■Ilium »ini|-v_-~" IT ' COLUMBIA LIBRARIES OFFS[~ Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/generalsurgicalp1879bill GENERAL SURGICAL PATHOLOGY AND THERAPEUTICS, fit Jfiftg-0m intern A TEXT-BOOK FOR STUDENTS AND PHYSICIANS. BY Dr. THEODOE BILLKOTH, PBOFE9SOE OF SURGERY IN VIENNA. TRANSLATED FROM THE FOURTH GERMAN EDITION, WITH THE SPECIAL PERMISSION OF THE AUTHOR, AND REVISED FROM THE EIGHTH EDITION, BY CHARLES E. HACKLEY, A.M., M. D., PHYSICIAN TO THE NEW YORK HOSPITAL, FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC., ETC. NEW YOEK: D. APPLETON AND COMPANY, 549 & 551 BROADWAY. 1879. Entered, according to Act of Congress, in the year 1871, by Charles E. Hacklet, in the Office of the Librarian of Congress, at Washington. Entered, according to Act of Congress, in the year 1S73, by Charles E. Hacklet, in the Office of the Librarian of Congress, at Washington. Entered, according to Act of Congress, in the year 1879, by Charles E. Hacklet, in the Office of the Librarian of Congress, at Washington. TRANSLATOR'S PREFACE TO THE REVISED EDITION. Since this translation was revised from the sixth German edition in 1874, two other German editions have been pub- lished. The present revision is made to correspond to the eighth German edition. In order to make use of the stereotype plates of the former edition as far as possible, some of the additions have been inserted in an appendix. These are numbered, and are referred to in the text by corresponding numbers. Lister's method of antiseptic treatment is referred to in various places ; and other new points that have come up within a few years are discussed. A chapter has been written on ampu- tations and resections. In all there are seventy-four additional pages, with a number of new woodcuts. CHAS. E. HACKLEY, M.D. New York, December, 18*78. TRANSLATOR'S PREFACE. During the past ten years the microscope has greatly ad- vanced our knowledge of Pathology ; and it will perhaps be acknowledged that most progress in the study of Pathological Anatomy has been made in Germany. Prof. Theodor Billroth, himself one of the most noted au- thorities on Surgical Pathology, has in the present volume given us a complete resume of the existing state of knowledge in this branch of medical science. The book might perhaps have been entitled " Principles of Surgery," but this would hardly have indicated the specific man- ner in which these principles have been inculcated. Most of the views found in these lectures have been floating through the journals for several years past ; but, so far as the translator knows, they are not so fully presented in any book in the English language. The only work in our language on the subject was published many years ago ; even the late editions are but little changed from the first ; moreover, the two works are, in most respects, entirely unlike. The fact of this publication going through four editions in Germany, and having been translated into French, Italian, Rus- sian, and Hungarian, should be some guarantee for its standing. Some few notes that have been inserted by the translator will be found enclosed in brackets [ ]. New York, December 1, 1870. PREFACE TO THE EIGHTH GERMAN EDITION. This edition also has been carefully revised, and some addi- tions have been made to it. It is the hope of the author that the book will continue to be acceptable and beneficial to students of surgery. In addition to previous translations, there has been a new English one made under the auspices of the New Sydenham Society, as well as one into Japanese by Dr. Susum Sato. TH. BILLEOTH. AUTHOR'S PREFACE TO THE SIXTH EDITION. The steady advance of science, and the progress that we our selves make as long as we have the inclination and strength to swim with the stream, become most apparent when we are from time to time obliged to go over our old work. On a similar occasion I have already expressed this thought, but do not hesi- tate to repeat it here ; for this perception of progress is a great support to us in the many dark hours when, with the greatest zeal to serve our fellow-men, we feel oppressed by the impotence of our knowledge and ability. I have again done my best to raise this book to the present level of our knowledge, and have untiringly striven to improve its form and contents ; the section on Deformities has been en- tirely rewritten, old woodcuts have been replaced by better ones, and some new ones have been added; prescriptions have been given in grammes. May this enlarged edition also be well received, and arouse in the student a love of surgery! TH. BILLKOTH. Vienna, November, 1872. PREFACE TO THE FOURTH EDITION. Almost every time that it has become my pleasant task to go over this book in preparing a new edition, I have thought, this time at least, there will not be much to alter ; nevertheless, I always found much, very much to improve, to cut out or to add. In so doing, I have always had the satisfaction of knowing that even in short periods the progress of science had been quite perceptible. We do not notice this much while swimming with the stream, but it becomes very evident when we have before us a book that is to a certain extent a photogram of the state of affairs two years since. The success that this edition meets with will show whether I have again succeeded in presenting my book in a shape to meet the requirements of physicians and students. The section on traumatic inflammation has been revised in accordance with recent advances. In the chapter on tumors, the part treating of carcinoma has been simplified, the term " connective-tissue cancer " being omitted, to prevent confusion. The liberality of the publisher has enabled me to increase the number of woodcuts by twenty-nine (Figs. 47, 53, 55, 58, 66, 68, 69, 70, 74, 91, 98, 99, 103, 106, 107, 108, 109, 110, 111, 112, 122, 123, 124, 125, 126, 127, 128, 132, 133). De. TH. BILLROTH. Yiexxa, November, 1869. CONTENTS, LECTUKE I. INTRODUCTION. Relation of Surgery to Internal Medicine. — Necessity of the Practising Physician heing acquainted with both. — Historical Eemarks. — Nature of the Study of Sur- gery in the German High-school, page 1 CHAPTER I. SIMPLE INCISED WOUNDS OF THE SOFT PARTS. LECTUEE II. Mode of Origin and Appearance of theae "Wounds. — Various Forms of Incised Wounds. — Appearance during and immediately after their Occurrence. — Pain, Bleeding. — Varieties of Haemorrhage ; Arterial, Venous. — Entrance of Air through Wounded Veins. — Parenchymatous Haemorrhage. — Hsemorrhagic Diathesis. — Haemorrhage from the Pharynx and Eectum. — Constitutional Effects of Severe Haemor- rhage, p. 17 LECTUEE III. Treatment of Haemorrhage. — 1. Ligature and Mediate Ligature of Arteries. — 2. Com- pression by the Finger ; Choice of the Point for Compression of the Larger Arte- ries. — Tourniquet. — Acupressure. — Bandaging. — Tampon. — 3. Styptics. — General Treatment of Sudden Anaemia. — Transfusion, . .... p. 26 LECTUEE IV. Gaping of the Wound.— Union by Plaster. — Suture ; Interrupted Suture ; Twisted Su- ture. — External Changes perceptible in the United Wound. — Healing by First In- tention, p. 41 LECTUEE V. The more Minute Changes in Healing by the First Intention. — Dilatation of Vessels in the Vicinity of the Wound. — Fluxion. — Different Views regarding the Causes of Fluxion, p. 49 LECTUEE VI. Changes in the Tissue during Healing by the First Intention. — Plastic Infiltration.— Inflammatory New Formation. — Eetrogression to the Cicatrix. — Anatomical Evi- X CONTENTS. dences of Inflammation. — Conditions under which Healing by First Intention does not occur. — Union of Parts that have been completely separated, . . page 58 LECTUEE VII. Changes perceptible to the Naked Eye in Wounds with Loss of Substance. — Finer Pro- cesses in Healing with Granulation and Suppuration. — Pus. — Cicatrization. — Obser- vations on "Inflammation." — Demonstration of Preparations illustrative of the Healing of Wounds, p. 70 LECTUEE VIII. General Eeaction after Injury.— Surgical Fever. — Theories of the Fever.— Prognosis. — Treatment of Simple Wounds and of Wounded Persons. — Burrowing Wounds. — Open Treatment of Wounds. — Lister's Method. — Coccobacteria Septica, . p. 88 LECTUEE IX. Combination of Healing by First and Second Intention. — Union of Granulation Surfaces. Healing under a Scab. — Granulation Diseases. — The Cicatrix in Various Tissues ; in Muscle ; in Nerve ; its Knobby Proliferation ; in Vessels. — Organization of the Thrombus. — Arterial Collateral Circulation, p. 99 CHAPTER II. SOME PECULIABITIE8 OF PUNCTURED WOUNDS, LECTUEE X. As a Eule, Punctured Wounds heal quickly by First Intention. — Needle Punctures ; Needles remaining in the Body, their Extraction. — Punctured Wounds of the Nerves. — Punctured Wounds of the Arteries : Aneurysma Traumaticum, Varicosum, Varix Aneurysmaticus. — Punctured Wounds of the Veins, Venesection, . . p. 130 CHAPTER III. CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. LECTUEE XI. Causes of Contusions. — Nervous Concussion. — Subcutaneous Eupture of Vessels. — Kup ture of Arteries. — Suggillations. — Ecchymoses. — Eeabsorption. — Termination in Fibrous Tumors, in Cysts, in Suppuration, and Putrefaction. — Treatment, p. 141 CHAPTER IV. CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. LECTUEE XII. Mode of Occurrence of these Wounds ; their Appearance. — Slight Haemorrhage in Con- tused Wounds. — Early Secondary Haemorrhages. — Gangrene of the Edges of the Wound. — Influences that effect the Slower or more Eapid Detachment of the Dead Tissue. — Indications for Primary Amputation. — Local Complications in Contused Wounds; Decomposition, Putrefaction, Septic Inflammations. — Contusion of Ar- teries ; Late Secondary Hemorrhages, p. 152 CONTENTS. xi LECTUEE XIII. Progressive Suppuration starting from Contused Wounds. — Secondary Inflammations of the Wound: their Causes; Local Infection. — Febrile Eeaction in Contused Wounds : Secondary Fever ; Suppurative Fever ; Chill ; their Causes. — Treatment of Contused Wounds : Immersion, Ice-bladders, Irrigation ; Criticism of these Methods. — Incisions. — Counter-openings. — Drainage. — Cataplasms. — Open Treat- ment of Wounds. — Prophylaxis against Secondary Inflammations. — Internal Treat- ment of those severely Wounded. — Quinine. — Opium. — Lacerated Wounds : Sub- cutaneous Eupture of Muscles and Tendons ; Tearing out of Muscles and Tendons ; Tearing out of Pieces of a Limb, page 164 CHAPTER V. SIMPLE FRACTURES OF BONES LECTUEE XIV. Causes, Different Varieties of Fractures. — Symptoms, Diagnosis. — Course and External Symptoms. — Anatomy of Healing, Formation of Callus. — Source of the Inflamma- tory Osseous New Formation. — Histology, p. 185 LECTUEE XV. Treatment of Simple Fractures. — Eeduction. — Time for applying the Dressing, its Choice. — Plaster of Paris and Starch Dressings, Splints, Permanent Extension. — Eetaining the Limb in Position. — Indications for removing the Dressings, p. 201 CHAPTER VI. OPEN FB AG TUBES AND SUPPUBATION OF BONE. Difference between Subcutaneous and Open Fractures in regard to Prognosis. — Vari- eties of Cases. — Indications for Primary Amputation. — Secondary Amputation. — Course of the Cure. — Suppuration of Bone. — Necrosis of the Ends of Frag- ments, ... p. 210 LECTUEE XVI. Development of Osseous Granulations. — Histology. — Detachment of the Sequestrum. — Histology. — Osseous New Formation around the Detached Sequestrum.— Callus in Suppurating Fractures. — Suppurative Periostitis and Osteomyelitis. — General Con- dition. — Fever. — Treatment ; Fenestrated, Closed, Split Dressings. — Antiphlogis- tic Eemedies. — Immersion. — Lister's Method. — Eules about Bone-splinters. — After-Treatment, . p. 216 APPENDIX TO CHAPTERS Y. AND VI. LECTUEE XVII. 1. Eetarded Formation of Callus and Development of Pseudarthrosis. — Causes often unknown. — Local Causes. — Constitutional Causes. — Anatomical Conditions. — Treatment: internal, operative; Criticism of Methods. 2. Obliquely-united Fractures; Eebrealring, Bloody Operations. — Abnormal Development of Cal- lus, p. 226 x ji CONTENTS. CHAPTER VII. INJURIES OF THE JOINTS. Contusion. — Distortion. — Massage. — Opening of the Joint, and Acute Traumatic Ar- ticular Inflammation. — Variety of Course, and Results. — Treatment. — Anatomical Changes, page 234 LECTUEE XVIII. Simple Dislocations; Traumatic, Congenital, Pathological Luxations, Subluxations. — Etiology.— Difficulties in Eeduction, Treatment; Reduction, After-Treatment.— Habitual Luxations.— Old Luxations, Treatment.— Complicated Luxations.— Con- genital Luxations, p. 242 CHAPTER VIII. G UNSH T-WO UN D S. LECTUEE XIX. Historical Eemarks.— Injuries from Large Missiles.— Various Forms of Bullet-Wounds. —Transportation and Care of the Wounded in the Field.— Treatment.— Compli- cated Gunshot-Fractures, p. 254 CHAPTER IX. BURNS AND FROST-BITES. LECTUEE XX. 1. Burns : Grade, Extent, Treatment.— Sunstroke.— Stroke of Lightning.— 2. Frost- bites : Grade. — General Freezing, Treatment. — Chilblains, . . .p. 266 CHAPTER X. ACUTE NON-TRAUMATIC INFLAMMATION OF THE SOFT PARTS. LECTURE XXI. General Etiology of Acute Inflammations. —Acute Inflammation : 1. Of the Cutis. a, Erysipelatous Inflammation ; i, Furuncle ; c, Carbuncle (Anthrax), Pustula Ma- ligna. 2. Of the Mucous Membranes. 3. Of the Cellular Tissue, Acute Abscesses. 4. Of the Muscles. 5. Of the Serous Membranes, Sheaths of the Tendons, and Subcutaneous Mucous Bursa?, ' . . . -p. 277 CHAPTER XI. ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, AND JOINTS. LECTURE XXII. Anatomy. — Acute Periostitis and Osteomyelitis of the Long Bones : Symptoms, Ter- minations in Resolution, Suppuration, Necrosis, Prognosis, Treatment. — Acute Ostitis in Spongy Bones. — Multiple Acute Osteomyelitis.— Acute Inflammations of the Joints. — Hydrops Acutus ; Symptoms, Treatment. — Acute Suppurative In- flammations of Joints : Symptoms, Course, Treatment, Anatomy. — Acute Articular Rheumatism. — Arthritis. — Metastatic Inflammations of Joints (Gonorrhoea!, Py- emic, Puerperal), p. 300 APPENDIX TO CHAPTERS I.-XI. Review. — General Remarks about Acute Inflammation, p. 317 CONTENTS. xiii CHATTER XII. GANGRENE. LECTUEE XXIII. Dry, Moist Gangrene. — Immediate Causes. — Process of Detachment. — Varieties of Gan- grene according to the Kemote Causes.— 1. Loss of Vitality of the Tissue from Mechanical or Chemical Causes. — 2. Complete Arrest of the Afflux and Efflux of Blood. — Incarceration. — Continued Pressure. — Decubitus. — Great Tension of the Tissue. — 3. Complete Arrest of the Supply of Arterial Blood. — Gangrena Spon- tanea. — Gangrena Senilis. — Ergotism. — 4. Noma. — Gangrene in Various Blood- Diseases. — Treatment, page 326 CHAPTER XIII. ACCIDENTAL TRAUMATIC AND INFLAMMATORY DISEASES, AND POISONED WOUNDS. LECTUEE XXIV. I. Local Diseases which may accompany "Wounds and Other Points of Inflammation : 1. Progressive Purulent and Purulent Putrid Diffuse Inflammation of Cellular Tissue. — 2. Hospital Gangrene. — 3. Traumatic Erysipelas. — L Lymphangitis, p. 338 LECTUEE XXV. 5. Phlebitis ; Thrombosis ; Embolism. — Causes of Venous Thrombosis ; Various Meta- morphoses of the Thrombus. — Embolism. — Red Infarction, Embolic Metastatic Abscesses. — Treatment, . p. 353 LECTUEE XXVI. II. — General Accidental Diseases which may accompany Wounds and Local Inflamma- tions. 1. Traumatic and Inflammatory Fever ; 2. Septic Eever and Septicaemia; 3. Suppurative Fever and Pyaemia, p. 362 LECTUEE XXVII. 4. Tetanus; 5. Delirium Potatorum Traumaticum; 6. Delirium Nervosum and Mania- Appendix to Chapter XIII. — Poisoned Wounds ; Insect-bites, Snake-bites ; Infec- tion from Dissecting Wounds.— Glanders. — Carbuncle. — Diseases from Mouths and Claws of Animals.— Hydrophobia, p. 386 CHAPTER XIV. CHRONIC INFLAMMATION ESPECIALLY OF THE SOFT PARTS. LECTUEE XXVIII. Anatomy: 1. Thickening, Hypertrophy ; 2. Hypersecretion; 3. Suppuration, Cold Abscesses, Congestive Abscesses, Fistulas, Ulceration. — Eesults of Chronic Inflam- mation. — General Symptomatology. — Course, p. 403 LECTUEE XXIX. General Etiology of Chronic Inflammation. — External Continued Irritation. — Causes in the Body. — Empirical Idea of Diatheses and Dyscrasiae. — General Symptomatology and Treatment of Morbid Diatheses and Dyscrasias. 1. The Lymphatic Diathesis (Scrofula); 2. Tuberculous Dyscrasia (Tuberculosis); 3. The Arthritic Diathesis ; 4. The Scorbutic Dyscrasia ; 5. Syphilitic Dyscrasia, . . . .p. 410 xiv CONTENTS. LECTURE XXX. Local Treatment of Chrome Inflammation : Rest, Compression, Moist "Warmth, Hy- dropathic Wraps, Eesorbents, Antiphlogistics, Derivatives, Eontanels, Setons, Moxae, the Hot Iron, page 429 CHAPTER XY. ULCERS. LECTURE XXXI. Anatomy. — External Peculiarities of Ulcers ; Form and Extent, Base and Secretion, Edges, Parts around. — Local Treatment according to the Local Condition of the Ulcer ; Fungous, Callous, Putrid, Phagedenic, Sinuous Ulcers, Etiology, Contin- ued Irritation, Venous Congestion, Dyscrasial Causes, . . . . p. 434 CHAPTER XYI. CHRONIC INFLAMMATION OF THE PERIOSTEUM, OF THE BONE, AND NECROSIS. LECTURE XXXII. Chronic Periostitis and Caries Superficialis. — Symptoms. — Osteophytes. — Osteoplastic, Suppurative Forms. — Anatomy of Caries. — Etiology. — Diagnosis. — Combination of Various Forms, p. 44S LECTURE XXXIIL Primary Central, Chronic Ostitis, or Caries. — Symptoms. — Ostitis Interna Osteoplas- tica, Suppurativa, Fungosa. — Abscess of Bone. — Combinations. — Ostitis with Cas- eous Metamorphosis. — Tubercles of Bone. — Diagnosis of Caries. — Dislocation of the Bones after their Partial Destruction. — Congestion Abscesses. — Etiology, p. 458 LECTURE XXXIV. Process of Cure in Caries and Congestion Abscesses. — Prognosis. — General Health in Chronic Inflammations of the Bone. — Secondary Lymphatic Enlargements. — Treatment of Caries and Congestion Abscesses. — Resections in the Conti- nuity, p. 468 LECTURE XXXV. Necrosis. — Etiology. — Anatomical Conditions in Total and Partial Necrosis. — Symp- toms and Diagnosis. — Treatment. — Sequestrotomy, p. 479 LECTURE XXXVI. Rachitis. — Anatomy. — Symptoms. — Etiology. — Treatment. — Osteomalacia. — Hypertro- phy and Atrophy of Bone, p. 495 CHAPTER XVII. CHRONIC INFLAMMATION OF THE JOINTS. LECTURE XXXVII. General Remarks on the Distinguishing Characteristics of the Chief Forms. — A. Fun- gous and Suppurative Articular Inflammations (Tumor Albus), Symptoms, Anato- my, Caries Sicca, Suppuration, Atonic Forms. — Etiology. — Course and Prog- nosis, P- 503 CONTENTS. XV LECTUEE XXXVIII. Treatment of Tumor Albus. — Operations. — Eesection of the Joints. — Criticisms on the Operations on the Different Joints, page 514 LECTUEE XXXIX. B. — Chronic Serous Synovitis. — Hydrops Articulorum Chronicus; Anatomy, Symp- toms, Treatment. — Typical recurring Dropsies of the Knee. — Appendix: Chronic Dropsies of the Sheaths of the Tendons, Synovial Hernias of the Joints and Sub- cutaneous Mucous Bursa?, p. 524 LECTUEE XL. C. — Chronic Eheumatic Inflammation of the Joints. — Arthritis Deformans. — Malum Coxse Senile. — Anatomy, Different Eorms, Symptoms, Diagnosis, Prognosis, Treatment. — Appendix I. : Foreign Bodies in the Joints : 1. Fibrinous Bodies ; 2. Cartilaginous and Bony Bodies ; Symptomatology, Operations. — Appendix II. : Neuroses of the Joints, p. 534 LECTUEE XLI. Anchyloses : Varieties, Anatomy, Diagnosis, Treatment ; Gradual Forced Extension ; Operations with the Knife, p. 546 CHAPTER XVIII. CONGENITAL DEFORMITIES OF THE JOINTS DUE TO MUSCULAR AND NER- VOUS AFFECTIONS AND CICATRICIAL CONTRACTIONS.— LOXARTHROSES. LECTUEE XLII. I. Deformities of Intra-uterine Origin due to Disturbances of Development of the Joint. — II. Deformities occurring only in Children and Young Persons, caused by Impaired Growth of the Joint. — III. Deformities from Contractions, or Paralysis of Single Muscles or Groups of Muscles. — IV. Limitation of Movements in the Joints from Contraction of Fasciae and Ligaments. — V. Cicatricial Contractions. — Treatment. — Extension by Apparatus, Straightening under Anaesthesia. — Com- pression.— Tenotomy and Myotomy. — Division of the Fasciae and Articular Liga- ments. — Gymnastics and Electricity. — Artificial Muscles. — Supporting Appara- tus, p. 558 CHAPTER XIX. VARICES AND ANEURISMS. LECTUEE XLIII. Varices : Various Forms, Causes, Various Localities where they occur.— Diagnosis.— Vein-stones.— Varix Fistulte. — Treatment. — Varicose Lymphatics, Lymphorrhoea. — Aneurisms : Inflammation of Arteries. — Aneurysma Cirsoideum. — Atheroma. — Various Forms of Aneurism.— Their Subsequent Changes.— Symptoms, Eesults, Etiology, Diagnosis. — Treatment: Compression, Ligation, Injection of Liquor Ferri, Extirpation, • . . . p. 576 CHAPTER XX. TUMORS. LECTUEE XLIV. Definition of the Term Tumor. — General Anatomical Eemarks ; Polymorphism of Tissues.— Points of Origin of Tumors. — Limitation of the Development of Cells to Certain Types of Tissue. — Eelation to the Generative Layers. — Mode of Growth. — Anatomical Metamorphosis of Tumors; their External Appearances, . . p. 595 XVI CONTENTS. LECTUEE XLV. Etiology of Tumors ; Miasmatic Influence. — Specific Infection.— Specific Eeaction o( the Irritated Tissues ; its Cause is always constitutional. — Internal Irritations ; Hypotheses as to the Character and Mode of the Irritant Action. — Course and Prognosis : Solitary, Multiple, Infectious Tumors. — Dyscrasia. — Treatment. — Prin- ciples of the Classification of Tumors, . page 605 LECTUEE XLVI. 1. Fibromata: a, Soft; b, Hard Fibroma. — Mode of Occurrence ; Operations; Ligature; Ecrasement ; Galvano-caustic. — 2. Idpomata : Anatomy ; Occurrence ; Course. 3. Chondromata: Occurrence; Operation. — L Osteomata: Forms; Operation, p. 618 LECTUEE XLVII. 5. Myoma. — 6. Neuroma. — 7. Angioma: a, Plexiform; b, Cavernous. — Operations, p. 637 LECTUEE XLVIII. 8. Sarcomata. — Anatomy : a, Granulation Sarcoma ; b, Spindle-celled Sarcoma ; c, Giant- celled Sarcoma ; d, Stellate Sarcoma ; e, Alveolar Sarcoma ; f, Pigmented Sarcoma. — Clinical Appearance. — Diagnosis. — Course. — Prognosis. — Mode of Infection. — Topography. — Central Osteosarcoma. — Periosteal Sarcoma. — Sarcoma of the Mam- ma, of the Salivary Glands. — 9. LympTiomata. — Anatomy. — Eelations to Leucasmia. — Treatment, « p. 645 LECTUEE XLIX. 10. Papillomata. — 11. Adenomata. — 12. Cysts and Cystomata. — Follicular Cysts of the Skin and Mucous Membranes. — Neoplastic Cysts. — Cysts of the Thyroid Gland. — Ovarian Cysts. — Blood-Cysts, p. 666 LECTUEE L. 13 Carcinomata. — Historical Eemarks. — General Description of the Anatomical Struct- ure. — Metamorphoses. — Forms. — Topography. — 1. Skin and Mucous Membranes with Pavement Epithelium. — 2. Milk Glands. — 3. Mucous Glands with Cylindrical Epithelium. — i. Lachrymal Glands, Salivary Glands, and Prostate Glands. — 5. Thyroid Glands and Ovaries. — Treatment. — Brief Eemarks about the Diag- nosis, p. 6S0 CHAPTER XXI. AMPUTATIONS, EXARTICULATIONS, AND RESECTION'S. LECTUEE LI. Importance of these Operations. — Amputations and Exarticulations. — Indications. — Methods. — After-Treatment. — Prognosis. — Conical Stumps. — Artificial Limbs. — History. — Eesection of the Joints. — History. — Indications. — Methods. — After- Treatment, P- 720 Appendix: Additions from the Eighth German Edition, p. 739 Index, P- 760 LIST OF WOODCUTS. FIG. PAGE 1. Diagram of connective tissue, with capillaries, . . . . .51 2. Diagram of incision, capillaries closed by blood-clots, collateral distention, 52 3. Diagram representing the surface of the wound united by inflammatory new formation, ......... 59 3 a. Vessels from mesentery of frog, ....... 60 3 b. Development of vessels, ....... 66 3 c. Vessels in vitreous body, . . . . . . . .67 4. Diagram of a wound with loss of substance, ..... 73 5. Pus-cells from fresh pus, ........ 75 6. Diagram of granulation of a wound, . ... . . . 77 7. Fatty degeneration of cells from granulations, . . . . .78 7 a. Epithelium of the cornea of a frog, ...... 78 8. Corneal incision three days old, ....... 82 9. Incised wound twenty-four hours old, ...... 83 10. Cicatrix nine days after an incision, . . . . . .83 11. Granulation-tissue, ........ 84 12. Young cicatricial tissue, ........ 84 13. Horizontal section through the tongue of a dog, .... 85 14. Same, ten days old, . . . . . . . .86 15. Same, sixteen days old, . . . . . . . . 86 16. Granulation-vessels, ........ 87 17. Seven-days-old wound in the lip of a dog, ..... 87 17 a. Micrococcus, ......... 103 18. Cicatrix from the upper lip of a dog, . . . . . . 113 19. Ends of divided muscular fibres, ....... 114 20. Eegenerative processes in transversely-striated muscle, . . . 115 21. Eegeneration of nerves, ........ 116 22. " " .■ 116 22 a. Nerves after division, ........ 117 23. Nodular nerve-terminations in an old stump, .... 119 24. Artery ligated in the continuity, . . . . . . . 120 25. Transverse section of a fresh thrombus, ..... 121 26. Transverse section of thrombus six days old, . . . . . 122 27. Ten-days-old thrombus, ........ 122 28. Completely-organized thrombus, ....... 123 29. Longitudinal section of the ligated end of an artery, . . . 124 30. Portion of a transverse section of a vein, with organized thrombus, . . 125 31. Artery, injected six weeks after ligation, ..... 127 32. Artery, injected thirty-five months after ligation, .... 127 33. Artery, injected three months after ligation, .... 128 34. Artery wounded on the side, with clot, ...... 135 XV111 LIST OF WOODCUTS. 35. Aneurisma traumaticum, .... 36. Varix aneurismaticus, ....'. 37. Aneurisma varicosum, ..... 38. Granular and crystalline hfematoidin, 39. Detachment of dead connective tissue in contused wouuds, 40. Central end of a torn brachial artery, 41. Evulsed middle finger, ..... 42. Arm torn out, with scapula and clavicle, . 43. Longitudinal section of a fracture four days old, 44. Diagram of a longitudinal section of a fracture fifteen days old, 45. Diagram of a longitudinal section of a fracture twenty -four weeks old 46. Fracture, with dislocation, after twenty-seven days, 47. Old united oblique fracture, 48. Longitudinal section through the cortical substance, 49. Inflammatory new formation in Haversian canals, 50. Ossification of inflammatory neoplasia on the surface of the bone and in the Haversian canals, ..... 51. Artificially-injected external callus, five days old, 52. Artificially-injected transverse section, eight days old, 53. Ossifying callus on the surface of a hollow bone, 54. Detachment of a superficial piece of a flat bone, 55. Detachment of a necrosed portion of bone, 56. Fracture of a long bone with external wound, 57. Necrosis of sawed surface of femur, 58. Bullets of various styles, .... 59. Tiemann's bullet-forceps, 60. Gunshot-fractures of femur and tibia, 61. Traces of lightning, .... 62. Conjunctiva affected with catarrh, . 63. Tissue from a prepuce infiltrated from inflammation, 64. Purulent infiltration of the cutis connective tissue, 65. Purulent infiltration of the cellular membrane, 66. Vessels of the walls of an abscess, 66 a. Growth of fungus from the cornea of a rabbit, 67. Venous thrombus, ..... 68. Fever curve after amputation of the arm, 69. Fever curve after resection of carious wrist, 70. Fever curve in erysipelas, 71. Fever curve in septicemia, .... 71 a. Giant cells from tubercles in various 6tages, 71 b. Minute tubercles in the peritoneum and on a cerebral artery, 71 c. Minute tubercles on a cerebral artery, 72. Cutaneous ulcer of the leg, .... 73. Granulations of a common ulcer, 74. Caries superficialis of the tibia, 75. Section of a piece of carious bone, 75 a. Ostitis malacissans, .... 76. Disappearance of chalky salts from periphery of bone, 77. Sclerosed tibia and femur, .... 78. Point of caseous degeneration in the spinal column, . 79. Destruction of the vertebral column, 80. Total necrosis of the diaphysis of a hollow bone, 81. Total necrosis of the diaphysis of a hollow bone with detached sequestrum, 82. Total necrosis of the diaphysis of a hollow bone after removal of sequestrum, LIST OF WOODCUTS. XIX 83. Total necrosis of the diaphysis of the femur, . 84. Total necrosis of the diaphysis of the tibia, 85. Necrosis of the lower half of diaphysis of femur, 86. The body extracted from Fig. 85, 87. Diagram of partial necrosis of a hollow bone, . 88. Diagram of Fig. 87 in the later stages, 89. Fig. 88, after removal of the sequestrum, 90. Scapula of a dog, resected with and without perioste 91. Eachitic malformations of the leg, 92. "Woman with extensive osteomalacia, 93. Section of knee-joint with fungous inflammation, 94. Degeneration of cartilage in fungous inflammation, 95. Subchondral caries of the astragalus, 96. Atonic ulceration of cartilage from the knee-joint, 97. Diagram of the ordinary ganglion, 98. Hernial protrusions of synovial membrane, 99. Degeneration of the cartilage in arthritis deformans 100. Osteophytes in arthritis deformans, 101. Fungous inflammation of the elbow-joint, 102. Osteophytes in arthritis deformans, 103. Multiple articular bodies, . . 104. Band-like adhesions in a resected elbow-joint, 105. Adhesion of articular surfaces of the elbow-joint, 106. Elbow-joint anchylosed by bony bridges, 107. Section of the shoulder-joint, 108. Section of the shoulder-joint, 109. Contraction of the fascia lata, 110. Cicatricial contractions after burns, . 111. Cicatricial contractions after burns, 112. Subcutaneously-divided tendon, 113. Varices, . . . 114. Cirsoid aneurism of the scalp, 11 5. Small fibroma, 116. From a myo-fibroma, . 117. Vessels from a cutis fibroma, 118. Neuroma, .... 119. Fibro-sarcomatous neuromata, 120. Cartilage tissue from chondromata, . 121. Chondroma of the fingers, 122. Odontoma of aback tooth, 123. Section of an odontoma, . 124. Pedunculated spongy exostosis, 125. Ivory exostosis of the skull, 126. Section from an ivory osteoma, 127. Osteoma of the muscular attachments, 128. Vessels from a plexiform angioma, . 129. Mesh-work from a cavernous angioma, 130. Tissue of granulation-sarcoma, 131. Tissue of glio-sarcoma, 132. Tissue of a spindle-celled sarcoma, . 133. Giant-cells from a sarcoma, 134. Giant-celled sarcoma with cysts, 135. Cell-globules from a sarcoma, 136. Mucous tissue from a myxosarcoma, PAGE 485 485 486 487 487 489 496 501 506 508 509 512 528 531 535 537 537 537 543 547 548 548 549 549 565 566 566 570 577 582 619 620 621 622 622 628 630 632 632 633 634 634 635 639 640 646 646 647 648 648 649 649 XX LIST OF WOODCUTS. fig. 137. Mucous tissue from an adenomyxoma, 138. Alveolar sarcoma from the deltoid muscle, 139. Alveolar sarcoma from the tibia, 140. Central osteosarcoma of the ulna, 141. Section of Fig. 140, 142. Central osteosarcoma of the lower jaw, 143. Section of Fig. 142, 144. Compound cystoma of the thigh, 145. Periosteal sarcoma of the tibia, . 146. Section of Fig. 145, 147. From an adeno-sarcoma of the female breast, . 148. From the cortical layer of a hyperplastic lymphatic gland 149. Sections of a wart, ..... 150. From a mucous polypus, 151. Adenoma of the thyroid, . ... 152. Commencing epithelial cancer of the lip, 153. Flat epithelial cancer of the cheeks, 154. Elements of an epithelial carcinoma of the lip, 155. From an epithelial cancer of the hand, . 156. Vessels from a carcinoma of the penis, 157. Papillary formation of a villous cancer, . 158. Mammary cancer, acinous form, 159. Soft mammary cancer, .... 160. From a mammary cancer, 161. Connective-tissue frame-work of a cancer of breast 162. Cancer of breast, tubular form, 163. Cancer of the mamma from an atrophied part, . 164. Vascular net-work from a very young nodule, 165. Vascular net-work around points of softening, . 166. Connective-tissue infiltration, etc., . 167. Cellular infiltration of fatty tissue, etc., 168. Cancer of the mucous glands from nose, 169. Adenoid cancer of the rectum, . 139. a. Villous sarcoma, 139 b. Psammona, .... 139 c. From a cerebral tumor, 139 d. Plexiform sarcoma, 139 e. From a cylindroma of the orbit, PAGE 649 651 651 655 655 656 656 657 658 658 660 663 667 670 672 686 686 687 688 689 693 696 696 697 698 698 699 700 701 705 706 708 709 752 754 755 755 756 SURGICAL PATHOLOGY AND THERAPEUTICS. LECTURE I. INTRODUCTION. Relation of Surgery to Internal Medicine. — Necessity of the Practising Physician being acquainted with both. — Historical Bemarks. — Nature of the Study of Sur- gery in the German High-schools. Gentlemen : The study of surgery, which you begin with this lecture, is now, in most countries, justly regarded as a necessity for the practising physician. We consider it a happy advance that the division of surgery from medicine no longer exists, as it did formerly. The difference between internal medicine and surgery is in fact only apparent ; the distinction is artificial, founded though it be on history, and on the large and increasing literature of general medicine. In the course of this work your attention will often be called to the frequency with which surgery must consider the general state of the body, to the analogy between the diseases of the external and inter- nal parts, and to the fact that the whole difference depends on our seeing before us the changes of tissue that occur in surgical diseases, while we have to determine the affections of internal organs from the symptoms. The action of the local disturbances on the body at large must be understood by the surgeon, as well as by any one who pays especial attention to diseases of the internal organs. In short, the surgeon can only judge safely and correctly of the state of his patient when he is at the same time a physician. Moreover, the physician who proposes refusing to treat surgical patients, and to attend solely to the treatment of internal diseases, must have some surgical knowledge, or he will make the grossest blunders. Apart from the fact that the country physician does not always have a colleague at hand to whom he can turn over his surgical patients, the life of the patient often de- pends on the correct and instantaneous recognition of a surgical disease. 1 2 INTRODUCTION When blood spouts forcibly from a wound, or a foreign body has entered the windpipe, and the patient is threatened with suffocation, then surgical aid is required, and quickly too, or the patient dies. In other cases, also, the physician ignorant of surgery may do much harm by not recognizing the importance of a case ; he may allow a disease to become incurable, and by his deficient knowledge cause unspeakable injury, in a case which might have been relieved by early surgical treatment. Hence it is inexcusable for a physician obstinately to stick to the idea of only practising internal medicine ; still more inex- cusable is it, in this idea, to neglect the study of surgery : " I will not operate, because in ordinary practice there is so little operating to be done, and I am not at all suited for an operator ! " As if surgery con- sisted only in operations. I hope to give you a better idea of this branch of medicine than is conveyed by the above remark, which un- fortunately is too popular. From the fact that surgery has to deal chiefly with patent dis- eases, it certainly has an easier position in regard to anatomical diag- nosis ; but do not regard this advantage too highly. Besides the fact that surgical diseases also often He deeply hidden, more is demanded from a surgical diagnosis and prognosis, and even in the treatment, than from the therapeutic action of internal medicine. I do not deny that in many respects internal medicine may hold a higher rank, just on account of the difficulties it has (and often so brilliantly overcomes) in localizing and recognizing disease. Very fine operation of the mind is often necessary to come to a proper conclusion, from the combination of symptoms, and the results of the examination. Physicians may point with pride to the anatomical diagnosis of diseases of the heart and lungs, where the careful student succeeds in giving as accurate a de- scription of the changes in the diseased organ as if he had it right under his eyes. How wonderful it is to gain an accurate knowledge of the morbid state of hidden organs, such as the kidneys, liver, spleen, intestines, brain, and spinal marrow, by the examination of a patient and the combination of symptoms ! What a triumph to diag- nose diseases of organs of which we do not know even the physiolo- gical function, as of the supra-renal capsules ! This is some compensa- tion for the fact that, in internal medicine, we must more frequently acknowledge the impotence of our treatment than is the case in surgery, although, from the advances in anatomical diagnosis, we have become more certain of what we can do, and of what we cannot. '""f" The irritation of the finer, cultivated portions of the mind in inter- nal medicine is, however, richly balanced by the greater certainty and clearness of diagnosis and treatment in surgery, so that the two branches of medical science are exactly on a par. And it must not INTRODUCTION. 3 be forgotten that the anatomical diagnosis — I mean the recognition of the pathological changes in the diseased organ — is only one means to the end, which is the cure of the disease. The true problems for the physician are to find out the causes of the morbid process, to prog- nosticate the course, conduct it to a favorable termination, or control it, and these are equally difficidt in internal and external medicine. Only one thing more is required of the practical surgeon : this is, the art of operating. This, like every art, has its knack ; the facility of operating secondarily depends on accurate knowledge of anatomy, on practice, and on personal aptitude. This aptitude may also be culti- vated by persevering practice. Just remember how Demosthenes suc- ceeded in acquiring fluency in speaking. This knack, which is certainly necessary, has long separated sur- gery from medicine in the strict sense ; we may historically follow this separation as it constantly became more practically felt, till in this century it was finally recognized as impractical and was abol- ished. The word " chirurgery " at once expresses that originally it was regarded as entirely manual, for it comes from x ei P an d vpyov, which literally mean " hand-work," or, in the pleonasm of the middle ages, " hand-work of chirurgery." Little as it comes within the scope of this work to give a complete sketch of the history of surgery, it still seems to me important and in- teresting to give you a short sketch of the external and internal de- velopment of our science, which will explain to you some of the va- rious regulations affecting the so-called " medical staff" still existing in different states. A fuller history of surgery can only be of use to you hereafter, when you shall have acquired some knowledge of the value or worthlessness of certain systems, methods, and operations. Then, in the historical development of the science, especially as regards op- erative surgery, you will find the key for some surprising and for some isolated experience, also for much that is incomplete. Many things that may be necessary for the comprehension of the subjects, I shall relate to you when speaking of the different diseases ; now, I shall only present a few prominent points in the development of sur- gery and of its present position. Among the people in former times, the art of healing was inti- mately associated with religious education. The Hindoos, Arabs, and Egyptians, as well as the Greeks, considered the art of healing as a manifestation made by the gods to the priests, and then spread by tradi- tion. Philologists were not agreed as to the age of the Sanscrit writ- ings discovered not long since ; formerly their origin was placed at 1000-1400 B. c, now it is considered certain that they were written in the first century of the Christian era. The Agur-Veda (" Book of 4 INTRODUCTION. the Art of Life ") is the most important Sanscrit work for medicine ; it is the production of Susrutas. It very probably originated in the time of the Roman Emperor Augustus. The art of healing was regarded as a whole, as is indicated by the following : " It is only the combina- tion of medicine and surgery that makes the complete physician. The physician lacking knowledge of one of these branches is like a bird with only one wing." At that time surgery was without doubt by far the more advanced part of the medical art. A large number of op- erations and instruments are spoken of; still, it is truly said " the best of all instruments is the hand ; " the treatment of wounds given is simple and proper. Most surgical injuries were already known. Among the Greeks all medical knowledge at first centred in^Es- culapius, a son of Apollo, and a scholar of the Centaur Chiron. Many temples were built to iEsculapius, and the art of healing was handed down by tradition through the priests of these temples ; the number of these temples induced various schools of iEsculapides, and, although every one entering the temple as a priest had to take an oath, which has been handed down to our own times (although of late its genuineness appears rather doubtful), that he would only teach the art of healing to his successors, still, as appears from various cir- cumstances, even at that time there were other physicians besides the priests. From one part of the oath, even, it is evident that then as now there were physicians who, as specialists, confined themselves to cer- tain operations ; for it says : " Furthermore, I will never cut for stone, but will leave this operation to men of that occupation." Of the different varieties of physicians we know nothing more accurate till the time of Hippocrates ; he was one of the last of the Asklepiades. He was born 460 b. c, on the island of Cos; lived partly in Athens, partly in Thessalian towns, and died 377 b. c. at Larissa. We might expect that medicine would be considered scientifically at this time, when the names of Pythagoras, Plato, and Aristotle, were shining in Grecian science ; and in fact the works of Hippocrates, many of which are still preserved, arouse our astonishment. The clear classical de- scription, the arrangement of the whole material, the high regard for the healing art, the sharp critical observations, that appear in the works of Hippocrates, and compel our admiration and respect for an- cient Greece on this branch also, clearly show that it is not a case of blind belief in traditional medical dogmas, but that there was already a scientific and elaborately perfected medicine. In the Hippocratic schools the art of healing formed one whole ; medicine and surgery were united, but there were various classes of medical practitioners ; besides the Asklepiades there were other educated physicians, as well as more mechanically instructed medical assistants, gymnasts, quacks, INTRODUCTION. 5 and workers of miracles. The physicians took scholars to train in the art of healing ; and, according to some remarks of Xenophon, there were also special army physicians ; especially in the Persian wars, they, together with the soothsayers and flute-players, had their places near the royal tent. It may be readily understood that, at a time when so much was thought of corporeal beauty, as was the case among the Greeks, external injuries would claim special attention. Hence, among physicians of the Hippocratic era, fractures and sprains were particularly studied ; still, some severe operations are treated of, as also numbers of instruments and other apparatuses. They seem to have been very backward regarding amputations ; probably the Greeks preferred dying to prolonging life after they were mutilated. The limb was only removed when it was actually dead, gangrenous. The teachings of Hippocrates could not at first be carried any fur- ther, for lack of knowledge of anatomy and physiology. It is true there was a faint effort made in this direction in the scientific schools of Alexandria, which flourished for some centuries under the Ptole- mies, and by means of which, after the wars of Alexander the Great, the Grecian spirit was spread, at least temporarily, over part of the Orient ; but the Alexandrian physicians soon lost themselves in phil- osophical systems, and only advanced the science of healing a little by a few anatomical discoveries. In this school the art of healing was at first divided into three separate parts — dietetics, internal medi- cine, and surgery. Along with Grecian culture, their knowledge of medicine was also brought to Rome. The first Roman physicians were Grecian slaves ; the freedmen among them were allowed to erect baths ; here, first, barbers and bathers became our rivals and col- leagues, and for a long time they injured the respectability of the pro- fession in Rome. Gradually the philosophically-minded took posses- sion of the writings of Hippocrates and the Alexandrians, and them- selves practised medicine, without, however, adding to it much that was new. The great lack of original scientific production is shown in the encyclopedial revision of the most varied scientific works. The most celebrated work of this nature is the " De Artibus " of Aulus Corne- lius Qelsus (from 25-30 b. c. to 45-50 a. d., in the time of the Em- perors Tiberius and Claudius). Eight books of this, " De Medicina" have come down to our time ; from these we know the state of medi- cine and surgery at that time. Valuable as are these relics from the Roman ages, they are only, as we have said, a compendium, such as is often published at the present day. It has even been denied that Celsus was a practising physician, but this is improbable ; from his writings we must, at all events, credit Celsus with using his own judg- ment. The seventh and eighth books, which treat on surgery, could not 6 INTRODUCTION. have been written so clearly by any one who bad no practical knowl- edge of bis subject. Hence we see that, since the time of Hippo- crates and the Alexandria school, surgery, especially the operative part, had made no great progress. Celsus speaks of plastic opera- tions, of hernia, and gives a method of amputation which is still occa- sionally employed. One part, from the seventh book, where he speaks of the qualifications of the perfect surgeon, is quite celebrated, as it is characteristic of the spirit which reigns in the book ; I give it to you : " The surgeon should be young, or at least little advanced in age, with a hand nimble, firm, and never trembling ; equally dexter- ous with both hands ; vision, sharp and distinct ; bold, unmerciful, so that, as he wishes to cure his patient, he may not be moved by his cries to hasten too much, or to cut less than is necessary. In the same way let him do every thing as if he were not affected by the cries of the patient." Claudius Galenus (131-201 A. d.) must be regarded as a phe- nomenon among the Roman physicians; eighty-three undoubtedly genuine medical writings of bis have come down to us. Galen re- turned again to the Hippocratic belief, that observation must form the foundation of the art of healing, and he advanced anatomy great- ly; he made dissections chiefly of asses, rarely of human beings. Galen's anatomy, as well as the entire philosophical system into which he brought medicine, and which seemed to him even more im- portant than observation itself, has stood firm over a thousand years. He occupies a very prominent position in the history of medicine. He did little for surgery in particular ; indeed, he practised it little, for in his time there were special surgeons, either gymnasts, bathers, or barbers, and so unfortunately surgery was handed down by tradition as a mechanical art, while internal medicine was, and long remained, in the hands of philosophic physicians ; the latter knew and com- mented freely on the surgical writings of Hippocrates, the Alexandri- ans, and Celsus, still they paid little attention to surgical practice. As we are only giving a faint sketch, we might here skip several cen- turies, or even a thousand years, during which surgery made scarcely any progress, indeed retrograded occasionally. The Byzantine era of the empire was particularly unfavorable to the advance of science, there was only a short flickering up of the Alexandria school. Even the most celebrated physicians of the later Roman times, Antyttus (in the third century), Oribasius (326-403 a. d.), Alexander of Tralles (525-605 A. D.), Paidus of JEgina (660), did relatively little for sur- gery. Some advance had been made in the position and scholarly at- tainments of physicians ; under Nero there was a gymnasium ; under Hadrian an athenseum, scientific institutions where medicine also was INTRODUCTION. V taught; under Trajan, there was a special medical school. Military medical service was attended to among the Romans, and there were special court physicians, " archiatri palatini," with the title of " per- fectissime," " eques," or *' comes archiatrorum," just as, among the Germans, " Hofrathe," " Geheimrathe," " Leibarzte," etc. That, as a result of the fall of science in the Byzantine reign, the art of healing did not totally degenerate, is due to the Arabians. The wonderful elevation that this people attained under Mohammed, after the year 608, aided in preserving science. The Hippocratic knowledge of medicine, with the later additions to it, passed to the Arabians through the Alexandrian school, and its branches in the Orient, the schools of the Nestorians ; they cherished it till their power was de- molished by Charles Martel, and returned it to Europe by way of Spain, though somewhat changed in form. Hhazes (850-932), Am- cenna (980-1037), Alhucasis (f 1106), and Avenzoar (f 1162), are the most celebrated, and for surgery the most important, of the Arabian physicians whose writings have been preserved ; the writings of the latter are the most important for surgery. Operative surgery suffered greatly from the dread the Arabians had of blood, which was partly due to the laws of the Koran ; it caused the employment of the ac- tual cautery to an extent that we can hardly comprehend. The dis- tinction of surgical diseases and the certainty of diagnosis had de- cidedly increased. Scientific institutions were much cultivated by the Arabians ; the most celebrated was the school of Cordova ; there were also hospitals in many places. The study of medicine was no longer chiefly private, but most of the students had to complete their studies at some scientific institution. This also had its effect on the nations of the West. Besides Spain, Italy was the chief place where the sciences were cultivated. In southern Italy there was a very cele- brated medical school at Salerno ; it was probably founded in 802 by Charles the Great, and was at its zenith in the twelfth century ; according to the most recent ideas, this was not an ecclesiastical school, but all the pupils were of the laity. There were also female pu- pils, who were of a literary turn ; the best known among these was Trotula. Original observations were not made there, or at least to a very slight extent, but the writings of the ancients were adhered to. This school is also interesting from the fact that it is the first cor- poration that we find having the right to bestow the titles " doctor " and " magister." Emperors and kings gradually took more interest in science, and founded universities; thus universities were founded in Naples in 1224, in Pavia and Padua in 1250, in Paris in 1205, in Salamanca in 1243, in Prague in 1348, and they were invested with the right of 8 INTRODUCTION. conferring academical honors. Philosophy was the science to which most attention was paid, and for a long time Medicine preserved her philosophical robe in the universities ; in some cases they adhered to Galen's system, in others to the Arabian or to new medico-philo- sophical systems, and registered all their observations under these heads. This was the great obstacle to the progress of the natural sciences, a mental slavery, from which even men of intellect could not free themselves. The anatomy of Mondino de I/uzzi (1314) differs very little from that of Galen, in spite of the fact that the author bases it on dissections he made of some human bodies. In surgery there were no actual advances ; Lanfranchi (fl300), Guido of Gauli- aco (beginning of the fourteenth century), ^Branca (middle of the fifteenth century), are a few of the noteworthy surgeons of those times. Before passing to the flourishing state of the natural sciences and of medicine in the sixteenth century, we must review briefly the composi- tion of the medical profession in the times of which we have been speaking, as this is important for the history. First, there were philo- sophically educated physicians either lay or monk, who had learned medicine in the universities or other schools ; i. e., they had studied the old writings on anatomy, surgery, and special medicine ; they prac- tised, but paid little attention to surgery. Another seat of learning was in the cloisters ; the Benedictines especially paid a great deal of attention to medicine and also practised surgery, although the supe- riors disliked to see this, and occasionally special dispensation had to be obtained for an operation. The regular practising physicians were sometimes located, sometimes travelling. The former were usually educated at scientific schools and received permission to practise on certain conditions. In 1229, the emperor Frederick II. published a law that these physicians should study logic (that is, philosophy and philology) three years, then medicine and surgery five years, and then practise for some time under an older physician; before receiving permission to practise independently, or, as an examiner lately said, of physicians who had just received their degree, " till they were let loose on the public." Besides these located physicians, of whom a great part were " doctor " or " magister," there were many " travelling doctors," a sort of " travelling student " who went through the market- towns in a wagon with a merry Andrew, and practised solely for money. This genus of the so-called charlatans, which played an im portant part in the poetry of the middle ages, and is still gleefully greeted on the stage by the public, carried on a rascally trade in the middle ages ; they were as infamous as pipers, jugglers, or hangmen ; even now these travelling scholars are not all dead ; although, in the nineteenth century, they do not ply their trade in the market-place, but INTRODUCTION. 9 ja the drawing-rooms as workers of miracles, especially as cancer-doc- tors, herb-doctors, somnambulists, etc. Let us now inquire the rela- tion, of those who practised surgery, to the above company. This branch of medicine was occasionally resorted to by almost all of the above ; still there were special surgeons, who united into guilds and formed honorable societies ; they received their practical knowledge first from a master, under whom they studied, and subsequently from books and scientific institutions. Surgical practice was chiefly confined to these persons, who were mostly located, but sometimes travelled about as " hernia doctors," " operators for stone," " oculists," etc. We shall become acquainted with some excellent men among these old mas- ters of our art. Besides the above, surgery was also practised by the " bathers," and later by " barbers " also, as it was among the Romans, and they were permitted by law to attend to " minor surgery," e. g., they could cup, bleed, treat fractures, sprains, etc. It will be readily understood that some strife would arise about the various and some- times indefinite privileges of these different grades of physicians, especially in large cities, where all classes of them were collected. This was particularly the case in Paris. The surgical society there, the " College de St. C6me," claimed the same privileges as members of the medical faculty ; they were particularly desirous for the Bacca- laureate and Licentiate. The " Society of Barbers and Bathers," again, wished to practise any part of surgery, just like the members of the College de St. Come. To gall the surgeons, the members of the fac- ulty supported the claims of the barbers, and, in spite of mutual tempo- rary compromises, the strife continued ; indeed, we may say that it still continues, where there are pure surgeons (surgeons of the first class and barbers) and pure physicians. It is only since about 1850 that the distinction was done away with in almost all the German states, and neither chirurgi puri nor medici puri were made, but only physi- cians who practised medicine, surgery, and obstetrics. To finish the question of external rank, we may notice that in Eng- land alone there is still a tolerably well-marked dividing-line be- tween surgeons and physicians, especially in the cities, while in the country " general practitioners " attend to both medical and surgical cases, and have an apothecar} r -shop even at the same time. In Germany, Switzerland, and France, circumstances often cause a physician to have more surgical than medical practice ; but the med- ical staff legally consists of physicians and assistants or barber-sur- geons, who, after examination, are licensed to cup, bleed, etc. This arrangement has finally gone into effect in the army also, where the so-called company surgeon, with the rank of sergeant, formerly had a miserable time under the battalion and regimental physicians. 1 INTltODtTCTION. In again taking up the thread of the historical development of surgery, as we enter the period of " Renaissance " in the sixteenth century, we must first think of the great change which then took place in almost all sciences and arts, on account of the Reformation, the discovery of printing, and the awakening spirit of criticism. Obser- vation of Nature began to reassume its proper position and gradually but slowly to free itself from the fetters of the schools ; investigation after truth again assumed its claims to being the only true way to knowledge — the Hippocratic spirit was again awakened. It was chiefly the new investigations, we might almost say the rediscovery, of anatomy and the subsequent restless progress of this branch, that levelled the road. Vesal (1513-1564), Falopia (1523-1562), and JEks- tachio (fl579), were the founders of our present anatomy ; their names, like those of many others, are known to you from the appellations of certain parts of the body. The celebrated JSomhastus Theophrastus Paracelsus (1493-1554) was among the first to criticise the prevailing Galenical and Arabic systems, and to claim observation as the chief source of medical knowledge. Finally, when William Harvey (1578-1658) discovered the circulation of the blood, and Aselli (1581- 1626) discovered the lymphatic vessels, the old anatomy and physiol- ogy were obliged to give place to modern science, which thence grad- ually progressed to our times. Even then it was a long time before practical medicine escaped in the same way from philosophic thral- dom. System was founded on system, and the theory of medicine constantly varied to correspond to the prevailing philosophy. We may claim that it was not till pathological anatomy made its great ad- vances in the present century that practical medicine acquired the firm anatomico-phvsiological foundation on which the whole structure now moves, and which forms a strong protection against all philosoph- ical medical systems. Even this anatomical direction, however, may be pushed too far and too exclusively. We shall speak of this hereafter Now we will turn our attention to the scientific development of surgery from the sixteenth century to our times. It is an interesting feature of that time that the advance of practi- cal surgery depended more on the surgical societies than on the learned professors of the universities. German surgeons had to seek their knowledge mostly in foreign universities, but part of it they worked out for themselves independently : Heinrich von Pfolspruntlf, a German friar (born the beginning of the fifteenth century), Hieron- ymus Brunschwig (born 1430), Mans von Gersdorf (about 1520), and Felix WiXrtz (fl576), surgeons at Basel, are first among these. We have writings of all of them ; Felix Wilrtz seems to me the most original of them; he had a sharp, critical mind. Fabry von Hilden INTRODUCTION. 11 (1560-1634), of Berne, and Gottfried Purman, of Halberstad and Breslau (about 1679), were men of great acquirements ; their writ- ings show a high appreciation for their science, they fully recognized the value and imperative necessity of exact anatomical knowledge, and by their writings and private instruction imparted it to their scholars as much as possible. Among the French surgeons of the sixteenth and seventeenth cen- turies, Ambroise Park, (1517-1590) is most prominent ; originally only a barber, from his great services, he was made a member of the So- ciety of St. C6me; he was very active as an army surgeon, was often called from home on consultations, and at last resided in Paris. Park, advanced surgery by what was for those times a very sharp criticism of treatment, especially of the enormous use of problematical remedies ; some of his treatises, e. g., on the treatment of gun-shot wounds, are perfectly classical ; he rendered himself immortal by the introduction of ligature for bleeding vessels after amputation. Pare, as the reformer of surgery, may be placed by the side of Vesal, as reformer of anatomy. The works of the above individuals, besides some others more or less gifted, held their place into the seventeenth century, and it is only in the eighteenth that we find any important advances. The strife between the members of the faculty and those of the College de St. Come still continued in Paris ; the great celebrity of the latter had more effect than the professors of surgery. This was finally prac- tically acknowledged in 1731 by the foundation of an "Academy of Surgery," which was in all respects an analogue of the medical faculty. This institution soon advanced to such a point that it ruled the sur- gery of Europe almost a century ; nor was this an isolated cause ; it formed part of the general French influence, of that universal mental dominion which the " grande nation " cannot even yet forget when German science has forever eclipsed French influence, after the con- flicts of 1813-'14. The men who' then stood at the head of the movement in surgical science were Jean Louis Petit (1674-1768), Pierre Jos. Besault (1744-1795), Pierre Francois Percy (1754- 1825), and many others in France; in Italy, Scarpa (1748-1832) was the most active. Even in the seventeenth century, surgery was highly developed in England, and in the eighteenth century it attained great eminence under Percival Pott (1713-1768), William and John Hunter (1728-1793), Benjamin Bell (1749-1806), William Chesel- den (1688-1752), Alexander Monro (1696-1767), and others. Among these was John Hunter, that great genius, as celebrated for anatomy as surgery; his work on inflammation and wounds still forms the basis of many of our present views. In comparison with these, the names of the German surgeons of 12 INTRODUCTION. the eighteenth century are insignificant ; most of them brought theii knowledge from Paris, and added little that was original : Lorenz Beister (1683-1758), John Ulrich Bilguer (1720-1796), and Chr. Ant. Theden (1719-1797), are relatively the most important. Ger- man surgery only obtained greater eminence with the commencement of the present century. Carl Caspar von Siebold (1736-1807), and August Gottlob Bichter (1742-1812), were distinguished men ; the former served as professor of surgery in Wurzburg, the latter in G5t- tingen ; some of Bidder's writings are valuable even now, especially his little book on rupture. On the threshold of our century you see professors of surgery again in the foreground, where they subsequently maintained their position, because they actually practised surgery. A predecessor of old Bichter, as professor of surgery at Gottingen, the celebrated Al- bert Holler (1708-1777), at once physiologist and poet, one of the last encyclopaedists, says, " Etsi chirurgiae cathedra per septemdecim an- nos mihi concredita fuit, etsi in cadaveribus dificilimas administrationes chirurgicas frequenter ostendi, non tamen unquam vivum hominem incidere sustinui, nimis ne nocerem veritus." To us this seems scarcely credible, so great is the change wrought by a hundred years. Even at the commencement of this century the French surgeons re- mained at the helm ; Boyer (1757-1833), Delpech (1776-1832), and par- ticularly Dupuytren (1777-1835), and Jean Dominique Larrey (1776- 1842), were almost undisputed authorities in their line. Besides them there arose in England the unimpeachable authority, Sir Astley Coop- er (1768-1841). Larrey, the constant companion of Napoleon I., left a large number of works ; you will hereafter read his memoirs with great interest. Dupuytren was chiefly celebrated for his excellent clinical lectures. Coopers monographs and lectures will fill you with astonishment. Translations of the writings of the above French and English surgeons first aroused German surgery ; but soon the subject was gone into most profoundly by original workers. The men who induced the German revolution in surgery were, among others, Vincenz von Kern, of Vienna (1760-1829), John JVep. Bust, of Berlin (1775- 1840), Philipp von Walther, of Munich (1782-1849), Carl Ferd. von Graefe, of Berlin (1787-1840), Conr. Joh. Martin LangenbecTc, of Gottingen (1776-1850), Joh. Friedrich Dieffenbach (1795-1847), Cajetan von Textor (1782-1860), of Wurzburg. The nearer we approach the middle of our century, the more the rugged bounds of nationality disappear from the domains of surgery. With increased means of communication, all advances in science spread with breathless haste to all parts of the civilized world. Num- berless writings, national and international medical congresses, and INTRODUCTION. 13 personal intercourse, have brought radical changes to the surgeons as well as to others. A generation of surgeons, upon whose works the profession looks with honor, appears to be now dying out; I mean men such as Stanley (1791-1862), Lawrence (1783-1867), and Brodie (1783-1862), in England; Boux (1780-1854), Bonnet (1809- 1858), Leroy (1798-1861), Malgaigne (1806-1865), Giviale (fl867), Jobert (1799-1868), and Velpeau (1795-1867), in France; Seutin (1793-1862), in Belgium ; Valentine Mott (1785-1865), in America ; Wutzer (1789-1863), Schuh (1804-1865), and others, in Germany. From our own generation also we have some losses to mourn, espe- cially the irreparable death of the gifted, indefatigable investigator 0. Weber (1827-1867) ; of the excellent Follin (-1867), one of the most solid of modern French surgeons; of Middeldorpf (1824-1868), the celebrated inventor of galvano-caustic operations. Among the living we might name many on whose shoulders rests the growing generation of German surgeons, but they do not yet belong to his- tory. But there is one point I must not leave unmentioned, that is, the introduction of pain-quelling remedies into surgery. The nineteenth century may be proud of the discovery of the practical use of sulphu- ric ether and chloroform as anaesthetics in all sorts of operations. In 1846 carne from Boston the first news that Morton the dentist, at the suggestion of his friend Br. Jackson, had, in extracting teeth, em- ployed inhalations of sulphuric ether, pushed to complete anassthesia, with perfect success. In 1859, Simpson, professor of obstetrics in Ed- inburgh, instead of ether, introduced in surgical practice chloroform, which acts still better, which, after various trials with other similar substances, still preserves its reputation. Thanks ! in the name of suffering humanity, a thousand thanks to these men ! In continuation of my previous remarks regarding German sur- gery, I will simply add that at present it stands at least equal to that of other nations, and is perhaps even superior to that of France at the present time. To perfect ourselves in the science of surgery, we no longer need to visit Paris. But, of course, it is nevertheless desirable for every physician to enlarge his experience and observation by visit- ing foreign lands. In the scientific as well as in the practical part of surgery, and of medicine generally, England is now more advanced than any other country. In America also great advances have been made in practical surgery. From the time of BTunter to the present day, English surgery has about it something noble. Surgery owes its great revolution in the nineteenth century to its attempt to unite all medical knowledge in itself ; the surgeon who succeeds in this, and also masters the entire mechanical side of the art, may feel that he has attained the highest ideal in medicine. 14 INTRODUCTION. Before entering on our subject, I will add a few remarks about the study of surgery as it is, or is said to be, pursued in our high- schools. In the four years' course of medical study which is customary in German universities, I would advise you not to begin surgery before the fifth semestre. You often desire to escape the preliminary studies and plunge at once into the practical. It is true, this is somewhat less the case since courses on anatomy, microscopy, physiology, chem- istry, etc., have been started in the high-schools, where you have some practice ; nevertheless, there is still too much haste to enter the clin ics. It is true, it is one way of gaining experience from the very start ; you consider it more interesting than bothering yourselves at first with things whose connection with practice you do not exactly un- derstand. But you forget that a certain school of observation must be gone through with, to enable us to make actually useful what we know. If any one just released from school should at once enter the hospital as a student, he would be in the same position as a child entering the world to collect knowledge. Of what use are the ex- periences of the child for his subsequent life among men ? How late it is before we see the true use of the most common observations of daily life ! Hence, to wade through the entire development of medi- cine in this empirical manner Avould be a long, tedious labor, and only a very gifted, industrious man would learn any thing in this way. After having made numerous errors, we must not place too great a value on " experience " and " observation," if by these terms we mean no more than the laity do. It is an art, a talent, a science, to observe critically, and from our observations to draw correct conclusions for our " experience ; " this is the strong point of the empiric ; the laity know experience and observation in the vulgar, not in the scientific sense, and they value the so-called experience of an old shepherd as high as, sometimes higher than, that of a physician ; unfortunately, the public are sometimes right on this point. But enough ! when a physician or any one else displays his experience and observation be- fore you, look sharply to see whether he has any brains. In making these remarks against pure empiricism, we do not by any means intend to say that you must be theoretically acquainted with all medicine before studying it practically, but you should bring a certain knowledge of the fundamental principles of natural science with you into the clinic. It is absolutely necessary to have a general idea of what you are to expect ; and you must know something of the tools before seeing them used, or taking them in your hands. In other words, you should know the outlines of general pathology and therapeutics, as well as of materia medica, before going to the bed- INTRODUCTION. 15 side of the patient. General surgery is only one part of general pathology, hence you should study the latter before entering the sur- gical clinic. First, you should gain a clear understanding of normal histology, at least of its general parts; pathological anatomy and histology should come with general surgery, about the fifth semestre. General surgery, the subject of the present lectures, is a part of general pathology, as we have already stated ; but it is nearer to practice than the latter. It comprises the study of wounds, inflam- mations, and tumors of the external parts of the body, or of those parts that may be handled from without. Special or topographical surgery occupies itself with the surgical diseases of different parts of the body, so that the most different tissues and organs are to be con- sidered according to their location ; for instance, while we here treat only of wounds, of their mode of recovery and treatment in general, special surgery treats of wounds of the head, breast, and abdomen, paying special attention to the participation of the skin, bones, and viscera. Were it possible to pursue the study of surgery for several years in a large hospital, and could careful clinical consid- eration of individual cases be carried on continuously with the regular studies, it would probably be unnecessary to treat of special surgery in separate systematic lectures. But, since there are many surgical dis- eases that perhaps may not occur for years even in a large hospital, but which should be known to the surgeon, the lectures on special surgery are by no means superfluous, if they are short and to the point. During my student days I occasionally heard the remark : " Why should I go to listen to special surgery and pathology ? I can read them more conveniently in my room." This may be all true, but un- fortunately it is rarely done, unless in the final semestres, when exam- ination is approaching. This reasoning is false in another respect also : the viva vox of the teacher, as old LangenbecJc, in Gottingen, used to say (and he had a viva vox in the best sense of the word), the winged word of the teacher is, or should be, more exciting and effective than what is read, and the accompanying demonstrations of diagrams, preparations, experiments, etc., should render the lectures on practical surgery and medicine particularly valuable for you. I attach great value to demonstration in medical instruction, for I know by experience that this kind of teaching is most exciting and per- manent. Besides these two sets of lectures on general and special surgery you have to practise operations on the cadaver ; this you may post- pone to the last semestres. I always like students to take their course in operations in the sixth or seventh semestres, along with their special surgery, so that I may give them the opportunity of oc- 10 INTRODUCTION. casionally operating, or even of amputating, under my direction. It gives courage in practice, if one has during student-life performed op- erations on the living subject. When you have followed the lectures on general surgery, you may enter the surgical clinic, and there, in the seventh and eighth semestres, openly give an account of your knowledge in special cases, and accustom yourselves to collecting your ideas rapidly, learn to distinguish the important from the unim- portant, and to learn generally in what practice really consists. You will thus learn the points where your knowledge is deficient, and may perfect yourselves by persevering study. When you have thus com- pleted the legal time of your studies, passed your examination, and have increased your medical knowledge by a few months or a year in various large hospitals at home or abroad, you will be in condition to appreciate the surgical cases turning up in practice. But, if you wish to devote special attention to surgery and operating, you are still far from the goal : then you must become accustomed to operating on the cadaver, enter a surgical ward as assistant for a year or two, un- tiringly study monographs on surgical subjects, perseveringly write out cases, etc. — in short, follow out the practical school from the lowest step. You must be fully acquainted with hospital service, even with the duties of the nurses ; in short, you should know practically even the most minute things appertaining to the care of patients, and should even perform the duties yourselves occasionally, so that you may be fully master of the entire medical service intrusted to you. You see there is much to do and to learn : with patience and perse- verance you will accomplish it all ; but these virtues are necessary to the study of medicine. " Student " comes from " to study ; " hence you must study faith- fully ; the teacher indicates to you what he considers the most impor- tant ; he may stimulate you in various directions ; what he gives you as positive may, it is true, be carried home in black and white, but, to cause this positive knowledge to live in you and become your mental property, you must depend on your own mental efforts, which form the true " study." When you conduct yourself as a passive receptacle, you may, it is true, acquire the name of a very " learned person," but, if you do not awake your knowledge into life, you will never become a good " practising physician." Let what you see enter your mind fully, warm you up, and so occupy your attention that you must think of it frequently, then the true pleasure and appreciation of this mental labor will fill you. Goethe, in a letter to Schiller, aptly says : " Pleas- ure, comfort, and interest in the affairs of life, are the only realities; all else is vanity and disappointment." CHAPTER I. SIMPLE INCISED WO UNDS OF THE SOFT PARTS, LECTURE II. Mode of Origin and Appearance of these "Wounds. — Various Forms of Incised "Wounds. — Appearance during and immediately after their Occurrence. — Pain, Bleeding.— Varieties of Hsemorrhage ; Arterial, Venous. — Entrance of Air through "Wounded Veins. — Parenchymatous Hsemorrhage. — Hemorrhagic Diathesis. — Haemorrhage from the Pharynx and Eectum. — Constitutional Effects of Severe Haemorrhage. The proper treatment of wounds is to be regarded as the most important requirement for the surgeon, not only on account of the frequency of this variety of injury, but because we so often inten- tionally make them in operating, even when operating for something that is not itself dangerous to life. Hence we are answerable for the healing of the wound, to as great an extent as it is possible by expe- rience to judge of the danger of an injury. Let us commence with incised wounds. Injuries caused by sharp knives, scissors, sabres, cleavers, hatchets, etc., represent pure incised wounds. Such wounds are usually recog- nizable by the regular sharp borders, where we see the smooth-cut surface of the unchanged tissue ; should the instruments be blunt, by very rapid motion they may still cause quite a smooth incised wound, while by slowly entering the tissue they would give the edges of the wound a ragged appearance ; occasionally, the variety of the injury does not become evident till the wound is healing, for wounds made with sharp instruments heal more readily and quickly (for reasons to be given hereafter) than those caused by the slow entrance of dull knives, scissors, etc. Rarely a perfectly blunt body makes a wound exactly like an incised one. This may occur from the skin being torn through by force ap- plied through a blunt object, at a point where it lies over the bone. Thus you will not unfrequently see scalp-wounds resembling incised 2 L8 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. wounds, although they may have been due to a blow from a blunt body, or from striking the head against a stone, beam, etc. ; similar smooth wounds of the skin also occur on the hand, especially on the volar sur- face. Sharp angles of bone may so divide the skin from within that it will look as if cut through, as, for instance, w 7 hen one falls on the crest of the tibia, and it divides the skin from within outward. As may be readily understood, sharp splinters of bone perforating the skin may also make woxmds with smooth surfaces. Lastly, the open- ing of exit of a bullet-wound, i. e., of the canal which represents the passage of a bullet, may sometimes be a sharp slit. The knowledge of these points is important, for a judge may ask you if a wound has been caused by this or that instrument, in this or that manner, points which may greatly affect the bearings in a crimi- nal suit. Hitherto we have only considered wounds made with a blow or stroke. But, by repeated cuts on a wound, the edges may acquire a hacked appearance, and thus the requirements for recovery may be very much changed. For the present, we leave such wounds out of consideration ; their mode of recovery and treatment is just the same as that in contused w T ounds, unless they can be artificially converted into simple incised wounds by paring off the jagged edges. The various directions in which the cutting instrument enters the body generally makes little difference, unless the direction be so oblique that some of the soft parts are detached in the form of a more or less thick flap. In these /op-wounds, the width of the bridge, uniting the half-separated portion with the body, is important, because on this depends the question as to whether circulation of blood can continue in this flap, or if it has ceased, and the detached portion is to be re- garded as dead. Flap-wounds are chiefly due to cuts, but may also arise from tearing ; they are very frequent in the head, where part of the scalp is torn off by a hard blow. In other cases a portion of the soft parts may be entirely cut out ; then we have a wound with loss of substance. By penetrating wounds we mean those by which one of the three great cavities of the body or a joint is opened ; they are most fre- quently due to stabs or gun-shot injuries, and may be complicated by wounds of the viscera or bones. By the general terms longitudinal and diagonal wounds we of course mean those corresponding to the long or diagonal axes of the trunk, head, or extremities. Diagonal or longi- tudinal wounds of the muscles, tendons, vessels, or nerves, are of course those dividing these parts longitudinally or diagonally. The symp- toms in the person wounded, induced more or less directly by the wound, are, first, pain ; then, bleeding and gaping of the wound. SYMPTOMS— PAIN. 19 As all the tissues, not excepting the epithelial and epidermoid, are supplied with sensory nerves, injury at once causes pain. This pain varies greatly with the nerve-supply of the wounded part, and with the sensitiveness of the patient to pain. The most sensitive parts are the fingers, lips, tongue, nipples, external genitals, and about the anus. Doubtless, each of you knows from' experience the character of the pain from a wound, as of the finger. The division of the skin is the most painful part ; injury of the muscles and ten- dons is far less so ; injury of the bone is always very painful, as you may find from any one that has recovered from a fracture; it has also been handed down to us from the times when amputations were made with- out chloroform, that sawing the bone was the most painful part of the operation. The mucous membrane of the intestines, on being irri- tated in various ways, shows very little sensitiveness, as has been occa- sionally observed on man and beast ; the vaginal portion of the ute- rus also is almost insensitive to mechanical and chemical irritation ; occasionally, it may be touched with the hot iron, as is done in treat- ing certain diseases of this part, without its being felt by the patient. It appears that the nerves requiring a specific irritation, as the nerves of special sense, are accompanied by few if any sensory fibres. The relation of the sensory nerves of touch to the sentient nerves in the skin cannot be regarded as decided, or whether there be any decided difference between them. In the nose and tongue, we have sensory and sentient nerves close together, so that in both parts, besides the specific sense peculiar to the organ, pain may also be per- ceived. The white substance of the brain, although containing many nerves, is without feeling, as may be seen in many severe injuries of the head. The division of nerve-trunks is the severest of all inju- ries. Some of you may remember the pain from rupture of a dental nerve on extraction of a tooth. Severing of thick nerve-trunks must cause overpowering pains. Sensitiveness to pain appears peculiar to individuals. But you must not confound this with various exhibitions of pain, and with the psychical power of suppressing, or at least limiting, this exhibition ; the latter depends on the strength of will, as well as on the temperament, of the individual. Vivacious persons display their pain, as well as their other feelings, more than phlegmatic persons. Most persons maintain that crying, as well as the instinctive powerful tension of all the muscles, especially of the masseters, gritting the teeth, etc., renders the pain more endurable. Personally, I have not been able to verify this statement, and I think it must be a mistake of the patients. Strong will in the patient may do much to suppress the show of pain. I well remember a woman in the Gottingen clinic, when I was a student, who, without chloroform, had the whole upper 20 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. jaw removed for a malignant tumor, and, during this difficult and painful operation, she did not once cry out, although several branches of the trifacial nerve were divided. Women generally stand suffer- ing better and more patiently than men. But the necessary exercise of psychical strength not unfrequently causes subsequent fainting, or excessive physical and psychical relaxation, of longer or shorter du- ration. You will certainly meet persons who, without any exercise of will, show so little pain from severe injury that we can only be- lieve that they really feel pain less acutely than others ; I have ob- served this most in flabby sailors, in whom all the sequelas of the injury are also generally very insignificant. The quicker the wound is made, and the sharper the knife, the less the pain ; hence, in large and small operations, it has always seemed, and very correctly too, for the advantage of the patient, that the incisions should be made with certainty and rapidity, par- ticularly in dividing the skin. The feeling in the wound, immediately after its reception, is a peculiar burning. It can scarcely be termed any thing but the feel- ing of being wounded ; there are a number of provincialisms for it — in Northern Germany, for instance, they say "the wound smarts." Only when a nerve is compressed by something in the wound, twisted or irritated in some way, there are severe neuralgic pains immedi- ately after the injury ; if these do not soon cease spontaneously, or after examination of the wound and removal of the local cause, if possible, they should be arrested by the exhibition of some internal remedy ; otherwise, they will induce and keep up a state of excite- ment in the patient that may increase to maniacal delirium. To avoid the pain in operations, we now always use ansesthet- ics; this subject will be treated of in the course on operations. Recently ether has come more into use on account of the number of deaths from chloroform. I now use a composition of 3 parts chloro- form, 1 sulphuric ether, and 1 absolute alcohol, which seems less dangerous than chloroform alone. In England, for some years, Spencer Wells, among others, has used and recommended bichloride of methyline, claiming that it acts as quickly as, and is less dan- gerous than, chloroform. Local anaesthetics, which have for their object temporary blunting of the pain in the part to be operated on, by application of a mixture of ice and saltpetre, or salt, have been again abandoned, or rather they have never been generally received. Recently these attempts have again acquired a general interest, as it seemed that a suitable method of local anassthesia had at last been found. An English physician, Richardson, constructed a small apparatus, by which a stream of pure ether [or, better, rhigo- SYMPTOMS-HAEMORRHAGE. 21 line] spray is for a time blown against one spot in the skin, and such cold is here induced that all sensation is lost. After procuring some of this ether (hydramylather) from England, I was satisfied of its perfect action. In a few seconds the skin becomes chalky white, and absolutely without sensation ; but the effect hardly extends through a moderately thick cutis ; and, if the ether be still blown against the cut surface, the frozen tissues cannot be distinguished from each other, and the knife, being coated with ice, will no longer cut. Hence, even in this more perfect form, local anaesthesia can only be used advantageously in a few minor operations. My former dread, that healing of the wound would be essentially interfered with by this freezing of the part, has been shown by experience to be groundless. For quelling the pain, and as a hypnotic, immediately after extensive injuries or operations, there is nothing better than a quarter of a grain of muriate or acetate of morphia ; this quiets the patient, and, even if it does not make him sleep, he feels less pain from his wound. Quite recently hydrate of chloral ( 3 ss- 3 j, in half a glass of water) has been used ; its narcotic action was discovered by Z/iehreich, 1869. Its effect is essentially hypnotic, but very uncer- tain ; it cannot supplant chloroform, but is a decided acquisition to our materia medica. Locally, for the relief of pain, we employ cold in the shape of cold compresses, or bladders filled with ice, applied .to the wound. We shall refer to this under the treatment of wounds. Lastly, we may give hypodermic injections. If, with a very fine syringe, furnished with a lance-shaped, sharp canula, which may be thrust readily through the skin, we inject a solution of ■£— £ of a grain of acetate or muriate of morphia, this remedy will exercise its nar- cotic effect at first locally on the nerves it comes in contact with, and then on the brain, as the solution is absorbed and enters the blood. Of late, this mode of employing morphia has been exceedingly popu- lar; immediately after an operation, or severe injury, such an injec- tion is given, and the pain is at once arrested. In a pure incised or punctured wound, haemorrhage is a second im- mediate symptom ; its extent depends on the number, size, and variety of the divided vessels. At present we shall only speak of haemorrhage from tissues previously normal, and distinguish capillary, parenchyma- tous, arterial, and venous haemorrhages, which must be considered sep- arately. As is well known, the different parts of the body vary greatly in vascularity, especially in the number and size of the capillaries. In spots of equal size the skin has fewer and smaller capillaries than most 22 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. mucous membranes ; it also has more elastic tissue and muscles, by which (as we may feel and see in the cold and so-called goose-flesh) the vessels are more readily compressed than they are in the mucous membranes, which are poor in elastic and muscular tissue ; hence simple skin-wounds bleed less than those in mucous membranes. Haemor- rhages from the capillaries alone cease spontaneously if the tissue be healthy, because the openings of the vessels are compressed by con- traction of the wounded tissue. In diseased parts, which do not con- tract, even haemorrhage from dilated capillaries may be very consider- able. Haemorrhage from the arteries is readily recognized, on the one hand, because the blood flows in a stream, which sometimes clearly shows the rhythmical contractions of the heart ; on the other, by the bright-red color of the blood. If there be impaired respiration, this bright-red color may change to a dark hue ; thus, in operations on the neck, performed to prevent threatening suffocation, and in deep anaes- thesia, dark or almost black blood may spurt from the arteries. The amount of blood escaping depends on the diameter of the totally- divided artery, or on the size of the opening in its wall. You must not, however, believe that the stream of blood corresponds exactly to the size of the artery ; it is usually much smaller, for the calibre of the artery generally contracts at the point of division ; only the larger arteries, such as the aorta, carotids, femoral, axillary, etc., have so little muscular fibre that they contract, in their circumference at least, to a scarcely perceptible extent. In very small arteries, this con- traction of the cut vessel has such an effect that, from the increased friction, the blood flows from them without spurting or pulsating ; in- deed, in very small arteries, this friction may be so decided that the blood flows with difficulty and very slowly, and soon coagulates, so that the haemorrhage is arrested spontaneously. The smaller the diameter of the arteries becomes, from diminution of the amount of blood in the body, the more readily haemorrhage will be arrested spon- taneously, while otherwise it would have to be arrested artificially. Hereafter, you will often have occasion to see in the clinic how freely the blood spurts at the commencement of an operation, and how much less it will be toward the end, even when we cut larger vessels than were at first divided. Thus decrease of the total volume of blood may cause spontaneous arrest of haemorrhage ; the weaker contractions of the heart have also some influence in this. Indeed, in internal haemor- rhages that we cannot reach directly, we employ rapid abstraction of blood from the arm (venesection) as a haemostatic ; in such cases the artificial excitement of anaemia is not unfrequently the only remedy we have for internal haemorrhage, paradoxical as this may seem to SYMPTOMS— HAEMORRHAGE. 23 you at the first glance. Haemorrhages from incised wounds of the large arteries of the trunk, neck, and extremities, are always so con- siderable that they absolutely require to be arrested, unless the open- ings in their walls be very small. But, when the terminal branch of an artery is ruptured without a wound of the skin, the hemorrhage may be arrested by pressure on the surrounding soft parts ; such in- juries subsequently induce other changes, to which your attention will be called under other circumstances. Haemorrhage from the veins is characterized by the steady flow of dark blood. This is especially true of small and middle-sized veins. These haemorrhages are rarely very profuse, so that, in order to obtain a sufficient quantity on letting blood from the subcutaneous veins of the arm at the bend of the elbow, we must obstruct the flow of blood to the heart. If this were not done, blood would only flow from this vein at the time of puncture, further haemorrhage would cease sponta- neously, unless kept up by muscular contractions. This is chiefly be- cause the thin walls of the veins collapse, instead of gaping, as the arteries do when divided. Blood does not readily flow back from the central end of the vein, on account of the valves ; we rarely have any thing to do with the valveless veins of the portal system. Haemorrhage from the large venous trunks is always a dangerous symptom. Bleeding from the axillary, femoral, subclavian or inter- nal jugular, is usually quickly fatal, unless aid arrive immediately ; wounds of the vena anonyma may be regarded as absolutely mortal. The blood does not flow continuously from these large veins, but the flow is greatly influenced by the respiration. In operations about the neck I have frequently seen patients live after their internal jug- ular vein had been wounded ; during inspiration the vessel collapsed so that it might have been regarded as a connective tissue string ; during expiration the black blood gushed up as from a well, or still more like the bubbling up of the water from a deep spring. In these veins near the heart, besides the rapid loss of blood, there is another element that greatly increases the danger ; this is the en- trance of air into the veins and heart, as occasionally takes place with a gurgling noise, on deep inspiration, when the blood rushes toward the heart ; this may cause instant death, though not necessarily. I cannot now enter more explicitly into this very remarkable phenom- enon, whose physiological effect has not, as it seems to me, been sat- isfactorily explained ; you will again have your attention called to this subject by the books and lectures on operative surgery. I shall merely mention that, on opening one of the large veins of the neck or the axillary vein, there may be a perceptible gurgling sound ; the patient instantly loses consciousness, and can rarely be restored to 24 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. life by instantaneous resort to artificial respiration, etc. Death is probably caused by the entrance of air-bubbles, which press forward into the medium-sized pulmonary arteries, and are there arrested, and prevent further access of blood to the pulmonary vessels. I have never met any thing of the kind, although I have seen air enter the internal jugular vein, and frothy blood then escape ; this had no perceptible effect on the state of the patient. Different ani- mals appear to be susceptible, to various extents, to the entrance of air into the vessels ; if we throw only a little air into the jugular vein of a rabbit it dies ; while we may sometimes throw several syringe- fuls into dogs without observing any effects. Besides the above varieties of haemorrhage, we distinguish the so- called parenchymatous hemorrhage, which is sometimes incorrectly identified with capillary haemorrhage. In the normal tissue of an otherwise healthy body, parenchymatous haemorrhages do not come from the capillaries, but from a large number of small arteries and veins, which from some cause do not retract into the tissue and con- tract, and are not compressed by the tissue itself. Bleeding from the corpus cavernosum penis is an example of such parenchymatous haem- orrhages, which also occur from the female genitals and in the peri- neal and anal regions, as well as from the tongue and spongy bones. These parenchymatous haemorrhages are especially frequent from diseased tissue ; they also occur after injuries and operations, as so- called secondary hemorrhages ; but we shall speak of these here- after. One other point we must refer to here : this is, that there are per- sons who bleed so freely from a small, insignificant wound, that they may die of haemorrhage from a scratch of the skin, or after extraction of a tooth. This constitutional disease is called a hemorrhagic dia- thesis / people affected with it are called hemophilen. The cause of this disease is probably abnormal thinness of the arterial walls ; this is congenital in most cases, but may probably result gradually from morbid degeneration and atrophy of the vascular tunics. This frightful malady is usually hereditary in certain families, especially among the males, the females being less liable to it. In these persons haemorrhage is caused not only by wounds, but light pressure may induce subcutaneous bleed- ing, spontaneous haemorrhages, as from the gastric or vesical mucous membrane, which may even prove fatal. It is not exactly in laige wounds where medical aid is called at once or very soon, but more particularly in slight wounds, that continued haemorrhages occur in such persons which are difficult to arrest, partly, as we above stated, on account of slight contractility or total lack of muscular tissue in the vessels, partly on deficient power of coagulation in the blood. It is SYMPTOMS— HEMORRHAGE. 25 true, the latter point has not been proved from the blood that escaped, for in the cases where attention was directed to this point the blood flowed like that of a healthy person. I shall also call your attention to some peculiarities in haemorrhages from certain localities, especially from those in the pharynx, posterior nares, and rectum, although, strictly speaking, this comes in the domain of special surgery. Wounds of the pharnyx or posterior nares, made through the open mouth by accident, are rare, but, as a result of con- stitutional disease, we may have very severe spontaneous haemorrhage from these parts, or these may result from operations, for we not un- frequently have to use knives and scissors here, or to tear out tumors with forceps. The blood does not always escape from the mouth and nose, but it may run down the pharynx into the oesophagus without being perceived. The general effects of rapid loss of blood come on rapidly, which we shall soon describe more minutely, but we ars unable to discover the source of the bleeding, which may be behind the soft palate. The patient soon vomits, and at once throws up large quantities of blood ; when this ceases there is another pause, and the patient, perhaps also the surgeon, thinks the haemorrhage has ceased, till more blood is vomited, and the patient grows still weaker. If the surgeon does not recognize these symptoms and apply proper remedies, the patient may bleed to death. I remember one case where several physicians gave various remedies for vomiting of blood and gastric haemorrhage after a little operation in the throat, and the source of the bleeding was finally recognized by an experienced old surgeon, who arrested it by local applications, and thus saved the life of the patient. The same thing may happen in haemorrhage from the rectum. From an internal wound the blood flows into the rectum, which is ca- pable of enormous distention ; the patient has a sudden desire to stool, and evacuates large quantities of blood. This may be repeated sev- eral times, till the rectum, irritated by the expansion, either contracts and thus arrests the haemorrhage, or till it is finally checked artificially. A rapid excessive loss of blood induces changes in the whole body, which are soon perceptible. The face, especially the lips, becomes pale, the latter bluish, the pulse is smaller, and at first less frequent. The bodily temperature sinks most perceptibly in the extremities ; the pa- tient, especially when sitting up, is subject to fainting-spells, dizziness, nausea, or even vomiting, his eyes are dazzled, and he has noises in the ears, every thing appears to whirl around; he collects his strength to hold himself up, he becomes unconscious, and finally falls over. These symptoms of syncope we refer to rapid anaemia of the brain. In a horizontal posture this soon passes off. Persons often fall into this 26 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. state from very slight loss of blood, occasionally more from loathing and aversion to the flowing blood than from weakness. A single fainting of this kind is no measure of the amount of blood lost ; the patient soon recovers his forces. Should the haemorrhage continue, the following synrptoms appear sooner or later: the countenance grows paler and waxy, the lips pale blue, the eyes dull, the bodily temperature is lower, the pulse small, thready, and very frequent, respiration incomplete, the patient faints frequently, constantly grows more feeble and anxious ; at last he remains unconscious, and there is twitching of the arms and legs, which is renewed by the slightest irritation, as by the point of a needle, etc. ; this state may pass into death. Great dyspnoea, lack of oxygen, is one of the worst signs, but even here we should not hesitate ; we can often do something even after apparent death. Young women especially can bear enormous loss of blood without immediate danger to life ; you will hereafter have occasion to witness this in the obstetrical clinic. Children and old persons can least bear loss of blood ; in young children the results of the application of a leech are often evident for years by a very pallid look and increased excitability. In very old persons great loss of blood, if not immediately fatal, may induce obstinate collapse, which after days or weeks passes on to death ; this is probably because the loss of blood is immediately supplied by serum, and in old persons the formation of blood-corpuscles goes on slowly ; the greatly-diluted blood proves insufficient to nourish the tissues, whose nutrition is at any rate very sluggish. When the patient comes to himself after severe haemorrhage, he has excessive thirst, as if the body were dried up, the vessels of the intestinal canal greedily take up the quantities of water drunk ; in strong, healthy persons, the cellular constituents of the blood are quickly replaced, it is true we do not exactly know from what source ; after a few days, in a person otherwise healthy, we can perceive few signs of the previous anaemia ; soon, too, his strength has recovered from the exhaustion. LECTURE III. Treatment ofHsemorrhage.— 1. Ligature and Mediate Ligature of Arteries.— Torsion.— 2. Compression by the Finger; Choice of the Point for Compression of the Larger Arteries. — Tourniquet. — Acupressure. — Bandaging. — Tampon. — S. Styptics. — General Treatment of Sudden Anajmia.— Transfusion. Gentlemen : You now know the different varieties of haemorrhage. Now, what means have we for arresting a more or less severe bleeding ? TREATMENT OF HEMORRHAGE— LIGATURE. 27 The number is great, although we use but few of them — only those that are the most certain. Here you have a field of surgical operation where quick and certain aid is required, so that the result must be unfailing. Still, the employment of these remedies requires practice ; cool-blooded quiet, absolute certainty, and presence of mind, are the first requisites in dangerous haemorrhage. In such circumstances a surgeon may show of what metal he is made. Haemostatics are divided into three chief classes : 1. Closure of the vessel by tying it — ligation. 2. Compression. 3. The remedies that cause rapid coagulation of blood, styptics (from OTv- injecting water ; decomposing vegetable matter also has a fever-exciting effect. Hence there are no specific fever- exciting substances, but the number of pyrogenous materials is in- numerable. I may here mention that the bad-smelling substances developed by the decomposition of the tissues are probably the least dangerous. I intentionally distinguish the products of decomposition in acute inflammations, which are usually odorless at first (whose activity as poisons we first learned by experiment), from those of decomposing dead bodies, which generally smell bad at once, although their pyro- genous action is similar. If a wounded patient has fever, it is for me a proof that there is decomposition going on in his wound, and that the products have passed into the blood, whether the wound smells or not. After the pyrogenous effect of the products of inflammation and decomposition had been absolutely confirmed, it remained to be proved that this material could be taken from the tissue into the blood, and -to be shown how this took place. For this purpose it was injected into the subcutaneous cellular tissue, where it spread around in the meshes of the tissue ; the effect, as to fever, was the same as when the injection was made directly into the blood ; hence the pyrogenous material is absorbed from the cellular tissue. Here there is another observation to be made : after a time, at the point where decomposing fluid or fresh pus has been injected, there is severe and not unfrequently rapidly progressive inflammation. For instance, I injected half an ounce of decomposing fluid into the thigh of a horse ; in twenty-four hours the whole leg was swollen, hot, and painful, and the animal very feverish. I did the same thing with the same result, with fresh (not decomposing) abscess pus, in a dog. This action of pus and putrefy- ing matter in exciting local inflammation I call phlogogenous. All pyrogenous substances are not at the same time phlogogenous ; some are more so than others, and, especially in the putrefying fluids, it makes a great deal of difference whether the poisonous power, which we do not know accurately, is present in greater or less quantities. It is not certainly determined whether the pyrogenous materials enter the blood through the lymph or blood-vessels; they may vary in this respect. Some points are in favor of the reabsorption taking place chiefly through the lymphatics. 5 There is still something to be said about the course of the fever 94 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. artificially induced in animals. The fever begins very soon, often even in an hour after the injection ; after two hours there is always considerable elevation of temperature : for instance, in a dog whose temperature in the rectum was 103° F., two hours after an injection of pus it may be 105°, and four hours after the injection 107°. It is im- material whether the substance be injected directly into the blood or into the cellular tissue. The fever may remain at its height from one to twelve hours, or even longer. The defervescence may be either gradually or by crisis. If we make new injections, the fever increases again ; by repeated injections of putrefying material we may kill the largest animal in a few days. Whether an animal shall die from a single experiment, depends on the amount and poisonous qualities of the injected material in relation to the size of the animal. A medium- sized dog, after the injection of a scruple of filtered decomposing fluid, may be feverish for a few hours and be perfectly well after twelve hours. Hence the poison may be eliminated by the change of tissue, and the disturbances induced by its presence in the blood ma}' again subside. I will now terminate these observations, and only hope I may have made this important subject, to which we shall frequently return, comprehensible to you. I feel convinced that traumatic fever, like any inflammatory fever, essentially depends on a poisoned state of the blood, and may be induced by various materials passing from the seat of inflammation into the blood. In the accidental traumatic diseases we shall again take up this question. Now a few words about the prognosis and treatment of suppurat- ing wounds. The prognosis of simple incised wounds of the soft parts depends chiefly on the physiological importance of the wounded part, both as regards its importance in the body and as regards the disturbance of function in the part itself. You will readily understand that injuries of the medulla oblongata, of the heart, and of large arterial trunks lying deep in the cavities of the body, should be absolutely fatal. Injuries of the brain heal rarely; the same is true of injuries of the spinal medulla — they almost always induce extensive paralysis and prove fatal by various secondary diseases. Injuries of large nervous trunks result in paralysis of the part of the body lying below the seat of injury. Openings into the cavities of the body are always very serious wounds ; should they be accompanied by injury of the lung, intestines, liver, spleen, kidney, or bladder, the danger increases ; many of these injuries are absolutely fatal. Opening of the large joints is also an injury which not Gnly often impairs the function of TREATMENT OF SIMPLE INCISED WOUNDS. 95 the joint, but is often dangerous to life from its secondary effects. External circumstances, the constitution and temperament of the pa- tient, have also a certain influence on the course of cure. Another source of danger is the accessory diseases which subsequently arise, and of which unfortunately there are many ; of these we shall here- after speak in a separate chapter. You must for the time being con- tent yourselves with these indications, whose further elucidation forms a very considerable part of clinical surgery. We may give the treatment of simple incised wounds very briefly. We have already spoken of the uniting of wounds without loss of substance, and the proper time for removing the sutures, and that is about all that we can regard as directly affecting the process of heal- ing. Still, as in ail rational therapeutics, here it is most important : 1. To prevent injurious influences that may interfere with the nor- mal course ; 2. Carefully to watch the occurrence of deviations from the normal, and to combat them at the right time, if possible. If we, 6rst of all, limit ourselves to local treatment, we have no remedy for decidedly shortening the process of healing by first inten- tion or by suppuration, say to half its time or less. Nevertheless, most wounds require certain care, although innumerable slight wounds heal without being seen by a surgeon. The first requirement for normal healing is absolute rest of the injured part, especially if the wound has extended through the skin into the muscles. Hence, in wounds at all deep, it is very necessary that the patient should not only keep his chamber, but that he should remain in bed for a time, as it is evident that the movement of injured parts, especially of in- jured muscles, must interfere with the process of healing. The sec- ond important point is cleanliness of the wound and its vicinity. Formerly it was always considered necessary to cover the wound, and to apply dressings in all cases. Of late I have grown doubtful if this be indeed necessary ; indeed, I would go so far as to assert that in many cases it is well not to apply any dressings. In wounds that have been sewed up, it has often been observed that it does no harm to leave them uncovered. If we wish to cover sutured wounds, on account of pain, redness, and swelling, or because they are in a part of the body upon which the patient must lie, we may apply various kinds of dressing ; we may smear the edges of the wound with pure, fine oil, best with almond-oil, and k^y on a fold of linen dipped in oil, which should be changed daily, till the sutures are removed ; or else we may apply a linen compress three or four layers thick, and the size of the wound, wet with water, and cover it with oil-silk, gutta- percha sheeting, or parchment-paper, and make a few loose turns of a bandage over it. 96 SIMPLE IXCISED WOUXDS OF THE SOFT PAETS. For some time past I have used as the immediate covering' of recent wounds merely a moistened thin sheet of gutta-percha, over this a moist compress ; and to prevent the latter from drying, 1 cover it with some waterproof stuff, such as glazed paper, gutta- percha, or oiled silk, and then cover with plenty of dry wadding (de- prived of fat and made bibulous by cooking in lye). This dressing may be removed without wetting or giving pain ; it is to be retained in place by a bandage or adhesive plaster. For moistening the compresses and the sheet of gutta-percha, which lies directly on the wound, we generally employ liquids which arrest the decomposition of the secretion from the wound and prevent its smelling badly, that is, which are antiseptics and deodorants, and at the same time may destroy any infectious matters clinging to the dressings. In my clinic, for this purpose we employ saturated solution of chloride of lime, aqua plumbi, solutions of carbolic acid, carbolate of soda, and sulphate of soda (10 per cent.). I have not noticed any decided difference in their effect, and on the score of economy use solution of chloride of lime for ordinary dressings. The frequency with which the dressings of a simple wound should be renewed depends on the amount of secretion. As a general rule, during the first four days the dressing above described should be removed at least twice daily ; if during the first and second days the secretion escapes in a few hours, the dressing should be changed at once. In doing this we no longer need to use a syringe, and to carefully work off the charpie from the wound, while the patient suffers tortures ; should it ever be necessary to inject fistulous wounds, of which we shall hereafter speak, we may use either a sim- ple syringe or an JEsmarch's douche, which consists of a cylindrical vessel 25 centimetres high and 12 in diameter, with a short tube in- serted at its bottom, on to which a rubber tube with a nozzle is applied ; when this vessel is held up by an attendant, it acts as a syringe. It is generally enough to wipe off the wound with a little wadding when changing the dressing, and it is not necessary to remove ever}'- trace of pus. In many cases this dressing may be continued for weeks, being after a time applied only once daily, and then every two or three days ; cicatrization goes on and the wound heals without doing any thing more. Nevertheless, independent of certain diseases of the granulations, of which we shall speak more particularly hereafter, it frequently happens that under a continuance of the same treatment the heal- ing is arrested ; for days the process of cicatrization does not ad- vance, and the granulating surface assumes a flabby appearance. TEEATMEXT OF SIMPLE IXCISED WOUNDS. 97 Under such circumstances it is advisable to change the dressing, to irritate the granulating surface by new remedies. These temporary arrests of improvement occur in almost every large wound. Under such circumstances you may order fomentations of warm camomile- tea ; several compresses may be dipped in the warm tea, wrung out, and from time to time applied fresh to the wound ; or you may pre- scribe lotions of lead- water. You may also paint the wound from time to time with a solution of nitrate of silver (two to five grains to the ounce of water). If the wound-surface be no longer large, you may finally make use of salves ; these should be spread thinly over charpie or linen ; the most suitable are the basilicon-ointment (compound resin cerate, consisting of oil, wax, resin, suet, and turpentine) and a salve of nitrate of silver (one grain to a drachm of any salve, with the addition of Peruvian balsam). If the cicatrization be already far advanced, we may employ zinc-salve (zinc, oxide 3 j, ung. aq. rosas § j), or let the dry charpie adhere, and have the last portion of the wound heal under the scab. A very peculiar and occasionally a very efficient method of hast- ening cicatrization of granulating wounds has been introduced by Heverdin. He found that a small portion of cutis taken from the surface of the body with concave scissors, and fastened with the raw surface on the granulations by means of adhesive plasters, not only becomes adherent, but the transplanted epidermis begins to grow and forms the centre of a so-called cicatricial island, whence the skin- ning over of the wound advances just as it does from the margins. In the clinic we have often resorted to this artificial skinning over of wounds with epidermis, and rarely ineffectually. The effect is perceived when we remove the plaster on the third day and find a red aureola around the transplanted piece ; this gradually grows, and on the sixth or eighth day is followed by a bluish-white border, just as in cicatrization at the edges of the wound. I do not underestimate the practical value of this proceeding, but it is even more interesting to me from the addition it forms to our knowledge of natural history. Here we have the most striking proof not only of the independence of cell-life in the tissues of man, but still more of the readily-excited formative power of the epithelium, which is here aroused by a change of the nutrient material, while the portion of the papillary layer of the cutis transplanted at the same time does not grow. Thiersch, Minnich, and Menzel have made observations showing that, eight hours or perhaps longer after death, epidermis may be successfully transplanted. The finer details of the histological changes in these transplantations have been carefully studied by Heverdin, and still more so by Amabile. Czerny has shown that 7 98 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. mucous membrane from the mouth (with flat epithelium) and from the nose (with cylindrical ciliated epithelium) may be successfully grafted on wounds. [Is this, perhaps, one cause for animals licking their wounds ?] The epithelium of these membranes preserves its character but a short time, then it is transformed into epidermis. [March 6, 1871, Dr. B. Howard presented, at the meeting of the New York County Medical Society, a case in which, after skin-grafting, cicatrization had progressed for a time, then seemed to be arrested ; whereupon he grafted small portions of the biceps muscle and thus induced a continuance of the cicatrization. The question was raised whether the renewed activity was not due to the previous skin-graft- ing. Dr. Stein stated that he had aroused these old ulcers by sprin- kling epidermis scales over their surface.] Regarding constitutional treatment, we can accomplish scarcely any thing with internal remedies in preventing or cutting short the sub- sequent fever. Still, certain dietetic rules are necessary. After the injury the patient should not overload his stomach, but, as long as he has fever, must live on low diet. This he usually does spontane- ously, as fever patients rarely have any appetite ; but, even after subsidence of the fever, the patient should not live too high, but only eat as much as he can digest while lying in bed or confined to his chamber, where he has no exercise. If the fever be high, and the patient desires some change of drink from cold water, which is generally preferred by fever patients, you may order acid drinks, as lemonade or some medicinal substance ; the patients soon grow tired of the ordinary lemonade ; they bear phosphoric or muriatic acid in water with fruit-juice, raspberry-vinegar in water, apple boiled in water, toast-water (infusion of toasted bread with some lemon-juice and sugar) ; some patients prefer almond-mucilage, water-ice dis- solved in water, oatmeal gruel, barley-water, etc. We may give the taste of the patient full play ; but it is well for you to attend to such things yourself. The physician should know as much about the cel- lar and kitchen as about the apothecary-shop, and it is even well for him to have the reputation of being a gourmand. HEALING BY FIRST AND SECOND INTENTION. 99 LECTURE IX. Combination of Healing by First and Second Intention.— Union of Granulation Surfaces. — Healing under a Scab. — Granulation Diseases. — The Cicatrix in various Tissues; in Muscle ; in Nerve ; its knobby Proliferation ; in Vessels.— Organization of the Thrombus. — Arterial collateral Circulation. To-day I have first simply to add a few words about certain de- viations from the ordinary course of healing, which occur so fre- quently that they must very often be counted as normal; at all events, as very frequent. It is not at all unfrequent for the two forms of healing above de- scribed, by first and second intention, to combine in the same wound. For instance, you unite a wound completely, and may sometimes ob- serve that at some places there is healing by the first intention, while at others, after removal of the sutures, the wound gapes, and subse- quently heals by suppuration. But it is much more common for a large and deep wound to heal superficially, and to suppurate for some time from the deeper part. If the entire surface of the wound be healthy, the cause of the in- complete healing is either that it was imperfectly coapted at the first dressing, or that blood and exudation escaped between the edges, which not only do not coagulate firmly enough to keep up the adhesion, but can even decompose and set up an inflammation which may spread rapidly and cause severe general disturbances. These important results of such wounds compel us specially to study their mechanical conditions and chemical changes ; from the first they are more or less complete fistulous wounds. It may be readily seen that where the skin has been divided, as for the removal of a deeply -situated tumor or a portion of diseased bone, a cavity is left if the skin is sewed up, which will remain filled with air and blood, unless the bleeding has been completely arrested, the wound well cleansed, and its edges brought well in contact. In cases where different tissues are wounded, and contract unequally, as in a wound going down to the bone, the surfaces would be very uneven and not be accurately apposed if the edges of the skin were simply united. Experience teaches that in such cases large wounded surfaces, even if loosely approximated, may be readily separated by secondary hemorrhages or fluid exudations, which often decompose while the skin above them is completely united. Then the parts around the wound swell and become painful, and high fever comes on. I will not here describe those dangerous states, septic phleg- mon and blood-poisoning, which may arise, but merely say that we 100 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. may often prevent the development of these processes by early evac- uation of the decomposing matter. It is not the mere presence of blood between the tissues that causes these affections, for that often occurs in severe contusions without wounds and induces no bad re- sults ; it is the decomposition of the blood, and the peculiarly phlogo- genous and pyrogenous properties of the first exudation, which cause the danger. Hence, in treating these wounds, we must take care, first, to prevent collection of blood and secretion in the wound, and secondly, in case this has not succeeded, to prevent decomposi- tion of these fluids, so that they may rest quietly until absorbed, as they would if the skin had not been injured. Of course, if there be no blood or secretion in the wound, they canhot decompose ; hence it is most important to prevent their col- lection. This would be most simply prevented by not closing up deep wounds, but filling them with charpie, wadding, or similar bib- ulous material, after carefully arresting the hasmorrhage ; this dress- ing must be renewed as often as it becomes saturated. This method was used for years, and was considered satisfactory, as no other way was known ; still, as we now know better methods, we think the reaction was considerable, although less than accompanied the irri- tative treatment of the middle ages ; inflammations spreading from the wound were frequent, and were referred to individual peculiari- ties, then to general influences of the atmosphere or to hospital air. It is only within the last twenty years that the propriety of the above treatment has been questioned, and new ways, based on differ- ent hypotheses, have been sought. This led to two opposite meth- ods : one entirely without dressings (open treatment of wounds), the other accurate closure and air-tight dressing (method by occlu- sion). In the open treatment of wounds, which can only be used with facility in wounds of the extremities, the part is so placed that the secretion may flow readily into a vessel placed beneath. The first two days this secretion is of a dark blood-color and thin ; from the third to the fifth day it becomes light brownish, then yellow, and soon in the vessel the pus-serum separates from the lumpy flakes of pus-cells ; at the ordinary temperature of the room this secretion does not begin to smell badly in twenty-four hours, unless consider- able quantities of decomposing dead shreds of tissue lie in the wounds and pass off with the secretion. This freedom from smell must strike any one who has smelt dressings that have been removed from a wound after being applied twenty-four hours. The bodily tem- perature to which this secretion is subjected while in the dressing is doubtless the cause of its more rapid decomposition. Should one a priori suppose that with such a dressing collection of the secretion OPEN TREATMENT OF WOUNDS. 101 with its evil results would be impossible, he will soon find practi- cally that the object of the open treatment of wounds will not be attained by absolute inattention, but that the form and position of the wound may greatly impede the escape of secretion, and also that the early, firm union of the skin may shut off certain parts of the wound as effectually as if a suture had been introduced, and thus the same severe diseases may be induced as by the old methods of treatment. In operations we may do much to make wounds of such a shape that the secretions will run off at once ; but in accidental wounds this is often difficult to do, and requires a certain experi- ence. In regard to the above-mentioned formation of pockets, we should prevent it by daily breaking up the adhesion, or from the first lay drainage-tubes in all the angles and hollows of the wound, through which any secretion from the deeper parts may readily es- cape. These drainage-tubes, introduced by Chassaignac, are made of vulcanized rubber of various calibre, with holes along the sides. The term " drainage " is taken from agriculture ; land may be drained by laying a system of porous tubes at a certain depth through the soil ; the water trickles into these tubes, and flows through them to large ditches. The results from careful trial of this method of open treatment for years far surpassed all previous ones. From the publications of JBartscher, Vezin, and J3urow, I had my attention called to this plan over ten years ago ; and as it fully agreed with the views I had arrived at from clinical and experi- mental observations and investigations on the poisonous peculiarities of the first secretion from wounds, I have pursued it with particular care, and have resorted to it in almost all deep wounds of the ex- tremities, whether incised or contused. It was only after being assured by some of the most prominent German surgeons that better results were obtained by Lister's careful antiseptic dressing that I would try it, so little did I think of the correctness of the theory. There is no doubt that it would be a great advantage for the pa- tient and a triumph for surgery if we could without danger induce healing by first intention in all large deep wounds. It is true, even in the open treatment of wounds, the surfaces may so come in con- tact as to heal almost entirely by first intention ; but this is rare, although partial adhesions are frequent and do not require breaking up if the patient remain free from fever and pain. Formerly, by applying bandages to press the surfaces of the wound together, or by deep sutures, attempts were made to induce immediate union ; although this- succeeded in some cases, it proved so dangerous in those where the surfaces of the wound were separated by blood or exudation, which putrified and could not escape, that conscientious 102 SIMPLE INCISED WOUNDS OF THE SOFT PAETS. surgeons soon abandoned it. Subsequently, when attempts were made by laying strips of oiled rag in the angle of the wound to give exit to the secretion, it rarely succeeded. In my opinion Lis- ter deserves great credit for having shown that numerous drainage- tubes, properly placed in the wound and cut off even with the sur- face, will completely carry off all secretion, even if an accurately- fitting compressive dressing of bibulous material be applied over the united wound ; if, by directly covering the wound with gutta-percha or oiled silk, we prevent the drainage-tubes from being stuck up by dried secretion, such a dressing has the advantage of an open dress- ing by allowing free escape of secretion, as well as that of a com- pressing dressing, by which union of large wounded surfaces is so greatly favored. To prevent the escaping secretion from decom- posing in the dressing and affecting the wound, the dressing should D3 frequently changed at first. In this care about dressings, as well as in cleanliness about operations, it seems to me, lies the great ad- vantage of Lister's method. But Lister started on the construction of his complicated dressing from different ideas ; he thought, just as I have repeatedly asserted, that the severe inflammations about wounds and the constitutional implications are almost alwaj's due to decomposition in the wound. I think that decomposition of dying tissue and exudation from the wound (for us a decomposition of albuminous substances with formation of pyrogenous and phlogoge- nous matters) is a chemical process that must, under certain circum- stances, always occur in these substances without the addition of new agents ; while Lister agrees with Pasteur's view that decompo- sition only occurs under the influence of small vegetable organisms, just as he claims that fermentation is only developed by yeast fun- gus. In regard to this question of living or dead ferments, I must refer you to organic chemistry. In physiology you have learned about salivary, pancreatic, and gastric ferments, which, although produced by cell-activity, no longer act as living organisms, but in a purely chemical way. In the same way, I think a substance may be formed as the last action of a dying tissue, that shall have some of the peculiarities of a ferment, and at the same time have a phlogo- genous action, and perhaps be very poisonous for the circulating blood. It does not seem to me to have been proved that the addi- tion of small organisms (vibriones or bacteria of Pasteur) is abso- lutely necessary to the formation of such substances. It is true, they are generally found in such fluids ; but this may be explained by the fact that these small organisms occur everywhere in air and water, and develop particularly in decomposing fluids. As we shall often have occasion to speak of these small organ- ORGANIC FERMENTS IN WOUNDS. 103 isms, whose significance is at present so much discussed, I will here give you a brief sketch of those forms that are most frequently found in decomposing tissues and fluids. They may be minute spheres (micrococcus, from p«poc, small, and 6 KOKKog, the germ), or minute rods (bacteria, from to f3anT7Jptov, the rod), which may be isolated, in pairs, or in chains of from 4 to 20 links (streptococcus, from 6 OTpeTTTog, the chain, and o KOKKog) ; often they are held in the shape of a sphere or cylinder by a glutinous substance which they throw out (coccoglia, from aotmog and r\ yXia or yXoia, glue). Fig. IT a. ct, Micrococcus (Monads of fftieter. Microspores of Klebs) ; b, Coccoglia or Gliacoccus (Zoogloea, Cohn) ; c, Streptococcus (Torula) ; d, Bacteria ; e, Vibriones ; /, Streptobacteria (Leptothrix of Hallier). Magnified 300-500 These elements vary greatly. in size, from a pale sphere, of such diameter that it can scarcely be perceived with the highest power of a microscope, to the size of a pus-cell ; they are sometimes mova- ble, at others quiet. It is pretty generally agreed that these minute organisms are vegetable in their nature, and belong to the algae ; but their accurate botanical position and relations to each other are • still matters of dispute ; their development is not yet explained, and until very recently some believed that they were the result of generatio cequivoca or abiogenesis, that is, existed without influence from any living organism. From my investigations, I think that all the above forms belong to one plant, which, being composed of coc- cus and bacteria, and being found chiefly in decomposing fluids, I have called Coccobacteria septiea. This plant seems to me to de- velop as follows : first, its germs are found in dry air, and may be 104 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. recognized under the microscope as fine dust ; placed in water, they swell and throw out more or less small pale spheres, micrococcus (a, Fig. 21 a). According to external circumstances, these assume the following forms : 1. While increasing by segmentation, they throw out a slimy cement (glia), by which they hang together in balls, like frog-spawn (coccoglia, or gliacoccus, b, Fig. 21 a) ; on the surface of fluids this form often appears as coherent bright-brownish mem- branes, and it also grows into the interstices of tissues, and is found as whitish-gray flakes in fluids ; this form is always without motion. Under certain circumstances the glia around these spheres and cyl- inders thickens to a membrane, the coccus becomes movable and es- capes through an opening in the capsule (ascococcus, from aotcog, tube). 2. The coccus divides always in one direction, and some of the divisions remain, like frog-spawn, united by a delicate envelope of glia (c, Fig. 21 a) ; these streptococci are sometimes in motion, wriggling slowly across the field of the microscope, but usually they are at rest ; we may find them in fresh secretion from the wound or in pus, and often in alkaline urine, without there being necessarily any bad odor ; the streptococcus, along with the isolated micrococ- cus and gliacoccus, are the forms of coccobacteria which occur most frequently in decomposing secretion from wounds or in diphtheria of wounds. With absolute rest the streptococcus may form long upright filaments, but this is very rare in living organisms, and is difficult to see under the microscope. 3. The coccus grows to rods, which increase in length and then divide across ; thus we have bacteria chains (/, Fig. 21 a), which may be moving or motionless. In some fluids the division of the bacteria goes on very rapidly, the rods becoming shorter, till they are finally square or rounded ; and so between coccus and bacteria there are numerous transition forms. Bacteria are not apt to enter the secretion from wounds, pus, or decomposing blood ; on the other hand, they develop and remain in all fluids of the cadaver and in watery exudations of almost all tis- sues ; in the latter they are very movable. All of these vegetations require plenty of water and organic substances, especially nitrogenous matters, for their rapid propaga- tion ; they bear abstraction of water up to a certain point, but if entirely dried out they die ; and although they will subsequently swell if placed in water, they have lost their power of vegetating. They can bear temperatures as low as the freezing point, and nearly V. up to the boiling point ; but when it reaches the boiling point they die. In fluids or moist tissues completely excluded from atmos- pheric air, they will vegetate till all the air contained in the fluid has been used up ; then, no more air being absorbed by the fluid, ORGANIC FERMENTS IN WOUNDS. 105 the coccobacteria die, as they cannot cause decomposition of water or any organized combination. Under these conditions some of these coccobacteria may be thrown into the atmosphere and be generally distributed by the evaporation of fluids, so common in nature. Still, when the air be- comes very dry, these vegetations might dry out, die, and become organic but no longer organizable dust ; but such an occurrence is provided against. As in many of the algae of stagnant water, hav- ing similar peculiarities and subject to being dried out, so in some of the elements of coccobacteria a larger quantity of peculiarly con- centrated protoplasm unites to form a glistening sphere with dark contours, which may be distinguished from other coccus, but hardly from fat globules. These little spheres have the peculiarities of fungus-germs and very resistant seeds ; they may be entirely dried, cooled far below the freezing and warmed above the boiling point, and kept hermetically closed for a long time, without losing their germinal activity ; hence they are called permanent germs (Dauer- sporen). According to my experience, they form very certainly and not very rarely, under certain circumstances, in bacteria ; but they also occur in coccoglia balls ; I cannot state whether some spheres of streptococcus also become permanent germs. These Dauersporen are the dried germs from which we started for development ; they require quiet in or on some fluid or moist body. I have here given you a brief review of the results to which my investigations on this point have led. But I must call attention to the fact that botanists have not yet proved the correctness of my views, and that they are at variance with those of most others who have investigated this subject, and who consider each of the forms above described as separate plants, and also make numerous species of each kind, especially according to the diseases induced by each. Let me also remind you that most pathologists term these algae fungi, and often call them all bacteria. It is to these small organisms that Pasteur, and after him Lister, attributes decomposition, at least those forms of it whose products are local and general poisons. If we could prevent their entrance into the wound or its secretions, according to this view, there would be no decomposition of the secretions, even if some of them did re- main in the wound. With this idea, Lister writes a number of rules to be followed in the operation and dressing of the wound, all aim- ing at the destruction of the germs of coccobacteria which might reach the wound through the hands of the operator and assistants or the air. After the operator and assistants, before each operation or dressing, have carefully washed with soap and water, they dip their 106 SIMPLE INCISED WOUXDS OF THE SOFT PARTS. hands in a five per cent, solution of carbolic acid; in the same way the parts about the seat of operation are to be carefully washed and moistened with the same solution of carbolic acid; and all instru- ments, sponges, and dressings used lie in this solution, which is sup- posed to kill all germs of coccobacteria. To prevent these germs from reaching the wound through the air during the operation and dressing, a two per cent, solution of carbolic acid is constantly sprayed on the part with a special apparatus, so that it falls on the wound in the form of a fine rain. We have already described the occlusion or "antiseptic" dressing, as it is termed, although the open treatment of wounds and some other methods are just as anti- septic. There is no reason for going any further into details here, where we are chiefly explaining principles. Lister's dressing, which seems so complicated, is in practice much simpler than would appear from the description ; for every step and rule the inventor had a definite reason, and there is nothing arbitrary or intentionally mys- terious. If we inquire into the practical working of this treatment, we hear chiefly praise, and many speak enthusiastically of its won- derful effects. Although my own experience with it is not very great, I can recommend it as being generally very good ; it is cer- tainly more popular than the open treatment of wounds; it is still a disputed point which of these methods answers best in treatment of wounds of the extremities. I urgently recommend you to perfect yourselves in the principles and practical application of Lister's treatment, and you will have many favorable results. It is different if we accurately examine the correctness of the theoretical views from which Lister starts, and inquire whether by his mode of operating and dressing he has attained his object. In regard to the latter point, it has been often proved that in the secre- tion of wounds treated according to Lister's method, and which healed rapidly without reaction, coccobacteria were found about as often as in secretion from wounds which were merely dressed with attention to cleanliness. This shows : 1, that the presence of these vegetations in itself proves nothing about the phlogogenous or other poisonous qualities of the secretion ; 2, that Lister's dressing is no guarantee for the destruction of bacteria. Against this second point it might be urged that there is no proof that these germs reach the wound only from without; it is possible that permanent germs enter the blood through the respired air, and, though they may not develop under normal circumstances, do so in the secretion of wounds. If this be possible, there is no sense in the theory of Lister's method as far as regards its attacking organic germs by chemical means. Indeed, it is my opinion that those not very frequent cases where HEALING BY THIRD INTENTION. 107 coccobacteria vegetations have been found in completely closed, deeply-seated points of inflammation, which never communicated with the air, can only be explained in the way above mentioned. Apart from the fact that Lister's dressing is expensive if followed out in all its details, and that more or less severe poisoning is often caused by the annoying dermatitis induced by the carbolic acid, this incongruence of theory and practice has led to the employment of more and more dilute solutions of carbolic acid, and its replacement by other antiseptic and less irritating acids and salts (salicylic acid, Thiersch; sulphide of sodium, Minich). Various changes have also been made in the mode of applying the dressing ( Volkmami, Bardelebeti) ; the spray has been entirely omitted, and in its place after the operation the wound has been washed with a more concen- trated antiseptic solution, etc., etc. Thus Lister's dressing has been variously modified, and from each modification the same favor- able results have been obtained as from the original dressing. This confirms me in the opinion formed when this method was first de- scribed, and which I have already stated, that the scrupulous clean- liness and the careful removal of secretion from the wound is the most important part of it, and that it is chiefly popular among sur- geons who formerly paid less attention to these points, and left the dressings to the dirty hands of nurses or to careless students or young physicians, while now the dressings are all applied according to definite principles of cleanliness. Moreover, the constantly spreading and more energetically preached doctrine of local infection from wounds, of which we shall treat hereafter, has led to a rec- ognition of the necessity of a rational treatment of wounds, and has contributed essentially to opening the way for the open treat- ment of wounds — to Lister's method and antiseptic lotions. There is still another mode of adhesion of the edges of wounds, which consists in the direct union of two adjacent granulating sur- faces. This mode of healing, which you may call healing by the third intention, is unfortunately very rare. The reason of this is evident : pus is constantly secreted from the surface of the granulations, and while this goes on the surfaces are only apparently in contact, for there is pus between them. Occasionally, it is true, we may, by press- ing the two granulation surfaces together, prevent the further forma- tion of pus, and then the two surfaces may adhere ; we accomplish this by drawing the flaps of the wound firmly together with good adhesive plaster, or by the application of secondary sutures, for which it is well to employ wire. Unfortunately, the attempt to hasten the cure by 108 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. these means so rarely succeeds, that they are only exceptionally em- ployed. The best results are obtained from secondary sutures when, six or seven days after the injury, they are applied about four or five lines from the edge of the wound, because the tissue is then more dense and firm, and the sutures cut through less quickly. There is still another mode of healing, viz., healing of a superficial wound under a scab. This only occurs frequently in small wounds, that secrete but little pus, for in these alone does the pus dry on the wound to a firmly-attached scab ; in profuse suppuration it is true the superficial layer of the pus may dry by evaporation of the watery portion, but, while new pus is constantly being secreted under it, it cannot form an adherent, consistent scab. When such a scab has formed, the granulation tissue develops to only a very small amount un- der it ; perhaps because on account of the slight pressure of the scab, the granulation tissue is less mucous, so that the epidermis can more readily regenerate under the scab ; such a small wound may be wholly cicatrized when the scab falls. The granulation surface may assume a totally different appearance from that above described, especially in large wounds. There are certain diseases of the granulations, whose marked forms I shall briefly sketch for you, although the varieties are so numerous that you will only learn them from individual observation. We may divide granulation surfaces as follows : 1. Proliferating fungous granulations. The expression " fungous ' means nothing more than " spongy ; " hence by fungous granulations we mean those that rise above the level of the skin, and lie over the edges of the wound, like fungus or sponge. They are usually very soft ; the pus secreted is mucous, glairy, tenacious ; it contains fewer cells than good pus, and most of the pus-cells, like granulation-cells, are filled with numerous fat-globules and mucous material, which is also more abundant than normal as intercellular substance ; and in these granulations Mindfleisch also discovered collections of Virchonfa mucous tissue, fully developed. The development of vessels may be very prolific ; the fragile tissue often bleeds on the slightest touch ; occasionally the granulations are of a very dark blue. In other cases the development of vessels is very scanty, often to such a degree that the surface is light red, or in spots has even a yellower, gelatinous appearance, in very ansemic persons, often also in youiwy children and very old persons. The most frequent cause of development of such proliferating granulations is any local impediment to the healing of the wound, such as rigidity of the surrounding skin, so that the con DISEASES OP THE GRANULATIONS. 109 traction of the cicatrix is difficult ; a foreign body at the bottom of a tubular granulating wound (a fistula) ; this abnormal proliferation is also particularly apt to occur in large wounds, which can only contract slowly ; it appears as if the activity of the tissue was occasionally ex- hausted, and no longer capable of continuing the requisite condensa- tion and cicatrization, so that it only produces relaxed, spongy granu- lations. As long as there are granulations of the above character, rising above the edges of the skin, cicatrization does not usually pro- gress. The wound would probably heal, but not for a very long time. We have plenty of remedies for hastening the healing under such cir- cumstances ; these are especially caustics, by which we partly destroy the granulation surface, and thus excite a stronger growth from the depth. At first you may cauterize the granulating surface daily, es- pecially along the edges, with nitrate of silver, whereupon a white slough will quickly form, which will become detached in twelve to twenty-four hours, or even sooner; repeat this cauterization as re- quired, till the granulating surface is even. Another very good rem- edy is sprinkling the wound with powdered red precipitate of mercury (hydrar. oxyd. rubrum), which also should be repeated daily, to im- prove the granulating surface. Compression with adhesive plasters also acts very well occasionally. If the granulations be exceedingly dense and large, we often may succeed soonest by cutting some of them off with the scissors ; the consequent haemorrhage is readily arrested by applying charpie. Where the proliferation is less, as- tringent lotions, such as decoction of oak-bark, cinchona-bark, lead- water, etc., may answer to excite the sluggish cicatrization. 2. By erethitic granulations we mean those characterized by great pain on the slightest provocation ; they are usually very proliferant granulations, which readily bleed; it is a very rare condition. In excessive erethism of the granulations, they are so sensitive that they cannot endure the slightest touch or any dressing ; a less degree of sen- sitiveness of the granulations is not so rare. On what it depends, is not very certain ; granulation tissue itself has no nerves ; in most cases touching it causes no sensation, only the conduction of the pressure to the subjacent nerves causes sensation. In the above excessive sensibil- ity, probably the ends of the nerves at the floor of the wound are degen- erated in a peculiar manner ; perhaps there are miniature thickenings of the finest nerve-ends, like those that we shall hereafter see on large nerve-trunks. It would be a thankworthy task to make a careful ex- amination of this question. We occasionally observe similar condi- tions in the cicatrices in large nerves, and shall speak of this hereafter. For this very painful sensitiveness, which not only interferes with healing, but greatly worries the patient, you may first try soothing 110 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. ointments, almond-oil, spermaceti-ointment, or simple cataplasms of boiled oatmeal or linseed-meal, or warm-water compresses. The nar- cotic compresses or cataplasms, made with the addition of belladonna or hyoscyamus-leaves, are of little benefit. If these applications do not answer, do not delay destroying the entire granulating surface, or at least the painful part, with caustic (nitrate of silver, caustic potash, or the hot iron), with the patient anaesthetized, or else excising the entire surface with the knife. If the great painfulness be due to hys- teria, anaemia, etc., you will not attain much by any local remedies, but should try to assuage the general irritability by internal remedies, such as valerian, assafcetida, iron, quinine, warm baths, etc. 3. In large wounds, especially in fistula granulations, a yellow rind sometimes forms on part of the granulation surface, which may be readily detached, and on careful examination is found to consist of pus cells, very firmly attached together. Although I have sometimes found coagulating filaments between the cells, they do not always occur, hence we must suppose that the cell-body, the protoplasm itself, is transformed into fibrine, as occurs in true croup, and especially in the formation of fibrinous deposits on serous membranes. Here there is also a croup of the granulations. The croupous membrane reforms even a few hours after its removal, and this is repeated for several days, till it either disappears spontaneously, or finally ceases on cau- terization of the affected part. Very similar white spots are occasion- ally found on larger granulation surfaces, which are probably not caused by fibrinous deposits, but by local obstruction of the blood- vessels. Under peculiar, unfavorable conditions, both states may re- sult in destruction of the granulations, in a true diphtheria of the wound, which we shall hereafter treat of as hospital gangrene. For- tunately, however, it rarely goes on to this disease, but the state of the wound improves again after a time, and the recovery takes the usual course. If disease of the granulating surface be accompanied by swelling, great pain, and fever, we have a true acute inflammation of the wound ; then the mucous granulation substance sometimes coagulates through- out to a fibrinous mass ; the wound-surface looks yellow and greasy. I shall treat of the causes of these secondary inflammations under the head of contused wounds. Usually the croupous inflammation, which has affected part or the entire surface of a wound, ends in sloughing of the diseased granulations, whereupon new granulations spring from the depths. It cannot be denied that the perfectly local, superficial, and inter- stitial deposit of fibrine strongly supports the view that Virchow has proposed for croupous processes generally. It was formerly sup DISEASES OF THE GRANULATIONS. m posed that in all inflammatory croupous process, especially in the ordinary form of acute inflammation of the lungs and pleura, the blood was over-rich in fibrine ; that there was a fibrinous crasis in the blood, as a result of which, the excessive fibrine escaping from the capillaries, coagulates partly on, partly in, the inflamed surface, and so led to the formation of these pseudomembranous deposits. Vir~ chow, on the other hand, proposed the idea that, by the inflammatory process, the tissue may be placed in a condition to cause coagulation of the fibrinous solution infiltrating it. I cannot here enter more par- ticularly into the various grounds on which Virchow bases this view, but shall only call attention to the fact that in the case in question (of fibrinous exudation on the granulating surface), at least there can be no rapidly coming and evanescent fibrous crasis of the blood ; but evidently it is a local process which may readily be removed by local remedies. According to the repeatedly-mentioned observations of A. Schmidt, we may infer that in certain quantitative and qualitative irritations of the tissue, more fibrogenous tissue than usual escapes from the capillaries. Virchow had even previously called attention to the fact that, from repeated irritation, simple serous exudation may become fibrinous or croupous. If you apply a spanish-fly blister to the skin, a vesicle filled with serous fluid forms — the superficial layer being lifted from the rete mucosum by the rapidly-forming serous exu- dation ; if we remove the vesicle and reapply the blister, in many cases after a few hours we shall find the surface covered with a fibrin- ous layer, which contains innumerable newly-formed cells ; indeed, is almost entirely composed of them. We may attain the same result by applying the plaster to skin already inflamed, or to a young cicatrix. The treatment of croupous inflammation of the granulations is purely local ; we should carefully seek for any causes of new irrita- tion, and try to remove them. Daily remove the fibrinous rinds, and cauterize the exposed surface with nitrate of silver, or paint it with tincture of iodine, and you will soon see this abnormal state of the granulating surface disappear. 4. Besides the above diseases of the granulations, there is occa- sionally a state of perfect relaxation and collapse, in which they pre- sent an even, red, smooth, shiny surface, from which the nodular, granular appearance has entirely disappeared, and, instead of pus, a thin watery serum is secreted. This state almost always occurs in the granulations at the end of life ; as already mentioned, you always find it in the cadaver. It is still necessary to add something about the cicatrices, con- cerning certain subsequent changes in them, their proliferation and their shape in different tissues. 112 SIMPLE INCISED WOUNDS OF THE SOET PAETS. Linear cicatrices of wounds, that have healed by first intention, rarely undergo subsequent degeneration. Large, broad cicatrices, especially when they lie immediately on the bone, often open again ; the epidermis, which is tender at first, being torn off by motion or by the least blow or friction, and there is superficial atrophy, an excoria- tion of the cicatrix. Sometimes the young epidermis is elevated like a vesicle, by exudation from the vessels of the cicatrix; there may also be some haemorrhage, so that the vesicle will be filled with bloody serum. Then, after removing the vesicle, you have an excoriation, as after simple rubbing off of epidermis. This opening of the cicatrix, if often repeated, may prove very annoying to the patient. You pre- vent this most readily by causing the patient to protect the young cicatrix for a time with wadding or a bandage. If the excoriation nas taken place, apply only mild dressings : oil, glycerine, zinc-salve, etc., or emplastrum cerussa. In these cases, irritating salves enlarge the wound, and consequently should be avoided. If the granulating surface be once perfectly covered with epider- mis, as already stated, the retrogressive changes to solid connective tissue take place in the cicatrix, and it atrophies. But in rare cases the cicatrix grows independently, and develops to a firm connective- tissue tumor. This is seen almost exclusively in small wounds that have long suppurated and been covered with spongy granulations, over which the epidermis formed exceptionally. You know it is the custom to pierce the ear-lobes of little girls, so that they may subse- quently wear ear-rings. This little operation is done with a coarse needle by the mother or the jeweller, and a small ear-ring is at once introduced through the fresh puncture. As a rule, this puncture soon heals — the ring preventing the closure of the opening. But in other cases there are active inflammation and suppuration ; indeed, if the suppuration continue, the ring may cut downward through the lobe ; granulations develop at the openings of entrance and exit ; finally, the trial is given up, and the ring removed ; then the opening often heals quickly. In other cases the granulations cicatrize, the cicatrix continues to grow, and on both sides of the lobe of the ear small connective-tissue tumors, small fibroids, form. These look like a thick shirt-button drawn through the hole of the ear, and they grow inde- pendently like a tumor. If you examine these tumors, on section you find them of pure white tendinous appearance, like the cicatrix itself. Microscopically the tissue is found to consist of connective tissue with numerous cells ; it is simply a proliferation, an hypertrophy of the cicatrix. I have seen this twice in the ear ; another case is mentioned by Dieffenbach in his operative surgery. I once saw similar tumors on the back of the neck, where they had formed at the CHANGES IN CICATRICES. 113 openings made for a seton ; they were about the size of a horse- chestnut. They should be carefully removed with the knife, and any subsequent granulations kept in subjection by nitrate of silver. [The translator has seen the above tumors on the lobe of the ear several times ; in all but two instances they occurred in mulatto females ; in one case the tumor had returned after a previous re- moval.] In the above description of the formation of granulations and cica- trices, for the sake of simplicity we have only referred to the process as it is found in connective tissue, but must now speak of it as it occurs in cicatrization of other tissues. The cicatrix in muscle is at first almost entirely connective tissue ; Fig. IS. Cicatrix from the upper lip of a dog. a, connective tissue of the cicatrix. The divided muscular fibres are here atrophied for a short distance, and terminate in a conical shape. Magni- fied 300 diameters. in the ends of the muscular fibres there is at first destruction, then at a certain boundary a collection of nuclei ; then there is rounding off of the fibres, sometimes club-shaped, sometimes of more conical form, and the stumps of the muscular fibres unite with the connective tissue of the cicatrix just as they do with the tendons ; the muscle cicatrix becomes an inscriptio tendinea. I myself have only observed them in wounds of muscle that had healed by first intention, and have never there seen any thing that I could decide was a new formation of mus- cular tissue. In suppurating ends of muscle, 0. Weber has witnessed a slight formation of new muscle ; this appears to occur chiefly in for- mation of granulations on muscle and in certain tumors. Weber is of the opinion that young muscular fibres typically form 114 SIMPLE IXCISED WOUNDS OF THE SOFT PARTS. from the cells of old ones, but considers it impossible to prove that no muscular cells originate from other young cells. As a result of bis examination of old muscular cicatrices, he also maintains that the re- generation continues a long time, and in most cases is more complete than is generally supposed. Maslowsky has affirmed the metamor- Fio. 19. Ends of divided muscular fibres from the biceps mnscle of a rabbit eight days after the injury ; abc, old muscular fibres; a, the contractile substance rolled up and balled together; the same way in the bundle above d ; the same with the sarcolemma drawn ont to a point ; c, into the pointed cornet-shaped sarcolemma tube extends a series of young muscular nuclei, between which there is very delicate transversly striated substance; e, the same with young, free muscle-cells ; /, two young ribbon-like muscular filaments ; g, the same of vari- ous size isolated. Magnified 450 diameters ; after 0. Weber. phosis of wandering cells to muscle-cells ; but I consider the cinnabar 'method employed by him as insufficient to prove this assertion. [Cin- nabar or vermilion injected into the blood is taken up by white cor- puscles, and may afterward be discovered on inflamed tissue.] Gmsenbauer has shown that, after injury, the muscular filaments usually break down into flakes, and then new young muscle-cells form, after the type of embryonal development, from the cells con- tained in the old muscle-filaments ; the amount of the new formation depends on the quality and duration of the irritation. If a nerve be divided, its ends separate, from their elasticity, they swell sbghtly, and subsequently unite by development of a new forma- tion of true nerve-tissue, so that the nerve is again capable of conduc- CICATRICES IN MUSCLES AND NERVES. 115 tion through the cicatrix. In large superficial cicatrices, new nerves develop ; when you have excised portions of skin and have brought to- gether and united parts lying at a distance, new nerves grow through the cicatrix and perfect power of conduction comes after a time, as may be often observed in plastic operations. These facts are very Fig. 20. Regenerative processes in transversely-striated muscular fibres after injury. Magnified about 500, after Ghisseribauer. remarkable, and physiologically are still entirely inexplicable. Just think how wonderful that these nerve-filaments, sensory and motor, should find each other in the new adhesion, and that even, as we must suppose, the stumps of the primitive fibres should unite as they had been united, so that correct conduction and localization might result as they actually do ! We cannot here go more exactly into this sub- ject. I will only mention that the more minute process, which has been very carefully followed by Schiff, Hjelt, and others, is generally as follows : first, in the stump of the nerve there is a destruction of the nerve-sheath, possibly also of the axis cylinder to a certain extent ; at the same time in the neurilemma there is a collection of cells, which proceeds to the development of spindle-shaped cells in the sub- stance lying between the ends of the nerve, and extending into the 116 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. stump. From these cells, just as in the embryo during intra-uterine life, newnerve-fibrillse develop upward and downward; the filaments, which are at first very pale, subsequently acquire a sheath, and then cannot be distinguished from ordinary nerve-filaments. The most recent Fig. 22. flllillll W I Wi B *'ll II Fig. 21. Eegeneration of nerves. Fig. 21, from a rabbit fifteen days after division ; young spindle-cells in the end of the nerve developed from the connective tissue and intimately connected with the neurilemma. Fig. 22, from the frog ten weeks after division; development of young nerve-cells from the spindle-cells. Mag- nified 300 diameters, after Hjelt. investigations as to the significance of wandering cells in new formation of tis- sue, as well as the special studies over the formation of nerves in portions of tadpoles' tails regen- erated after injury, have made me doubt the former view, that young regenerated nerve-filaments were composed of spindle- cells. It seems to me much more probable that the divided axis- cylinders grow out in- to young nerve-filaments, and that the elongated spindle-cells, which undoubtedly exist in the nerve-callus in certain stages, either belong to the connective tissue of the neurilemma or are detached portions of young nerve-filaments containing nuclei. The last investigations of Neumann and Eichhorst confirm pre- vious ones in regard to the immediate results of division, but show that the young nerve-filaments grow directly from the axis-cylinder, as well from the central as from the distal part, meet together, and blend, as the offshoots from a capillary wall sink into the wall of another vessel, and so may form a communicating canal between two vessels {Arnold). The process in the wounded nerve corresponds most beautifully with that in wounded muscle. In the muscular as in the nervous filament several young filaments sprout from one primitive filament (a, Fig. 22 A ; compare Fig. 20). So it is shown that muscles, vessels, nerves, and epithelium are not regenerated from proliferating connective-tissue cells or wan- dering cells, but from throwing out offshoots from their tissue, or from cells derived from the protoplasm of their tissue. It is very probable that connective-tissue cells also, especially those still con- CICATRICES IN MUSCLES AND NERVES. 117 taining protoplasm, send out offshoots at the wounded part in which nuclei subsequently form, as is done in the nerves of the tadpole's tail. This point should be investigated again ; till then we may re- gard wandering cells as the source of the young regenerated tissue. Since Schwann's teaching about the development of tissue from cells, we are so convinced that every new tissue proceeds from young cells, that the announcement of independent growth of a perfect tissue without intervention of cells finds little credit ; and the increase Nerve of a rabbit : a, seventeen days after division ; 6, fifty days ; c frog's nerve, thirty days. Mag- nified about 600. After Eiehhorst. of cells by offshoots, with subsequent development of nuclei in these offshoots, is a procedure that histologists have long kept in the background, substituting for it cell-division, although botanists have ascribed a very prominent role to this mode of development in plants. From "the latest published observations we see that the capillary walls, the axis-cylinder of nerves, and the contents of mus- cular filaments possess this capacity for outgrowth without direct participation of new cells. Eokitansky ascribed to connective tis- sue the capacity for independent outgrowth. In the human being the regeneration of nerves only takes place within certain limits, which, it is true, cannot be very accurately de- fined. The complete regeneration of large nerve-trunks, as of the sciatic or median nerves, does not occur ; nor does it take place after excision of large portions of nerve, if the ends remain, say three or four lines apart. Very accurate apposition of the ends of the nerve is necessary, for apparently the transformation of the newly-formed intermediate substance to nerve-substance can only take place by means of the nerve-stump, although there are different opinions about 118 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. the mode of this process ; we shall see similar conditions in the heal- ing of broken bones, where bony union only follows accurate coapta- tion of the fragments. Now, how is it in this respect with brain and spinal tissue ? In the human being there is no regeneration here after injury, or after loss of substance from idiopathic inflammation, or at least not sufficient to restore the power of conduction. In animals, indeed, as Broicn-Seqitard has shown in pigeons, after dividing the spinal marrow, there may be regeneration with disappearance of the paralysis, which has of course occurred in all parts below the point of division. Unfortunately, this power of regeneration of nerves decreases in proportion to the higher development of the vertebrate animals, and it is least in man. As is known, in young salamanders whole extremities grow again when they have been amputated. What a pity this is not so in man ! However, as regards the nerves, Nature occasionally seems to make a fruitless attempt at regeneration ; for quite often the nerve-ends in amputation-stumps, instead of simply cicatrizing, develop to club-shaped nodules, which are occasionally ex- cessively painful, and require subsequent excision. These nodules on the nerves consist of an entanglement of the primitive nerve-filaments, which develop from the stump of the nerve as if they would grow to meet opposite nerve-ends. The cicatrices in the continuity of nerves also are sometimes nodular from the formation of convoluted primitive filaments. Such small nerve-tumors (true neuromata) are occasion- ally excessively painful, and must be removed with the knife. But there are also traumatic neuromata, which are not at all painful, as I have seen in old amputation-stumps. In general, these proliferations of nerve-cicatrices are to be compared with the previously-mentioned hypertrophy of connective - tissue cicatrioes, and with proliferating bone, which, although rarely, is formed in great excess in the healing of broken bones. The process of healing after injury of great vessels, especially of arterial trunks, has been carefully determined by experiment. If a large artery be ligated in an amputation or for disease in its continu- ity, as the ligature is drawn tight, the tunica intima is ruptured, and the tunica muscularis and adventitia are so constricted that their inner surfaces folded up lie in exact apposition. You may satisfy yourselves of the frequent although not necessarily universal rupture of the in- ternal tunic, by ligating a large arterial trunk in the cadaver, for you not unfrequently experience a slight grating or crackling under the finger when tightening the ligature ; you may also see it on cutting open a ligated artery after detachment of the ligature. From the point of ligation to the next branch leaving the artery, both at the cen- tral and peripheral ends, the calibre of the vessel fills with coagulated FORMATION OF THROMBUS. 119 Flo. 23. Nodular nerve-terminations in an old amputation-stump of the arm. From a preparation in the Anatomical Museum at Bonn. Copied after Froriep, " Surgical Copperplates." Bd. I., Taf. 113. blood, the so-called thrombus (from 5 -&po[i[3og, the blood-clot). The enveloping ligature kills the enclosed tissue, which gradually breaks down into pus, and when this process is completed the ligature falls, or, as we technically express it, " the ligature has cut through," " comes away." When this has taken place, the calibre of the artery must be permanently and certainly closed, or there will at once be another haemorrhage. Under unfavorable circumstances it may certainly happen, in small as well as in arteries of medium or large size, that the ligature cuts through too soon, and then dangerous, sudden secondary haemor- rhage occurs. "We may foresee this if the wall of the artery was dis- eased ; often calcified arteries cannot be ligated, as the ligature does not compress them or cuts through them at once ; sometimes the ar- tery is softened (as, for instance, when part of its course has been through the wall of a large abscess) so that on ligation the ligature cuts through and must be applied farther up. But unfortunately, in perfectly healthy subjects, as I found in the last war, haemorrhages too often occur from the point of ligation of large arteries, where carefully-applied ligatures cut through before the organic closure was firm enough to resist the current of blood ; this greatly impairs the value of such operations, which are often temporarily necessary to save the patient's life. 120 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Fig. 24. Artery ligated in the continuity. Throm- bus ; after Froriep. Passing now to the consideration of what has taken place in the end of the vessel from the coagulation of the blood till the firm closure, experiments on animals and accidental observations on man have given the following : the blood-clot at first lying loose in the vessel gradually becomes more firmly attached to the wall of the vessel, and con- stantly grows harder, but still remains red for a long time ; it does not lose its color for weeks or months, and then does so first in the centre, so that the rest of it still retains a slight yellowish tinge. After the detachment of the ligature, the thrombus is so hard and so firmly attached to the walls of the vessel that the calibre is entirely closed. The preparation (Fig. 24) shows you the thrombus formation in an artery after ligation in the continuity; the lower thrombus reaches to the point of departure of the first branch, the upper one not so far ; the former is the rule as laid down in most books, the latter is a not uncommon exception. Plugging of the artery by a blood-clot, which becomes firm, is, however, only a provisional state, for the thrombus does not remain so for all future time, but the cicatricial tissue shrinks and atrophies ; this takes place in the course of months and years, at which time the closure of the artery at the point of division has become solid by adhesion of the walls of the vessel If you examine such an artery a few months after the ligation, you find nothing of the thrombus ; but the artery termi- nates in a conical point of cicatricial connective tissue. The above changes, which we may follow with the naked eye, show that in the blood-clot there is a change which essentially consists in its increasing firmness and coherence to the wall of the vessel ; we shall now study with the microscope on what this transformation of the blood-clot depends. If you examine the recent blood-clot, you find it to consist of red blood-corpuscles, a few colorless blood-cells, and of fine filaments and coagulated fibrine, arranged in irregular net- work. If you take a thrombus two days after the ligation of a small or medium-sized artery, it is firmer than at first, and is broken up with difficulty ; the red blood-cells are little changed, the white ones are greatly increased ; they have sometimes two and three nuclei as pre- viously, sometimes single pale, oval nuclei with nucleoli; some of these cells are almost double the size of white blood-cells. The fine filaments of the fibrine are united to an almost homogeneous mass, which is difficult of division. If you again examine a thrombus six days old, the red blood-cells have almost disappeared, the fibrine is FORMATION OF THROMBUS. 121 Fig. 25. more firm and homogeneous, and even more difficult to separate than previously ; a large number of spindle-shaped cells with oval nuclei, showing distinct divisions, appear. From the above, it appears that even quite early a number of living cells appear in the blood- clot, whose further development will be seen from what follows. Since we obtain a more accurate understanding of the changes in the thrombus and its relation to the arterial walls, by making transverse sections of the thrombosed artery, we shall proceed to do this. This preparation shows a transverse section of a recent throm- bus in a smallartery; within,the delicate mosaic formed by the crowded red blood-corpuscles, among them a few round white blood-cells (which have been rendered visible by car- mine) ; next comes the tunica intima, laid together in regular folds, in which the blood-clot clings ; then the tunica muscularis ; then the tunica adventitia, with the net-work of elas- tic fibres ; to the right some adherent loose connective tissue. The next preparation (Fig. 26) is the transverse section of a human artery, closed with a thrombus for six days ; we see no red blood-cells ; the white ones are greatly increased, mostly round ; but, in the tunica adventitia and surrounding connective tissue, there has already been some cell infiltration. If we now examine a ten-day-old thrombus from a large muscular artery of the thigh of a man (Fig. 27, a), we find it already containing numerous spindle-cells, which are partly arranged in striae (subsequently vessels) ; the intercellular substance is filamentary, here rendered transparent by acetic acid. Finally, there is also formation of blood-vessels in the organized thrombus, as you see in the following preparations (Figs. 28 and 29). It has been established, by the investigations of 0. Weber, that the vessels of the thrombus communicate partly with the calibre of the thrombosed vessel, partly with its vasa.vasorum. The process of healing in transversely-divided veins appears at the first glance to be much simpler than in the arteries ; even in the large veins of the extremities, the divided ends fall together, and ap- pear to heal at once, as soon as the blood has been obstructed at the next valve above ; at these valves clots form, and they are often much larger than is desirable; this formation of clots extending toward the heart will hereafter occupy our earnest attention. But I have of late Transverse section of a fresh thrombus. Magnified 300 diameters. 122 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. observed that the tunica intima of the divided vein does not by any means so fold together and adhere, but that here also there is a clot, although a small one, which is organized like the arterial thrombus. Fig. 26. Transverse section of a thrombus six days old. 300 diameters. Fia. 27 Ten-day-old thrombin, a. Organized thrombus; 6, Tunica intima; c, Tunica muscularis; d, Tunica adventitia. 300 diameters. FORMATION OF THROMBUS. 123 If you draw conclusions from these preparations, presented in such a fragmentary way, it appears that in the clotted blood there is a cel- lular infiltration, which here leads to development of connective tissue ; in short, that the thrombus becomes organized. The thrombus is not a permanent tissue, but gradually disappears again, or, at least, is re- duced to a minimum, a fate which it shares with many new formations resulting from inflammation. Fig. 28. Completely-organized thrombus in the human arteria tibialis postica. a, Thrombus with ves- sels, perfectly united with the innermost layer of the intima; b, the lamellae of the tunica intima; c, the tunica muscularis, traversed by numerous connective tissue and elastic fila- ments ; (I, Tunica adventitia. Magnified 300 diameters. After Rindfleisch. Peculiar reasons caused me to investigate more accurately the or- ganization of the thrombus. The importance of this process is rather extensive ; a point on which you cannot at present judge well, but will hereafter be in a position to estimate fully, when we come to treat of diseases of the vessels. From my investigations up to the present time, I do not think I dare retract the assertion that coagulated fibrine may, by aid of cells, be transformed into connective-tissue intercellular substance, although I cannot decide whether this be due to true metamorphosis, or to a gradual substitution of cell protoplasm for disappearing fibrine. Some have attempted to refer the origin of the cells, which appear in con- 124 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. etantly-increasing numbers in the thrombus, to the wall of the vessel ; the arteries, as well as the veins, are coated with a lining of epithe- lium, which to some extent represents the innermost lamella of the tunica intima. These epithelial cells and the nuclei of the striated Fig. 29. Longitudinal section of the ligated end of the crural artery of a dog, fifty days after ligation; the thrombus is injected; a a, tunica intima and media; b b, tunica adventitia. Magnified 40 diameters. lamellae of the intima have been claimed a priori by some authors, so that they could let new cells be formed from them, and grow into the thrombus ; in his last work, Thiersch also inclines to this view. I acknowledge that I myself formerly strongly combated the supposi- tion that the blood could of itself become organized to connective tissue with vessels ; but from examinations of transverse sections of thrombosed arteries, I am satisfied of its correctness. After having abandoned the idea of proliferation of stable tissue-cells in inflamma- tion, we can no longer talk of a proliferation of the intima in the old sense. But whence come, then, these newly-formed cells ? I have no doubt that they originate from the white blood-cells, which have been FORMATION OF THROMBUS. Fig. 30. a I c 125 d Portion of a transverse section of a human femoral vein, with an organized vascular thrombus, 18 days after amputation of the thigh ; a a, Tunica intima ; b b, media ; c c, adventitia ; d d, enveloping cellular tissue ; 7%, organized thrombus with vessels ; the layering of the fibrine is still distinctly visible in the periphery of the thrombus. Magnified 100 diameters. partly enclosed in the thrombus, partly may have wandered into it, according to the observations of V. Recklinghausen and Bubnoff. As regards the red blood-cells, it seems that they gradually unite with the coagulated fibrine, lose their shape, become intercellular substance, and lose their coloring matter, which is separated as granules or crys- tals of hematoidin. Little as we know whence blood-cells come, and whither they go, still it is certain that the white cells enter the blood from the lymphatic vessels, and that they enter the latter from the lymphatic glands or connective tissue elsewhere ; they are cells that originate directly from connective-tissue cells, or from a protoplasm analogous to connective tissue. Are these cells still viable when en- closed in a blood-clot ? After coming to rest here, can they transform themselves to tissue ? It is impossible to affirm or deny these questions absolutely ; since JSubnoff has shown that wandering cells enter the thrombus, and may there continue their movements, there is no necessity for supposing that the white blood-cells (which are identical with wandering cells) enclosed in the thrombus, on coagula- 126 SIMPLE IXCISED WOUXDS OF THE SOFT PARTS. tion, no longer move, and cannot be transformed into tissue. Hith- erto there have been no investigations as to whether wandering cells pass through the walls of arteries as readily as through those of veins, as JBubyxoff^s investigations only refer to venous thrombi. Some of my investigations in this direction showed me that minute cinnabar granules passed through the carotid of a dog into the thrombus, but I could not satisfy myself that they were replaced by wandering cells. So at present it is uncertain whence the numerous wandering cells in an organizing arterial thrombus originate, and how they enter there. Tschausoff, in a very carefully-studied work that has lately appeared, calls attention to the fact that a great portion of large thrombi are destroyed by disintegration. This is very true, but he goes too far when he entirely denies the provisional organization of the thrombus, and supposes that the disintegration of the clot is immediately fol- lowed by the adhesion of the walls of the vessel, to which I have called attention as the definite termination of the whole process. 6 As I have already stated, peculiarly favorable conditions are re*- quisite for the blood-clot to become organized. It is an absolute law in the human organism, that non-vascular tissues, which are nourished by means of cells alone, have no great extent ; the articular cartilages, the cornea, the tunica intima of these vessels, the tissues, are all in thin layers ; in other words, the cells of the human body cannot, like those of plants, carry nutrient fluid to any given distance, but are limited in their conductive power ; at certain distances new blood-vessels must appear, to supply and carry off the nutrient fluid. The blood-clot, consisting of cells with coagulated fibrine, is at first a non-vascular cellular tissue, which can only maintain its existence in thin layers. This appears from observations, which we shall hereafter often have occasion to mention ; namely, that large blood-clots are not organized at all, or only in their peripheral layers, while they disintegrate in the centre. From this it appears that, in healing by the first intention, a small amount of blood lying between the edges of the wound does no harm, while a larger amount interferes with healing, or prevents it altogether. You will soon be able to verify this observation in the clinic. The formation and organization of the thrombus have engaged the attention of surgeons and anatomists since the time of John Hunter and even yet they are not fully understood. We must con- sider them here on account of their general histogenetic interest, al- though of late it is doubtful whether thrombi are practically as im- portant for the results of ligation as was formerly supposed. Even Porta called attention to the fact that the quick adhesion and union of the tissue around the ligated artery was as important as organiza- tion of the thrombus. Surgeons have kept this point well in view, CIRCULATION AFTER LIGATION. 127 always striving, by most carefully operating and attending to the wound, to attain healing by the first intention. But it was the suc- cess of acupressure which first showed clearly that the adhesion of the tissues by coagulable exudation even in forty-eight hours is enough to keep securely the compressed or twisted artery, even when it is the size of the femoral. Although ICocher has shown that, even after acupressure, thrombi occur in arteries, yet they are too small to check bleeding in a large artery within forty-eight hours. Hence, even from this point of view, attempts to replace the ligature by other methods, which leave no threads in the wound but permit its entire closure by first intention, should be encouraged without denying in any way the extraordinary advantages of the ligature. Let us now look at the fate of the circulation after ligating a large artery in the continuity. Suppose that, for a haemorrhage in the leg, the femoral artery has been ligated ; how does the blood now reach the leg ? how will the circulation go on ? Just as on closure of capil- lary districts, under increased pressure, the blood presses through the next permeable vessels, which are thereby dilated ; the same thing occurs on closure of small or medium-sized arteries. Under increased pressure, the blood flows through the branches close above the thrombus, and from the numerous arterial anastomoses, both in the Fig. 32. Fig. 3]. Carotid artery of a rabbit, injected 6 weeks after ligation. After Porta. Carotid artery of a goat, injected 35 months after "ligation. Af- ter Porta. 128 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. long axis and various transverse axes of the limb, reaches other arteries, through which it soon again streams into the peripheral end of the ligat- ed vessel. An arterial collateral circulation is established to the side of the ligated and thrombosed portion of the arterial trunk. Without this, the part of the body lying below this point would not receive suffi- cient blood and would die ; it would dry up or putrefy. Fortunately, arterial anastomoses are so free that, even after ligation of a large artery, like the axillary or femoral, such a case is not apt to occur ; in diseased arteries, however, which do not distend sufficiently, mortifi- cation of the affected extremity may occur. The modes in which these new vascular connections form vary greatly. Years ago, Porta made very profound researches on this point, and from his numerous experiments stated the following, as the types of collateral circula- tion: 1. Direct collateral circulation is established; i. e., there are strongly-developed vessels, which pass from the central end of the artery directly to the peripheral end. These uniting vessels are Fig. 33. chiefly the dilated vasa vasorum, and the vessels of the thrombus ; it might happen that one of these uniting vessels should di- late so much as to acquire the appearance of being simply the trunk regenerated. 2. There is an indirect col- lateral circulation ; i. e., the connecting branches of the next lateral arteries are greatly di- lated, as in the following case, Fig. 33. The most striking examples of both varieties of collateral circulation have here been cho- sen ; but when you examine the numerous sketches of JPorta, and yourselves repeat these ex- periments, you will find that in most cases direct and indirect collateral circulation are com- bined, so the only value of the classification is to group the different forms in some way. It is an excellent anatomi- Femoral artery of a large dog, injected 3 mouths after ligatioii. After Porta. CIRCULATION AFTER LIGATION. 129 cal exercise, to represent for yourselves how, after ligation of the different arteries of one or both extremities, or of the trunk, the blood will reach the parts beyond the point of ligation ; in this you would be well assisted by the plates of arterial anastomosis in Krause's text-book of anatomy. In the surgery of old Conrad Martin Lan- genbeck, these conditions are carefully described in the chapter on aneurisms. The reversal of the blood-current, which not unfrequently takes place in these collateral circulations, occurs with wonderful rapidity, when the anastomoses are free ; if, for instance, we ligate the common carotid in a man, and then divide the artery beyond the liga- ture, the blood escapes with great force from the peripheral end, that is, backward as from a vein. In all such cases, where the artery to be ligated has free anastomoses, if a piece is to be cut out of the artery, we should first ligate both central and peripheral ends, to be insured against haemorrhage ; this is an important practical rule, which is often neglected. CHAPTER II. SOME PECULIARITIES OF PUNCTURED WOUNDS. LECTURE X. A.8 a Rule, Punctured Wounds heal quickly by First Intention. — Needle Punctures ; Needles remaining in the Body, their Extraction. — Punctured Wounds of the Nerves. — Punctured Wounds of the Arteries : Aneurysma Traumaticum, Varicosum, Varix Aneurysmaticus. — Punctured Wounds of the Veins, Venesection. Most punctured wounds are simple wounds, and usually heal by first intention ; many of them are at the same time incised wounds, when the puncturing instrument has a certain breadth ; some have the characteristics of contused wounds, when the puncturing instru- ment was blunt ; in this case there is generally more or less suppura- tion. "We make many punctured wounds with our surgical instru- ments, as with acupuncture needles — fine, long needles, that we occasionally employ to examine whether and how deep below a tumor or ulcer the bone is destroyed, etc. ; with acupressure needles, which we use for arresting haemorrhage ; with the trocar, a dagger with a three- sided point, furnished with a closely-fitting canula, an instrument for drawing off fluid from cavities. Dirk, sword, knife, and bayonet punctures are often simultaneously incised and contused wounds. If these punctured wounds be not accompanied by injury of large arteries, veins, or bones, and do not enter any of the cavities of the body, they often heal rapidly and without treatment. The most frequent punctured wounds are those made with needles, especially in women, and how rarely a doctor is called for them ! Such an injury is only complicated by a needle, or a part of one, en- tering the soft parts so deeply that it cannot readily be extracted. This occasionally happens in different parts of the body, as from a person sitting or falling on a needle, or some such accident. If a needle has entered deep under the skin, the symptoms are usually so NEEDLE WOUNDS. 131 slight that the patients rarely have any decided sensation of it ; in- deed, they often cannot say whether the needle has really entered, and where it is. And in the soft parts this body usually induces no external symptoms, but may be carried in the body for months, years, or even a lifetime, without trouble, if it do not enter a nerve. The needle rarely remains stationary at the point where it entered, but wanders about ; it is shoved along to other parts of the body by con- traction of the muscles, and thus may come to light a long distance from the point of entrance. Cases have been observed where hyster- ical women, from the peculiar vanity of attracting the attention of physicians, have inserted numerous needles in different parts of the body; these needles appeared now here, now there. Even when needles have been swallowed, they may without danger pass through the walls of the stomach and intestines, and come to the surface at any part of the abdominal wall. JS. von Langenbech found a pin in the centre of a vesical calculus ; on more careful inquiry, it was found that, when a child, the patient had swallowed a pin. The pin may have passed through the intestine into the bladder ; here triple phos- phates were deposited around it in layers, and this was possibly the origin of the calculus. Dittle had a similar experience. When the needle has remained for a time in the soft parts without exciting pain, or when needles, passing through the body from within outward, come to the surface close under the skin, they usually excite a little suppuration ; the piercing feeling becomes more decided ; we make an incision at the painful spot, let out a little thin pus, and in the pus-cavity find the needle, which may be readily removed with forceps. It is difficult to explain why this body, which for months has moved about in the body, should at length excite suppuration when it arrives under the skin ; you must here satisfy yourselves with a simple knowledge of the facts. The following interesting case may render the course of these injuries more clear to you : In Zurich a perfectly idiotic female deaf mute, thirty years old, was brought to the clinic with the diagnosis : typhus. No history of the case could be obtained from the patient or those about her, who were also lack- ing in intelligence. The patient, who often remained in bed for days, had complained for a short time of pain in the ileo-csecal region, and had moderate fever. Examination showed a swelling at this point, which increased the following days, and was very painful on pressure ; the skin reddened, fluctuation became evident. It was clearly not a case of typhus, but you may imagine what different diagnoses there were as to the seat of the suppuration, for there was undoubtedly an abscess ; it might be inflammation of the ovary, perforation of the vermiform process, an abscess in the abdominal walls, etc., etc. ; still, 132 SOME PECULIARITIES OF PUNCTURED WOUNDS. something could be said against all these hypotheses. After a few days the reddened skin became very thin, the abscess pointed about the height of the anterior superior spinous process of the ilium, a few fingers' breadths above Poupart's ligament, and I made an incision through the skin ; there was evacuated a gassy, brownish, sanious pus, with a strong fecal odor. As I examined the abscess-cavity with my finger, I felt a hard, rod-like, firm body in the depth of the abscess, and projecting slightly into it. I began to extract it, and pulled and pulled till I brought out a knitting-needle almost a foot long, which was somewhat rusty and pointed down toward the pelvis. The ab- scess-cavity was clothed with flabby granulations. When I tried to examine the opening that the needle must have left behind, I could no longer find it ; it had closed again, and was covered by the granu- lations. The abscess took a long time to heal ; it at last did so without further accident, so that in four weeks the patient was dis- missed. As I showed the unfortunate cretin the extracted needle, she laughed in her idiotic way ; that was all we could make out of her ; perhaps this may have indicated some slight recollection of the needle. It is most probable that the patient had inserted the needle into the vagina or rectum — procedures in which even women not idiotic find some incredible pleasure, as you may see in DieffenhacKs operative surgery in the chapter on extraction of foreign bodies. It is not im- possible that in this case the needle passed by the side of the vaginal portion of the uterus through the caecum, for, from the gas-containing pus of the abscess, we may decide that there was at least a temporary communication with the intestine. It is true this cannot be regarded as absolutely certain, for pus in the vicinity of the intestines by the development of stinking gases may putrefy, even when no communi- cation with the interior of the intestines exists or has existed. The extraction of recently-entered needles may be very difficult, especially as the patients are not unfrequently very undecided in their information about the location of the body, and occasionally from shame will not acknowledge how the needles (in the bladder, for in- stance) obtained entrance. We should, with the left hand, fix the spot where we shall most probably find the foreign body, carefully endeavoring to press the skin together in folds ; we must at the same time be careful that the needle does not again change its position while we are making the incision. Sometimes we feel the body more or less distinctly, and can cause pain by pressing on it ; these attempts must decide the point of our incision. After dividing the skin, we attempt to seize the needle with a pair of good dissecting forceps ; very tense bands of fascia may readily deceive us, especially about the fingers, for with forceps our sense of feeling is always uncertain. EXTRACTION OF FOREIGN BODIES. I33 If we cannot find the needle, we may move the parts some ; the needle is then sometimes moved into a position where it may be seized more readily. The extraction of foreign bodies requires a cer- tain amount of practice and manual dexterity, which we acquire only with time and practice ; here natural knack is of great service. Punctured wounds, made with instruments not very sharp, are occasionally interrupted in their process of healing. Externally they heal by first intention, but after a few days there are suppuration and inflammation in the deeper parts ; the wound either opens, and the whole tract of the wound suppurates, or the pus breaks through at some other point. This occurs particularly in cases where a foreign body, as the point of a knife, remains behind, or where the wound was made with a blunt instrument. In examining the wound, you should always bear in mind the possibility of a foreign body remain- ing behind, and, if possible, see the instrument with which the injury was done, and find exactly in what direction the instrument passed, so that you may know about what parts are injured. However, even in unfavorable cases there are occasionally very little inflammation and suppuration. A short time since a man came to the clinic who, a few days previously, had fallen a moderate height from a tree, lighting on his left arm, while engaged clipping the small branches. On the dor- sal surface, a few inches below the elbow, the arm was swollen ; on the volar surface, just above the wrist, there was a slight excoriation ; the arm could be extended and flexed without pain ; only pronation and supination were impaired and painful. There was no solution of continuity of the bones of the forearm ; the bones were certainly not broken through. At the swollen spot on the dorsal side, an inch below the elbow, immediately under the skin, we could, however, feel a firm body, which could be pressed back somewhat, but it at once returned to its old position. It felt just as if a piece of bone had been broken off lengthwise, and lay close under the skin. Incompre- hensible as it must seem for such a detachment of bone to occur by simply falling on the arm, without fracture of the radius or ulna, I nevertheless had the patient anaesthetized, and again made the at- tempt to press into position the suspected fragment ; but it did not succeed. As it lay so close under the skin that it would necessarily have perforated ere long, I made a small incision through the skin to extract it. To our great astonishment, I drew out, not a fragment of bone, but a small branch, five inches long, which was quite firmly held by the two bones of the forearm. It was incomprehensible how this twig could have entered the forearm; but, on more careful examination at the above-mentioned excoriated spot on the volar surface, we found a linear, slit-like wound, which had already closed, 134 SOME PECULIARITIES OF PUNCTURED WOUNDS. through which the body had apparently passed so quickly that the patient had not noticed its entrance. After its extraction the very moderate swelling entirely subsided ; the small wound discharged but little pus, and was entirely closed in eight days. These favorable conditions of punctured wounds have given rise to the so-called subcutaneous operations, which were introduced into surgery more particularly by Stromeyer and Dieffenbach, and consist in passing a pointed, narrow knife under the skin, and dividing ten- dons, muscles, or nerves, for various purposes of treatment, without making any wound in the skin other than the small punctured wound through which the tenotome is introduced. Under these circum- stances the wound almost always quickly closes by first intention, while in open wounds of tendons there is almost always suppuration, often extensive death of the tendon. Of this we shall speak further in the chapter on deformities (Chapter XVHX). If the puncture has entered one of the cavities of the body, and caused injury there, the prognosis will always be doubtful ; there is more or less danger, according to the physiological importance and vulnerability (the greater or less susceptibility to dangerous inflam- mation) of the organ implicated. Such a punctured wound is not so dangerous as a gunshot wound. We shall not at present pursue this subject further, but must now say something about punctured wounds of the nerves and arteries of the extremities. Punctured wounds of nerves naturally induce, according to their extent, paralysis of variable amount; otherwise they have the same effect as incised wounds of the nerves. Regeneration occurs the more readily when the whole breadth of the nerve has not been punc- tured. The case is different when a foreign body, as the point of a needle or a bit of glass, is left in the nerve-trunk ; they may heal in here as in other tissues. The cicatrix in the nerve which contains this body may remain excessively painful at every touch ; there may also be neuralgia or nervous pains extending excentrically. Moreover, the severest nervous diseases, acute or chronic, may be induced by these foreign bodies. Epileptiform spasms, with an aura, a pain in the cicatrix preceding the spasm, have been observed after such in- juries ; some surgeons also assert that traumatic tetanus may also be induced by this nervous irritation. This appears to me very doubtful, but of this hereafter. The first of these diseases, the so-called reflex epilepsy, may usually be cured by the extraction of the foreign body. Punctured wounds of arterial trunks or their large branches may induce various results. A very small puncture usually closes by the elasticity and contractility of the coats ; indeed, there is not always a hasmorrhage, any more than there is always escape of fa?ces from PUNCTURED WOUNDS OF ARTERIES. 135 a small puncture of the intestine. If the wound be slit-shaped, the bleeding may also be insignificant if the opening gapes but little ; but in other cases severe arterial haemorrhage is the immediate result. If compression be at once made, and a bandage accurately applied, we shall usually succeed not only in arresting the haemorrhage, but also in closing the puncture in the artery, just as we should one in the soft parts. If the bleeding be not arrested, as already stated, we should at once ligate the artery, after enlarging the wound up and downward, or at a higher point in the continuity. The closure of the arterial wound takes place as follows : A blood- clot forms in the more or less gaping wound of the arterial wall ; this clot projects slightly into the calibre of the vessel ; but externally it is usually somewhat larger, and looks like a mushroom. As described in intra-vascular thrombus, this clot is transformed to connective tissue ; and thus there is permanent organic closure, without change of the calibre of the artery. This normal course may be complicated FlG - M - by layers of new fibrine from the circulating blood, depositing on the part of the plug projecting into the calibre of the vessel, and ,i i • , i i , p • Artery wounded on the side, with clot, fonT thus closing it by a clot, forming a ^ys after the injury; after Porta. complete arterial thrombosis ; but this is rare. Should it happen, we would have the same result as after a thrombosis following ligation — development of collateral cir- culation, and eventual obliteration of the vessel by organization of the thrombus. Punctured wounds of the arteries do not always take so favorable a course. In many cases, soon after the injury, we notice a tumor at the seat of the young cutaneous cicatrix, which gradually enlarges and jDerceptibly pulsates isochronically with the systole of the heart and with the arterial pulse. If we place a stethoscope over the tumor, we may hear a distinct buzzing and friction sound. If we compress the chief artery of the extremity above the tumor, the pul- sation and murmur cease and the tumor diminishes somewhat. We call such a tumor an aneurism (from avevpvveiv, to dilate), and this particular form, arising from wound of an artery, we call aneurisma spurium or traumaticum, in contradistinction to the aneurisma verum, arising spontaneously from other diseases of the artery. Whence comes this tumor, and what is it ? Its origin is as fol- lows : The external wound is closed by pressure, the blood can no longer flow out of it ; but it forms a way through the opening, which is not yet firmly closed by the clot, into the soft parts, and winds 136 SOME PECULIARITIES OF PUNCTURED WOUNDS. about among them as long as the pressure of the blood is stronger than the resistance of the tissues ; a cavity filled with blood is formed in immediate communication with the calibre of the artery, part of the blood soon coagulates, and there is slight inflammation of the tissue about it ; a plastic infiltra- Fio. 35. tration, which leads to con- nective tissue new forma- tion, and this thickened tissue forms a sac, into and from whose cavity the blood flows, while the pe- riphery of the cavity is filled with layers of clotted blood. The buzzing and friction that we perceive in the tumor arise partly from the blood flowing out through the narrow open- ing in the artery, partly by its friction against the coagulum, and lastly by the regurgitation of the blood into the artery. Such a traumatic an- eurism may also occur in another, more secondary way ; the arterial wound at first heals, and subse- quently, after removal of the pressure bandage, the young cicatrix gives way, and then for the first time the blood escapes. Traumatic aneurisms are not always caused by punctured wounds of arteries, but rupture of their coats by great tension and contusions, without any external wound, may result in their development. Thus, in his surgical lectures, A. Cooper tells of a gentleman who leaped a ditch while out shooting, and at the time felt a pain in the hollow of his knee, which prevented his walking. An aneurism of the popliteal artery soon developed in the bend of the knee, that finally had to be operated on. The artery was partly ruptured by the leap. Rupture of the tunica intima and muscularis is sufficient to permit the forma- tion of an aneurism. Should the tunica adventitia remain uninjured, Aneurisma tranmaticam of the brachial artery ; after Froriep, " Surgical Copperplates." Bd. IV., Plate 483. ANEURISM FROM PUNCTURED WOUNDS. 137 the blood may detach it from the tunica media ; this forms a variety of aneurism called aneurisma dissecans (dissecting aneurism). Cases of punctured wounds with subsequent aneurisms occur particularly in military practice, but not unfrequently also in civil practice. I saw a boy with an aneurism, as large as a hen's-egg, of the femoral artery, about the middle of the thigh, that had been caused by puncture with a pen-knife, on which the boy fell. A short time since I operated on an aneurism of the radial artery, that had developed in a shoemaker after an accidental puncture with an awl. An aneurism is a tumor communicating directly or indirectly with the calibre of an artery. This is the common definition. The communication is immediate in the case just described of a simple traumatic aneurism. Still, the anatomical conditions of this tumor may be more complicated. For instance, in a venesection at the bend of the elbow, that is, from intentionally puncturing a vein for the purpose of abstracting blood, besides the vein, the brachial artery may be wounded ; this is one of the most frequent causes of traumatic aneurism, or at least was so formerly, when bleeding was more common. In such a case, besides the dark, venous blood, we may readily perceive the bright, arterial blood ; the whole arm is at once bound up and the artery compressed, and in some cases the openings in both vessels heal at once without further consequences. But occasionally it happens that this accident is followed by an aneurism ; this may have the simple form above de- scribed ; but the openings in the two vessels may so grow together that part of the arterial blood will flow directly into the vein as into an arterial branch, and must then meet the stream of venous blood. This Fig. 36. Varix aneurismaticus. a, Brachial arterv ; after Hell. Froriep, " Surgical Copperplates." Bd. III.. Taf. 263. 138 SOME PECULIARITIES OF PUNCTURED WOUNDS. causes obstruction of the venous current and consequent sacculations, dilatations of the calibre of the vein, which we generally term vari- ces / in this particular case the varix is called varix aneurismaticus, because it communicates with an artery like an aneurism. Another case may arise : an aneurism forms between the artery and vein, both of which communicate with the aneurismal sac. Fig. 37. Anenrisma varicosnm. a, Brachial artery; 6 median vein. The aneurismal sac is cut open ; after Borsey. Froriep, "Surgical Copperplates." Bd. HE., Taf. 263. "We call this aneurisma varicosion. There may also be some varieties in the relation of the aneurismal sac, vein, and artery, to each other, which, however, are only important as being curious, and change neither the symptoms nor treatment, and fortunately have no particular names. In all these cases where arterial blood flows directly or indi- rectly through an aneurismal sac into the veins, there is distention of the veins and a thrill in them, which may be both felt and heard, and may even be occasionally perceived in the arteries ; it probably results from the meeting of the currents. However, this thrill in the vessels is not characteristic of the above state, for it may sometimes be in- duced simply by pressure on the veins, and occurs in some diseases of the heart. We also occasionally see a weak pulsation in veins dis- tended by the above causes, which would even earlier give a correct diagnosis. Quite recently I saw a number of aneurisms resulting from gun- shot-wounds ; in three cases affecting the femoral and external iliac arteries, the above-mentioned thrill was very prominent, rendering it pretty certain that there was a communication between the artery and vein, as was proved by autopsy in one case ; but there were no varices in any of these cases ; hence their development is not a neces- VENESECTION. 139 sary result of communication between arteries and veins, or else they may in some cases not develop for some years. Aneurisms of the arteries, in whatever form they come, if they only remained small, would cause no great inconvenience. But in most cases the aneurismal sacs grow larger and larger ; functional dis- turbances occur in the affected extremity, and finally the aneurism may rupture, and a profuse haemorrhage terminate life. In most cases the treatment must consist in ligating the aneurismal artery ; but of this hereafter. I have considered it practical to explain to you here the development of traumatic aneurisms, as in practice they are mostly due to punctured wounds ; w-hile in other text-books you w T ill find them systematically treated of among diseases of the arteries. We shall speak, in a separate chapter, of spontaneous aneurisms and their treat- ment. Punctured wounds of veins heal just like those of arteries, so that I need add nothing here to what was said above ; we need only re- mark here that extensive coagulations form more readily in veins than in arteries; traumatic venous thrombosis after venesection, for in- stance, is far more frequent than traumatic arterial thrombosis after punctured wounds of arteries, and, what is far worse, the former variety of thrombosis has much more serious results than the latter ; on this point you will perhaps hereafter hear more than will be agreeable to you. We have frequently mentioned venesection, which is a very frequent small surgical operation. We shall here briefly review its performance, although you comprehend such things quicker and better by once see- ing them than I could represent them to you. Should I attempt to tell you under what circumstances venesection should be performed, I should have to enter deeply into the whole subject of medicine ; quite a large book might be written on the indications and contraindications, the admissibility, the benefits and injuries of venesection ; hence I pre- fer to say nothing on these points as on so many others which you will pick up in a few minutes at your daily visits to the clinics, and for whose theoretical exposition without special cases we should require hours. In regard to the history, we will only mention that, Avhile for- merly venesection was performed on any of the subcutaneous veins, now it is only done in the veins of the bend of the elbow. If you wish to bleed a patient, you first apply a pressure-bandage to the arm, to cause obstruction of the peripheral veins ; for this purpose we em- ploy a properly-applied handkerchief or the old-fashioned scarlet bleed- ing-ribbon, a firm bandage two or three finger-breadths wide with a buckle ; when this is firmly applied the veins of the forearm swell up and the vena cephalica and basilica with their corresponding median 140 SOME PECULIARITIES OF PUNCTURED WOUNDS. veins appear in the bend of the elbow. You choose, for opening, the vein which is most prominent. The arm of the patient is flexed at an obtuse angle ; with the left thumb you fix the vein, with the lancet or a very pointed straight scalpel in the right hand you puncture the vein and slit it up longitudinally two or three lines. The blood escapes in a stream ; you allow sufficient to flow, cover the puncture with your thumb, remove the bandage from the arm above, and the bleeding will cease spontaneously ; the wound should be covered with a small com- press and a bandage; the arm should be kept quiet three or four days, then the wound will be healed. Easy as this operation is in most cases, it still requires practice. Puncture with the lancet or scalpel is to be preferred to the spring-lancet; the latter was formerly very pop- ular, but is now very justly going out of fashion ; the spring-lancet is a so-called fleam, which is driven into the vein with a spring; we allow the instrument to operate, instead of doing it ourselves more certainly with the hand. Various obstacles may interfere with venesection. In very fat per- sons it is often difficult to see or feel the veins through the skin ; then besides compression we employ another means, that is holding the forearm in warm water, which increases the afflux of blood to this part of the body. Moreover, after opening the vein the fat may impede the escape of the blood by fat-lobules lying in the opening; these should be quickly snipped off with the scissors. Occasionally the flow of blood is mechanically obstructed by the arm being rotated or bent at a different angle after the puncture has been made, so that the open- ing in the vein no longer corresponds to that in the skin ; this is to be met by changing the position of the arm. There are other causes for the blood not flowing properly; such as the puncture being too small, a frequent fault with beginners ; the compression is too weak, this may be improved by tightening the bandage ; or, on the contrary, the com- pression is too great, so that the artery is also compressed, and little or no blood flows from the arm, this may be obviated by loosening the venesection bandage. Aids for increasing the flow of blood are : dip- ping the hand in warm water, and having the patient rhythmically open and close the hand, so that the blood may be forced out by the muscular contractions. We shall speak further on this point, as op- portunity offers, in the clinic. CHAPTER III. CONTUSIONS OF THE SOFT PARTS WITHOUT WO UJSTBS. LECTURE XI. Causes of Contusions. — Nervous Concussion. — Subcutaneous Eupture of Vessels. — Rup- ture of Arteries. — Suggillations. — Ecchymoses. — Eeabsorption. — Termination in Fibrous Tumors, in Cysts, in Suppuration, and Putrefaction. — Treatment. By the action of a blunt object on the soft parts, the skin will sometimes be injured, sometimes it will not ; hence we distinguish con- tusions with or without wounds. We shall first consider the latter. These contusions are partly caused by the falling or striking of heavy objects on the body, partly by the body falling or striking against a hard, firm object. The immediate result of such a contusion is a crushing of the soft parts, which may be of any grade ; often we per. ceive scarcely any change, in other cases the parts are ground to a pulp. Whether the skin suffers solution of continuity by this application of force depends on various circumstances, especially on the form of the con- tusing body and the force of the blow, also on the nature of the parts un- der the skin ; for instance, the same force would cause contusion without a wound in a muscular thigh, that applied to the spine of the tibia would cause a wound, for in the latter case the sharp edge of bone would cut the skin from within outward. The elasticity and thickness of the skin also come into consideration ; these not only vary in different per- sons, but may differ in different parts of the body of the same indi- vidual. In contusion without wound we cannot immediately recognize the amount of destruction, but only indirectly from the state of the nerves and vessels, and also from the subsequent course. In contusion the first symptom in the nerves is pain, just as it is 142 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. in wounds, but pain of a duller, more undefined character, although it may be very severe. In many cases, especially when he has struck against a hard body, the patient has a peculiar vibrating, threatening feeling in the injured part; this feeling, which extends some distance beyond the seat of injury, is caused by the concussion of the nerves. For instance, if we strike the hand or finger quite hard, only a small part is actually contused, but not unfrequently there is concussion of the nerves of the whole hand, with great trembling, dull pain, on account of which the fingers cannot be moved, and there is almost complete loss of feeling for the moment. This condition passes off quickly, usually in a few seconds, and then a burning pain is felt in the contused part. The only explanation we have of this temporary symptom is that the nerve-substance of the axis cylinder suffers molecular displacement from the blow, which spontaneously passes off again. These symptoms of concussion (the commotion) do not by any means accompany all contusions ; they fail especially in cases where a heavy body comes against a limb at rest, but they are not unfrequently of great signifi- cance in contusions of the head ; here commotio cerebri is not unfre- quently united with contusio cerebri, or the former appears alone, for instance, in a fall on the feet or buttocks, whence the concussion is prop- agated to the brain and may induce very severe accidents or even death, without any preceptible anatomical changes. Concussion is es- sentially a change in the nervous system, hence we speak chiefly of cerebral or spinal concussion. But the peripheral nerves also may be concussed with the above symptoms ; but since in such cases the more localized contusion is especially prominent, this nervous state is per- haps too much neglected. Severe concussion of the thorax may in- duce the most dangerous symptoms simply from concussion of the cardiac and pulmonary nerves, whereby the circulation and respiration are disturbed, although for the most part only temporarily. Nor can a reflex action of the concussed nerve, especially of the sympathetic on the brain, be entirely denied. Doubtless some of you, when wrestling or boxing, have received a blow in the abdomen ; what terrible pain ! a feeling of faintness almost overcomes you for a time ; here we have an action on the brain and on the heart; one holds his breath and gathers his strength, to prevent sinking to the earth. Concussion of the ulnar nerve often occurs, when we strike the elbow hard ; most of you proba- bly know the heavy, dull pain, extending even to the little finger. Compression of sensitive nerves is said to cause contraction of the cerebral vessels, as is shown by recent experiments on rabbits ; possi- bly this explains the faintness from severe pain. All these are symptoms of concussion in the peripheral nerves. Now, as we do not know what specially takes place in the nerves, we CONTUSIONS OF NERVES AND VESSELS. 143 cannot judge whether these changes have any effect, and, if so, what, on the subsequent course of the contusion, and of the contused wound ; hence we cannot here study the nerves any further. Some unim- peachable observations seem to prove that this concussion of periph- eral nerves may induce motor and sensory paralysis, as well as atrophy of the muscles of a limb ; but the connection between cause and effect is often difficult to prove. Contusions of the nerves are distinguished from concussions by the fact that in them certain parts of the nerve-trunks, or their whole thickness, is destroyed, to the most varied extent and degree, by the force applied, so that we find them more or less pulpy. Under these circumstances, there must be a paralysis corresponding to the injury, from which we determine the nerve affected, and the extent of the effect. On the whole, such contusions of nerves without wounds are rare, for the chief nerve-trunks lie deep between the muscles, and so are less apt to be injured directly. It must a priori be acknowledged that concussion may affect other organs and tissues than nerves, and induce temporary or per- manent disturbances, not only of the functional but of the nutritive processes. Such disturbances may also have an important influence on the course of repair after the injury, and are mentioned by some surgeons as the chief causes of inflammations that are occasionally very violent and develop easily-decomposing exudations and infiltra- tions. I am far from denying the influence of an energetic concus- sion on a bone whose medulla and vessels are thereby torn, without its being fractured ; under some circumstances the results of such an injury might be more extensive and tedious than those of a fracture from too great bending; but we should not ascribe the frequent severity of the course of contused wounds entirely to this cause. Contusions of the vessels must be much more apparent, since the walls of the smaller vessels, especially of the subcutaneous veins, are destroyed by the contusing force, and blood escapes from them. Hence, subcutaneous hcemorrhage is the almost constant consequence of a contusion. It would be much more considerable if in this variety of injury the wound of the vessel had sharp edges, and gaped ; but this is not usually the case. Contused wounds of the vessel are rough, uneven, ragged, and these irregularities form obstacles to the escape of the blood; the friction is so great that the pressure of the blood is unable to overcome it ; fibrinous clots form on these inequal- ities, even extending into the calibre of the vessel, causing mechanical closure of the vessel, or thrombus. Contusion of the wall of a ves- sel, with alteration of its structure, may alone cause coagulation of the blood ; for Brixcke has proved that a living, healthy intima of the 144 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. vessel is very important for the fluidity of the blood within the vessel. We shall again return to this subject, under contused wounds. The counter-pressure of the soft parts prevents an excessive escape of blood, for the muscles and skin exercise a natural compression ; hence, these subcutaneous hasmorrhages, even when from a large vessel of the extremities, are very seldom instantly dangerous to life. Of course, it is different in hasmorrhages into the cavities of the body ; here there is little besides movable parts, that can offer no sufficient opposition to the escape of the blood ; hence, these hasmorrhages are not infrequently fatal. This may be in two ways : partly from the amount of blood escaping — into the thorax or abdomen, for instance — partly from the pressure of the blood on the parts in the cavity — on the brain, for instance — which are not only partly destroyed by the blood flowing from large vessels, but are compressed in various direc- tions, and their functions thus impaired. Hence, hasmorrhages in the brain cause rapidly-occurring paralyses, and often, also, disturbance of the sensorium. In the brain we call this escape of blood, as well as the symptoms induced by it, apoplexy (from ano and ■kXtjoog), to knock down). If a large artery of an extremity be contused, the conditions are the same as in a stitched or compressed punctured wound. A traumatic aneurism, a pulsating tumor, forms, as described in the last lecture. But this is rare as compared with the numerous contusions occurring daily, and is so, doubtless, because the larger arteries lie quite deep, and the arterial coats are firm and elastic, so that they tear far less readily than the veins, although a short time since, in the clinic, we saw a subcutaneous rupture of the anterior tibial artery. A strong, muscular man had a fracture of the leg ; the skin was uninjured ; the tibia was fractured about the middle, the fibula rather higher. The considerable tumor that at once formed at the seat of fracture pulsated visibly and perceptibly to the touch on the anterior surface of the leg. There was very evident buzzing sound in it, which I was able to de- monstrate to the class. The foot was dressed with splints and band- ages ; we avoided the application of an immovable dressing, so that we might watch the further course of the traumatic aneurism that had evidently formed here. "We renewed the dressing every three or four days, and could see the tumor gradually becoming smaller and pulsat- ing less strongly, till it finally disappeared, a fortnight after the injury. The aneurism had been cured by the compression from the bandage. Nor was the recovery of the fracture interrupted ; eight weeks after the injury, the patient had full use of his limb. The most frequent subcutaneous hasmorrhages in contusions are from rupture of the subcutaneous veins. These effusions of blood CONTUSIONS OF BLOOD-VESSELS. 145 cause visible symptoms which vary, partly from the quantity of the effused blood, partly from the distribution of the blood in the tissue. The more vascular a part, and the more severely contused, the greater the extravasation. The extravasated blood, if it escapes from the vessels slowly, forms a passage-way between the connective-tissue bundles, especially those of the subcutaneous connective tissue and muscles ; this must cause infiltration of the tissue with blood and con- sequent swelling. These diffuse and subcutaneous haemorrhages we term suggillations or suffusions. The more relaxed and yielding, and the easier to press apart the tissue is, the more extensive will be the infiltration of blood, if it flows gradually but continually from the vessels for a time. Hence, as a rule, we find the effusions of blood in the eyelids and scrotum quite extensive, because the subcutaneous connective tissue there is so loose. The thinner the skin, the more readily and quickly we shall recognize the suggillation ; the blood has a blue color through the skin, or presses into it and gives it a steel- blue color. Under the conjunctiva bulbi, on the contrary, the blood appears quite red, as this membrane is so thin and transparent. Blood extravasations in the cutis itself appear as red spots (purpura) or strias (vibices) ; but in this form they are very rarely due to contu- sion, they are caused by spontaneous rupture of the vessels ; whether because the walls of the vessels are particularly thin in some persons, as in those already mentioned as being of h hemorrhagic diathesis, or because they are especially brittle and tender from some unknown condition of the blood, as in scorbutis, some forms of typhus, morbus maculosus "Werlhofii, etc. Contusion of the cutis may usually be rec- ognized by a very dark-blue color, passing into brown ; also by stria- tion of the epidermis with so-called chaps, or, as they are technically termed,. excoriations, flaying of the skin. If much blood escape suddenly from the vessels and be effused in the loose cellular tissue, a more or less bounded cavity is formed. This form of effusion of blood is called ecchymosis, ecchymoma, he- matoma, or blood-tumor. Whether the skin be discolored at the same time, depends on how deep the blood lies under it. In deep effusions of blood, diffuse as well as circumscribed, we often find no discoloration of the skin, especially soon after the injury ; we only perceive a tumor whose rapid development immediately after an injury at once shows its nature ; this tumor feels soft and tense. The cir- cumscribed effusion of blood offers the very characteristic feeling of fluctuation. You may most readily obtain a clear idea of this feeling by filling a bladder with water and then feeling its walls. In surgical practice the recognition of fluctuation is very important, for there are innumerable cases where it is important to determine whether we 10 146 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. have to deal with a tumor of firm consistence, or with one containing fluid. You will be shown in the clinic how it is best to make this examination in different cases. Some of these effusions of blood have received particular mines according 1 to the localities where they occur. Thus those coming 1 on the heads of the newly-born, between the various coverings of the skull and in it, are called cephalhematoma (from icecpaXrj, head, and aifiaroo), to soil with blood), cephalic tumors of the newly-born. The extravasations in the labia majora, from contusions or the spontaneous rupture of distended veins, have received the neat name of episiohmma' toma or episiorrhagia (from sTrelotov, the external genitals). Effu- sions of blood in the pleura and pericardium have also special desig- nations : hmmatothwax, hmmatopericardium, etc. On the whole, we attach little importance to these euphonic Latin and Greek names ; but you should know them, so as to understand them when reading medical books, and not seek for any thing mysterious behind them ; also that you may use them so as to express yourself quicker, and be readily understood. The subsequent course and symptoms are very characteristic of these subcutaneous effusions of blood. Looking first at the diffuse effusions of blood, immediately after the injury, we are rarely able to decide how extensive the bleeding has been or still is. If you ex- amine the contused part the second or third day after the injury, you notice that the discoloration is more extensive than on the first day ; this appears to increase subsequently ; that is, it becomes more per- ceptible. The extent is sometimes astonishing. We once had in the clinic a man with fractured scapula ; at first there was only slight dis- coloration of the skin, although there was a large fluctuating tumor. On the eighth day, the whole back from the neck to the gluteal mus- cles was of a dark steel-blue, and presented a peculiar, almost comical appearance, the skin looking as if painted. Such widely-spreading extravasations are particularly apt to occur in cases of fractured bones, especially of the arm or leg. But fortunately this partly dark-blue, partly bluish-red color, along with which the skin is not sensitive and scarcely swollen, does not remain so, but further changes take place ; first there is further change of color, the blue and red pass into mixed brown, then to green, and finally to a bright lemon yellow. This pecu- liar play of colors has given rise to the expression of " beating one black and blue," or " giving one a black eye." The last color, the yellow, usually remains a long time, often for months ; it finally dis- appears, and no visible trace of the extravasation remains. If we ask ourselves whence come these various colorings of the skin, and if we have the opportunity of examining blood extravasa- CONTUSIONS OF BLOOD-VESSELS. 147 Fig. 88. tions in various stages, we find that it is the coloring matter of the blood which gradually passes through the metamorphoses and shades of color. When the blood has escaped from the vessels and entered the connective tissue, the fibrine coagulates. The serum enters the connective tissue, and thence passes back into the vessels ; it is re- absorbed. The coloring matter of the blood leaves the blood-corpus- cles, and in a state of solution is distributed through the tissue. The fibrine and blood-corpuscles, for the most part, disintegrate to fine molecules, and in this state are reabsorbed by the vessels ; as in the thrombus a few white blood-cells may attain a higher development. The coloring matter of the blood which saturates the tissues passes through various, not thoroughly understood metamorphoses with change of color, till it is finally transformed into a permanent coloring matter, which is no longer soluble in the fluids of the body — hcematoidin. As in the thrombus, this is partly granular, partly crystalline ; in a pure state it is orange-colored, and if scanty gives the tissue a yellow- ish color, if plentiful a deep orange hue. Heabsorption of the extravasa- tion almost always takes place in diffuse suggillations, as the blood is very widely distributed through the tissues, and the vessels that have to accomplish the reabsorp- tion have not been affected by the contusion ; it is the most desirable and under favorable circumstances the most frequent result after sub- cutaneous and intermuscular effusions of blood. The case is different in circumscribed effusions, in ecchymoses. Here the first question is as to the extent of the effusion, then about the state of the vessels surrounding it ; the more developed the latter, the less they have been injured by the contusion, the more hope there is of early reabsorption ; but its occurrence is always less constant in large effusions of this variety. There are various factors which inter- fere with it ; in the first place, there is thickening of the connective tissue around the effusion of blood, as around a foreign body (as in traumatic aneurism also), by which the blood is entirely encapsulated ; the fibrine of the effusion is deposited in layers on the inner surface of this sac, the fluid blood remains in the middle. Thus the vessels about the blood-tumor can take up very little fluid, as they are sepa- rated from the fluid part of the blood by layers of fibrine, which are Granular and crystalline hsematoidin, partly orange, partly ruby-red in color. Magni- fied 400. 148 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. often quite thick. Here we have the same conditions as in large fibrinous exudations in the pleura ; there also the fibrous deposits on the walls greatly interfere with reabsorption. This can only take place perfectly when the fibrine disintegrates to molecules, becomes fluid, and thus absorbable ; or when it is organized to connective tis- sue, and supplied with blood and lymph vessels. This is not so very rare in pleuritic deposits. But there is also another fate for such extrava- sations. The fluid portion of the blood may be completely reabsorbed, and a firm tumor composed of concentric, onion-like layers may remain. This results occasionally from extravasations in the labia majora; a so- called fibrous tumor is thus formed ; in the cavity of the uterus, also, such fibrous tumors occasionally develop. Some hasmatomata may be partly organized to connective tissue, and gradually take up lime-salts and entirely calcify ; a rare termination, but one that occurs in effu- sions of blood in large goitres. Another mode is the transformation of the blood-tumor to a cyst / this is seen in the brain, and in soft tumors. Besides other modes of origin, some cysts in goitres may owe their origin to such effusions. By a cyst or encysted tumor we mean sacs or bags containing more or less fluid. The contents of these cysts, resulting from extravasation of blood, are darker or lighter ac- cording to their age ; indeed, the blood-red may totally disappear from them, and the contents become quite clear or only slightly clouded by fat molecules. In large circumscribed extravasations you will find numerous and beautifully-formed hematoidin crystals more rarely than in small diffuse ones, for in the former fatty disintegration of the elements of the blood predominates, hence excretion of choles- terine crystals is more common in them. The capsule enclosing these old effusions arises partly from organization of the peripheral parts of the blood-clot, partly from the circumjacent tissue. Suppuration of circumscribed extravasations is far more frequent than the two last described metamorphoses, but is not so common as reabsorption. The inflammation in the vicinity, and the plastic pro- cess in the peripheral part of the extravasation, from which, in the two preceding cases, the thickened connective tissue was developed, which encapsulated the blood, assume a more acute character in the case we are about to speak of; a boundary layer is formed here also, but not slowly and gradually as in the preceding cases, but by rapid cell-formation ; plastic infiltration of the tissue does not lead to devel- opment of connective tissue, but to suppuration ; the inflammation after a time attacks the cutis, and it suppurates from within outward, and is finally perforated, and the pus mixed with blood is evacuated ; the walls of the cavity come together, cicatrize and grow together, and healing thus takes place. We shall speak more exactlv of this CONTUSIONS OF BLOOD-VESSELS. 149 mode of healing when treating of abscess ; we call any pus-tumor, i. e., circumscribed collection of pus under the skin at any depth, an abscess : hence we term the above process the conversion of an ex- travasation of blood into an abscess. This process may be very pro- tracted, it may last three or four weeks, but, if not dangerous from its location, it generally runs a favorable course. We recognize the sup- puration of an extravasation of blood by the increasing inflammatory redness of the skin, the growth of the tumor, increasing pain, occasion- ally accompanied by fever, and finally by thinning of the skin at some point, where it is finally perforated. Lastly, there may be rapid decomposition of the extravasation ; fortunately, this is rare. Then the tumor grows hot, tense, and very painful, the fever usually becomes considerable, chills and other severe general symptoms may occur. This termination is the worst, and the only one that requires speedy relief. Whether there shall be reabsorption, suppuration, or putrefaction of an extravasation, depends not only on the amount of the effused blood, but very much on the grade of the contusion that the tissues have suffered ; as long as these may return to their normal state, re- absorption will be probable ; if the tissues be broken down and pass into disintegration or decomposition, they will induce suppuration 01 decomposition of the blood ; briefly, the effused blood will have the same fate as the contused tissue. While the skin is uninjured we cannot judge accurately how much the muscles, tendons, and fascire, are injured ; occasionally the size of the extravasation may give some aid on this point, but it is a very uncertain measure ; it is better to test the amount of functional ac- tivity of the affected muscles, but even the results thus given must be carefully accepted ; the amount of force that has acted on the part may lead to an approximate estimation of the existing subcutaneous destruction. In contusion of muscles, as in wounds, healing takes place from the crushed muscular elements undergoing molecular disin- tegration and being absorbed, or by being eliminated with the pus on suppuration of the extravasation, but then there is new formation both of connective tissue and muscle. The largest extravasations, either diffuse or circumscribed, are usually accompanied by injuries of the bones ; but it will be better to consider the injury of the bone in a separate section. If a portion of the body be so crushed as to be entirely or mostly incapable of living, it becomes cold, bluish red, brownish red, then black; it begins to putrefy; the products of putrefaction enter the neighboring tissues and the blood ; the local inflammations, as well as the fever, assume peculiar forms. As this is the same in contusions with or without wounds, we shall speak of it later. 150 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. The treatment of contusions without wound has for its object the conduction of the process to the most favorable termination possible, that is, to reabsorption of the extravasation ; when this takes place, the injuries to the other soft parts also progress favorably, as the whole process remains subcutaneous. We here refer solely to those cases where the contusion of the soft parts and the extravasation are the only objects of treatment; where the bone is broken it should be treated first of all, the extravasation of itself would scarcely be an ob- ject for special treatment. If called to a contusion that has just oc- curred, the indication may be to arrest any still continuing haemor- rhage ; this is best done by compression, which, where convenient, is to be made by evenly-applied bandages. In North Germany, when a child falls on its head, or knocks its forehead, the mother or nurse at once presses the handle of a spoon on the injured spot to prevent the formation of a blood-bruise. This is a very suitable popular remedy ; by the instantaneous compression the further escape of blood is hin- dered, as is also its collection at one point, because it is compelled by the pressure to distribute itself in the surrounding tissue ; an ecchy- mosis just forming may thus be transformed into a suggillation, so that the blood may more readily be absorbed. You may occasionally at- tain the same object by a well-applied bandage. But we rarely see the injury so early, and in the great majority of cases there is also an injury of a bone or joint, and the treatment of the blood-extravasation is a secondary object. The use of cold, in the shape of bladders or rubber bags filled with ice, or of cold lotions, to which it is an old custom to add vinegar or lead-water, is resorted to as a remedy in recent contusions; it is said to prevent excessive inflammation. But you must not rely too much on these remedies ; the means that most aids the reabsorption of blood extravasations is regular compression and rest of the part. Hence it is best to envelop the extremities in moist bandages, and over them apply wet cloths, which are to be renewed every three or four hours. Other remedies, which usually act well in inflammations of the skin, such as mercurial ointment, are of little use here. But I must not forget arnica ; this remedy is so honored by some families and physicians that they would consider it unpardonable to neglect prescribing lotions of infusion of arnica, or of water with the addition of tincture of arnica. Faith is mighty ; one believes in arnica, an- other in lead-water, a third in vinegar, as the potent external reab- sorbent. In all cases the effect is doubtless simply due to the moist- ure and the variation of temperature of the skin caused by the com- press, whereby the capillaries are kept active, now brought to contrac- tion, now to dilatation, and thus placed in a better state for reabsorp- tion because thev are active. TREATMENT OF BLOOD-EXTRAVASATIONS. 151 Diffuse blood-extravasations of the skin with moderate contusion of the soft parts are usually absorbed without much treatment. If a circumscribed extravasation does not change considerably in the course of a fortnight, there is nevertheless no indication for further interfer- ence. We then paint the swelling once or twice daily with dilute tincture of iodine, compress it with a suitable bandage, and not unfre- quently see the swelling gradually subside after several weeks. Should it become hot, and the skin over it grow red and painful, we must expect suppuration ; then even the continued application of cold will rarely change the course, though it may alleviate it. Then, in order to hasten the termination of the suppuration, which cannot be avoided, we may apply warm fomentations, either simply of folded muslin wet with warm water or cataplasms ; now you quietly await the further course ; if the general health be not impaired, but the pa- tient feels pretty well, you calmly await perforation ; it will perhaps be weeks before the skin gradually becomes thinner at some point and finally opens, the pus is evacuated, the walls of the large cavity fall together, and in a short time the parts are all healed. At the commencement of this lecture I mentioned a case where, with a frac- tured scapula, there was an enormous partly diffuse, partly circum- scribed extravasation ; here there was a strongly-fluctuating tumor, which was not reabsorbed, while the diffuse effusion was rapidly re- moved ; the suppuration did not end in perforation till the fifth week, then one and a half to two quarts of pus were evacuated ; a week later this enormous cavity was healed, and the patient left the hospi- tal well. Why we do not here interfere earlier and aid Nature by an incision, we shall consider more closely when we treat of abscesses. Should the tension of the swelling rapidly increase, however, dur- ing the suppuration of the extravasation, and high fever with chills occur, we may suppose that the blood and pus are decomposing, that there is putrefaction of the enclosed fluid. Fortunately, this is rare, and occurs almost exclusively where there is great crushing of the muscles or splintering of the bone. With such symptoms of course the putrid fluid should be quickly evacuated ; then you should make a large incision through the skin, unless this be forbidden by the ana- tomical position of the parts ; in which case several small incisions should be made at points where the fluid may escape freely and easily. These incisions greatly alter the aspect of the case ; you have changed the subcutaneous contusion to an open contused wound. Now other conditions come into play, which we shall treat of in the next lecture. We must still mention that, if extensive putrefaction of the soft parts follows such contusions, amputation is indicated, although this unfortu- nate case rarely happens without coincident fracture of the bones. CHAPTER IV. CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. LECTURE XII. Mode of Occurrence of these Wounds ; their Appearance. — Slight Hemorrhage in Con- tused "Wounds. — Early Secondary Haemorrhages. — Gangrene of the Edges of the "Wound. — Influences that effect the Slower or more Eapid Detachment of the Dead Tissue. — Indications for Primary Amputation. — Local Complications in Contused "Wounds ; Decomposition, Putrefaction, Septic Inflammations. — Contusion of Ar- teries ; Late Secondary Haemorrhages. The causes of contused wounds, of which we have to treat to-day, are the same as those of simple contusions, only in the first cases the force is usually greater than in the latter, or the body by which they are induced is of such a form as to divide the skin and soft parts easily, or else parts of the body have been injured where the skin is particularly thin, or lies over parts unusually firm. The kick of a horse, blow from a stick, bite of an animal or a man, being run over, wounding with blunt knives, saws, etc., are frequent causes of contused wounds. Nothing, however, causes more contused wounds than rapidly-moving wheels and rollers of machinery, cutting- machines, circular-saws, spinning-jennies, and the various machines with cog-wheels and hooks. All of these instruments, the product of advancing industry, do much injury among the operatives. Men and women, adults and children, with crushed fingers, mashed hands, ragged, lacerated wounds of the forearm and arm, are now among the constant patients in the surgical wards of hospitals in every large city. Innumerable persons are thus maimed of fingers, hands, or arms, and many of these patients die as a result of their injuries. If to these you add (what recently is becoming rarer, it is true) railroad injuries, those caused by blasting, building tunnels, etc., you may APPEARANCE OF CONTUSED WOUNDS. 153 imagine, not only how much sweat, but how much blood, clings to the many evidences of modern culture. At the same time it is not to be denied that the chief cause of these accidents is the carelessness, often the foolhardiness, of the workman. Familiarity with the dan- gerous object renders persons at last careless and rash ; some pay for this with their lives. Gunshot wounds also essentially belong to contused wounds ; but, as they have some peculiarities of their own, we shall treat of them in a special chapter. Lacerated wounds, and tearing out of pieces from the limbs, we shall consider at the end of this chapter. Fractures of bones of the most varied and dangerous varieties ac- company contused wounds from all the above causes ; but for the present we shall leave these out of consideration, and treat only of the soft parts. In most cases, the appearance of a wound indicates whether it was due to incision or contusion. You already know the character of in- cised wounds, and I have alluded to some cases where a contused wound had the appearance of an incised one, and the reverse. Con- tused wounds, like incised, may be accompanied by loss of substance, or there may be simply solution of continuity. The borders of these wounds are generally uneven, especially the edges of the skin ; the muscles occasionally look as if chopped ; tags of the soft parts, of various sizes, not unfrequently large flaps, hang in the wound, and may have a bluish-red color, from the blood stagnated or effused in them. Tendons are torn or pulled out, fascias are torn, the skin, for some distance around the wound, is not unfrequently detached from the fascia, especially if the contusing force was combined with a tear- ing and twisting. The grade of this destruction of the soft parts of course varies greatly, and its extent cannot always be accurately de- termined, as we cannot always see how far the contusion and tearing extend beyond the wound ; from the subsequent course of the wound we often satisfy ourselves that the contusion extended much further than the size of the wound indicated ; that separation of muscles, di- visions of fasciae, and effusions of blood, extended under the skin, which may have been but little torn. It is unfortunate that the skin- wound gives no means of judging of the extent and depth of the con- tusion, for it renders it very difficult to correctly estimate such an in- jury at the first examination ; while the appearance of the wound gives the laity no idea of danger, the experienced surgeon soon sees the gravity of the case. Since the injury, especially when due to machinery, is very rapidly done, the pain is not great; and immediately after the injury the pain from contused wounds is often very slight ; the more so, the greater 154 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. the injury and crushing of the parts. This is readily explained by the nerves in the wound being 1 entirely mashed and destroyed, conse- quently incapable of conducting ; moreover, what I told you in the last lecture about local concussion of nerves, the so-called stupor of the injured part, comes into play. At first sight it seems rather remarkable that these contused wounds bleed little, if any, even if large veins or arteries be crushed or torn. There are well-observed cases to show that, after complete crushing of the femoral or axillary artery, there v/as absolutely no primary haemorrhage. It is true, this is rare ; in many cases where there is complete solution of continuity of a large artery by a contusion, although there is no spirting stream, there is constant trickling of blood ; this, coming from the femoral artery, would speedily cause death. I have already told you how this arrest of hemorrhage takes place in small arteries, but will make it clearer to you by an illustra- tion. A railroad hand was run over by a locomotive, so that the wheel passed over his left thigh just below the hip-joint. The unfor- tunate was at once brought on a litter to the hospital ; meantime he had lost much blood, and came in very pale and anaemic, but perfectly conscious. After complete removal of the torn clothing, we found a horrible mangling of the skin and muscles. The bone was crushed to atoms, the muscles were partly mashed to pulp, partly hung in tags from the wound, the skin was torn up as far as the hip-joint. At no point of this horrible wound did an artery spirt, but from the depth con- siderable blood constantly trickled out, and the general state of the pa- tient clearly showed that he had already lost much blood. It was evident that the only thing to be done here was to amputate at the hip-joint, but in the condition the patient then was, this was not to be thought of; the new loss of blood from this severe operation would undoubt- edly have been at once fatal. Hence it was, first of all, necessary to arrest the haemorrhage, which evidently came from a rupture of the femoral artery. I first tried to find the femoral in the wound, while it was compressed above ; but all the muscles were so displaced, all the anatomical relations were so changed, that this was not quickly done, hence I proceeded to ligate the artery below Poupart's ligament. After this was done, most of the bleeding ceased, but not entirely, on account of the free arterial anastomosis ; and as no regular dressing could be applied, on account of the existing mangling, I surrounded the limb firmly with a tourniquet, close below where I proposed to exarticulate. Now the bleeding stopped; we gave various remedies to revivify the patient ; wine, warm drinks, etc., were ad- ministered, so that, toward evening, he had so far recovered that his temperature was again normal, and the radial pulse was again good. HEMORRHAGE FROM CONTUSED WOUNDS. 15 5 I should have preferred postponing the operation till the following day, if, in spite of ligature and tourniquet, with the strengthening of the heart's beat, there had not been some bleeding from the wound, so that I feared the patient might bleed to death during the night. Hence, with the able help of my assistants, I exarticulated the thigh as rapidly as possible. During the operation the absolute loss of blood was not great, but it was too much for the already-debilitated patient. At first all seemed to go well ; the spirting vessels were all ligated, the wound cleansed, and the patient placed in bed ; soon he suffered from restlessness and dyspnoea, which increased, finally con- vulsions occurred, and the patient expired two hours after the opera- tion. Examination of the femoral artery of the crushed extremity showed the following : In the upper third of the thigh there was a crushed and torn part, comprising about one-third the calibre of the artery. The tags of the tunica intima, as well as the other coats of vessel, and the connective tissue of the sheath, had rolled up into the calibre of the artery, and the blood could only escape slowly ; the surrounding tissue was completely saturated with blood. In this case, no clot had formed in the artery, as the escape of blood was still too free to permit this ; but, if you imagine that the contusion had affected the entire circumference of the artery, you may understand how the tags of the coats of the vessel pressing into its calibre from all sides might have rendered the escape of the blood more difficult, or even impossible ; then a thrombus would have formed, and stopped the vessel, and gradually have become organized, so as to cause permanent closure, just as after ligation. If no hemorrhage had followed the partial crushing of the artery in this case, if, for instance, the crushing had occurred without an external wound, possibly a clot would simply have formed at the part roughened by the contusion, a thrombus forming from the wall ; in this case there might have been crushing of the artery with preservation of its calibre, a result that is said to have been observed. If you apply the above-described condition of a large crushed ar- tery to smaller arteries, you will understand how there may here more readily be complete spontaneous plugging of the calibre of the vessels partly by in-rolling of the fragile, torn tunica intima, partly by con- traction of the tunica muscularis and by the tags of the adventitia, and that consequently bleeding may fail almost entirely in such con- tused wounds. Observation of this led a French surgeon, Chassaignac, to invent an instrument for crushing off portions of the body ; he terms this operation kcrasement, the instrument he calls an ecraseur. It con- sists of a strong metallic ligature, composed of small links, which 156 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. is to be applied around the part to be removed, and then drawn slow- ly into a strong metal frame by means of a ratch arrangement. When the instrument is properly used it causes absolutely no haemor- rhage. Little favor as the instrument at first found among surgeons, from their dislike to contused wounds in operative surgery, there is no doubt of its advantages in suitable cases. Wounds caused by ecrasement usually heal with very little local or general reaction ; co- incident inflammations occur less frequently with this class of wounds than with pure incised wounds. Nevertheless ecrasement will always be limited to a small number of operations. There is another factor for limiting the haemorrhages in extensive contusions, that is, the weakening of the heart's action caused by the injury, probably due to reflex action. Persons badly injured, besides suffering from loss of blood and injury of the nerve-centres, are usually for a time in a state of numbness or stupor ; the word most commonly used to express this state of depression is " shock." The fright from the injury and all thoughts about it, which follow in rapid succession, unite in producing great psychical depression, which has a paralyzing effect on the heart's action. Still, even in persons not greatly af- fected psychically by the injury, as old soldiers who have often been wounded, or very phlegmatic persons, a severe injury is not entirely without this effect, so that we must suppose that there are purely physical causes for shock. Contusions of the abdomen have an even more depressing effect on the nerve-centres than do those of the ex- tremities, as I have already told you. In this connection the so-called beating-experiment (Klopfversuch) of Golz is very interesting : if we repeatedly strike a frog sharply on the belly with the handle of a scalpel, he becomes as it were paralytic ; as a result of paresis of their walls, the abdominal vessels distend greatly and take up almost all the blood, so that all the other vessels and even the heart become blood- less, and the latter only contracts feebly. When the patient has recovered from this state of psychical and physical depression, the heart begins to act with its former or even greater energy, then haemorrhages may occur from vessels that had not previously bled. This variety of secondary haemorrhage occurs after operations, when the effect of the anaesthetic has passed off. Hence the patient should be carefully watched at this time, to guard against such secondary haemorrhages, especially if, from the locality of the in- jury, there be reason to suspect that a large artery has been injured. Now we must again examine somewhat more attentively the local changes in the wound. Although doubtless the processes that take place in the contused wound, the changes on its surface and final healing, must be essentially the same as in incised wounds, still in the appearances in the two cases HEALING OF CONTUSED WOUNDS. 15 7 there are considerable differences. One very important circumstance is, that in contused wounds the nutrition of the edges of the skin and soft parts is more or less extensively destroyed or impaired, or, to ex- press this more anatomically, the circulation and nerve influence in the borders of contused wounds are more or less lost. This at once pre- vents the possibility of healing by first intention, as this requires per- fect vitality in the surfaces of the wound. Hence contused wounds always heal with suppuration. This observation causes us to introduce sutures or try firm union by plasters very rarely ; you may consider this as a general rule. There are exceptions to this rule, which you will only learn exactly in the clinic, and of which I shall only incidentally remark, that occasionally we fasten large, loose flaps of skin in their original position, not be- cause we expect them to unite by first intention, but that they may not from the first retract too much and atrophy to too great an ex- tent. Granulation and suppuration are esentially the same as in wounds with loss of substance, except that they are slower, and we might say more uncertain at many places. In incised wounds with loss of sub- stance also a thin superficial layer of tissue is occasionally lost, if it be not very well nourished ; but this is insignificant as compared with the extensive loss of tissue-shreds that occurs in contused wounds. Many days, often for weeks, tags of dead (necrosed) skin, fascia, and tendons, hang to the edges of the wounds, while other parts are luxuriantly granulating. This process of detachment of the dead from the living tissue takes place as follows : A cell infiltration and formation of vessels, lead- ing to development of granulations, start from the borders of the new tissue ; granulations form on the border of the healthy tissue, and their surface breaks down into pus. With this change to the fluid state as it were the solution and melting of the tissue, of course the cohe- sion of the parts must cease, and the dead shreds, which previously were in continuity with the living tissue by their filamentary connec- tion, must now fall. Hence part of the surface of contused wounds almost always be- comes necrosed (from vetcpog, dead), gangrenous (from r\ yayypaiva from ypaivo), I consume), which are both expressions for parts in which circulation and innervation have ceased, or which are entirely dead. The part where the detachment takes place is technically called the line of demarcation of the gangrene. These technical terms, which refer to every variety of gangrene, no matter how it occurs, you must only notice provisionally here. I will try to render this process of detachment of necrosed tissue by suppuration more distinct by means of a diagram. 158 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. In the portion of connective tissue represented, suppose c, the border of the wound, be so destroyed by the injury that its circulation is arrested and it is no longer nourished ; the blood is coagulated in the vessels as far as the shading extends in the diagram. Now cell- infiltration and inflammatory new formation begin at the outer edge of the living tissue, at the border between a and b where the vessels termi- nate in loops ; these vascular loops dilate, grow, and multiply ; in the tissue the infiltration is constantly increased by wandering cells, as if the edge of the wound were here ; granulation tissue is formed ; this turns to pus, on the surface, that is, close to the dead tissue, and then of course the necrosed part falls, because its cohesion with the living tissue has ceased. Hence detachment of the necrosed shreds of tissue results from inflammation with suppuration ; when the dead por- tion of tissue has fallen, the subjacent, suppurating layer of granula- tions comes to light, having been already developed before the detachment of the necrosed part. What you here see in connective tissue is true of the other tissues, bone not excepted. DiagTam of the process of detachment of dead connective tissue in contused wounds. Magni- fied 300 diameters; ff, crushed necrosed part; b, living tissue; c, surface of the wound. HEALING OF CONTUSED WOUNDS. 159 In many cases, on the fresh borders of the wound we may see about how much will die, but by no means in all cases, and we can never decide from the first as to the bordering line of the dead tissue. Completely crushed skin usually has a dark-blue violet appearance and feels cold ; in other cases we at first see no change in it, but in a few days it is white, without sensation, later it becomes gray, or, when quite dry, grayish or brownish black. These various colors depend chiefly on the amount of coagulated blood remaining in the vessels or infiltrated in the tissue itself by the partial rupture of the vessels. The healthy skin is bordered by a rose-red line which loses itself in a diffuse redness ; this is due to collateral dilatation of the capillaries, and is partly also a symptom of fluxion, of which we have before spoken ; it is the reaction redness about the wound, which we have already described ; for the living wound-surface only begins where the blood still flows through the capillaries. In muscles, fascias, and tendons, we can decide far less frequently, and often not at all, from the appearance at first, how far they will be detached. The time required for the dead tissue to be separated and detached from the living varies greatly with the different tissues. This de- pends first on the vascularity of the tissues ; the richer a tissue in capillaries, the softer it is, the more readily cells spread in it, and the richer it is by nature in cells capable of development, so much the more rapidly will the formation of granulations and the detachment of the necrosed parts come about. All these circumstances combine best in the subcutaneous cellular tissue and in the muscles, least so in tendons and fasciee ; the cutis stands in the middle in this respect. The circumstances are the most unfavorable for the bones ; conse- quently the separation of the dead from the living takes place most slowly. Of this more hereafter. Rich supply of nerves seems to have little effect in this process. But there are many other influences that hinder the detachment of the dead parts, or, what is the same thing, that retard the forma- tion of granulations and pus ; such as continued action of cold on the wound, as might be effected by applications of bladders of ice. The cold keeps the vessels contracted. The cell-movements, the escape of cells from the vessels, go on very slowly under the influence of low temperature. Treatment by continued warmth, as by the application of cataplasms, has the opposite effect ; by this means we increase the fluxion to the capillaries and cause them to dilate, as you may readily see from the redness you induce on the healthy skin by application of a hot cataplasm ; it is known that the high temperature also hastens the cell-activity. 160 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. It is entirely impossible to tell beforehand the influence of the general state of the patient on this local process. It is true we may say in general terms that it is energetic in the strong, stout, and young, more moderate and sluggish in weak persons; but on this point we are often deceived. From what has already been said you may suppose that contused wounds need much longer to heal than more simple incised ones. It will also be evident that there may be circumstances under which amputation of the limb will be necessary, all the soft parts being en- tirely mashed and torn. There are cases where the soft parts are so torn from the bone that this alone remains ; so that on the one hand cicatrization cannot occur, and on the other, if the extremity did heal in months or years, it would be perfectly useless, and hence it would be better to remove it at once. Still, even the simple complete detach- ment of the skin from the greater part of an extremity may some- times, though rarely, render amputation necessary, as in the case of a girl who lost the skin from the wrist to the ends of her fingers be- tween the rollers of a spinning machine. Fortunately such cases are not frequent; in similar injuries of sin- gle fingers we mostly leave the detachment to nature, so that no more is lost than is absolutely incapable of living ; for we should always remember in maiming of the hand that every line, more or less, is of importance, that especially single fingers, and particularly the thumb, should be preserved whenever possible, for such fingers, if only slightly capable of performing their functions, are more useful than the best- made artificial hand ; for the foot and lower extremity there are other considerations, of which we shall hereafter speak when we come to complicated fractures of bones. "Would that this maiming and slow healing, bad as they are, were the only cares we had with our patients having contused wounds ! Unfortunately there is a whole series of local and general complica- tions which directly or indirectly endanger life. We shall first speak of the chief local complications ; for the more general, the " accidental diseases in wounds," we reserve a future chapter. Considerable danger may arise from the decomposing tissue on the wound infecting the healthy parts. Putrid matters act as fer- ments on other organic combinations, especially on fluids containing them; they induce progressive decomposition. We might wonder that such extensive decomposition of the part which is injured, if not killed, should not occur more frequently than it actually does. But in most cases cell-action occurs so quickly on the border of the living tissue that a sort of living wall is formed ; this new formation does not read- ily permit the passage of putrid matter, and the granulation surface, HEALING OF CONTUSED WOUNDS. 161 if once formed, is particularly resistant to such influences. In many places it is a popular remedy to cover ulcers with cow-dung and other dirtj' things; this never causes extensive putrefactions on granulating wounds. But if you apply such substances to fresh wounds, and bind them firmly on so that the tissue may be mechanically impregnated with putrid matter, they will usually become gangrenous to a certain depth, and then an energetic cell-formation opposes the putrefaction. The reason why decomposing matters act so injuriously on fresh wounds, and so slightly on granulating ones, I consider to be, that they are chiefly absorbed by the lymphatic vessels. If you inject a drachm of putrid fluid into the subcutaneous cellular tissue of a dog, the result will be inflammation, fever, and septicaemia. If you make a large granulating surface on a dog, and dress it daily with charpie soaked in putrid fluid, it will have no decided effect. Certain dis- solved putrid matters may pass through the walls of the veins and capillaries ; but surgical experience teaches that lymphangitis ac- companies poisoned wounds much oftener than phlebitis does. The more the tissue is saturated with fluid, the more it is disposed to decomposition. Hence, the cases where great cedematous swell- ing occurs after contusions are the most dangerous in this respect ; but this oedema comes on very readily as the venous circulation is obstructed, from extensive rupture and crushing of the vessels, which indeed often extend far beyond the borders of the wound. Imagine a forearm caught under a stone weighing several hun- dred-weight ; there will probably be only a small skin-wound, but extensive crushing of the muscles, tendons, and fasciae of the forearm, and mashing and rupture of most of the veins ; great cedematous swelling will speedily result, as the blood from the arteries is driven with greater energy into the capillaries, and cannot escape by its cus- tomary passage through the veins, and hence, under the increased pressure, the serum escapes through the capillary walls into the tissue in greater amount. What a tumult in the circulation and in the whole nutrition ! It must soon appear where the blood can still cir- culate, and where not. In the wound, at first, under the influence of the air, decomposition of the parts incapable of living begins ; this advances to the stagnating fluids, and, in unfortunate cases, it con- stantly progresses ; the whole extremity swells terribly as far as the shoulder ; the skin becomes bright red, tense, painful, covered with vesicles, from the escape of serum from the cutaneous capillaries under the epidermis. These symptoms usually appear with alarming rapidity the third day after the injury. As a result of this disturb- ance of circulation, the whole extremity may become gangrenous ; in other cases, only the fasciae, tendons, and some shreds of skin die. 11 162 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. There is cell-infiltration of all the connective tissue of the extremity (of the subcutaneous cellular tissue, the perimysium, neurilemma, sheaths of the vessels, periosteum, etc.), which leads to suppuration. Toward the sixth or eighth day the whole extremity may be entirely saturated with pus and putrid fluid. Theoretically, we might imagine such cases curable ; that is, we might imagine that, by making suit- able openings in the skin, the pus and dead tissue might be evacu- ated. But this rarely occurs in practice. If the case has undergone the above distention, generally only quick amputation can save the patient, and even this is not always successful. "VVe may term this variety of infiltration sanio-serous. There is a cellular-tissue inflam- mation, caused by local septic infection ; a septic phlegmon, whose products again have great tendency to decomposition, but which finally leads to extensive suppuration and necrosis of tissue if the patient lives through the blood-infection which always accompanies it. The earlier such processes limit themselves, the better the prognosis ; with the advance of the local symptoms the danger of death of the patient increases. With the detachment of dead portions of tissue, we must again return to the arteries. An artery may be contused, so as not to be fully divided, and the blood continues to flow through it although part of its wall is incapable of living, and becomes detached on the sixth to the ninth day, or even later. As soon as this occurs, there will be a haemorrhage in proportion to the size of the artery. These late secondary haemorrhages, which usually come on suddenly, are exceed- ingly dangerous, as they attack the patient unexpectedly, sometimes while sleeping, and frequently remain unnoticed until much blood has escaped. Besides the above manner, late arterial secondary haemor- rhage may also result from suppuration of the thrombus, or of the wall of the artery. I observed a case of this kind late in the third week after a severe operation in the immediate vicinity of the femoral artery, in which, however, the artery was not wounded. The bleeding began at night ; as the wound looked perfectly well, and the patient had for some time slept the whole night, and for some days had been promised permission to get up the next day, there was no nurse in his private room. He woke in the middle of the night (the twenty-second day after the operation), found himself swimming in blood, and rung at once for the nurse. She instantly called the assist- ant physician of the ward, who found the patient unconscious. He at once compressed the artery in the wound, and, while I was being called, every thing was done to restore the patient. I found him pulseless, unconscious, but breathing, and the heart still beating. SECONDARY HEMORRHAGE. 163 While I made ready to ligate the femoral artery, the patient died he had bled to death. A very sad case ! A man otherwise healthy, strong, in the bloom of life, near recovery, must end his life in this miserable way ! Rarely has a case so depressed me. Still there was no blame anywhere, as it happened all the circumstances had been very favorable. The nurse was awake in the next room, the physician was only down one flight of stairs in the same house, and was with the patient in three or four minutes ; but the bleeding must have existed before he woke. He was probably awakened by the feeling of wet- ness in the bed. On autopsy, a small spot of the femoral artery was found suppurated and perforated. Fortunately, it is not always a femoral that bleeds, nor does the bleeding always come so precipi- tately, or at night ; hence, we should not become dissatisfied with our art from such a rare case. Usually such arterial haemorrhages from suppurating wounds are at first insignificant, and soon cease under styptics or compression ; but after a few days the bleeding comes on more actively, and is more difficult to arrest ; finally, the haemorrhages recur more and more quickly, and the patient constantly becomes worse. In all severe arterial haemorrhage instantaneous compression is the first remedy. Every nurse should understand compressing the -arterial trunks of the extremities ; but they soon lose their presence of mind, as in the above case, and, in their first terror, run themselves for the surgeon, instead of compressing the vessel and sending some one else. Compression is only a palliative remedy. The bleeding may cease after it ; but, if it be considerable, and you are sure of its origin, I strongly advise you at once to ligate the artery at the point of election, for this is the only certain remedy. You should do this the sooner if the patient be already exhausted ; remember that a sec- ond or third such bleeding will surely cause death. Hence, in the operative course, you should particularly practise ligating the arteries, so that you may find them so certainly that you could operate when half asleep. In these particular cases much time is unnecessarily lost in applying styptics, which usually act only palliatively, or not at all. Ligation of arteries is only a trifle for one who knows anatomy thor- oughly, and has employed his time well in the operative courses. Anatomy, gentlemen ! Anatomy, and again anatomy ! A human ife often hangs on the certainty of your knowledge in this branch. While treating of secondary haemorrhages, we shall speak of parenchymatous haemorrhages. The blood rises from the granula- tions as from a sponge ; we nowhere see a bleeding, spirting vessel. The whole surface bleeds, especially at every change of the dressing. This may be due to various causes : great friability or destructibility of the granulations, that is, their defective organization, may be the fault, 164 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. and this malorganization of the granulations again may depend on con- stitutional diseases (haemorrhagic diathesis, scorbutis, septic or pyaemic infection). Still, local causes about the wound are imaginable, as, if extensive coagulation gradually formed in the surrounding veins, the circulation in the vessels of the granulations would be so affected ; the pressure of blood would so increase that not only the serum might escape from them, but they would rupture. It is true I have hitherto had no opportunity of confirming this by autopsy, but I have seen very few of these parenchymatous haemorrhages. The latter explanation sounds very plausible ; so far as I know, it originates with Strorneyer. He calls such haemorrhages " haemostatic." According to the causes, it may be more or less difficult to arrest such haemorrhages ; in most cases ice, compression, and styptics, will be proper, or, in severe cases, ligation of the arterial trunk, although this occasionally fails. This form of haemorrhage occurs chiefly in very debilitated persons, who have been exhausted by suppuration and fever, and hence has a bad significance for the general state of the patient. LECTURE XIII. Progressive Suppuration starting from Contused Wounds. — Secondary Inflammations of the Wound : their Causes ; Local Infection. — Febrile Reaction in Contused Wounds : Secondary Fever ; Suppurative Fever ; Chill ; their Causes. — Treatment of Contused Wounds : Immersion, Ice-bladders, Irrigation ; Criticism of these Methods. — Incisions. — Counter-openings. — Drainage. — Cataplasms. — Open Treat- ment of Wounds ; Lister's Dressing. — Prophylaxis against Secondary Inflamma- tions. — Internal Treatment of those severely Wounded : Quinine ; Opium. — Lacerated Wounds : Subcutaneous Eupture of Muscles and Tendons; Tearing out of Muscles and Tendons ; Tearing out of Pieces of a Limb. The granulating surface that develops on a contused wound is generally very irregular, and often has numerous angles and pockets ; there is suppuration not only of the surface of the wound, but of the surrounding contused parts under the uninjured skin ; hence the neighboring skin often appears undermined by pus. The inflamma- tion and suppuration often unexpectedly extend between the muscles, along the bones, and in the sheaths of the tendons, because these parts were also affected by the injury. The process of inflammation, once excited, creeps along, especially in the sheaths of the tendons and in the cellular tissue ; new collections of pus form, superficially or in the depths ; the injured part remains swollen and oedematous ; on the surface the granulations are smeary, yellow, swollen, and spongy. When we press in the vicinity of the wound, the pus flows INFLAMMATION OF CONTUSED WOUNDS. 165 slowly from smaller or larger openings, which have formed sponta- neously, and this pus which has remained for a time in the depth is not infrequently thin and bad smelling. Should the process con- tinue long, the patient becomes more miserable and weak ; he has high and continued fever. A wound, which perhaps at first appeared insignificant, perhaps about the hand, has extended horribly, and in- duced severe general disturbance. The sheaths of the tendons about the hands and feet are particularly favorable for the extension of deep suppurations, which readily attack the joints, while, on the other hand, articular inflammations of the extremities readily attack the sheaths of the tendons. These states may take a very dangerous turn, and you should be constantly on your guard. From the constant pu- rulent infection, as well as from the daily loss of pus, even the strong- est man may emaciate in a few weeks, and die with symptoms of febrile marasmus. We now know two forms of inflammation which may attack con- tused wounds : 1. Rapid, progressive, septic inflammation, which begins about the wound during the first three or four days (rarely in less than twenty-four hours, and just as rarely after the fourth day), and which is caused by local infection from parts that decompose in the wound. 2. Progressive purulent inflammation, which is particu- larly apt to occur in wounds of the hands or feet during the cleansing of the wound from necrosed shreds of tissue, without the pus becom- ing ichorous, although butyric acid often formed in it. But, even when the wound has entirely cleaned off and granu- lated, when the inflammation is bounded, and the wound begins to cicatrize, new inflammation, with severe results, may begin. These secondary progressive inflammations of suppurating wounds, occur- ring even several weeks after the injury, and sometimes coming as unexpectedly as lightning from a clear sky, are of great importance, and are sometimes very dangerous. They are almost always of sup- purative nature, and may be fatal from intense, phlogistic, constitu- tional infection, just as often as the primary progressive suppurations. In some cases, also, they prove dangerous from their location, as in wounds of the head. These cases are so striking and tragical that we must give them special consideration. Suppose you have brought a case of severe crushing of the leg, with fracture, successfully through the first dangers. The patient has no fever; the wound granulates beautifully, and has even begun to cicatrize. Suddenly, in the fourth week, the wound begins to swell ; the granulations are croupous or spongy, the pus thin; the whole limb swells. The pa- tient again has high fever, perhaps repeated chills. The symptoms may pass off, and every thing go on in the old track ; but it often 166 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. turns out badly. In a few days the strongest man may become a corpse. Some time since such a case occurred in Zurich, in a fellow- student with a wound of the head ; it may serve you as a warning example. The young man received a blow over the left vertex ; the bone was injured very superficially ; the wound healed quickly by first intention ; only a small spot continued to suppurate. As the patient felt quite well, he paid no attention to the little wound, and went about as if perfectly well. Suddenly, in the fourth week, after a walk, he had severe headache and fever. The following day there was about a teaspoonful of pus collected under the cicatrix, which was evacuated by an incision. This did not have the desired beneficial effect on the general condition ; the fever remained the same. In the evening delirium began, then sopor. The fourth day the previously vigorous man was dead. It was easy to diagnose that there had been suppurative meningitis. This was proved on autopsy. Although at the spot, as big as a pea, where slight suppuration had been so long kept up, the bone was but slightly discolored by purulent infiltration, still the suppuration on, in, and under the dura mater was greatest at the part exactly corresponding to this point ; so that the new inflam- mation undoubtedly started from the wound. A short time since, here in Vienna, in private practice, I saw a perfectly similar case, also fatal, in a man who several weeks previously had received an appar- ently insignificant wound, from a piece of a soda-water bottle that burst, at the upper part of the forehead, along the margin of the hairy scalp. The inflammations occurring under such circumstances, as already remarked, are usually of a diffusely purulent character, but other forms accompany it, or occur spontaneously, such as diphtheritic in- flammation of the granulations {traumatic diphtheria, hospital gan- grene), inflammation of the lymphatic trunks {lymphangitis), and a specific form of capillary lymphangitis of the skin, erysipelas or ery- sipelatous inflammation ; and, lastly, inflammation of the veins {phle- bitis). Not infrequently all of these processes may be seen mixed together. We shall hereafter study these diseases more accurately, under accidental traumatic diseases. But here we must consider the causes of these secondary inflammations, before passing to the treat- ment of contused wounds ; and, in so doing, we must anticipate somewhat. All of these forms of inflammation, and their reflex action on the organism, are so intertwined, that it is impossible to speak of one without mentioning the other. As causes of secondary inflammations in and around suppurating wounds that have begun to heal, we may mention the following : 1. Excessive flow of blood to the wound, such as may be induced by too INFLAMMATION OF CONTUSED WOUNDS. 167 much motion of the part, or by great bodily exertion, as well as by exciting drinks, mental agitation, in short, by any great excitement ; in wounds of the head, such congestions are particularly dangerous. Congestion, as caused by too tight bandages, may prove injurious in the same way. 2. Local or general catching cold ; about catching cold as a cause of inflammation we know little more than the simple fact that, under certain circumstances, which cannot be accurately defined, a sudden change of temperature induces inflammations, especially in a locus minoris resistentice of an individual ; in a wounded person the wound is always to be considered as a locus minoris resistentice. The danger of catching cold after injury was certainly over-estimated formerly ; I hardly know of any certain examples. 3. Mechanical irritation of the wound. This is very important. The pus from the wound is never reabsorbed by the uninjured granulations ; but, if they be destroyed by mechanical manipulations, as by improper dressings, much probing, etc., which cause the wound to bleed frequently, new inflammations may be induced. Any foreign bodies in the wound might prove serious in this way, such as pieces of glass, lead, or iron, or sharp splinters of bone ; for the first changes which take place in the wound, the vicinity of such foreign bodies is less important, but, when, from muscular movements, and the motion communicated to the tissue from the arteries, the sharp angles of a foreign body keep up constant friction in a part, severe inflammation occurs after a time. 4. Chemical ferments ; here I mention first soft foreign bodies, such as pieces of clothing, paper wads, which have entered the tissue through gunshot wounds ; these substances become impregnated with the secretions from the wound, then the organic material (paper, wool) decomposes, and acts as a caustic and ferment in the wound. I am in- clined to believe that necrosed splinters of bone also act rather as chem- ical than as mechanical irritants ; in the Haversian canals, or medullary cavity, they always contain some organic decomposing substance ; all such pieces of bone have a putrid smell when extracted ; if the sur- rounding granulations were partly destroyed by the sharp angles of such a fragment of bone, the putrid matter passes from it into the open lymphatic vessels, or possibly even into the blood-vessels, and so induces, not only local, but, at the same time, constitutional infec- tion. Necrosed tags of tendon and fascia at the bottom of suppu- rating wounds may induce the same results, although this rarely hap- pens. In hospitals, especially, there are some rare cases where we can find none of the above causes ; such occurrences naturally induce pe- culiar alarm, and attempts have been made to explain them by certain injurious influences of the hospital atmosphere, especially such as is filled with the smell of pus. Many circumstances speak against the 168 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. view that the injurious substances are gaseous ; by good ventilation the air of the hospital may be kept pure, but this is no protection against the affection in question ; moreover, we cannot excite inflam- mations by any of tne gases developing from pus or putrefying sub- stances, unless, perhaps, by sulphuretted hydrogen, when dissolved in water and injected into the subcutaneous cellular tissue. Putrid fluids and pus from other patients would not intentionally be brought in contact with wounds ; we have previously shown that the vicinity of the wound may, under some circumstances, be infected by pus from the wound, and excited to new inflammation. Hence there is little left but the supposition that the injuriously-acting substances are of a molecular, dust-like nature ; they may float about in the air of the hospital, but they may also adhere to the bandages, charpie, com- presses, etc., with which we dress the wounds, or to the instruments, forceps, probes, sponges, etc., with which we touch the wound. May they not be fungi, or other organic germs, whose nature we do not at present know, like those we know to excite fermentation ? This is possible, for in every cubic foot the air holds quantities of such germs, and in the hospital such organic germs of animal or vegetable nature might develop in the secretions from wounds, in the sputum or excrement, and the more so in proportion as the readily-decomposing secretions and excretions are collected in hospitals, or in badly- built water-closets and sewers. On this point we can only haz- ard conjectures, while we may make experiments with dry putrid sub- stances and dry pus, by powdering them, and then introducing them into the healthy tissue of animals. Such experiments have been made by 0. Weber and myself, and they have shown that both animal and vegetable putrid, dry substances, as well as dry pus, induce inflam- mation ; if we pulverize these substances, stir them up quickly with water, then inject them into the subcutaneous cellular tissue of ani- mals, they will excite progressive inflammation, just as putrid fluids and fresh pus do. Now, it must at once be acknowledged that in a hospital such injurious dust-like bodies may readily cling to dressings and bedclothes ; possibly, also, to instruments. In short, it is possible that the direct injurious influence of hospital air on a wound may be due to fine dust-like particles of putrid or purulent matter coming in contact with it from the dressings or instruments. There can be no doubt that such injurious materials may enter the body in other ways besides through wounds, as through the lungs ; indeed, we explain the occurrence of all so-called infectious diseases by the entrance in the or- ganism of substances which have a sort of fermenting influence on the blood ; but, whether the morbid materials which excite the infectious diseases chiefly occurring in the wounded be different from those arising INFLAMMATION OF CONTUSED WOUNDS. 169 from the wound itself, may be a disputed point, so far as we at present know. We shall return to this point when speaking of accidental traumatic diseases. You will suspect me of contradicting myself here, because in yesterday's lecture I said that no molecular body could en- ter the tissues through an uninjured granulation-surface. I must still claim this as usual ; a strong, uninjured granulation-surface is a de- cided protection against infection through the wound. But, when the infecting material itself is very irritating, so that it destroys the granulating surface by causing decomposition, a passage-way is opened for the poison to enter the tissues. Still more, there are certain sub- stances which are carried into the granulation-tissue, and perhaps even further, by the pus-cells. If you sprinkle a granulating surface on a dog with finely-powdered carmine, some cells take up the small carmine granules and wander with it into the granulation-substance ; after a time you find cells with carmine in the granulation-tissue. I consider this an abnormal retrograde movement of the pus-cells, which we generally believe to pass from the granulation-tissue to the surface of the wound ; it is true, no one has seen this. Nevertheless, from the above experiment, it is evident that even molecular substances may pass from without into the tissue of the edges of the wound, and, if these substances be very decomposable or cauterant, they will excite active inflammation. But all of the millions of molecular organisms in the atmosphere are not taken up by the wound, nor do they each induce inflammation. My belief is that all micrococci do not neces- sarily have a phlogogenous action, but only those which are formed in certain products of inflammation, such as decomposing pus or fluids of the body, putrid urine, etc., and which have there ab- sorbed the ferment. This is the most frequent cause of micrococ- cus in hospital ; hence its development there is to be combated with particular energy. I do not believe that these substances, whether lifeless or living molecules, are always the same, but I think they are very numerous, as are the causes of inflammation generally ; they may all have certain chemical peculiarities in common, as we might suppose from their similar action, although we know nothing about them, except this action ; they also differ somewhat in their mode of action on this or that tissue ; the absorbability of such sub- stances may vary with the part of the body, and possibly, also, with the individual ; but the large number of these injurious substances is, in fact, small as compared with the innumerable variety of organic substances generally. Febrile reaction is usually greater from contused than from incised wounds; according to our view, this is because, from the decomposi- tion, which is much more extensive in crushed than in incised parts, 1T0 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. far more putrid matter enters the blood. If in any case the putrid matter is particularly intense, or very much of it is taken up (es- pecially in diffuse septic inflammations), the fever assumes the charac- ter of so-called putrid fever / the state thus induced is called septi- cemia ; we shall hereafter study it more closely. If the suppurative inflammation extends from the wound, there is a corresponding con- tinued inflammatory or suppurative fever ; this has the character of remittent fever with very steep curves and occasional exacerbations, mostly due to progress of the inflammation, or to circumstances that favor the reabsorption of pus. If we call the fever, that often, but not always, accompanies traumatic inflammation, simple traumatic fever, we may term the fever that occurs later " secondary fever " or " suppurative fever." This may immediately succeed the traumatic fever, if the traumatic inflammation progresses regularly; but the traumatic fever may have ceased entirely, and the wound be already healing, and when new secondary inflammations, of which we have fully treated, attack the wound, they are accompanied by new suppu- rative fever ; in short, inflammation and fever go parallel. Occasion- ally, indeed, the fever appears to precede the secondary inflammation, but this is probably because the first changes in the wound, which may be only slight, have escaped our observation. At all events, on every accession of fever that we detect, we should at once seek for the new point of inflammation, which may be the cause. I am far from asserting that it is necessary to measure the temperature in all cases of wounds ; undoubtedly any experienced surgeon, accustomed to examine patients, would know the condition of his patient without measuring the temperature, just as an experienced practitioner may diagnose pneumonia without auscultation and percussion ; but no one who understands the significance of bodily temperature doubts that its measurement may sometimes be a very important aid to diagnosis and prognosis. It is with it as with every other aid to observation ; it is not difficult to detect a dull percussion-sound in the thorax where it should not exist ; but the art and science of determining the sig- nificance of this dull percussion-sound in any given case must be learned ; so, too, with measurement of temperature : for instance, we must learn whether a low temperature in any given case be of good or bad omen. I shall enter into more detail on this subject in the clinic. Experience teaches that secondary fever is often more intense than primary traumatic fever. While it is most rare for the latter to begin with a chill (a slight chilliness after great loss of blood and severe concussion is not usually accompanied by high temperature), it is not at all so for a secondary fever to commence with severe " chill." INFLAMMATION OF CONTUSED WOUNDS. 171 We shall at once study this peculiar phenomenon more attentively. Formerly the chill was always regarded as essentially dependent on blood-poisoning ; if we now regard fever generally as due to intoxi- cation, we must seek some special cause for the chill. Observation shows that the chill, which is always followed by fever and sweating, is always accompanied by rapid elevation of temperature. If we ther- mometrically examine the temperature of the blood of a patient with chill, we find it high and rapidly increasing, while the skin feels cool ; the blood is driven from the cutaneous vessels to the internal organs. As already remarked, Traiibe considers this as the cause of the ab- normal febrile elevation of temperature. We shall not discuss this at present ; at all events, there is so great a difference between the air and the bodily temperature that the patient feels chilled. If we un- cover a patient with fever, who lies wrapped up in bed and does not feel chilly, he at once begins to shiver. Man has a sort of conscious feeling for the state of equilibrium in which his bodily temperature stands to the surrounding air ; if the latter be rapidly warmed, he at once feels warmer, if it be rapidly cooled, he at once feels cool, chilly. This trivial fact leads us to another observation. This sensitiveness for warmth and cold, this conscious feeling of change of temperature, varies with the individual ; it may also be increased or blunted by the mode of life ; some persons are always warm, others ever too cold, while for others the temperature of the air is comparatively a matter of indifference. The nervous system has much to do with this. Ac- curate studies of Traube and Jbchmann have in fact shown that the nervous excitability of an individual has a great effect as to whether, in a rapid elevation of temperature of the blood, the change will be much perceived or not ; hence that in torpid persons, in comatose condi- tions, chills do not so readily occur with fever, as they do in irritable persons already debilitated by long illness. I can only confirm this from my own observation. Although I have a general idea that, where there is sufficient irritability, rapid elevation of temperature and chill chiefly occur when a quantity of pyrogenous material enters the blood at once, still I cannot deny that the quality of the material is also important. We know nothing of this quality chemically, but we may conclude that it has varieties, because both the fever-symp- toms and their duration often vary greatly, and that this does not solely depend on the peculiarities of the patient. According to my observations, in man reabsorption of pus and recent products of in- flammation is more apt to induce chills than is absorption of putrid matter, which is perhaps more poisonous and dangerous. I do not wish to weary you with too many of these considerations, and so shall return to the subject in the section on general accidental trau- 172 CONTUSED AND LACERATED WOUXDS OF THE SOFT PARTS. matic and inflammatory diseases, which you may regard as a contim> ation of this study of fever. I will only remark here that both the septic and purulent primary and secondary inflammations, with their accompanying fever, may also occur from incised wounds, especially after extensive operations (as amputations and resections). We have considered this condition along with contused wounds, because it complicates them much more frequently than it does ordinary incised wounds. Now we pass to the treatment of contused wounds. In many cases contused wounds require no more treatment than incised wounds ; the conditions for healing exist in both. Hence, in a contused wound it is only necessary to anticipate any accidents, or at all events to master them so that they may not become dangerous. In both respects we may do something. Formerly it was always sup- posed that the air with its oxygen and its ferments particularly favored the decomposition of dead, organic bodies, hence of contused parts ; to prevent this, the wound was excluded from the air, and, to prevent warmth acting as an aid to decomposition, the wounded part' was kept cool. We attain both objects by placing the injured part in a vessel of cold water, whose temperature is always kept cool by ice. This treatment is called " immersion " or " continued cold-water bath." I first saw this used with excellent effect by my earliest teacher in surgery, Prof. JBaurn, in Gottingen. This mode of treatment is only really practical in the extremities ; in the leg as high as the knee, and in the arm to a little above the elbow. We place suitably-constructed arm and foot vessels filled with cold water in the patient's bed, and have the wounded extremity kept in it day and night. The patient's position should be such that he lies easily, and that the extremities may never press too hard on the edge of the vessel. This is all very simple ; you will often see this apparatus in my clinic. In the most common injuries of the hand, a basin with cold water is sufficient in private practice. In parts which cannot be kept in water in this sim- ple way, we try to exclude the air by applying moist linen compresses, which readily adapt themselves to the injured part ; over these we apply a rubber bag (or a bladder) filled with ice, which is to be re- placed as it melts. It is still more efficacious to wrap up a limb well and pack it in a vessel with ice. A third method of applying cold water is the so-called irrigation. For this we require special appara- tuses. The injured extremity is laid in a tin trough, supplied with an escape-tube. Above the extremity we place an apparatus from which a continued stream of cold water drops from a moderate height on the wound. Lastly, we may simply cover the wound from time tc time with compresses dipped in ice-water. TREATMENT OF CONTUSED WOUNDS. 173 I have seen all these modes of treatment in practice. Here is mj opinion of them : none of them act certainly as prophylactics. In contused wounds of the hands and feet the water-bath is best ; for, under this treatment, extensive suppuration is rarest. To attain the same favorable results by the ice-treatment, we must cover not only the wound but the parts around with the ice-bladders ; pack the parts in ice. In applying cold-compresses, we shall only really obtain the effect of cold if we change the compresses every five minutes, for they warm very quickly, and the usual treatment with cold-compresses actually amounts to nothing more than keeping the parts moist; hence, this is, strictly speaking, no peculiar mode of treatment ; never- theless, as I have already remarked, most small contused wounds heal under it spontaneously, without our placing them under unnatural conditions by the use of cold. Irrigation is not a bad plan of treat- ment, but it is troublesome, and it is often difficult to avoid wetting the bed ; the condition of the wound subsequently does not differ from that in the more simple treatment by immersion or ice, so that I have not felt obliged to resort to irrigation. In France, this method is practised and highly esteemed by some surgeons. Apart from the prevention of accidents, for which all remedies are as useless here as venesection is in pneumonia, we have still in the above modes of treatment important means for combating the usual local accidents, I have still a few special remarks to make about the water-bath. As we here leave out of consideration injuries of the bones and joints, I know of no contraindication to it. in contused wounds of the hand, forearm, foot, and leg. In most cases of these injuries the bleeding is so slight, and ceases so soon spontaneously, that the patient can place the extremity under water very soon if not immediately after the injury, without the occurrence of haemorrhage ; but the blood clinging to the part should first be washed off, the water itself be perfectly pure and transparent, and, if it becomes clouded by the secretion of the wound, it should be kept clear by frequent re- newals. Even when the wound is two or three days old, the water- bath may still be employed with advantage ; later, it is of little use. If the patients lie comfortably in bed with the tub, they are more contented and free from pain under this treatment than under any other. The temperature of the water may vary greatly without much changing the condition of the wound ; only ice temperature, and the high temperature obtained by cataplasms, cause a somewhat different appearance ; but from 54° to 90° or 100° F. it does not vary much in looks. Perhaps suppuration comes on a little sooner at the higher temperature, but the difference is not great. Hence, we may adapt 174 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. the temperature of the water to the feelings of the patient. At first the patients generally prefer a lower temperature (54°-68° F.), later a rather higher one (88°-95° F.) ; but there are also patients who, even during the first day, complain of chills if the temperature of the water falls below 68° F. Hence we see that it is rather indifferent whether we employ warm or cold water baths. In some persons, on the third or fourth day, there arises a state which renders immersion unbearable, that is, swelling of the epidermis of the hands or feet, and the accompanying tense, burning sensations, which somewhat re- semble the action of a blister. The thicker the epidermis, the more disagreeable this accident. It may be avoided by rubbing the injured extremity with oil, before placing it in the water, and adding a hand- ful of salt to the water ; this does no harm to the wound. An im- portant question is, How long shall continued immersion be employed ? Rules for this can only be given after considerable experience. I have found from eight to twelve days enough. After this we may leave the limb out of the water at night, enveloping it in a moist cloth cov- ered with oiled silk ; a few days later we may employ this dressing during the day also, and use the water-bath only morning and even- ing, or mornings alone, leaving the limb in it half an hour or an hour to bathe and cleanse it. Finally, we leave off the water entirely, and treat the granulating, cicatrizing w r ound after the simple rules already giveD. The changes in wounds under this treatment are somewhat different from those previously described. In the first place, all goes on much slower ; sometimes, especially in the treatment with the cold-water bath, the contused wound looks as fresh for four or five days as when first received. The same thing is noticed for some time under the treatment with bladders of ice. This is not so astonishing as it at first seems, for, as is well known, decomposition of organic substances goes on more slowly in water than in the air. Subse- quently the pus usually remains on the wound as a flocculent, half- coagulated layer, and must be washed or syringed off to obtain a view of the subjacent granulations, which are infiltrated with w T ater, and often quite pale. This observation is very important, and protects us from illusions in regard to the efficacy of the water-bath in deep sup- purations ; we might suppose that the pus flowed from the wound directly into the water and was there diffused, so that it would simply be necessary to place the suppurating part in water to have it always clean. The icater-bath does not favor the escape of pus / it rather prevents it. Pus on the granulations, or in cavities, coagulates at once on contact with water, and usually remains on the wound ; wash- ing or syringing is necessary for its removal. Swelling of the granu- lations entirely prevents the escape of pus from deep parts. Hence TREATMENT OF CONTUSED WOUNDS. 1Y5 we see, where there is suppuration from a cavity, that the water-bath is of no use, but is even injurious, and that an extremity should at once be removed from the water as soon as deep progressive inflam- mations extend out from the wound. By this we do not mean to ex- clude a half-hour's bath of the part. Should there be no progressive inflammations, there would be no particular harm from leaving the wound in the water for two, three, or four weeks, only the healing would be much retarded. In the water the parts remain greatly swollen ; the granulations are full of water (artificially cedematous), pale, and cicatrization and contraction of the wound will not occur. If you then remove the extremity from the water, the wound soon contracts ; in a few days the granulations look stronger, and the pus better ; healing progresses. Now I must say something about the continued treatment by ice. Suppose you cover the contused wound from the first with a bladder of ice ? Here, also, you will find that the crushed parts are very slowly detached, and that no smell arises from the wound, unless large masses of tissue become gangrenous ; to prevent the latter, if possi- ble, I apply charpie, or a thin compress wet with chlorine-water, next to the wound, and have it frequently renewed. If we now continue the treatment four to six weeks, all the necessary changes in the wound will go on very slowly and sluggishly ; the cicatrization and contraction of the wound are also very slow under the influence of the ice, and hence this method is entirely out of place if we desire to hasten the process of healing. Most surgeons believe that we may prevent severe inflammations by applying bladders of ice to the re- cent wounds ; hence you will find ice applied at once to most cases of contused wounds. Occasionally this proves very grateful to the patient, by relieving his pain,, but it does not seem to me a prophy- lactic antiphlogistic ; for centuries, men have sought such a prophy- lactic, just as they have for one for inflammations of internal organs. By the application of ice to recent wounds, we can neither prevent sanio-serous infiltration, nor suppurative inflammations, at least, this is my opinion. As already stated, many believe in the prophylactic action of ice, and are convinced that by this means only they can save persons badly injured. I have become satisfied that the dangerous complications to wounds often occur in spite of the ice, and are not unfrequently wanting when ice is not used, when from the nature of the wound they might be expected. From what has been said, you might almost suppose that I consider ice an inefficient remedy that may be dispensed with, still, you will see it much employed in my clinic ; in my opinion, cold is one of the best antiphlogistics, especially in inflammation of an external part where it can act directly. Hence, 1 76 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. ice is proper where there is inflammation, especially if accompanied by great fluxion, with a tendency to suppuration of the wound. If inflammation of the cellular tissue, the sheaths of tendons or muscles, or of a neighboring joint begin, you should apply ice to the inflamed part, and thus avoid the excessive hyperasmia, and so the increase ot the inflammation. You think I am here contradicting myself, when I say that ice is of no use in preventing the development of inflamma- tion about a wound, but it is of use in lessening the commencing inflam- mation and preventing its spread. But let me explain this by an ex- ample, and you will readily see the difference. When any one suffers from headache, he certainly would not think of being bled for every attack, to prevent inflammation of the brain ; but, if the latter be really developing, venesection may be a very efficacious remedy to arrest its further development and spread. By the aid of ice, we do not always succeed in arresting the suppuration extending from the wound, but occasionally the cedematous skin grows redder, becomes painful, and, when you press on it, a thin, serous, or sometimes quite consistent pus occasionally flows slowly from some of the angles of the wound. Under such circumstances, the retained pus, especially if bad smelling and ichorous, must be set free, and allowed to flow unobstructedly ; for this purpose, deep incisions should be made in the soft parts, and then kept open. ~When this should be done, and how it may best be done in individual cases, you will have to learn in the clinic. For probing such suppurating cavities, I prefer a slightly-curved silver catheter, which I pass through the wound to the end of the canal, then press the end up against the skin and here make the in- cision. For enlarging these so-called counter-openings, just as in other wounds, you use a tolerably long probe-pointed knife, straight or curved (JPotfs knife). As a rule, the counter-opening should not exceed an inch in length ; if necessary, we may make several of this length; in such cases there is usually no use in dividing the soft parts of the forearm or leg longitudinally, as was formerly taught. To prevent these new openings from closing again too soon, which, however, rarely happens, you may introduce several silk threads through the pus canals, tie the ends together, and leave them for a time. In place of these setons of silk or linen threads, caoutchouc tubes, with numerous lateral openings, have recently been used ; they have received the name of drainage-tubes, an expression taken from agricultural technology ; sometimes, at least, these tubes facilitate the escape of pus very well, but their principle is not new, nor can we accomplish such wonders with them as is claimed by Chassaignac, their inventor, who has written a book in two thick volumes about them. In making these counter-openings, you will not unfrequently strike on dead shreds of tendon or fascia, which should then be removed. TREATMENT OF CONTUSED WOUNDS. 177 The skilful use of the above remedies is an art of experience ; what you cannot accomplish with them in suppuration, you will not accomplish with any thing else. One of our colleagues of former days would shake his head doubt- fully, if he heard that we had talked so long about the treatment of contused wounds and secondary suppurations, without having men- tioned cataplasms. " Tempora mutantur I " Formerly cataplasms belonged to suppurating wounds as undoubtedly as the lid to the box, and now, three or four weeks may pass in my wards without cata- plasms being once employed for their original uses. The employ- ment of moist warmth, whether in the form of cataplasms or of thick cloths dipped in warm water, is useless in the treatment of contused wounds, and, in the treatment of secondary suppurations, it is occa- sionally injurious ; under them the wounds become permanently re- laxed, the soft parts swell, and healing is not advanced. Moreover, cataplasms only truly act as moist warmth when often renewed ; their renewal is tiresome, the poultice easily sours, or may be scorched, and finally, the whole mess cannot be carefully watched in a hospital ; a cataplasm covered with pus may be removed, new poultice added, and it may then be placed on another patient. In some hospitals at least half of the surgical patients wear poultices ; hundred-weights of grits and flaxseed, etc., for poultices, are used monthly in the surgical wards ; they are almost banished from my wards ; as occasion offers, I shall show you the cases where they may be used with advantage. Hence, little as I can recommend the use of moist warmth as the ordinary treatment of wounds, I consider it very suitable in those where there is an extensive hard (fibrinous diphtheritic) infil- tration of the cellular tissue. In these cases the moist warmth is not only pleasant to the patient, by rendering the tense skin soft and pliable, but it appears to aid removal of the hardened inflammatory products, either by their reabsorption or breaking down into pus. In such cases I apply warm moist cloths covered by some waterproof material. Hitherto I have not mentioned that the absolute rest of an injured part is always necessary ; it may seem singular that I should mention it at all ; you may think this should be considered a matter of course. I lay particular stress on it, because injurious substances are taken from the wound into the blood ; hence every muscular movement, and every consequent congestion of the wound, in short, everything that drives the blood and lymph more strongly into the vicinity of the wound, may eventually prove injurious. 12 178 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. Nor is an elevated position of the injured part to be neglected where it can be tried. You may readily prove on yourselves that gravity has something to do with the movement of the blood ; if you let your arm hang perfectly relaxed for five minutes, you will feel a heaviness in the hand, and the veins on the back of the hand will look swollen ; if, on the contrary, you elevate the hand for a time, it will become whiter and smaller. While debilitated persons are lying in bed, in the morn- ing, for instance, their faces look fuller than when they have borne the head erect for the day. Recently, Vblkmann has strongly recom- mended vertical suspension of the arm as a powerful antiphlogistic in inflammations of the hand; consequently, I have employed this method, and in cases of cutaneous inflammations have found it very efficacious ; it appears to do less good in deep inflammations, as of the wrist. Hereafter, the water-bath, ice-treatment, and cataplasms, will prob- ably give place to the open treatment of wounds, from which I have seen very good results in contused as well as in incised wounds (p. 95), I did not say this at the commencement of the section, because I do not consider my experience of this mode of treatment sufficiently ex- tensive for me to give a final judgment. The dreaded access of air to the surface of the wound, even the air of badly-ventilated hospitals, is not, in my opinion, so injurious as dressings and sponges of doubt- ful cleanliness ; the idea that air is injurious to suppurating wounds rests chiefly on the observation that the entrance of air to abscess cavities with rigid walls, and into serous sacs, usually induces sup- puration ; apart from the fact that, in many of these cases, it is not proved that it is indeed the entrance of air which excites the inflam mation, we must also attribute much of the blame to the fact that in the pus-sacs the air is warmed and impregnated with watery vapor from the pus ; this enclosed air now becomes a true hatching-place for those minute organisms which cause decomposition, and which are always more or less present in the atmosphere. Every observing housekeeper knows that meat or game hanging in the open air spoils far less readily than when shut up in a cupboard, even when the air in the latter is kept cool by ice. Free air does no harm to the wound, imprisoned air is very dangerous. I have already mentioned (p. 96), that a wound treated openly from the start has no bad smell, unless large shreds of tissue on it become gangrenous ; in accordance with this also, flies do not deposit their eggs in open wounds, while they are apt to creep into dressings to do so ; I must say these observa- tions surprised me very agreeably, because I feared that flies would render the open treatment of wounds impossible in summer. The longer I carefully try the open treatment of wounds, the more it sat- TREATMENT OF CONTUSED WOUNDS. 179 isfies me. No method guarantees a perfect immunity from acci- dental traumatic diseases, and even in the open treatment of wounds there may be superficial adhesions and formation of pockets in which decomposition of the secretion may occur. We must learn to antici- pate such things. Many surgeons now prefer the method of occlusion by thoroughly disinfected dressings and early application of drainage-tubes for car- rying off secretion, after Lister's method. It is asserted that by this means a milder course is secured, as in subcutaneous contusions ; that the shreds of dead tissue do not decompose, but dry up without smell and are thrown off with very little suppuration; that the blood-clots are either directly organized or escape from the wound as odorless gray crumbs ; that acute septicaemia and progressive sup- purations never occur ; and that the severe accidental traumatic dis- eases, of which we shall hereafter speak, are never developed. I recommend this method to you most warmly. In general I would advise you, as students and practitioners, to study and accurately learn one of the modes of treatment recom- mended to you, and not to be easily led off from your therapeutic principles. In your practice employ what you have well and thor- oughly learned. Believe me, your patients and yourselves will thus come out the best. In the treatment of secondary inflammation, most careful prophy- laxis is to be recommended ; avoidance of congestion of the wound, catching cold, all mechanical and chemical irritations, and especially infection. Hereafter, when speaking of accidental traumatic diseases in general, we shall state what may be done in the latter respect by ventilation and proper use of the room in the hospital. For avoiding local infection of the wound by dressings or instruments, we would give the following advice : Be exceedingly careful in the dressings, cleansing the wOund, choice of compresses, charpie, and wadding ; al- ways see to the most perfect cleanliness of the mattresses, straw beds, coverings, oiled muslin, parchment-paper, and in short of every thing about the patient. The bleeding of the wound on dressing should be avoided by carefully syringing it with EsmarcNs wound-douche, of which there should be two or three in every ward ; we should never apply dry compresses, charpie, or wadding to the wound, but should previously wet all these articles in solution of chloride of lime or other antiseptic, and later, when the wound begins to cicatrize, with lead- water ; and for removing the pus we should never use sponges, nor should we use them in operating, but do it all by syringing or by wiping off with wadding wet with water or chlorine-water ; if we cannot avoid the use of sponges, they should be new ones, and disinfect 180 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. them at once with hypermanganate of potash or carbolic acid. Or- ganic beings never develop in chlorine-water (aqua chlori, with equal parts of water), solution of chloride of lime (chloride of lime two drachms, water one pint), nor do they in lead-water, in solution of acetate of alumina (alum 20, acetate of lead 35, water 400), of permanganate of potash, or in sulphide of soda 50, glycerine 25, water 450 (Polli, Minnich). Lister has recommended carbolic acid as a peculiarly efficacious antiseptic ; it may be diluted with oil, glycerine, or water, or made into a paste with chalk, and then spread on tin-foil, to make an air-tight covering for the wound. "Deodor- izing powder" (coal-tar and plaster of Paris), sprinkled dry on putre- fying sores, is also good where the wound is not too deep. These different modes of application, under the name of " Lister's dress- ing," have been regularly tried, and it is a good thing for the pro- fession to study and become thoroughly acquainted with any method of treatment. Lister has accomplished one good, at least, in having directed attention to the antiseptic treatment, and given it a definite practical value. I consider carbolic acid as a very serviceable anti- septic, but have not found it to possess any special advantage over the remedies and modes of treatment above mentioned. You must pay special attention to the instruments with which you touch the wound, such as probes, forceps, knives, scissors; every thing should be wiped before being used, or, if it be at all suspicious, it should be quickly rubbed with cleaning powder. In order to carefully ob- serve all these precautions, you must be perfectly satisfied of their necessity. If, in spite of all our care, decomposition, gangrene, or phleg- monous inflammation has started in the contused wound or its vicin- ity, we must abandon the protective dressing directly applied to the wound ; the cavities of the wound and abscesses should be dilated and filled with wads of charpie or wadding dipped in a strong anti- septic solution. After numerous experiments I always return to acetate of lead and alumina ; it is a very active desiccant and deodor- ant, without disagreeable odor. It is true, the dirty dark -gray color, due to sulphuret of lead from the sulphuretted hydrogen in the sanies and the lead in the antiseptic solution, is disagreeable, but it is harmless. Till the mortified tissues have been entirely saturated with the solution of acetate of alumina and lead, the dressing must be frequently changed, or the solution may be poured over the dress- ing every two hours. When the wound begins to clean up, one dressing daily is enough ; on simple granulating wounds this solution is too drying, irritating, and painful; later we use protective dress- ings or salves. Next to acetate of alumina and lead, chloride of lime LACERATED WOUNDS. 181 solution is most active ; but as its effect is due to development of chlorine, it is very temporary, and dressings with this substance must be frequently renewed to deodorize or disinfect well. Gly- cerine is a good disinfectant, and acts excellently if poured freely on the dressing every two hours. If applied early, it withdraws so much water from the necrosed shreds of tissue that there is no smell ; but if decomposition has once begun, its deodorizing effect is very slow. After using it freely for three or four days, the wound often becomes so red and sensitive that we must refrain from further ap- plications. Solutions of chloride of zinc are also recommended for washing out purulent cavities ; I have rarely found its superficial cauterizing effect very obstinate. Strong solutions of carbolic acid in oil or water (five per cent, and over), when applied to large sur- faces, not unfrequently cause dangerous symptoms of poisoning, and are not so effectual for deodorizing, mummifying necrosed tissues, and limiting putrefaction, as acetate of alumina and lead. I have no personal experience of the antiseptic properties of salicylic acid (recommended by Kolbe and Thiersch), or of sulphite of soda (rec- ommended by Polli and MinnicK). If, however, secondary inflammations attack the wound, they should be treated as already advised; retained pus should be removed, foreign bodies extracted, etc., then the wound treated with ice, per- haps, till all is brought in order again, and the patient free from fever. In such cases shall we prescribe any thing for our patients besides cooling drinks and medicines, regulating their diet, etc. ? The febris remittens not unfrequently accompanying such suppurations renders the patient dull, peevish, and often sleepless. Two remedies are proper here — quinine and opium ; quinine as a tonic and febrifuge, opium as a narcotic, especially in the evening, to secure a night's rest. With such patients I usually pursue the following method : As long as they are little if at all feverish, I give nothing ; if they grow feverish toward evening, in the afternoon I give two doses of quinine (five grains each) in solution or powder, and in the evening before bedtime from the eighth to half a grain of muriate of morphia, or a grain of opium. As soon as the fever ceases, I stop these medi- cines ; you must especially avoid liberality with opium, when it is not required, for it is constipating. Now a few words about lacerated wounds. In general, these are less dangerous than contused wounds, because they are more exposed, and we have no need to fear that the injury is deeper than we can see ; we perceive how the skin, muscles, nerves, and vessels are torn ; 182 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. healing by first intention may be tried for and succeeds occasionally although suppuration generally occurs. But stay, ruptures are not always exposed; there are also subcutaneous ruptures of muscles, ten- dons, or even of bones, without there having been any contusion. A person wishes to leap a ditch, and makes a start, but fails in his at- tempt ; he falls, and feels a severe pain in one leg, and limps on it. On examination, just above the heel (the tuberositas calcanei), we find a depression in which the thumb may be laid ; the motions of the foot are imperfect, especially extension. What has happened ? The tendo Achillis has been torn from the calcaneus by the great muscular ac- tion. The same thing occurs with the tendon of the quadriceps femoris, which is attached to the patella, with the patella itself, which may be torn in two, with the ligamentum patellae, with the triceps brachii, which may be torn from the olecranon, and generally carries a piece of the latter along with it. Here you have a few examples of such subcutaneous ruptures of tendons ; I have seen subcutaneous rupture of the rectus abdominis, of the vastus externis cruris, and other muscles. These simple subcutaneous ruptures of muscles are not serious injuries ; they are readily recognized by the disturbance of function, by the depression, which may be seen and still better felt, which at once occurs, but subsequently is masked by the effused blood. The treatment is simple : rest of the part, placing it so that the rup- tured ends may be brought in contact by relaxation of the muscle, cold compresses, lead-water lotions for several days ; after eight or ten days the patient can generally rise without pain ; at first there is a connective-tissue intermediate substance, which soon condenses so much, by shortening and atrophy, that a firm tendinous cicatrix forms; the course is just the same as in subcutaneous division of tendons, of which we shall speak in the chapter on deformities. Functional disturbances of any considerable amount rarely re- main ; occasionally there is some weakness of the extremity and loss of delicate movements, especially in the hand. For such subcutaneous rupture of muscles and tendons to be caused by contusion, the crushing force would have to be very great; such a contusion would probably run a bad course ; extensive suppu- rations and necroses of tendons might be expected. Here, again, you see how varied may be the course of injuries apparently the same, according to the mode of their origin. In injuries by machinery there is often such a wonderful combination of crushing, twisting, and lacerating, that even with great experience it is very difficult to give any accurate prognosis of their course. The favorable course of cases, where small or even large portions of a limb (as the hand) are torn off, is especially worthy of mention. I have seen two cases where LACERATED WOUNDS. 183 fingers were torn off; I will briefly narrate one of them: a mason was employed on a scaffolding, and suddenly felt it giving way under him; Fig. 40. Fig. 41. Fig. 42. Torn-oat middle finger, with all its Arm torn out, with scapula tendons. an( j clavicle. 184 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. from the roof of the house against which the scaffold rested there huno- a loop; the falling man grasped this, but only succeeded in get- ting the middle finger of the right hand through the loop ; he hung a moment and then fell to the ground. Fortunately, the height was not o-reat, and he was not injured, but the middle finger of the right hand was gone; it was torn out at the joint between the first phalanx and the metacarpal bone, and it still hung in the loop. The two tendons of the flexors and that of the extensor remained attached to the fin- ger ; they had been torn off just at the insertion of the muscles ; the man dried his finger with the tendons, and subsequently carried it in his purse as a memento of the circumstance. I saw a similar case in the clinic at Zurich (Fig. 41). Cure resulted without much inflam- mation of the forearm, and actually no treatment was required. In Zurich I saw two cases where the hand was torn out ; in one case there was enough skin remaining to leave the healing to itself, in the other case an amputation of the forearm was necessary. Both cases terminated favorably. In war it is not very rare for arms and legs to be torn from their sockets by large cannon-balls. I have also seen a case where a boy fourteen years old had the right arm with the scap- ula and clavicle so torn from the thorax, by a wheel of machinery, that it was only attached at the shoulder by a strip of skin two inches wide (Fig. 42). The axillary artery did not bleed a drop; both ends were closed by torsion (Fig. 40). The unfortunate fellow died soon after the injury. Tearing out of entire extremities is usu- ally quickly fatal. CHAPTER V. SIMPLE FB AC TUBES OF BOWES. LECTURE XIV. Causes, Different Varieties of Fractures. — Symptoms, Diagnosis. — Course and External Symptoms. — Anatomy of Healing, Formation of Callus. — Source of the Inflamma- tory Osseous New Formation. — Histology. Gentlemen: Hitherto we have been exclusively occupied with injuries of the soft parts ; it is time to consider the bones. You will find that the processes that Nature excites for the restoration of the parts are essentially the same that you already know ; but the circum- stances are more complicated, and can only be fully understood when you are perfectly acquainted with the mode of healing in the soft parts. Every person knows that bones may be broken, and again be firmly united ; this can only be done by bony tissue, as you will at once see ; hence it follows that new bony substance must be formed ; the cicatrix in bone is usually bone ; a very important fact, for, if this were not the case, if the broken ends only grew together by connec- tive tissue, as divided muscles do, the long bones particularly would not be united firmly enough to support the body, and after the sim- plest fractures many men would be cripples for life. Still, before fol- lowing the process of the healing of bones to its more minute details, a study that has always been pursued with great zeal by surgeons, I must tell you something about the origin and symptoms of simple fractures ; I say " simple or subcutaneous fractures " in contradistinc- tion to those accompanied by wounds of the soft parts. Man may even come into the world with broken bones : the bones of the foetus may be broken, while in the uterus, by abnormal con- tractions of that organ, or by blows or kicks on the pregnant abdomen, and such intra-uterine fractures generally heal with considerable dislo- cation : as we shall see in other instances, the vis medicatrix natures 186 SIMPLE FRACTURES OF BOXES. is a better physician than surgeon. Of course, fractures of the bones may occur at any age, but they are most frequent between the ages of twenty-five and sixty years, for the following reasons : The bones of children are still pliable, and hence do not break so easily ; if a child falls, it does not fall heavily. Old people have, as is commonly remarked, brittle, friable bones ; or, anatomically expressed, in old age the medullary cavity grows larger, the cortical substance thinner ; but old persons are less in danger of fractures of the bones, because their lack of strength prevents their doing hard and dangerous work. It is during the age when men are most exposed to hard work that injuries generally and fractures especially are most liable to occur. The less frequency of fractures among women is due to the variety of their occupation. It is also due entirely to external circumstances that the long bones of the extremities, especially of the right side, break more frequently than those of the trunk. It is evident that diseased bones, which are already weak, break more easily than healthy ones ; hence certain diseases of the bones greatly predispose to fractures, especially the so-called English disease, " rickets," which is due to deficient de- posit of lime-salts in the bones, and only occurs in children; also softening of the bones or "osteomalacia," which depends on ab- normal dilatation of the medullary cavity, and thinning of the cor- tical substance, and which is, to a great extent, accompanied by a " fragihtas ossium," and even by total softness and flexibility of the bones. As special causes of fractures, we have the two following : 1. The action of external forces, the most frequent cause ; this action may vary in the following ways : the force — for instance, a blow or kick — meets the bone directly, so that it is crushed or broken ; or the bone, especially a long bone, is bent more than its elasticity permits, and breaks like a stick that is bent too much ; here the force acts indi- rectly on the point of fracture. In the mechanism of the latter variety, instead of the single hollow bone, you may consider a whole extremity or the entire spinal column as a stick, flexible to a certain extent, and on this supposition found your idea of the indirect action of the force. Let us have a couple of examples to explain this : If a heavy body falls on a forearm at rest, the bones are broken by direct force ; if a person falls on the shoulder, and the clavicle is broken obliquely through the middle, this is the result of indirect force. In both cases there is usu- ally contusion of the soft parts ; but in the latter case it is more or less removed from the point of fracture ; in the former at that point, which evidently is to be regarded as less favorable. 7 2. Muscular action may, though rarely, be the cause of fracture. As I already indicated, when speaking of the subcutaneous rupture of VARIETIES OF SIMPLE FRACTURES. 187 muscles, the patella, the olecranon, and part of the calcaneus also, may be torn off by muscular action, that is, obliquely fractured. The way in which the bones break under these varied applications of force varies, but some types have been formed that you should know. First, we distinguish complete and incomplete fractures. Incomplete fractures are again subdivided into fissures, i. e., clefts, cracks ; they are most frequent in the flat bones, but occur also in the long bones, especially as longitudinal fissures accompanying other fractures ; the cleft may gape or appear simply as a crack in glass. Infraction, or bending, is a partial fracture, which, as a rule, only occurs in very elastic, soft bones, and especially in rachitic children ; you may best imitate this fracture by bending a quill till its concave side breaks in. In children, such infractions of the clavicle are not rare. What we mean by splintering is evident ; the most frequent causes are machine-cutters, sabre-strokes, etc. Lastly, the bone may be perforated without entire solution of continuity, as by a punctured wound through the scapula, or a clean shot through the head of the numerus. The latter variety of injury is called a perforated fracture. Complete fractures are subdivided into transverse, oblique, longi- tudinal, dentate, simple, or midtiple fractures of the same bone, com- minuted ; all of these expressions explain themselves. Lastly, we must mention that persons as old as twenty years may also have a solution of continuity in the epiphyseal cartilages, although this is rare, and the long bones break more readily at some other point. Frequently it is easy to recognize that a bone is broken, and a non-professional person may make the diagnosis with certainty; in other cases the diagnosis may be very difficult, and occasionally can only be a probable one. Let us take up the symptoms one after another. First, accustom yourself to examine every injured part accurately, and compare it with healthy parts ; this is particularly important in the extremities. You may not unfrequently know what the injury is by simple ob- servation of the injured extremity. You ask the patient how it hap- pened, having him undressed meantime, or, if this be painful, have his clothes cut off, that you may accurately examine the injured part. The manner and severity of the injury, the weight of any body that has fallen on the part, may indicate about what you have to expect. If you find the extremity crooked, the thigh bent outward, for instance, and swollen, if suggillations appear under the skin, if the patient can- not move the extremity without great pain, you may with certainty decide on a fracture ; here you need no further examination to decide on the simple fact of a fracture, it is not necessary to put the patient to any pain on this account ; you have only to examine with the 188 SIMPLE FRACTURES OF BONES. hands to find how and where the fracture runs ; this is less necessary, on account of determining the treatment, than to be able to decide whether and how recovery will result. In this case you have made the diagnosis at a glance, and in surgical practice it will often be easy for you to recognize very quickly the true state of affairs, when you are accustomed to use your eyes thoughtfully, and when you have ac- quired a certain habit in judging of normal forms of the body. Never- theless, you should know perfectly how you arrived at this sudden diagnosis. The first point was the mode of the injury, then the de- formity ; the latter is caused by two or more pieces of bone (frag ments) having been displaced. This dislocation of the fragments is due partly to the injury itself (they are driven in the direction that they maintain, from the bending of the bone), partly to the muscular action which no longer affects the entire bone, but only a part ; the muscles are excited to contraction, partly by the pain from the injury, partly by the pointed ends of the bone ; for instance, the upper por- tion of a fractured thigh-bone is elevated by the flexors, the lower por- tion is drawn up near or behind the upper fragment by other muscles, and thus the thigh is shortened and deformed. The swelling is caused by the effusion of blood (we speak here of a fracture that has just oc- curred) ; the blood comes chiefly from the medullary cavity of the bone, and also from the vessels of the surrounding soft parts which have been crushed or torn by the ends of the bone ; it looks bluish through the skin, if it works up to the skin, as it gradually does. The patient can only move the extremity with great pain ; the cause of this disturbance of function is evident, we need waste no words on it. If we examine each of the above symptoms separately, none of them, either the mode of injury, the deformity, swelling, effusion of blood, or functional disturbance, will alone be evidence of a fracture, but the combination is very decisive ; and you will often have to make such a diagnosis in practice. But all these symptoms may be absent when there is fracture. If there has been an injury, and none of the above symptoms are well developed, or only one or other of them distinctly exists, manual examination must aid us. What will you feel with your hands ? You should learn this thoroughly at once. I so often see practitioners feel about the injured part for a long time with both hands, causing the patients unspeakable pain, and after all finding out nothing by their examination. By the touch you may perceive three things in fractures : 1. Abnormal mobility, the only pathognomonic sign of fracture ; 2. You may often detect the course of the fracture, and often whether there are more than two fragments ; 3. By moving the fragments you will often experience a rubbing and cracking of the fragments against each other, the so-called " crepita- SYMPTOMS OF SIMPLE FRACTURES. 189 Hon" — strictly to crepitate means to crackle ; this is a sound, and still we say, we feel crepitation ; it is no use to object to this ; this is an abuse of the word, which has so gone into practice, however, that it cannot be rooted out, and every one knows what it means. An edu- cated touch usually feels at once all that can be detected by the touch ; hence it is unnecessary to make the patient suffer long under this examination. Crepitation may be absent or very indistinct ; of course, it only exists when the fragments can be moved, and when they are quite near each other; if they be considerably displaced laterally or be drawn far apart by muscular contraction, or if there be blood between the fragments, no crepitation can be felt, and it is often difficult to detect when the bones lie deep. Hence, if we detect no crepitation, this, in opposition to all the other symptoms, does not prove that there is no fracture. Still, even where there is crep- itation, you may mistake its origin; you may have a feeling of fric- tion under other circumstances ; for instance, the compression of blood coagula or fibrinous exudations may give a feeling of crepitation ; this soft crepitation, which is analogous to pleuritic friction, you should not and will not mistake for bony crepitus after some experi- ence in examination ; when opportunity offers, I shall hereafter call your attention to other soft friction-sounds which occur especially in the shoulder-joint in children and old persons. For experienced sur- geons, in certain fractures severe pain at a fixed point is enough for a correct diagnosis, especially as in contusions the pain on grasping the bone is mostly diffuse, and rarely so severe as in fracture. If we are examining an extremity, it is best to seize it with both hands at the suspected point, and attempt motion here ; this manipulation should be firm, but not rough, of course. I must add something about the dislocation of the fragments; this may vary, but the displacements may be divided in various classes, which from time immemorial have had certain technical designations, which are still used, and which consequently must be explained. Simple lateral displacement is called dislocatio ad latus / if the fragments form an angle like a half- broken stick, it is called dislocatio ad axin. If a fragment be rotated more or less on its axis, we call it dislocatio ad peripheriam y if the broken ends be shoved past each other vertically, it is a dislocatio ad longitudinem. The expressions are short and distinctive, and easily remembered, especially if you represent to yourselves the displace- ments by diagrams. "We now pass to a description of the course of healing of a frac- ture. You will rarely have the opportunity of seeing what happens when no bandage is applied, as the patient generally sends early for a surgeon. But occasionally the laity undervalue the importance of 190 SIMPLE FRACTURES OF BOXES. the injury ; several days pass before the pain and duration of the affection at last cause the patient to apply to a surgeon. In such cases, besides the symptoms of fracture already given, you find great oedema, and in some few cases inflammatory redness of the skin about the point of fracture ; under such circumstances the examination may be very difficult ; occasionally the swelling is so considerable that an exact diagnosis as to the course and variety of the fracture is out of the question. Hence the earlier we see a fracture the better. The subsequent external changes at the point of fracture may best be studied on bones that lie superficially, and which cannot be sur- rounded with a bandage, as on fracture of the clavicle. After seven to nine days, the inflammatory cedematous swelling of the skin has subsided, the extravasated blood has run through its discolorations and goes on to reabsorption, and a firm, immovable, hard tumor lies around the point of fracture ; this is larger or smaller according to the dislocation of the fragments ; it is, as it were, poured around the frag- ments, and in the course of eight days becomes as hard as cartilage ; this is called callus. Pressure on it (the fragments can with difficulty be felt through it) is painful, though less so than previously ; subse- quently the callus becomes absolutely firm, the broken ends are no longer movable, the fracture may be regarded as healed ; for the clav- icle this requires three weeks, in smaller bones a shorter, and in larger ones a much longer time. But this does not end the external changes ; the callus does not remain as thick as it was ; for months or years it grows thinner, and, if there was no dislocation of the fragments, after a time no trace of the fracture will remain ; if there was a dis- location that could not be reduced by treatment, the ends of the bone unite obliquely and after absorption of the callus the bone remains crooked. To find out the changes that take place in the deeper parts, how the fractured ends unite, we try experiments on animals. We make artificial fractures on dogs or rabbits, apply a dressing, kill the ani- mals at various stages, and then examine the fracture ; we may thus obtain a perfect representation of the process. These experiments have been made innumerable times. The results have always been essentially the same ; but, if we speak of rabbits alone, there are certain variations which, as proved by numerous experiments, depend on the amount of dislocation and of extravasation of blood. Hence, before showing you a series of such preparations, I must give you the result of these investigations, and exemplify them by a few diagrams ; then you will hereafter readily understand the slight modifications. We shall first confine ourselves to what we can see with the naked eye and a lens. If you examine a rabbit's leg three or four days after FORMATION OF CALLUS. 191 the fracture, and, while it is firmly held in a vice, saw the bone longi- tudinally, you find the following : the soft parts about the fracture are swollen and elastic ; the muscles and subcutaneous cellular tissue look fatty ; the swollen soft parts form a spindle-shaped, not very thick tumor about the seat of fracture. About the broken ends we find some dark extravasated blood, and the medullary cavity at the same point is somewhat infiltrated with blood. The amount of this escaped blood varies, being sometimes very slight, again considerable. At the point of fracture the periosteum may be readily recognized, and is in- timately connected with the other swollen soft parts (which are the seat of plastic infiltration). Occasionally it is somewhat detached from the bone at the point of fracture. The whole thing looks about as follows (Fig. 43) : Fig. 44. Fig. 43. ..-& ..C Longitudinal section of a fracture of a rabbit's bone, four days old; a, ex- travasated blood ; b, swollen soft parts external callus ; c, periosteum. Diagram of a longitudinal section of a fTfteen-day-old fracture of a long bone ; a, internal callus ; b, inner, c, outer layer of ossification of the external callus; d, new periosteum. The di- mensions of the callus, in proportion to the entire lack of dislocation of the fragments, are represented as far toogreal,but this facilitates the pre- liminary understanding of the case. If we now examine a fracture in a rabbit after ten or twelve days, we find that the extravasation has either entirely disappeared, or that only a slight amount remains. I will not raise the question as to whether it has been entirely reabsorbed, or has partly organized to callus. The spindle-shaped swelling of the soft parts has mostly the appearance and consistence of cartilage, and has also the same micro- scopical characteristics ; in the medullary cavity also we find young 192 SIMPLE FRACTURES OF BONES. cartilage formations in the vicinity of the fracture. The broken bone sticks in this cartilage as if the two fragments had been dipped in sealing-wax and stuck together ; the periosteum is still tolerably dis- tinct in the cartilaginous mass, but it is swollen, and its contours are indistinct. Although there are traces of ossification even now, they do not become very decided or evident to the naked eye for some days (perhaps the fourteenth to the twentieth day after the fracture). Then we see the following (Fig. 44) : In the vicinity of the fracture there is young soft bone : 1. In the medullary cavity (a). 2. Immediately on the cortical layer (5), and some distance up and down beneath the periosteum, which has disap- peared in the whole spindle-shaped callus tumor. 3. In the periphery of the callus, which is still mostly cartilaginous (c). The periosteum which previously lay within the callus has now disappeared ; in its place a thickened layer of tissue has formed on the outside of the callus, which represents the periosteum (d). The young bone-sub- stance is soft, white, and in it we may see a kind of structure ; for small parallel pieces of bone, corresponding to the transverse axis of the bone, may be distinctly seen, especially on examination with a lens. The cartilaginous callus formed from the surrounding soft parts, into which the periosteum also has been partly transformed, now forms an enclosed whole, and ossifies entirely, partly from without (c), partly from within (b), till finally the ends of the bone stick in bony, as they previously did in the cartilaginous callus. This bony callus, which consists entirely of spongy bone-substance, is called by Du- puytren "provisional callus" As it is completed, the bone is usually firm enough to be again capable of function ; but the callus does not remain in its present condition any more than a recent cica- trix of the soft parts does. A series of changes occurs in it in the course of months or years, for up to this point you may still compare the union to that by sealing-wax, which is not a true organic union. So far the firm cortical substance is only united by loose young bone- substance ; the medullary cavity is plugged with bone ; the healing is not yet solid ; Nature does far more. We shall now study the subsequent changes ; they are confined to the spongy substance of the callus. At a certain time this ceases to increase, and then changes, by reabsorption of the bony substance that has formed in the medullary cavity (Fig. 45), and by the disappearance of a great part of the external callus. Meantime, formation of new bone has commenced between the fractured cortical layers, so that this has become solid by the time the external and internal callus disap- pears. This connecting bony substance between the fragments grad- ually increases in density, to such an extent that it becomes as hard as UNION OF FRACTURES. 193 Fig. 45. the bone in the normal cortical substance. In case there has been little or no displacement of the fragments, the bone is thus so fully restored that we can no longer determine the point of fracture, either on the living- person or the anatomical preparation. The above changes occur in a long bone of a rabbit, where there has been little displacement, in about twenty-six or twenty-eight weeks, but in the long bones of man last much longer, so far as we can judge from preparations that we accidentally have the opportunitj^ of ex- amining. The entire process, so excellently con- trived by Nature, is essentially the same as what we observe in the normal devel- opment of the long bones ; for there, too, Longitudinal section of a fractured 1 . . bone from a rabbit, after twenty- the Same reabsorption and condensation four weeks. Progressive reab- sorption of the callus. Restora- tion of the medullary cavity, natural size ; after Gurlt. Except the regeneration take place in the medullary canal and the cortical layers of the long bones, as we have just studied in formation of callus. of nerves, no such complete restoration of a destroyed part takes place in any other part of the human body as we have seen occurs in the bones. I must still add a few remarks about the healing of flat and spongy bones. In the case of the first, which we see most frequently in the healing of fissures of the cranial bones, the development of provi- sional callus is very slight, and occasionally appears to be entirely wanting. In the scapula, where dislocation of small, or half or wholly detached fragments is more apt to occur, external callus forms more readily, although even here it never becomes very thick. On the union of spongy bones, too, in which, as a rule, there is also but little dislocation, there is less development of external callus than in the long bones ; while, on the other hand, the cavities of the spongy sub- stance in the immediate vicinity of the fracture are filled with bony substance, of which part, at least, subsequently disappears. As may readily be imagined, the conditions will be somewhat more complicated when the ends of the bone are much dislocated, or when fragments are entirely broken off and displaced. In such cases there is such a rich development of callus, partly from the entire sur- face of the dislocated fragments and from the medullary cavity, and partly in the soft parts between the fragments, that for some distance all the fragments are embedded in a bony mass, and organically glued 13 194 SIMPLE FRACTURES OF BOXES. together. The larger the circle of irritation from the dislocated frag- merits, the more extensive the formative reaction. In man we most frequently have the opportunity of seeing callus formation in greatly dislocated fractures of the clavicle, where it is very evident that the extent of the new formation of bony substance is directly proportional to the amount of dislocation. You may read- ily understand how, in this way, with extensive formation of neo- plastic bone-substance, there may be perfect firmness, even with great deformity at the point of fracture. Still, one would hardly believe, without satisfying himself on the point, from preparations, that with time, even in such cases, Nature has the power of restoring, not only the outward shape of the bone (except the curvature and rotation), but also the medullary cavity, by reabsorption and condensation, Pis. 4G. Fig. 47. Fracture of the tibia of a rabbit, with great dislocation, with extensive formation of callus, after 27 days. Natural size, after Skuts'cJi. (GurWs Fractures, vol. i., p. 270.) Old united oblique fracture of a human tibia ; the ends of the fragments have been rounded off by absorption, the external callus reabsorbed ; formation of the me- dullary cavity incomplete. Size dimiu- ished. Gurlt, 1. c, p. 287. Numbers of points, nodules, inequalities and roughnesses of all sorts, that are formed on the young callus in recent cases, so disappear in the course of months and years, that in their place there is only left some dense, compact, cortical substance. FOEMATION OF NEW BONE. 195 It will now be interesting to investigate the true origin of the newly-formed bony substance ; is it produced by the bone itself, by the periosteum, by the surrounding soft parts, or is the extra vasated blood transformed into bone, as was believed by old observers? Must formation of cartilage always precede that of bone, or is this unnecessary? These questions have received various answers, till quite recently. To the periosteum, especially, great power of pro- ducing bone has at one time been ascribed, at another denied. In what follows, I will briefly give you the results of my investigations on this subject. The new formation that results from the fracture occurs in the medulla and Haversian canals of the bone, in the periosteum, and in- filtrated in the adjacent muscles and tendons ; possibly the extrava- sated blood may also have something, but very little, to do with the formation of the callus ; a large extravasation is disturbing here, as in healing of wounds of the soft parts, for part of it must be organized, while the remainder is absorbed. The inflammatory new formation here, also, at first consists of small round cells, which increase greatly in number, and infiltrate the tissues mentioned, and then almost take their place. Before following the fate of this cell-formation further, I must briefly consider its course in the Haversian canals. The cell-in- filtration in the connective tissue of the medullary cavity offers nothing peculiar, except that the fat-cells of the medulla disappear in the mass as the wandering cells take possession of the territory. Suppose the following figure (Fig. 48) to represent the surface, or the fractured surface, of a bone on which, as you know, the Haversian canals open; in these canals lie blood-vessels, surrounded by some connective tissue. If this bony surface be in the vicinity of a fracture, numerous Fio. 48. Diagram of a longitudinal section through the cortical substance of a long hone, a, surface : %, Haversian canals, with blood-vessels and connective tissue ; c. periosteum. Magnified 400 diameters. 196 SIMPLE FRACTURE OF BONES. cells first come between the connective tissue in the Haversian canals ; should this cell-infiltration be very rapid, it would entirely compress the blood-vessels, and cause the death of the bone, a process which we shall hereafter learn. But, if the cell-increase in these canals goes on slowly, their walls are gradually absorbed, as it would appear, by the inflammatory new formation itself; the canals are dilated, the cells fill them, and at the same time the blood-vessels increase by forming loops. From the observations of Cohnheim, we must suppose that in inflammation of bone, also, the young cells in the Haversian canals are not newly formed, but are white blood-cells escaped from the ves- sels. This has no effect on the subsequent course. Now, let us turn to the changes of form that we observe in the osseous tissue. As the connective tissue of the osseous canals is con- tinuous, both with the periosteum and medulla, the cell-infiltration into the bone, periosteum, and medulla, is also continuous. The cause of the atrophy of bone along the walls of the Haversian canals, which takes place in this, as in most other new formations in the bone, is difficult to explain; the disappearance of the connective tissue and muscular substance, as well as of other soft structures, when the in- flammatory new formation occurs in them, is less strange ; but it is truly remarkable that hard bony substance should thus be dissolved. This process might be represented by the following diagram (Fig. 49) : Fia. 49. Diagram of inflammatory new formation in the Haversian canals, a, surface; 5 5, Haversian canals, dilated, filled with cells and new vessels ; c, periosteum. Magnified 400 diameters. You see that the dilatation of the osseous canals is not regular, but of uneven widths ; the bone looks as if gnawed out ; this is not necessarily so, the atrophy of the bone may be more regular ; accord- ing to my idea, these irregularities result from the collection of cells in groups, or from looping of the vessels, which press against the FORMATION OF CALLUS. 197 bone and cause its atrophy. Virchow and others believe that these protuberances correspond to the nutrient territory of certain bone- cells, which in this process aid in reabsorption of the bone. I think I have refuted this, by showing that even dead portions of bone and ivory are also affected by the inflammatory new formation ; we shall speak more of this when treating of pseudarthrosis. At present it is not known how the lime-salts are dissolved in this process ; I think orobably the new formation in the bone develops lactic acid, which changes the carbonate and phosphate of , lime into soluble lactate of lime, and that this is taken up and removed by the vessels ; but this is only hypothesis. It would also be possible for the organic basis of the bone, the so-called osseous cartilage, to be first dissolved by the inflammatory neoplasia, and then there would be a breaking-down of the chalky substance, whose molecules would be subsequently re- moved, even if undissolved. Although I have conversed with many chemists and physiologists on this point, none of them have given me a simple explanation of this process, nor could they indicate any mode of experimenting that might aid in solving the question. In the above diagrams, if we suppose the fractured surface where there is no periosteum, in place of the surface of the bone, you will understand how the new formation (the young callus) grows from it out of the Haversian canals as above described, similar neoplasia from the other fragment meets and unites with it, as in healing of the soft parts. It is evident that the bone through which the inflam- matory neoplasia thus grows must become porous, from the reabsorp- tion that takes place on the walls of the canal ; if you macerate a bone in this stage, till the young neoplasia decomposes, the dry. bone will appear rough, porous, gnawed, while young bone-substance is deposited on it and in its medullary cavity. I must again repeat that in drawings and descriptions we have, for the sake of clearness, made the callous formation appear much more extensive than it really is, and that here, as in wounds of the soft parts, the regenerative processes do not usually extend very far or very deep, but are merely enough for healing, rarely in excess. In this whole explanation we have not mentioned the bone-cells or stellate bone-corpuscles ; I am convinced that they have as little to do with these processes as the fixed connective-tissue cells, and that the bone-substance, like the soft parts, is dissolved by a certain amount of inflammation, and replaced by new. So far we only know the neoplasia in the state where it consists essentially of cells and vessels, as the soft parts do under the same circumstances ; if there was retrogression to a connective-tissue cica- trix here as there is there, we should have no solid bone formed, but a 198 SIMPLE FRACTURE OF BONES. connective-tissue union, psendarthrosis (from ipevdrjg, false ; ap&puxjtg, joint), a false joint ; we shall hereafter describe these exceptional cases. Under normal circumstances the neoplasia now ossifies, as you already know. This ossification may either occur directly or after the inflamma- tory neoplasia has been transformed to cartilage. You know that both of these modes are seen in normal growth of the bone ; direct ossifica- tion of young cell-formation, for instance, in the periosteum of the growing bone, or formation of cartilage with subsequent ossification ? as at first in the entire skeleton and in growth of the bones length- wise. Callus from fractures varies greatly in this respect in men and animals. In rabbits the callus is always changed to cartilage before ossification, as it also is in children. In old dogs the callus usually ossifies directly, as in the human adult ; we are far from knowing the causes of these differences. To obtain a histological representation of these processes, let us return to our former diagram (Fig. 49) ; now imagine that the cells, lying in the spaces caused by reabsorption in the Haversian canals and surface of the bone, soon ossify and first fill these spaces (Fig. 50), then collect on the surface and in the medulla, Fig. 50. Diagram of ossification of inflammatory neoplasia on the surface of the bone and in the Havej "sian canals. Osteoplastic periostitis and ostitis. Magnified 400 diameters. and thus form the external and internal callus. Periostitis and ostitis, which lead chiefly or exclusively to the formation of new bone, we call osteoplastic ; in the present case the callus is the result of this. FORMATION OF CALLUS. 199 As previously remarked, the periosteum is used up in the neopla- sia and in ossifying callus, in its place, externally around the callus, a thick connective-tissue layer develops, from which new periosteum is formed. I will show you a few more preparations in explanation Fig. 51. Artificially-injected external callus, of slight thickness, on the surface of a rabbit's tibia, in the vicinity of a five-day-old fracture. Longitudinal section— a, callus ; 6, boue. Magnified 20 diameters. of the process in the periosteum. You see (Fig. 51) the peculiar course of the vessels almost at right angles to the bone, which enter „ e , the bone throuo-h the youno; callus. r IQ. 52. ° ./ o ^emmmm ^ ne ossification of the callus begins, mantle-like, around these vessels, and the little columns which first appear in the external callus are thus formed (see remarks on Fig. 44). You have a good representation of the formation of external (periosteal) and internal (endosteal) callus in the following (incomplete) transverse sec- tion of the tibia of a dog, from . the immediate vicinity of an eight-day- old fracture, in which you must also observe the vessels of the cortical sub- stance, which are considerably dilated as compared with normal (Fig. 53). Lastly, observe the following prepa- ration. It is an eight-day-old, already ossified, external callus on the surface Artificially-injected transverse (section of Q £ t he tibia of a dog, magnified 250 the tibia of a dog, from the immedi- £>> .o ate vicinity of an eight-day-old frac- times (Fig". 53). ture. a, internal callus ; b, external; \ &* /* cc, cortical layer of the bone. Magni- If we now view the process as a fled 20 diameters. x . whole, we see that the cell infiltra- tion in the bone itself, as well as in all the surrounding parts, aids in the formation of callus, and that hence the periosteum plays no ex- clusive osteoplastic role. This might have been concluded a priori^ 200 SIMPLE FRACTURE OF BONES. because if the periosteum alone formed the external callus, as was formerly supposed, the portions of the bone free of periosteum, as those places where tendons are attached to the bone, could form no callus ; this is directly contradicted by observation. In normal growth, also, the periosteum does not by any means play the im- portant part ascribed to it in the formation of bone ; for we may just as correctly regard the layer of young cells lying on the surface of the bone, and extending into the Haversian canals, as belonging to the bone, as to refer it to the periosteum. Fig. 53. ^^^S WM™ M^m % 1 *■' Ossifying callus on the surface of a hollow bone, near a fracture. Longitudinal section magnified 800. As appears, the ossifying callus is not limited to the periosteum, but extends in between the muscles. Recent investigations concerning the growth of bones, made by