The predisposing cause of mortification is principally de- bility; a languid habit is often observable to take place after great weakness has been induced on the system, by the severe attack of small pox, measles, scarlet fever, &c. Sores also are remarked to slough from the use of mercury exciting salivation, so as to produce the same effect, viz. debility ; also after con- siderable haemorrhage ; numerous other instances might be adduced, as any interruption to the circulation; as in hernia, &c.; ossification of the arteries; old age; pressure, by long continued lying in the same posture : but this may be referred at once to debility, erysipelas, and severe injuries, as gun-shot wounds, bruises, &c. &c. Climate, specific diseases ; as fluxes, &c. may be also enumerated.
It will be necessary to give a caution here, in amputating the limbs of those persons w hose disposition of body is favoura- ble for the formation of gangrene, to take care that they do not lose much blood, as the very worst effects have been known to result from such loss. Inflammation is the proximate cause of mortification ; if there be any exception to this, it is in hydro-thorax, but very rare even in this case. Frost bitteu part* do not die without previous inflammation.
LECTURE Y.
59
Treatment.
It consists, in the first place, of local evacuations, such as leeches to the part, scarifying, &c. and to strengthen the habit by a generous diet, and tonic medicines ; if the patient have been accustomed to take wine, or spirits of any kind, it will be advisable to allow him them in a moderate degree, so as not to heat him too much ; apply spirituous lotions, as spirits of wine and the liquor ammoniac acet. and camphor combined; turpentine also, in some instances, may be applied warm : re- lieving the parts by perspiration is proper, for which purpose the stale beer or wine lees poultices are useful ; but they should not be used before fomentations and emollient cataplasms have been applied, as the latter are preferable, owing to the inflam- matory state of the parts. Hunter advises that all the applica- tions made use of should be cold ; but it would be more prudent to consult the feelings of your patient, and warm ap- plications are occasionally seen to sooth and afford ease, where cold would not be productive of the same result. Opium alone, given in small doses, to ease the excessive pain suffered, will occasionally be preferable to its combination with the bark; but be careful, previous to its being administered, to open the bowels gently ; these are the means used to arrest the progress of the disease.
It mortification have already begun, apply stimulating poul- tices, as those already mentioned, stale beer, w ine, lees, &c. ; but the most advantageous poultice that the author has wit- nessed, and which has been employed from Hunter’s time to the present moment, with uniform success, is crop of beer united with oatmeal, and a spoonful of yenst added to it, and applied cool, and renewed at least twice daily, by it, the pro- giess of the mortification becomes checked, a separation from the living parts effected, and a secretion of healthy matter pro- duced. At the same time give decoction of bark internally, either combined with ammonia or opium, in small doses. If a diarrhoea be induced, unite the bark and opium with the aro- matic confection; this has been found to check it: but if it should be prolonged, give the misturu creta: with opium. If die patient be delirious, apply a large blister on the nape of his
60
LECTURE V.
neck, and internally give the camphorated mixture, with musk. Bark, in mortification, is combined with other medicines, by some, as the sulphuric acid, by others it is altogether omitted, and ammonia, opium, or musk, substituted; in some patients, bark certainly will disagree and prove prejudicial, under any form ; while in others it will be of the most decided advantage. Ward’s paste is sometimes made use of with great success; it is composed of the following ingredients, made into an elec- tuary : — Piper. Nigr. 3 ij. pulv. emul. camp. sem. foenicul. in pulv. aa ^ ss. Mellis Anglic, q. s. ut form, electuar. 3j. bis terve in die sumendus. This has been found very useful in sloughy and ill-conditioned sores of a scrofulous nature.
Allow the patient a generous diet, and introduce aromatics in it ; porter, good beer, wine or brandy may be given.
On the subject of Amputation.
It is certainly not right to operate till after the complete se- paration of the dead from the contiguous parts, that is, until a line of separation becomes evident, and this is one point among the few on which surgeons are unanimous; because, if you amputate before, you will still have the seeds of the disease in the system : but if mortification be the effect of a wound, or a division of an artery, then you may operate, as here there will have been no predisponent cause to gangrene ; also when ulcers are very large and extensive, it may be done with ad- vantage. Parts will often, as has been, before observed, se- parate without amputation ; but if we have reason to suspect that the stump will be very long and tedious, or that it would exhaust the patieut in the efforts to repair so extensive an in- jury, it will be preferable to take off the limb ; if the morti- fication have been considerable, the cure would at least prove troublesome, the stump of a bad form, and ultimately of little utility to the patient. With respect to giving opium, I have omitted one circumstance, it will be better to give it before, than after gangrene has taken place. Mortification is often the result of an ossification of arteries ; in old people it cannot be cured by any means that we are acquainted with. Mortifi- cation commonly attacks the toes and extremities of tall
LECTURE V.
61
people, for reasons easily explained, such as a degree of torpor in the circulation of those parts, owing to the great distance from the heart, by which the blood is not sufficiently propelled into them. It now and then is seen to proceed from the most trifling causes imaginable. It has been known to come on from cutting a nail to the quick, (the nail of the toe is meant). A gentleman had, unluckily, cut his nail in this man- ner; mortification ensued : on examining the course of the arteries, they were found ossified, and it was not difficult to foretel that he would not survive three weeks; which was the case, for he died in a fortnight afterwards. Mortification has been known to proceed from an opening made into a tumour on the great toe. The treatment in these cases consists in the use of fomentations; stimulating poultices; opium in- ternally; wrapping the feet and legs in flannel or wool ; apply- ing bottles of hot water to the feet, &c. &c.
LECTURE VL
'
OF THE FURUNCULUS, OR BOIL.
A uoil is a circumscribed, painful, inflammatory swelling, of considerable hardness to the feel, very prominent, and of a dark red colour. Boils are not generally of any considerable size ; a cyst is formed in the cellular structure for the reception of the matter, which is generally tedious in its formation : ex- cept where large, or when several exist at the same time, they do not affect the constitution. They mostly occur in young people, and are thought to be a salutary operation of nature. In their treatment, the object we ought to have principally in view is to facilitate the suppurative process, by every means in our power : poultices of an emollient nature are to be em- ployed, and an opening made into the most prominent part (which approaches when the process is nearly complete to that of a cone), an early opening is not recommended. The matter is of a thicker consistence than we And formed in abscesses ; it ought to be squeezed out, as the whole of it will not readily flow itself. If the boil be large, and very painful, it will be advisable to have recourse to opium : if the patient be much debilitated, bark and the sulphuric acid may be given ; mild purgatives are to be employed.
LECTURB VI.
63
ON THE CARBUNCLE.
A carbuncle is an abscess in which the cellular structure takes on a sloughy state; it differs not from a common process in its containing matter. The first appeal ance it assumes is similar to a boil, and of a bluish colour, raising a little above the skin, having within it commonly a bloody serum. It can be distinguished from other swellings by pressure, which causes a discharge in several parts of its surface ; it occurs mostly in old people, and in those accustomed to a debauched life, as tending in a great degree to debilitate and undermine the con- stitution. In England we see it preceded and accompanied by typhoid symptoms; abroad it marks the plague and other malignant disorders. Richerand tells us, in some provinces of France there is a particular species of this malignant boil. Carbuncles are occasionally seen very extensive, and the danger is proportionable to the extent and seat of the disease : Some- times, wheu on the neck, they are to be considered in a favour- able point of view, at other times not so, and this will be fa- vourable or not, according to the concurring circumstances. When in the rectum, the prognosis is unfavourable. As these malignant boils so easily take on a gangrenous or mortified dis- position : the same treatment here will be necessary as in those affections. Warm fomentations (the warmer in reason the better) are to be made use of ; emollient poultices will also be proper. Stimulants also, as turpentine or the mercurial plaster, &c. may be of advantage. Incisions should be made, which will relieve the skin greatly, by taking oft’ the sloughy substance ; but making openings in the very beginning of the disease, with any other view, than that of taking off the distention of the skin, would be improper. YY hen an opening is made, which ought to be done early, squeeze as much of the contents out as you possibly can, without occasioning consideiable pain; the constitutional treatment will consist m the exhibition of bark, aromatic confection, opium, &c. as recommended for mortification; allowing a generous and nourishing diet. Porter, wine, 8tc.
2
64
LECTURE VI.
ON BURNS AND SCALDS.
Burns may be divided into tlrree states or conditions :
The 1st. consists in a simple vesication, in which the cuticle remains unbroken.
The 2d. where the cuticle is extensively separated from the surface of the skin, so that the papillae of the extremities of nerves are exposed, which is most frequently the case, from the application of fire.
The 3d. in which the life of the cutis vera is gone, and where the process of suppuration is absolutely necessary.
The danger of the first state is but little, provided the vesi- cations are not disturbed, however extensive they may be, although on this subject there has been a severe controversy : in this state, the Liquor, plumb, acet. dll. et Apint. vin. should be frequently applied cold ; the chief object is to keep the blis- ter from breaking, as a considerable discharge would come on : otherwise no great irritation, and consequently no attendant danger arise. The spirit, vin. and acet., also a camphorat- ed lotion, as liq. plumb, acet. jss. spirit, camphor* jss. aq. distill, fhss. ft. lotio, may be applied with the same view.
The danger attending on the second, or that state in which the cutis is bare and exposed, is greater than in the preceding, owing to the increased sensibility of the parts, and it is no un- common thing for death to take place soon after such an acci- dent, when extensive, in consequence of the system receiving such a violent and immediate shock ; in this case you will find the pulse quick and small, and the patient frequently chilly, perhaps every quarter of an hour : so that he ultimately falls a victim to the first impression. It is somewhat curious, and at the same time worthy of remark, that children sometimes die of injuries apparently of a trivial nature: an instance of this occurred some time ago, in the case of a child, who died from a trifling scald on the nates, the same evening of the day the accident happened. Burns produced by hydrogen gas differ in their nature from those arising from other causes, and require a different treatment : in the one case a stimulus is necessary, in the other not. This was ascertained some time ago, in one of 1
LECTURE VI.
63
(.
llic hospitals in this metropolis, from the following circum- stance : — A young gentleman, who came from the North of England, and had seen a variety of burns and scalds, in which the turpentine (at that time so much talked of) had been used indiscriminately, and which he averred with success ; advised it for a patient in the hospital in which he was a dresser; but the fatal effects of it wrere very soon obvious ; besides this, it is necessary to observe, that should the patient -survive the acci- dent, still it is likely that death will take place, from secondary irritation. The practice usually followed is to administer opium and wine, and to apply lime water and milk, for the purpose of lessening the degree of irritability present, and also preventing the increased discharge, which would subsequently take place from the use of the stimulants. The old applica- tion, the liq. calcis, with oil, is still frequently used. Where granulations have arisen, as they will, extensively, in a few days, the following lotion is to be applied: — Ii. Zinci sulph. gr. \j. aq. fontanas J iv. M. ft. lotio. ; this will, in a short time, pro- duce a new cuticle, even over an extensive surface.
With respect to the third state, though there is no immediate danger, yet there is a remote one, for the" skin being destroyed, separates and forms an eschar, which must naturally debilitate the living powers, by calling on them beyond their natural eapacity. It is in this state that“we find so much benefit de- rived from the application of the ol. terebinth, first recom- mended by Dr. Keates ; this stimulates the parts, and promotes a quick restoration of them, and it is in those burns where the cutis is destroyed, that it has bean used with such manifest advantage and decided success. The author might instance the extensive iron-works at Cyfartha, Pendarren, Douglass, Tredegar, Sirhowey, Beaufort, Nantyglow, and Llanelly, in proof of this assertion ; and it is only in those cases where it has been used indiscriminately, that it has afforded any other than a satisfactory result; in some cases it is combined with linseed oil, in others used alone, in the first instance, and after- wards united with yellow basilicon for the subsequent dress- ings.
In the species before alluded to (the second) it has been
F
m
LECTURE VI.
already shown that turpentine will be more injurious than otherwise; and in children, if the life of the skin remain uninjured, it is an application of great severity. A case oc- curred in Guy’s Hospital, where the skin was uninjured, which afforded a very good opportunity of judging of its effects. A man was scalded nearly the same in both legs ; the white wash was applied to the one leg, and the turpentine to the other — in the former a new cuticle was soon formed : in the latter a sore was produced which was very irritable. A ridiculous objection has been made to what appeared a very convincing proof of the relative benefit of each application; that if two remedies be made use of at the same time, one counteracts the other : but here let one question be asked. Is it not very possible, in case of two buboes, by fomentations, &c. to bring one to suppurate, while, by an opposite mode of treatment, we disperse the other? — Still there can be no doubt as to the truth of those cases mentioned by the dresser, of the efficacy of turpentine in the North of England ; but burns, produced by hydrogen gas, are not attended with consequences so serious as others. Mr. Hey, of Leeds, recommends the use of turpentine : but it should not be applied when there is simple vesication, or in the second species, but only when the skin is destroyed.
It will be necessary to distinguish each species as here laid down, and the remedies will be found, by experience, to be those mostly successful; it will now be proper to state in as brief a manner as possible, what other applications and treat- ment have been advised by authors. Pare, Haldanus, and many others, think no injury will arise from puncturing the Vesicles, which they countenance ; but the author recollects a case, in practice, which directly bears on this point. Mrs. Baskerville scalded her left foot rather extensively ; the vesicles were punctured, and the fluid discharged ; but whether there was some peculiarity in her disposition and habit of body, or to whatever cause it may be attributed, so as to leave the punc- turing the vesicles totally out of the question, a mortification ensued, and was restrained with difficulty : this case was tedi- ously prolonged, but she perfectly recovered in the course of
L&CTUKE VI.
67
some time. Now what will Parti and others say, if the me- dical practitioner (a house pupil of John Hunter s, and a man as capable of practising as any provincial surgeon in the king- dom) attributed the principal mischief originally to the bad practice of puncturing the vesicles, which he most decidedly dis- approved of. Sir James Earle recommends ice, or the coldest water, made of a solution of sal ammoniac and saltpetre, to be applied either by means of linen, or that old favourite of the public, in these cases, scraped raw potatoes. Mr. Cleghorn, of Edinburgh, extols vinegar in burns and scalds, to be applied a little warmed ; and it must be allowed, that the fact of Hun- ter’s deeming a communication to thik effect, from M%. Cleg- horn, of sufficient importance to be published in the Medical Facts and Observations, contributed, riot a little, to raise the estimation of this remedy; the vinegar to be applied till the pain ceases, then a poultice, and afterwards pow'dered chalk. It is not a little curious, that two remedies; diametrically oppo- site to each other, should have attracted public attention, nearly at the same time. Sir James Earle’s, of ice, &c. ; and Dr. Kentish’s stimulating applications ; and I too wrill recollect Mr. AbernetliyV remarks on tetanus, ever to be forgotten ; they were to this effect: — that if the warrp bath be serviceable in tetanus, the cold one, reasoning ri priori, cannot be so, although authors would endeavour to reconcile us to those contradictions; if the cold bath be beneficial, on the same principle the warm bath cannot be advantageous. The author would think, unless rightand wrong are synonymous, applications so different cannot universally be useful, unless burns anti scalds are found to vary very much from what arc generally seen, both as to their different states and extent of the violence. Bat we must endeavour to draw a line of distinction at all events. Cold applications, it must be allowed, are not advisable in every kind of burns and scalds, neither are stimulating ones; hence let us see it we cannot tempt these two authors of Iceland and ot Guinea to approach each other. Dr. Kentish advises the parts to be bathed with the rectified spirits of wine, with or without camphor ; then the oleum terebinthinae with the ung. resin, flat, on lint, on the burns ; in the second application,
F 2
68
LECTURE VI.
laudanum or proof spirits may be substituted : and the oint- ment to be mixed with camphorated oil instead of turpentine* or the’ung. liquor, acet. plumb., or lapis calaminaris ; he then advises powdered chalk to be applied. The first dressings should remain on twenty-four hours.
Very great deformity now and then occurs from the granu- lations on the chin, adhering to those of the breast : of the thigh, to the abdomen : of the fore-arm, to the upper, &c. 8tc. : in the former the under lip is drawn down, and the saliva, by trickling over the breast, is apt to excoriate it ; here, by putting your finger behind the portion of skin, you can divide it, and then apply adhesive plaster; but should the union be complete, then the operation will be useless, of which several instances could be mentioned. We should, in the first instance, endea- vour to prevent its taking place, by interposing some body between, as the deformity is sometimes excessive, and the loss of character certain ; the best thing we can do is to apply ad- hesive plaster over the granulations, and upon this a soft cushion. The same treatment and attention is required for the thigh and fore-arm ; it is of no advantage to divide the skin between the arm and fore-arm, the deformity will exist. Sir James Earle has mentioned a case where the chin was united to the breast, on which he operated with benefit.
m
LECTURE VII.
ON WOUNDS.
Wounds are divided into four kinds : — the incised , or those which are occasioned by some cutting instrument ; the lace- rated, or those which are caused by parts being violently torn asunder; the contused, or that species arising from a blow happening to a part, by which the vitality of that part is de- stroyed ; fourthly, and lastly, the punctured, or those made by a sharp pointed instrument : of all the varieties of wounds, these are the most to be dreaded, on account both of their more immediate as well as remote effects ; from this description of wounds arise the locked jawf, 8cc. &c.
OF THE INCISED WOUND.
The direct effect of this species of wounds, is, besides the separation of the parts, the immediate discharge of a quantity of blood, greater or less, according to the-magnitude of the vessels divided. The more remote effect is that of inflamma- tion, and in the course of a very few hours the wound becomes covered with a gluey matter; the first object required is to put a stop to the haemorrhage, and this should always be done by means of pressure, if it be possible. It is always better to avoid
70
LECTURE VII.
applying ligatures if they can be done without, and in general, pressure, made for the space of five minutes, will be sufficient to stop the bleeding, more particularly if assisted by a dossil of lint oh the wound. This suppression of haemorrhage arises from the coagulation of blood around the extremities of the divided vessels, as well as in the mouths themselves. Then the subsequent inflammation, which always supervenes, is taken advantage of ; in order to facilitate a cure of the wound, the edges are brought together by means of adhesive plaster, and adhesion takes place, which glues the edges fast together ; in ob- serving the process of nature in healing wounds, the opinion that was formerly entertained of the bond of union, as this pro- cess was then termed, between the divided parts, is entirely ex- ploded ; no wound is united by the blood alone ; it was then thought that a coagula of blood was the uniting medium, but there is only one example ©f the healing of wounds, in which it happens that a clot of blood acts as an auxiliary to the healing process, and this is in the division of arteries. If a ligature be applied upon an artery, there is a clot of blood immediately formed within this artery, just above the ligature, but it does not become the immediate bond of union : inflammation takes place on the inner membrane of the vessel : coagulable lymph is poured out, and the part ultimately becomes organized by the elongation of the original vessels. But setting aside this one solitary example, we shall not find a parallel one, in w hich the blood forms the uniting bond. If a muscle or a tendon be divided with a sharp instrument, the reunion first ensues by the effusion of coagulable lymph into the cavity of the wound, and also whenever we are anxious to produce union by adhesive in- flammation.
The first necessary step must be to clear away all the sur- rounding blood, and that between the lips of the w ound, and unless this is done, it will prevent the adhesion, by being inca- pable of being rendered vascular; after this the parts are to be brought together neatly and closely by the adhesive straps, and supported by proper bandages.
In the course of a few days, eo-agulable lymph having been thrown out, vessels may be traced into this newly formed sub-
lecture VII.
71
stance, anti these are found to proceed fiom the divided ves- sels, as well as from the surrounding cellulai membiane. X have seen the tendo achilles of a dog which had been divided purposely, ten days before, at the end of which time the dog was killed, and the process examined ; there was about an inch of newly formed tendon, and this was rendered vascular, accord- ing to the above-mentioned manner \ to produce this, an increas- ed action is set up in the surrounding parts.
It is found that the newly formed part mostly takes on the same structure as the parts to which it is immediately united.
Supposing that it is skin only that is divided, inflammation takes place, coagulable lymph is effused, and this becoming- organized from the surrounding skin, by means of an extension of its vessels, a similar substance becomes replaced ; the cuticle also is reproduced, and in the course of time the rete muco- sum is also renewed, though a considerable time will elapse previous to its complete restoration. If cellular membrane, newly formed, exactly resemble that which previously existed, being reticulated ; the cells in the first instance are filled with lymph which causes it to appear denser ; but this is soon removed by the absorbent vessels. A similar process is going on when tendons are divided, as well as when injuries happen to the bones. Thus from these examples it is evident that the body is possessed of a power of reproducing a structure like in every respect to that which had been destroyed. To this however there are some exceptions, as has been mentioned, with respect to cartilages, as bone is reproduced, resulting from an increased action in the neigh- bouring vessels ; but if an experiment be made in any young animal, bone is not produced, but cartilage, so that the pecu- liarity in some degree depends upon the age. A second ex- ception is when muscles are divided, they are united by a ten- dinous substance. A third is with regard to glands ; these are not restored to their perfect state by means of a simple effusion of lymph, they will be found to have arteries, veins, nerves, and absorbent vessels, but no excretory duct, as the original gland had.
It will be found that this union by adhesion will take place
72
LECTURE V.IJ.
between soft parts and bone ; inflammation produces a severing of the parts, as the periosteum from the tibia, between which an effusion of lymph is produced, and by being endowed with vitality connects the two parts firmly together. This is often perceived in injuries done to the scalp, as well as the tibia, if the parts are applied together when found separated. This process will take place both in flat and iu cylindrical bones; as this is the case the obsolete practice of cutting away a portion of the scalp in fractures of the cranium, is done away with ; and for- merly, if the periosteum were separated from the tibia, it was the practice to cut it off, which occasioned tedious exfoliations : whereas, had it been laid down it would have united in a short time, and prevented the necessity at all for so tedious a process.
With respect to this union, it will be found not to hold good in an attempt to unite the articulating cartilages and the cel- lular membrane,' or common integuments : one of these is laid bare, as in removing a finger, and the integuments are Ibrought over it, as in the common amputation of a large extremity, they never become united to the cartilage, from a cavity being left, in which a fluid is secreted, which causes a tumour in the extremity of the stump ; therefore as this is now well known to happen, surgeons generally pare off the articulating cartilage, until the bones bleed, from which surface granulations arise, which will be sufficiently vascular to unite by the adhesive inflammation.
We are not to be deterred from attempting union by this process, even though the parts are much separated; for if they remain attached by a very small piece of integument alone, they will often unite, though apparently no chance of it existed. A case might here be adduced, which occurred in a near relation of Mr. Astley Cooper’s : — A boy playing with a dog, enraged him, when the animal seized the lad by the nose, and nearly bit it off; it hung down by a small portion of the cartilaginous septum : the parts being immediately brought to- gether, in the regular situation, so good an union took place, that the sour is scarcely perceptible, and no deformity is apparent.
lecture VII.
73
When Tippoo Snib, or Hyder Ali, took any English or Se- poys in the Mysorean wars, it was their general custom to cut off th tar noses, by which they were able to know them again when taken, then they invariably were put to death. In these cases, the native surgeons were in the habit of cutting a trian- gular piece of integuments from the forehead, twisting it half round, but not entirely separating it, and bringing it in such a manner as to form a nose ; the edges of the old wound on the face were pared off, and the edges of the skin brought down were inserted into the face; the form of the nose was sup- ported by parchment, or any other convenient substance stuffed in each nostril, until it gained power to support itself : in the course of some days the integuments thus brought down will unite, and the nose appear a very good substitute for the old one. The scar on the forehead will remain long a mark; but in time it will not be much perceived. In about 24 days after the operation the part which remained whole and twisted round may be removed at the root of the artificial nose, which clearly proves that inosculation must have ensued between the vessels of the nose and those of the cheek. This operation has been successfully performed in the west end of the town very lately.
In animals it has been found by experiments that parts which have been entirely separated, and even transplanted to another animal of a different gender, will unite and become supplied with blood vessels from their new possessor. Some analogical experiments of Hunter led him to take up the fanciful opinion, that he could convert a hen into a cock, by taking out the testes of the latter and inserting them into the abdomen of the former. This he actually tried, and though he did not succeed to the extent of his wishes, yet inflammation taking place, the new substance introduced was supplied with blood from the hen, and remained united there; yet nothing further w'as observed with respect to the change in the sex. The tooth of an animal just extracted was inserted into the comb of a cock, and this being bound on, united, and remained firmly attached and ad- herent, being supplied with vessels from that appendage.
Mr. Lucas of Guy’s hospital, has a preparation in which tlwe spur of a cock being inserted into his comb, it not only
74
LECTURE Vll.
united to this, but even to the bone of the cranium. With respect to similar analogical experiments on man, they have not been carried to a sufficient extent; yet Hunter ascertained that a sound tooth taken from the alveolar process of one per- son might be transplanted into that of another, and unite. Garengeot mentions a case nearly similar to some of those which have latterly been published, of parts of the body being entirely removed, afterwards replaced, and uniting. He says, a soldier’s nose was bit off completely, but on being directly- restored to its original situation, it became united. A marvel- lous case has been told of a man having his nose completely- removed, which fell into the gutter, the removed part wiped clean, replaced, and all did well. Few have gone the length of this case. — They will do pretty well for our credibility where they extend only to all-but separated, as innumerable instances could be adduced of such cases uniting well ; but when they are carried further, in the present state of our knowledge, they only stagger our belief in the truth of the asserted and attested cases.
Case. — A tailor’s wife holding a piece of w ood for her hus- band to cut through with a sharp cleaver, unluckily by his aiming a very straight forward blow, nearly, that is, “ all- but” separated his wife’s second linger of the left hand : she came under the author’s care, who suggested the propriety of attempting an union : she caught eagerly at the proposal, and this was deemed a very fair case to see the extent union could be carried to ; the parts were not entirely detached, but were held together by a small piece of integument only : in a month the finger was healed.
The mode of retaining parts in contact with each other when divided, are two, viz. the application of adhesive plaster, and using sutures. When the first is made use of, it should be applied in the form of slips across the wound, taking care to leave interstices between each for the escape of any matter which may be secreted, or blood which might be effused; for if this be not done, these acting as extraneous substances, will
LECTURE VII.
75
force the lips of the wound asunder, and thus render the sup- purative process and granulations necessary to heal it. The ex- ceptions to the use of adhesive plaster to every case of incised wound are but few. In the eye-lids, cheeks, and lips, sutures must be used, on account of the great mobility of these parts ; also in the scrotum, after extirpation of the testicle, &c. In wounds that are triangular, a suture had better be placed at the raised angle. When the muscles have been divided transversely, it is in general only necessary that the position of the limb should be attended to, as if it be placed in that posture by which the divided muscles can be relaxed, the edges of the wound will readily approximate ; and if a suture through a muscle should be incautiously or erroneously applied, it will occasion inflammation and violent spasms.
Ligatures should never be applied upon small arteries that are divided in incised wounds of parts, for by so doing, a greater surface is left to be filled up by granulations, which might have been healed by the adhesive process. The appli- cation of a roller moderately tight upon a slump or wound, will generally be sufficient to suppress the haemorrhage, even from the second rate arteries, and must remain on 24 hours. How- ever, below the knee, when a leg is amputated, all the vessels of any importance must be tied, as pressure cannot act upon those between the bones, or contiguous to them. There is a circumstance all surgeons that consider the welfare of their patients should avoid, namely, an idle curiosity of opening the wound or stump too soon ; the time that wounds ought to be allowed to remain unopened will be from three days to seven or eight, according to the extent and nature of the wound. After the operation for amputation, some are curious and desirous to see how the healing process goes on; in this it will often happen that the adhesive inflammation will give wav, and the parts recede, by which suppuration must ensue before the wound can possibly heal. The straps should not be removed undei seven days ; intervals must always be left between them, that any discharge taking place may have an opportunity of escaping. If there be pain or great inflammation after the amputation, it may be mostly removed by the application of
'76
LECTURE VII.
cold water to the stump ; if an oozing of blood ensues, by which the rollers and bandages are rendered stiff and uncom- fortable, it will be advisable to remove them, but the straps must remain. If a number of lymphatics are divided, the effusion of this fluid will retard the union of the wound.
CONTUSED WOUNDS.
A contused wound is occasioned by the collision of a blunt instrument or surface against a part of the body ; under these circumstances, it would be absurd to attempt union by the adhesive process. These wounds are not merely lesions of continuity, but are accompanied with such force and violence done to the substance of the part, that suppuration and slough- ing generally ensue, if the force applied have been sufficient to destroy the vitality of the part. In the course of a few hours inflammation comes on, and the absorbents take up the living substance immediately in contact with the dead part, and by this means it is separated from the other. The treatment is to be quite different from that of incised wounds : — carefully remove any extraneous bodies ; use leeches, fomentations, and poultices. It is also requisite, if the injury be extensive, to support the constitution under the process. After the bowels have been opened, opium and antimony are the best internal medicines: in some wounds of this description, the bark is found liable to irritate the stomach ; hence in these cases it would be better to omit it.
LACERATED WOUNDS.
Lacerated wounds are different from the other species, as the haemorrhage from them is much less. Sometimes whole limbs will be torn off with little or no blood being lost. Cheselden "has related a case which came in St. Thomas’s
o
Hospital, "where the arm and scapula were torn off, without any haemorrhage. These wouuds are often dangcrousj on account
/
LECTURE VII.
77
of their containing extraneous substances ; and they are more liable to be succeeded by tetanus than either of the two before mentioned.
Treatment. — After washing the wound very clean, and re- moving all extraneous bodies, it may be right to apply adhesive plaster to bring the edges of the wound together, or as near so as possible, to prevent nature from having so large a cavity to fill up as she otherwise would have by granulations ; afterwards apply emollient poultices. Leeches may be neces- sary, and sometimes the lancet is required, if the irritation be great. Opium, Sic. must be employed in these cases, the action of the bowels being previously regulated.
in'
LECTURE VIII.
ON PUNCTURED WOUNDS.
When wounds of this description are produced by any sharp pointed instrument, the effects resulting from them are three-fold : they excite inflammation of the absorbent vessels, they may wound the fascia, and they may destroy life by in- ducing tetanus. With respect to the first species, namely, that by which inflammation of the absorbent vessels is excited. The symptoms attendant upon a wound of this kind are as follows : red lines are seen extending from the wound to the next ab- sorbent gland in the course of these vessels ; on feeling them they are found to be hard and knotted where the valves are placed. The contiguous glands are enlarged; sometimes matter is formed in the vessels or glands, occurring in the lat- ter; and this also more frequently happens in wounds of the leg and foot than in those incident to the arm, on account of the vessels being larger in the part, and the circulation in the blood vessels more languid.
LECTURE VIII.
79
When suppuration takes place in the absorbents, from the inflammation consequent upon a punctured wound, the consti- tutional affection and irritation runs extremely high. These wounds are accidents frequently affecting medical men, who are in the habit of opening or dissecting bodies. A pupil in one of the hospitals in this city in sewing up a body, punctured lus linger about ten o,clock in the day : at nine the same eveuing, inflammation came on in the part, and became very considei- able ; on the ensuing day the local and constitutional symptoms were very severe 5 in the evening delirium came on, and he died 37 hours after the accident. It is generally thought that the putrid matter was the cause of these violent symptoms, it being inoculated under the skin by the instruments used ; but the body was quite fresh, and had been dead but a short time. From this case, and many others which have occurred, and which are seen every season, where no matter of the above kind could possibly have been introduced, it is evident that the severity of the symptoms depends upon the con- stitution of the patient, for these appearances will arise from pricking the linger or hand with scissars or needles, which could not have putrid matter upon them when entering the skin. Treatment. — Cut a piece of lunar caustic into a pointed shape like a point of a black lead pencil, and introduce this into the wound, and cauterize the whole internal surface of it. When this is done, very severe symptoms are prevented from coming on. If this should not have been done in the first instance, from fear of occasioning unnecessary pain, or too great confidence in yourselves to be materially alarmed about such an injury, at least dilate the wound ; should inflammation and pain have arisen, leeches and fomentations must be applied. The antiphlogistic regimen adopted to its full extent; calomel accompanied or succeeded by saline medicines ; opium and antimony must be given at the discretion of the surgeon. From imagining that a putrid diathesis existed, many surgeons were in the habit formerly of giviug wine, bark, &c. to correct it, and never allowed the symptoms resulted from inflamma- tion; the consequence was, that many died under this plan of treatment.
1
80
LECTURE VIII.
Mr. Astley Cooper, in dissecting, some years ago, punctured his finger; he had very severe symptoms resulting from it : he did not confide in his own knowledge, fearful he might not be so able to judge of the treatment necessary for himself, so satis- factory, as if well, and prescribing for another ; a medical prac- titioner was sent for, who recommended wine, &c. and Mr. Cooper had the resolution to submit to it for a very short time, but sufficiently long to find it only exasperated the disease : on / adopting the antiphlogistic regimen, he got better, though it was a long while before he became perfectly recovered, which change of air materially contributed to.
If the puncture be deep, the nitric acid may be used, as the caustic will scarcely reach the bottom of it ; these wounds hare been converted by some surgeons into simple ihcised wounds, by boldly laying them open ; but unless the wounds are deep, it is better practice to use the caustic liberally, as it will ever be attended with a prevention of the symptoms.
Although many have attempted to account for the pheno- mena, attendant upon these apparently trivial wounds, yet a great deal very unsatisfactory and inconclusive has been ad- vanced ; every thing depends on the form of the wound ; when a sharp-pointed instrument perforates the body, the cells of the cellular membrane are exposed, and the termination of
the absorbent vessels into these cavities : hence they become / , #
inflamed, and a progressive inflammation is set up in these vessel's, until they reach the next gland ; but when an incised wound occurs, blood is effused into the cavity, or coagulable lymph, by which the extremities of the vessels, of the absor- bents, are covered, and thus are prevented from removing into an inflamed state.
The second species of this description of wounds, are those which penetrate the fascia of any part of the body ; dangerous symptoms will here take place, frequently from the matter effused being confined by a tense covering, and unable to make its way out.
Case. — A botanist, in getting over a gate, ran a nail into his thigh, penetrating the fascia ; the inflammation was great, a day or two after the accident, and the constitutional symptoms were
LECTURE VIII.
81
also considerable; there was a swelling around the wound, fomentations and poultices were used, without any benefit, for some time; it then became necessary to make an incision down to the fascia, which was laid open, and which gave dis- charge to a large quantity of matter, when immediately the very urgent symptoms, before existing, were relieved. This is to be the mode of treatment in every case of this kind, and the incision must be made free, and to penetrate the fascia completely, otherwise the diseased symptoms will not abate. Mr. Jones applied to the author under the following circum- stances:— His son, a lad 12 years old, had, in going into the cellar with his shoes off-, trod on a nail or spike, which had entered in the hollow of his foot; he was in great pain, very much disturbed, and had no rest since the accident; the wound was immediately dilated, fomented, and poulticed. Opium was administered with saline medicines, to procure ease ; very little relief was obtained during the two succeeding days: when the leg was again examined, it then became evident there was a collection of matter confined under the theca, which the first dilatation of the wound had not reached ; a free and liberal opening was made now, by me, through it, by which a large collection of matter was evacuated ; the boy was much reduced during his short confinement. He now became. easy, slept well, and by the use of tonics and a generous diet, soon reco- vered.
Mr. Price’s servant met with a similar injury in the palm of the hand, and as he was not seen by me, in the first instance, fomentations and poultices were used; ultimate relief, however, was not obtained till a free opening was made through the aponeurosis, when every untoward symptom disappeared.
The third species of punctured wounds are those where nerves are affected ; when these occur tetanus is produced. Though tetanus is not always arising from injuries of the nerve? alone, as it will frequently be induced when wounds of tendons have occurred of a slight nature, either in the hands or feet, but mostly in the feet; this may be considered rather a medical disease, and comes with greater propriety under the province of
e
82
LECTURE VIII.
the physician, yet, as it is a consequence of wounds, it is right to notice it here.
It is divided into trismus and tetanus: trismus when confined to the muscles of the jaw and throat only ; tetanus when the whole body becomes more or less affected : and this last species when the body is bent forwards, is called emprosthotonos: when bent backwards, opisthotonos. It commences with general uneasiness and restlessness ; the suppurative discharge from the wound suddenly diminishes, and at length totally ceases; the surface becomes puffy and dried ; at first red, afterwards marbled. This phenomenon is accompanied with acute pains, which are increased by exposure to the atmospheric air, and by the slightest touch of external bodies. The pain continues to extend till the whole limb is affected; the Wounded parts inflame ; the muscles are seized with convulsive twitchings, accompanied or preceded by violent cramps ; a stiffness is felt about the neck, similar to that brought on by cold: the jaw. becomes fixed; the muscles of the back are then affected, which produces opisthotonos; the muscles of the limbs next; then those of the abdomen ; these are hard, but the body is not bent equally forward by the spasms in them : the limbs get stiff’, and the countenance has a peculiar smile on it, termed the risus sardonicus ; the last muscles becoming affected are the diaphragm and intercostals. The pulse is extremely quick previous to death, but it has never discovered intermission in it, which would indicate spasm of the heart ; cold perspirations pervade the body. The muscular irritation extends rapidly; deglutition becomes difficult, and in a short time impossible, on account of the forcible constriction of the pharynx and oesophagus. Although occasionally delirious, the functions of the brain however remain uninjured to the last moment of existence, so that the unhappy patient sees himself dying. When tetanus is general all the muscles are ’affected at once; the limbs become straight and immovable. The opisthotonos happens more rarely than the emprosthotonos, and it has been observed to be more speedily fatal. By the forcible extension of the vertebra of the neck forcing back the head, a compres- sion on the spinal marrow is produced, tmd a permanent con-
LECTURE VIII.
83
striction of the larynx and pharynx. The immediate causes of death may be imputed to the pressure on the abdominal viscera, the derangement which the organs of respiration ex- perience, to the stricture of the heart, and eventually to the congestion of the brain 5 and these appearances are confirmed by dissection.
The disease is divided into two species; the acute and chronic : the former proves so rapidly fatal, that little opportu- nity is afforded for the exhibition of medicines, and what has been given and done has mostly failed in arresting its progress. The latter has often been relieved, and has sometimes got well spontaneously. D. J. Larrey tells us, “ Experience shows that tetanus left to nature is in all cases fatal the surgeon then ought to have recourse without a moment’s delay to such means as the disease indicates, to remove the causes of irritation, and re-establish the suppressed excretions. In the former, . opium, camphor, musk, castor, &.c. and venesection, tepid bath, &c. have been often tried, and as often failed. In these cases, indeed, no reliance can be placed on such medicines; and with respect to opium, though apparently it has sometimes proved its beneficial effects, yet it frequently has been given to a great extent without any service being derived from its use. Mr. Stocker, of Guy’s Hospital, gave an ounce of the tincture of opium at a dose without its producing any sensible effect; the man died. On the medical treatment little can be said that would promise success ; I shall therefore select two passages from D. J. Larrey’s excellent work, which is more expressive on this subject than any other that I have perused. u Would it not be better to remove at once the wounded limb by ampu- tation the moment the symptoms of tetanus appear, than to wait for the resources of nature; and of the very uncertain remedies we possess for the cure, which so rarely takes place?” The unexampled success he met with ought to encourage its adoption.
In the chronic species more has been attributed to medicines than they deserve. Persons in these cases will often recover without a grain of physic. The cold bath has, we are told, been used with advantage, so also has the warm. I must
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84
LECTURE VIIT.
here, from the testimony that has been adduced, favour the cold bath. Relief has been afforded by the administration of large doses of steel, in the form of the tinctura ferri muriat. and ferri sulph., as well as from the free use of opium, and other antispasmodics, in this species.
Trismus will be induced from slight injuries, or from cold alone ; but it is not dangerous ; the electric aura will frequent- ly remove it, and will be found to have more influence than any other application, or medicine, in its removal; it must, however, be applied merely in the form of aura, as it will only exasperate the affection, if it be given in the form of sparks or shocks.
WOUNDS OF ARTERIES.
When arteries are wounded, they may generally be dis- covered to be injured very readily, by the blood being of a florid red colour, or by its escaping per saltum ; syncope will be produced, which will have the effect of arresting the pro- gress of the blood to the wounded vessel, and consequently put a stop to the haemorrhage, for the time being, at least; this affords an opportunity for the vessel to contract in diameter, and also to be closed by the formation of a coagula of blood in the mouth of the vessel, therefore, during this state of the system, a salutary effort of Nature is going forward, and ought to be encouraged, and not, as is usually the case, prevented by the administration of stimulants, &e. The manner in which the haemorrhage is suppressed is as follows : — when syncope is induced, the artery contracts, not exactly at the extremity, but above it, as far as the first anastamosing branch ; this will resist the flow of blood from the heart; the second circum- stance assisting this, is the retraction of the artery ; its drawing itself within its sheath, and blood which will become in a coagulated state, is accumulated round its extremity: and this will satisfactorily account for the stoppage of the bleeding, when the artery has been completely divided, which resists every application when only partially so. The third principal
lecture VIII.
85
circumstance is tlie sealing up of tlie end of tlie vessel by a clot formed within it, that is, formed within the cavity of the sheath, and projecting a very little way into the mouth of the vessel; this principally suppresses the haemorrhage, by its external pressure. These three circumstances always occur when an artery is divided by means of a sharp cutting instrument.
But when an artery is torn asunder, the mode of bleeding being stayed, is rather different. Arteries, in these cases, sel- dom bleed any. The cellular membrane here is twisted around the vessel, and acts in the same manner as a ligature. A man had his thigh torn off by the recoiling of a cable in a Margate hoy ; he was taken into an hospital, and the stump was ampu- tated ; the end of the artery had exactly the above-mentioned appearance. He recovered, for no bleeding happened at the time of the accident; this, however, is not always the case, for sometimes arteries are torn off, leaving the mouths open and completely exposed ; in these cases the texture of the vessel is destroyed by the extending power made use of, and this may be proved by experiment on the dead subject, for if an artery be very much lengthened, its circular form is altered, and it will collapse in a similar manner to a vein. Contused wounds of arteries do not shew themselves as very dangerous until some time after the accident has been received, namely, at the period when the sloughs separate. A person received a contused wound from a fall on the neck, nothing particular occurred at the time, and the man appeared going on well, but on the sloughing off of the bruised parts, a portion of the carotid artery came away along with them, and the man died instantaneously, from the effect of the haemorrhage. Punc- tured wounds of arteries produce every appearance of aneurism, and require the same operation.
Arteries have three coats: the external, which is white, dense, and very elastic ; the middle or thickest, composed of muscular fibres, arranged in a circular form ; and the internal which is extremely thin and smooth, possessing, considering its delicate structure, considerable elasticity and firmness, in a longitudinal direction, but w'eak, and easily torn in the circular.
m
LECTURE VIII.
We have ample proof of its vascularity, and it has been inferred that it is by no means destitute of sensibility. Arteries are connected with their sheaths, by means of fine cellular struc- ture: thus, when divided, they are capable of contraction as far as the first anastamosing branch, and retraction within their sheaths ; they possess a similar structure to other parts of the body, being supplied with arteries, veins, nerves, and absor- bents ; hence they are as susceptible of change as other parts of the body, and as able, when injured, to repair that injury, by a similar process, by the adhesive inflammation.
When pressure cannot be employed or trusted to suppress haemorrhage, ligatures become necessary. But for the imme- diate and suddenly arresting the profuse flow of blood, the ap- plication of a tourniquet will be required ; it cannot, with safety, be continued long, and its extent of operation is con- fined to the limbs. Every surgeon ought to understand the form and method of applying this instrument; if on the lower extremity, the best place will be about one-third the length of the thigh downwards, as the artery will be here passing close to the bone, and consequently easily compressed. If the upper extremity, about yths downwards, on the inner side of the biceps muscle. Temporary pressure may be made in the groin, on the femoral artery, by means of a key or something of the kind, and under the clavicle on the axillary artery also.
From Dr. Jones’s truly valuable work on haemorrhage, the intentions of applying ligatures are these: — To cut through the internal and middle coats of the artery, and to bring the wounded surfaces into apposition, thus allowing of the forma- tion of a coagulum of blood within the artery, exciting inflam- mation, and causing an effusion of lymph, which glues the clot to the sides of the vessel ; the using and applying ligatures, so as to divide the two coals, seems to be the desirable end to which we should be directed ; as When applied to an un- wouuded artery, a complete obliteration of the canal will be effected; hence broad flat ligatures, as used formerly, are objected to. The ligature ought to be round, firm, and not too thick, and applied as circular as possible, and drawn
LECTURE VIII.
87
round the vessel with sufficient lightness, then apply a knot ; always tie a large artery as separately and distinctly from sur- rounding parts as possible; and Dr. Jones coincides in opi- nion with Mr. Abernelhy, that it is the safest and best to use two ligatures, and to divide the artery between them, in cases especially of aneurism; and when large arteries are divided, this plan ought to be pursued ; ligatures usually separate from the largest artery in about a fortnight, from those of less size, in six or seven days. Never use force to detach them, but gentle efforts may be attempted, at each dressing, after the above period has elapsed.
When an artery is divided, or becomes impervious, blood is supplied to the limb, thus deprived of its nourishment by the principal trunk, by means of the enlargement of the collateral or anastamosing branches. When the accident happens in the carotid artery, the jugular vein must necessarily be divided.
OF SECURING THE ARTERIES.
The carotid artery may be tied without disturbance to the functions of the brain. Hebenstreit mentions a successful case of this vessel being tied, wounded in removing a can- cerous tumour. Mr. Abernethy secured this artery, in a large lacerated wound on the neck ; but his patient died. This experienced surgeon recommends the incision to be made on that side of it next the trachea, where no important parts are exposed to injury, carefully avoiding the par vagum in the ligature.
The subclavian artery has never been tied above the clavicle; but Mr. Keate had a case in which he successfully put a liga- ture upon this vessel, under the bone ; but it would be much better to make the incision above it, on account of the artery being more superficial in this situation: below, a great deal of care is requisite to avoid the subclavian vein and cephalic vein, and the thickness of the pectoral muscle will add to the diffi- culty of applying the ligature.
88
LECTURE VIII.
The axillary artery has been successfully tied by Mr. Hall, of Cheshire, wounded with a scythe. Mr. White, of Man- chester, details an unsuccessful instance ; but on dissection, three of the nerves were found included in the ligature. It is very seldom necessary to secure this vessel from a wound in it, as it is seldom seen injured ; in cases of amputation, at the shoulder-joint, it has been repeatedly operated on; it is rather a difficult thing to do this, from its being surrounded by the axillary plexus of nerves, from which it must be very carefully separated.
The brachial artery is closely accompanied by the median nerve; this artery has been frequently injured in bleeding from the arm. When this is the case two ligatures will be required, otherwise haemorrhage will occur, in consequence of the blood being returned into the lower part of the wounded artery, through the medium of anastamosing vessels.
Note. — The operations for each of these arteries will be found detailed under the article Aneurism.
The ulnar artery must be distinguished from the cubital nerve accompanying it ; the vessels must be taken up with a tena- culum ; the situation may be readily found by bending the arm and hand, when the tendon of the flexor carpi ulnaris will come into view ; the artery may be found on the inner side of it; the nerve, however, is between it and the tendon : two ligatures are required on this vessel, one above, and the other below the wound.
The radial artery is more frequently umunded than any other artery in the body, on account of its superficial situation, and it may be found on the outer side of the flexor carpi radialis; if two ligatures are not applied, it is liable to form a tumour of an aneurismal kind, from its anastamosing with the rami from the ulnar artery ; it should be taken up with a tenaculum, for though no nerves are present here, yet the tendons being numerous and small, may be accidentally included in the liga- ture. When this vessel is divided, where it passes down be- tween the thumb and fore-finger, on the back part of the hand, an incision must be made on the lower extremity, and it must
LECTURE VIII.
89
be tied; as the other end is apt to be retracted among the tendons, it is recommended to tie the vessel on the fore-part of the wrist, where the pulse is felt.
The femoral artery is occasionally divided; it must be tied under the edge of the Sartorious muscle, as in the operation which will be detailed hereafter for popliteal aneurism ; avoid- ing the anterior crural nerve, and the femoral vein.
To tie the popliteal artery, accurate knowledge and great presence of mind is required, as the vessel lies so very deeply imbedded in the muscles, the sciatic nerve must not be taken up instead of the artery. Mr. Cline saw a case of aneurism where the nerve was taken up instead of this vessel, and included in the lower ligature, the consequence of which was the death of the patient speedily. The nerve is much more superficially seated, and is on the outside. The popliteal vein is between the tw'o.
When the posterior tibial artery is wounded high up, the operation is attended with a great deal of difficulty. An incision must be made four inches in length : this will lay bare the gastrocnemii muscle, the fibres of which must be divided transversely, in order that they may retract and al- low of more space for the surgeon to find the vessel $ they should only be cut across, on the inner side, as the artery is situated here; the posterior tibial nerve must be avoided. A person who did not well understand the anatomy of the parts, would be deterred from operating, and be inclined to use lint and sponge, but which ought to be reprobated, as in two in- stances of this kind, where these were employed, mortification ensued from the high degree of inflammation induced by their remaining in the wound. When the artery is wounded lower down, it may easily be found just behind the malleolus interims. In wounds of the interosseal artery, Mr. Hey, of Leeds, re- commends a portion of the fibula to be sau'ed off; but it is not, except in very rare cases indeed, in the least degree necessary, as the vessel may always be found by making an incision close to the inner side of the bone where it lies.
The anterior tibial artery, in like manner to the posterior, is very difficult of access, when requiring to be tied at its upper
90
LECTURE VIII.
extremity, but when lower down, it is easily discovered. In a case published by Mr. White, this vessel was wounded high up, and he used sponge with success ; and this mode of treat- ment would be advisable, as the difficulty of tying it is great: when wounded on the foot, it is very evident to the feel, and ought to be secured.
91
LECTURE IX,
ON WOUNDS OF VEINS.
The largest vein that can be found on the external surface of the body may be wounded without any serious consequences resulting from it. The axillary vein is sometimes injured dur- ing an operation for the extirpation of the lymphatic glands in the axilla, yet the haemorrhage, from this large vessel, may be easily restrained by the application of a dossil of lint to the mouth of the bleeding vein. The femoral vein, close to Pou- part’s ligament, has been seen to be completely divided by a gun-shot without any immediate bad effects, though from the nature of the wound, the patient ultimately died. Although it may be said that generally no important consequences will follow the division of a large vein, yet, if inflammation take place in the vessel, dangerous symptoms will arise, though the divided vessel be only of the second or third class in point of magnitude. The truth of this remark is amply proved by numerous examples. In the simple operation of bleeding, patients have d?ed from the inflammation which has been in- duced in the vein, and which was formerly attributed to the puncture, either of a nerve or a tendon.
92
LECTURE IX.
The symptoms, denoting an accession of this inflammation, are a large or broad chord, felt under the skin both above and below the wound, in the vein: this is different from the hard line perceptible to the touch, when an absorbent vessel is in- flamed, as in this latter case the tumefied vessel is not larger than a pack-thread, while in an inflamed vein it is as large as the little finger : when this symptom exists in a vein, matter is formed within it ; this is contained in a cyst, and sometimes bursts externally, making its way through the coats of the tumour : or the coats of the tumour give way, and the matter becomes mixed with the venous blood. This circumstance of inflammation and suppuration in a vein, after bleeding, is more commonly occurring in animals than in the human species. It was from these that Hunter first discovered the cause to arise from inflammation, which was formerly placed to the account of an injured tendon or nerve. The causes of the affection are these : — the size of the wound ; from its not being carefully closed, and from the patient not being possessed of a healthy stamina. The treatment of these cases will be the same, in the first instance, as used for inflammation, and if not subdued, then by fomentations and poultices applied to the part itself, and evaporating lotions to the other parts of the vein and arm, as the spir. vin. camph., &c. When inflam- mation happens in a vein, Hunter judiciously advises us to apply pressure on the vessel above the seat of the injury, so as to prevent its extension, and confine it within certain limits, thus facilitating an adhesion of the sides. Mr. Abernethy re- marks, in some cases it will be actually necessary to com- pletely divide the vessel, with this intention, to arrest the pro- gress of the inflammation; Mr. Samuel Cooper observes, “ Might it not be better to put a ligature upon the suppurat- ing vein above the affected part ?” The answer clearly is, “certainly not;” and the following remarks will explain this subject.
A ligature on a vein is a much more dangerous operation than what surgeons in general are aware of. It has frequently been made use of to cure varices in the veins of the lower ex- tremities more particularly, and some few years ago it was put
LECTURE IX.
93
often in practice, but at the present time it is strongly repro- bated, on account of the fatal consequences which have re- sulted in a number of cases ; in three or four which the author has in Ins recollection, the vena saphena major was tied to effect the cure of ulcers and varices of the legs, without any mis- chievous consequences; but other cases have been witnessed, in which the patients died. It was then thought the mere division of this vessel would be sufficient, as it was very rightly conjectured, the ligature produced the bad symptoms ; this was often done with success, but two cases happened nearly at the same time, which terminated fatally. On the w hole, it is strongly recommended, not to operate in either way, if it be not, in consultation, held to be advisable, as the reputa- tion of a young surgeon might be entirely blasted by an un- fortunate case of this description ; and if any thing further be required to forbid this practice, it is, that there has not occurred one case where the disease was cured by its adoption (setting the fatality of it out of the question) unless a bandage was worn constantly afterwards, and as this bandage alone will always relieve, if not entirely cure, which it does frequently, it is much better to use a roller and evaporating lotions, accompanied with a purgative medicine occasionally. Numberless cases yield to this mode of treatment ; but even if it do not succeed, it is by no means prudent to resort to the above operation, which ought to be strongly deprecated.
WOUNDS OF THE NERVES.
When a nerve is divided, the effect is a destruction of the sensation and voluntary motion in the part to which that nerve was distributed, and a partial loss of involuntary motion in that part ; the power of arterial action is not destroyed, though it is most certainly weakened. Nerves, when divided, will unite again, so as to carry on the actions of the part in a greater or less time, according to the size of the nerve. A small nerve will require from ten to twelve w'eeks, a large one from four to six mouths. The sciatic nerve was divided in a fracture,
94
“LECTURE IX.
when six months elapsed before the patient could use his limb in the least. Electricity assisted very much this case. The brave Kosciusko had his sciatic nerve cut across in a battle in Poland, by a sabre : many months after, he came to England, and was obliged to be carried from one room to another. When union takes place, it is effected by means of the forma- tion of ganglion ; but if the extremities are very distant, union happens through the medium of a narrow nervous substance. If nerves are only partially divided, from their state of extension and tenseness, they will occasion excessive pain, and it will be advisable to make a complete division of the vessel, when it can be so ascertained. The only treatment it is possible to adopt, will be to place the ends of the nerves as nearly in appo- sition and contact as possible ; the rest of the cure must be left to Nature.
WOUNDS OF TENDONS.
These wounds arise from two causes : — from cutting instru- ments, and from the action of the muscles. The tendo achilles appears to be mostly divided, and the treatment, in this case, may be extended to the division of tendons in other parts of the body : pay attention to the relative situation of the in- cised muscle, with respect to its flexion and extension. The heel of the patient must be raised, and the foot extended as much as possible; in order to secure the foot in this position, a piece of adhesive plaster must be bound circularly round the calf of the leg, but previous to the application of this, a broad piece must be applied from the sole of the foot, over the heel, to the calf, at its posterior part; the circular piece is then to be put on, with the intention of securing and rendering the longitudinal piece firmer in its situation ; it is, therefore, to be secured above it. The slightest dressing must be applied to the wound, if there be any, and not the least pressure made upon it. However, if there exists much inflammation, leeches and fomentations must be had recourse to, to abate it, previous
LECTURE IX.
95
to tiie use of the plasters: great care must be taken to avoid pressure upon the ends of the tendon, otherwise it would be glued to the posterior part of the tibia and muscles, and thus prevent its motion in a great degree. The patient is to be ^onfined to his bed four or live days, at the expiration of which time he may get up, but must immediately have a high heeled shoe put on, to prevent the rupture of the newly formed ten- don, which would certainly take place, with very little exertion, if this were not done — he may be allowed to walk a little. The shoe should be one inch and a half high at the heel at least, and must be worn four or five weeks, gradually taking it down to its level.
Mr. Hunter ruptured his tendo achilles in dancing, and was supposed to be the first who improved on the old method of treating this accident, it being the practice formerly to stitch the ends of the tendons together. From his observation and experience, and what he reaped from others, particularly in the case of the Duke of Queensberry, he has completely establish- ed his mode of treatment as the best. Dr. Alexander Monro, of Edinburgh, met with this accident — he was confined five months by the treatment employed, w'hich is more complicated than what is now practised.
There is a partial rupture either in the tendon or some of the fibres of the gastrocnemei muscle occasionally occurring, always ensuing from muscular exertions : at the time it hap- pens the patient has a sensation of being struck on the part with a stone, he becomes lame, and a hollow may be perceived where the fibres have given way ; there is a slight ecchymosis from extravasation of blood in the part : if it be neglected, the patient will be lame for the remainder of life.
July gth, 1815, Col. Williams, of the 2d Garrison Battalion, met with this accident from a very trifling cause : making rather a longer extension in his walking to hear the news brought by the mail of the victories of the Duke of Wellington, he put his foot on a round stone and slipped. The author adopted the following plan: he pressed the muscle down, and applied a roller to retain it in that situation ; his stocking was put on,
and a cabinet-maker in the town immediately made, under his
2
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LECTURE IX.
inspection, of splints, a permanent apparatus to retain his leg and foot immovable, and in an extended posture ; it was fixed on the foot and on the calf of the leg, and answered every intention perfectly, making not the least pressure on the rup- tured tendon, — an evaporating lotion was occasionally applied^ — this was continued on for a week, but he was not confined at all to his bed ; a high heel shoe -was then substituted, and by being careful in his steps he was enabled to bustle about stoutly ; the heel was gradually depressed, and he recovered with scarcely any lameness.
On the 23d of January, 1816, the Colonel completely rup- tured the tendon ; the same means were again employed, and with the same success ; — he was however advised to continue the use of the high heel shoe longer before it was diminished. The lameness gradually lessened, and he found much benefit from putting his leg under a water spout every morning, which 6eemed to strengthen it very much.
Whether partially or completely divided, the same intentiom are to be kept in view.
WOUNDS OF THE ABDOMEN.
These may be divided into two kinds, namely, those which penetrate the parietes of the abdomen, without injuring any viscus ; and those which enter the cavity, and wound some one or more of the contained viscera. It is singular that very large wounds have been made into this cavity, without wounding any of these parts; this is arising from their eluding the blows, in consequence of their great mobility and lubricity. A cu- rious case, illustrative of this fact, w’as seen in a lady who divided the abdominal muscles and peritoneum from the ensi- form cartilage to the symphysis pubis, with a razor, without injuring in the least degree the intestines. In these cases, where none of the viscera are wounded, which may be known almost always by the attendant symptoms, the gastroraphe must be adopted as soon as possible, which means the sewing up of the wound, in order to shut up the cavity; then apply adhesive
LECTURE IX.
y?
plaster, aud a proper bandage to suppoit the paits in contact, in some cases the common interrupted suture will be best, if the wound be not very extensive. The antiphlogistic regimen must be adopted. Bleeding, purging, &c. must be had re- course to in order to obviate any undue degree of inflammation which will come on.
In the second case, where some viscus, as the stomach, is wounded, there are, immediately after, faintings, vomiting of blood, and the contents of this organ ; as well also as some of it being discharged from the wound, paleness, cold sweats, pulse scarcely perceptible, &c. In some few cases, where the wounds have been small, the patients have recovered : here nothing must be taken by the mouth for a week ; let the patient have strong nutritive glysters administered to support him, with opium; at the end of the week he may take a little jelly; in ten days a little broth, &c.; and' so on at the discre- tion of the practitioner. It will be necessary to bleed largely, and an attempt must be made to effect union by the adhesive inflammation.
If a surgeon be called to a wound in the intestines, and the gut does not protrude, nothing local can be done ; we are not warranted to enlarge the opening : opium must be adminis- tered and large bleedings had recourse to ; and although the pulse will be feeble and weak, yet the antiphlogistic regimen must be strictly adhered to: — but should the intestine protrude, the nature of the injury will be very obvious; and if the wound be only a very small one it may be returned, as in all probability it will unite by the adhesive process; but if not large, yet sufficient to let the faces escape, it may be closed by the appli- cation of a ligature around the orifice, cutting the ends of the thread close off. In an operation for strangulated hernia, per- formed at Guy’s Hospital, Mr. Astley Cooper found the intes- tine wouiided, and the small opening he included in a ligature, and the man did very well. Mr. Travers says, that a ligature applied round a portion of intestine acts in a similar manner to one applied on an artery ; the inner coats become divided, the external (the peritoneal) remains entire : from the interior co- agulablc lymph becomes deposited, and an union effected.
H
<J8
LECTURE IX.
Mr. John Bell recommends one stitch only, and the ligature to be attached with the gut to the external wound. Mr. Travers tells us, that the absolute contact of the everted surfaces of a divided intestine, in their entire circumference, is requisite to secure the animal from the danger of abdominal effusion — and that wounds amounting to a direct division of the canal are irreparable, and invariably fatal.
Dr. Smith, of Philadelphia, tried Mr. John Bell’s plan on dogs ; but in both instances they died from extravasation of faeces in the abdomen. Mr. Travers made the same experi- ment on four dogs, and he allowed the intestine to retract into the abdomen. Mr. Travers made one experiment with three stitches, cut the threads away, and returned the gut, being in all five cases, which were fatal : thus Dr. Smith and himself seem, as far as inferences can be drawn from the brute crea- tion, to controvert Mr. John Bell’s plan.
Longitudinal wounds must evidently be easier repaired than transverse, and the cause Mr. Travers assigns is, that they maintain a state of approximation by their longitudinal fibres resisting the action of the circular.
From what Mr. Travers has premised, he advises stitching a bowel at as many points as possible ; now from the following experiments this does not at all seem necessary. Mr. Astley Cooper repeated an experiment made by Duvergers, in which he had succeeded, on a dog — the interrupted suture was used. The trachea of a calf was included in the gut, and three stitches were employed to bring the divided intestine into contact; on the fifteenth day he killed the dog, and found the union com- plete. Mr. Cooper made another similar one, omitting the trachea of the calf, and the animal did well. Dr. Thompson divided the small intestine of a dog, and used five stitches — he cut the ends of the ligatures off’, and returned the gut ; the wound externally was secured with one stitch — and he also succeeded. Dr. Thompson repeated the experiment, and in six weeks he killed the dog, when it became apparent that the ligatures employed would make their way into the intestine, and be evacuated with the faeces ; cutting the ends of the liga- tures off was originally recommended by Mr. Benjamin Bell.
lecture IX.
99
Thus we have five experiments in opposition to Mr. Travers’s assumption, exclusive ot those made by Dr. Smith, who em- ployed four stitches with equal success.
Thus it would appear, that, unless there is a complete divi- sion of the tube, from three to four sutures are all that is necessary, and in the latter case probably it would be advisable to make as many as five : one fact is clear, the ends are to be cut off close to the intestine — that I believe is universally agreed on : — it would appear, that inflammation is much more violent and unrestrainable when the small intestines are wounded than the large. It has been recommended by some specula- tive surgeons, to introduce one end of the gut into the other, when divided; if these gentlemen had attended more to ex- periment, and less to theory and some fanciful notions of their own, they would have been convinced of the impossibility of effecting such an absurdity. In all these wounds the apparent debility, weakness of pulse, and coldness