■ a*. tip *'.; '-'•.:!■•,'''''■ i& <>%,"/< ^ Si •».'* ■•fc t 5rfr->■:••• sfi ■4 ,£, -; — V :-1 ..ft ■ '<" ■M $-:) l^!ig^!*J^^3tffi»!^- v^^'^ NATIONAL LIBRARY OF MEDICINE NLM DDSblTOb A C tV * w— Boston Medical Library Association, 19 BOYL$ Receive 5 PLACE, 1 SURGEON GENERAL'S OFFICE LIBRARY. Section, ... jro..ij..G>.$ijrr NLM005619068 GENERAL SURGICAL PATHOLOGY AND THERAPEUTICS, (it Jfiftg %tduxm. A TEXT-BOOK FOB STUDENTS AND PHYSICIANS. BY De. THEODOE BILLROTH. PBOFESSOB OF STJEGEEY IN VIENNA. TRANSLATED FROM THE FOURTH GERMAN EDITION, WITH THE SPECIAL PERMISSION OF THS AUTHOR, AND REVISED FROM THE SIXTH EDITION, BY CHARLES E. HACKLEY, A.M., M.D., SUBGEON TO THE NEW YORK EYE AND EAB INFIEMABY, PHYSICIAN TO THE NEW YORK HOSPITAL, FELLOW OF THE NEW YOEK ACADEMY OF MEDICINE, ETC., ETC LLBRAKY SUf»3E0N GENERAL'S OFFICE I DLL. -3- 4901 NEW YORK: D. APPLETON AND COMPANY, 549 & 551 BROADWAY. 1877. I B533a I 673^ c,2. Entered, according to Act of Congress, in the year 1871, by Charles E. Hackley, in th« Office of the Librarian of Congress, at Washington. Entered, according to Act of Congress, in the year lb73, by Cuables E. IIacklet, m the Office of the Librarian of Congress, at Washington. *J TRANSLATOR'S PREFACE TO THE REVISED EDITION. The success attained by the English translation of this work encourages the translator to believe that it is adapted to the present needs of the medical profession, and to hope that this revised edition may meet with an equally favorable reception. Since publishing the fourth edition of his work, Prof. Billroth has had increased experience during the late Franco-Prussian War ; much of which is detailed in his " Chirurgische Briefe aus den Kriegs-Lazarethen in Weissenburg und Mannheim 1870," and many deductions from which will be found in the following pages. Notices of skin-grafting and various other topics recently discussed, as well as many new woodcuts, are among the addi- tions to this edition. \ 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 ineulcated. 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 [ ]. 47 West Thirty-first Street, New York, December 1, 1870. 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. BILLEOTH. 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 {umors, 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 G8, 69, 70, 74, 91, 98, 99, 103, 10G, 107,108, 109, 110, 111, H2a 122, 123, 124, 125,126, 127,128, 132, 133). Dr. TIL BILLROTH. Vienna, November, 1869. CONTENTS. LECTUKE I. INTRODUCTION. Relation of Surgery to Internal Medicine.—Necessity of the Practising Physician being acquainted with both.—Historical Remarks.—Nature of the Study of Sur- gery in the German High-school,.........page 1 CHAPTER I. SIMPLE INCISED WOUNDS OF TEE SOFT PARTS. LECTUKE 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.—Hsemorrhagio Diathesis.—Haemorrhage from the Pharynx and Eectum. — Constitutional Effects of Severe Haemor- rhage, ..............p. 17 LECTUKE 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 LECTUKE 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 LECTURE 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 LECTURE VI. Changes in the Tissue during Healing by the First Intention.—Plastic Infiltration.— Inflammatory New Formation.—Retrogression to the Cicatrix.—Anatomical Evi- vhi CONTENTS. dences of Inflammation.—Conditions under which Healing by First Intention doei not occur.—Union of Parts that have been completely separated, . . page 58 LECTURE 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. 67 LECTUEE VIII. General Reaction after Injury.—Surgical Fever.—Theories of the Fever.—Prognosis.— Treatment of Simple Wounds and of Wounded Persons.—Open Treatment of Wounds,..............p. So 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,.......p. 96 CHAPTER II. SOME PECULIARITIES OF PUNCTURED WOUNDS. LECTURE X. Asa 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, . . p. 119 CHAPTER III. CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. LECTURE XI. Causes of Contusions.—Nervous Concussion.—Subcutaneous Rupture of Vessels.—Kup ture of Arteries.—Suggillations.—Ecchymoses.—Reabsorption.—Termination in Fibrous Tumors, in Cysts, in Suppuration, and Putrefaction.—Treatment, p. 13C CHAPTER IV. CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. LECTURE 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 Rapid Detachment of°the Dead Tissue.—Indications for Primary Amputation.—Local Complications in Contused Wounds; Decomposition, Putrefaction, Septic Inflammations.—Contusion of Ar- ....... P. 141 teries ; Late Secondary Haemorrhages, CONTENTS. is. 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.—Prophylaxis against Secondary Inflammations.—Internal Treat- ment of those severely Wounded.—Quinine.—Opium.—Lacerated Wounds : Sub- cutaneous Rupture of Muscles and Tendons; Tearing out of Muscles and Tendons; Tearing out of Pieces of a Limb,........page 155 CHAPTER V. SIMPLE FRACTURES OF BONES. 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,.......p. 175 LECTURE XV. Treatment of Simple Fractures.—Reduction.—Time for applying the Dressing, its Choice.—Plaster of Paris and Starch Dressings, Splints, Permanent Extension.— Retaining the Limb in Position.—Indications for removing the Dressings, p. 191 CHAPTER VI. OPEN FRACTURES AND SUPPURATION 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. 200 LECTURE XVI. Development of Osseous Granulations.—Histology.—Detacnment 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.—Antiphlogistic Remedies.—Immersion.—Rules about Bone-splinters.—After-Treatment,. p. 20C LECTURE XVII. lus, CONTENTS. CHAPTER YTI. INJURIES OF THE JOINTS. Contusion. —Distortion. —Opening of the Joint, and Acute Traumatic Articular Inflammation. — Variety of Course, and Results. — Treatment. — Anatomical Changes,.............page 224 LECTURE XVIII. Simple Dislocations; Traumatic, Congenital, Pathological Luxations, Subluxations.— Etiology.—Difficulties in Reduction, Treatment; Reduction, After-Treatment— Habitual Luxations.—Old Luxations, Treatment.—Complicated Luxations.—Con- genital Luxations,............p. 2oii CHAPTER VIII. G UN S H 0 T-W 0 UND S. LECTURE XIX. Historical Remarks.—Injuries from Large Missiles.—Various Forms of Bullet-Wounds. —Transportation and Care of the Wounded in the Field.—Treatment.—Compli- cated Gunshot-Fractures,..........p. 243 CHAPTER IX. BURNS AND FROST-BITES. LECTURE XX. l. Bums: Grade, Extent, Treatment.—Sunstroke.—Stroke of Lightning.—2. Frost- bites : Grade.—General Freezing, Treatment.—Chilblains, . . . .p. 255 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; b, 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 Bursae,.........p. 266 CHAPTER XI. ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, AND JOINTS. LECTURE XXII. inatomy.—Acute Periostitis and Osteomyelitis of the Long Bones: Symptoms, Ter- minations in Resolution, Suppuration, Necrosis, Prognosis, Treatment.—Acute Ostitis in Spongy Bones.—Acute Inflammations of the Joints.—Hydrops Acutus ■ Symptoms, Treatment.—Acute Suppurative Inflammations of Joints: Symptoms Course, Treatment, Anatomy.—Acute Articular Rheumatism.—Arthritis.—Metas- tatic Inflammations of Joints (Gonorrhoeal, Pyemic, Puerperal), . . p. 289 CONTENTS. xi CHAPTER XII. GANGRENE. LECTURE XXIII. Dry, Moist Gangrene.—Immediate Causes.—Process of Detachment.—Varieties of Gan- grene according to the Remote 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,..........pa^e 307 CHAPTER XIII. ACCIDENTAL TRAUMATIC AND INFLAMMATORY DISEASES, AND POISONED WOUNDS. LECTURE 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.—4. Lymphangitis, p. 319 LECTURE XXV. B. Phlebitis ; Thrombosis; Embolism.—Causes of Venous Thrombosis ; Various Meta- morphoses of the Thrombus.—Embolism.—Red Infarction, Embolic Metastatic Abscesses.—Treatment,...........p. 331 LECTURE XXVI. II.—General Accidental Diseases which may accompany Wounds and Local Inflamma- tions. 1. Traumatic and Inflammatory Fever; 2. Septic Fever and Septicaemia; 3. Suppurative Fever and Pyaemia,........p. 340 LECTURE XXVII. 4. Tetanus; 5. Delirium Potatorum Tratimaticum; 6. Delirium Nervosum and Mania.— Appendix to Chapter XIH.—Poisoned Wounds ; Insect-bites, Snake-bites; Infec- tion from dissecting Wounds.—Glanders.—Carbuncle.—Hydrophobia, . p. 363 CHAPTER XIV. CHRONIC INFLAMMATION, ESPECIALLY OF THE SOFT PARTS. LECTURE XXVIII. Anatomy: 1. Thickening, Hypertrophy; 2. Hypersecretion; 3. Suppuration, Cold Abscesses, Congestive Abscesses, Fistulae, Ulceration.—Results of Chronic Inflam- mation.—General Symptomatology.—Course,......p. 378 LECTURE XXIX. General Etiology of Chronic Inflammation.—External Continued Irritation.—Causes in the Body.—Empirical Idea of Diathesis and Dyscrasia.—General Symptomatology and Treatment of Morbid Diatheses and Dyscrasiae. 1. The Lymphatic Diathesis (Scrofula); 2. Tuberculous Dyscrasia (Tuberculosis); 3. The Arthritic Diathesis; 4. The Scorbutic Dyscrasia ; 5. Syphilitic Dyscrasia,.....p. 3SS sii CONTEXTS. LECTURE XXX. Local Treatment of Chronic Inflammation: Rest, Compression, Resorbents, Antiphlo- gistics, Derivatives, Fontanels, Setons, Moxae, the Hot Iron, . . . page 399 CHAPTER XV. 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- 404 CHAPTER XVI. 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- 418 LECTURE XXXIII. 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. 428 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. 436 LECTURE XXXV. Necrosis.—Etiology.—Anatomical Conditions in Total and Partial Necrosis.—Symp- toms and Diagnosis.—Treatment.—Sequestrotomy,.....p. 44.7 LECTURE XXXVI. Rachitis.—Anatomy.—Symptoms.—Etiology.—Treatment.—Osteomalacia.—Hypertro- phy and Atrophy of Bone,..........p. 463 CHAPTER XVII. CHRONIC INFLAMMATION OF THE JOINTS. LECTUKE 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. 471 CONTENTS. xiii LECTURE XXXVHI. Treatment of Tumor Albus.—Operations.—Resection of the Joints.—Criticisms on the Operations on the Different Joints,........pa„e ^gg LECTURE XXXIX. B.—Chronic Serous Synovitis.—Hydrops Articulorum Chronicus; Anatomy, Symp- toms, Treatment.—Appendix: Chronio Dropsies of the Sheaths of the Tendons, Synovial Hernias of the Joints and Subcutaneous Mucous Bursa?, . . p. 492 LECTURE XL. C. Chronic Rheumatic Inflammation of the Joints.—Arthritis Deformans.—Malum Coxae Senile.—Anatomy, Different Forms, Symptoms, Diagnosis, Prognosis, Treatment.—Appendix: Foreign Bodies in the Joints: 1. Fibrinous Bodies; 2. Cartilaginous and Bony Bodies; Symptomatology, Operations, . . p. 502 LECTURE XLI. Anchyloses, Varieties, Anatomy, Diagnosis, Treatment; Gradual Forced Extension; Operations with the Knife,..........p. 513 CHAPTER XVIII. CONGENITAL DEFORMITIES OF THE JOINTS DUE TO MUSCULAR AND NER- VOUS AFFECTIONS AND CICATRICIAL CONTRACTIONS.—LOZARTHROSES. LECTURE XLII. I. Deformities of Intra-uterme 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.—HI. 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. 525 CHAPTER XIX. VARICES AND ANEURISMS. LECTURE XLIII. Varices: Various Forms, Causes, Various Localities where they occur.—Diagnosis.— Vein-stones.—Treatment.—Aneurisms : Inflammation of Arteries.—Aneurysma Cir- soideum.—Atheroma.—Various Forms of Aneurism.—Their Subsequent Changes. —Symptoms, Results, Etiology, Diagnosis.—Treatment: Compression, Ligation, Injection of Liquor Ferri, Extirpation,........p. 543 CHAPTER XX. TUMORS. LECTURE XLIV. Definition of the Term Tumor.—General Anatomical Remarks; Polymorphism of Tissues.—Points of Origin of Tumors.—Limitation of the Development of Cells to Certain Types of Tissue.—Relation to the Generative Layers.—Mode of Growth.— Anatomical Metamorphosis of Tumors; their External Appearances, . . p. 562 siv CONTENTS. LECTURE XLV. Etiology of Tumors ; Miasmatic Influence.—Specific Infection.-Specific Reaction of 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,.......Pa£e 571 LECTURE XLVI. 1. Fibromata: a, Soft; b, Hard Fibroma.—Mode of Occurrence; Operations ^Ligature; Ecrasement; Galvano-caustic—2. Lipomata : Anatomy; Occurrence ; Course. 3. Chondromata: Occurrence; Operation.—4. Osteomata: Forms; Operation, p. 585 LECTURE XLVII. 5. Myoma.—6. Neuroma.—7. Angioma: a, Plexiform; 6, Cavernous.—Operations, p. 603 LECTURE XLVIII. 8. Sarcomata.—Anatomy: a, Granulation Sarcoma; b, Spindle-celled Sarcoma; c, Giant- celled Sarcoma; d, Stellate Sarcoma; e, Alveolar Sarcoma;/, 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. Lymphomata.—Anatomy.—Relations to Leucaemia. —Treatment,.............p. 611 LECTURE 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. 632 LECTURE L. 13. Careinomata.—Historical Remarks.—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.—4. Lachrymal Glands, Salivary Glands, and Prostate Glands.—5. Thyroid Glands and Ovaries.—Treatment.—Brief Remarks about the Diag- nosis, ....... ......p. 646 LIST OF WOODCUTS. 1. Diagram of connective tissue, with capillaries, .... 2. Diagram of incision, capillaries closed by blood-clots, collateral distention, 3. Diagram representing the surface of the wound united by inflammatory new formation, ........ 4. Diagram of a wound with loss of substance, .... 5. Pus-cells from fresh pus, ....... 6. Diagram of granulation of a wound, ..... 7. Fatty degeneration of cells from granulations, .... 8. Corneal incision three days old, ..... 9. Incised wound twenty-four hours old, ..... 10. Cicatrix nine days after an incision, ..... 11. Granulation-tissue, ........ 12. Young cicatricial tissue, ...... 13. Horizontal section through the tongue of a dog, 14. Same, ten days old, ....... 15. Same, sixteen days old, ....... 16. Granulation-vessels, ....... 17. Seven-days-old wound in the lip of a dog, .... 18. Cicatrix from the upper lip of a dog, ..... 19. Ends of divided muscular fibres, ...... 20. Regenerative processes in transversely-striated muscle, 21. Regeneration of nerves, ....... 22. " " ..... 23. Nodular nerve-terminations in an old stump, .... 24. Artery ligated in the continuity, ..... 25. Transverse section of a fresh thrombus, ..... 26. Transverse section of thrombus six days old, 27. Ten-day-old thrombus, ....... 28. Completely-organized thrombus, ..... 29. Longitudinal section of the ligated end of an artery, 30. Portion of a transverse section of a vein, with organized thrombus, 31. Artery, injected six weeks after ligation, .... 32. Artery, injected thirty-five months after ligation, . 33. Artery, injected three months after ligation, .... 34. Artery wounded on the side, with clot, .... 35. Aneurisma traumaticum, . . . 36. Varix aneurismaticus, ....... 37. Aneurisma varicosum, ....... 38. Granular and crystalline haematoidin, . . . 39. Detachment of dead connective tissue in contused wounds, 40. Central end of a torn brachial artery, ..... PAGE 49 50 XVI LIST OF WOODCUT; FIG 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 90. 91. 92. 93. Evulsed middle finger, ....... Arm torn out, with scapula and clavicle, . Longitudinal section of a fracture four days old, Diagram of a longitudinal section of a fracture fifteen days old, Diagram of a longitudinal section of a fracture twenty-four weeks old Fracture, with dislocation, after twenty-seven days, Old united oblique fracture, .... Longitudinal section through the cortical substance. Inflammatory new formation in Haversian canals, Ossification of inflammatory neoplasia on the surface of the bone and in th Haversian canals, ......•• Artificially-injected external callus, five days old, Artificially-injected transverse section, eight days old, Ossifying callus on the surface of a hollow bone, Detachment of a superficial piece of a flat bone, Detachment of a necrosed portion of bone, Fracture of a long bone with external wound, Necrosis of sawed surface of femur, Bullets of various styles, ..... Tiemann's bullet-forceps, ..... Gunshot-fractures of femur and tibia, Traces of lightning, ..... Conjunctiva affected with catarrh, .... Tissue from a prepuce infiltrated from inflammation, . Purulent infiltration of the cutis connective tissue, . Purulent infiltration of the cellular membrane, . Vessels of the walls of an abscess, .... Venous thrombus, ...... Fever curve after amputation of the arm, Fever curve after resection of carious wrist, Fever curve in erysipelas, ..... Fever curve in septicaemia, .... Cutaneous ulcer of the leg, ..... Granulations of a common ulcer, .... Caries superficialis of the tibia, .... Section of a piece of carious bone, Sclerosed tibia and femur, ..... Point of caseous degeneration in the spinal column, Destruction of the vertebral column, .... Total necrosis of the diaphysis of a hollow bone, Total necrosis of the diaphysis of a hollow bone with detached sequestrum, Total necrosis of the diaphysis of a hollow bone after removal of sequestrum Total necrosis of the diaphysis of the femur, .... Total necrosis of the diaphysis of the tibia, Necrosis of the lower half of diaphysis of femur, The body extracted from Fig. 84, ... Diagram of partial necrosis of a hollow bone, Diagram of Fig. 78 in the later stages, Fig. 87, after removal of the sequestrum, Scapula of a dog, resected with and without periosteum, Rachitic malformations of the leg, .... Disappearance of chalky salts in osteomalacia, Woman with extensive osteomalacia, Section of knee-joint with fungous inflammation, LIST OF WOODCUTS. xvn FIG. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135, 136. 137. 138. 139. 140. 141. 142, 143. 144. 145. 146. 147. Degeneration of cartilage in fungous inflammation, Subchondral caries of the astragalus, Atonic ulceration of cartilage from the knee-joint, Diagram of the ordinary ganglion, Hernial protrusions of synovial membrane. Degeneration of the cartilage in arthritis deformans, Osteophytes in arthritis deformans, Fungous inflammation of the elbow-joint, Osteophytes in arthritis deformans, Multiple articular bodies, Band-like adhesions in a resected elbow-joint, Adhesion of articular surfaces of the elbow-joint, Elbow-joint anchylosed by bony bridges, . Section of the shoulder-joint, Section of the shoulder-joint, Contraction of the fascia lata, Cicatricial contractions after burns, Cicatricial contractions after burns, Subcutaneously-divided tendon, Varices, .... Cirsoid aneurism of the scalp, Small fibroma, From a myo-fibroma, . Vessels from a cutis fibroma, Neuroma, Fibro-sarcomatous neuromata, Cartilage tissue from chondromata, Chondroma of the fingers, Odontoma of a back tooth, Section of an odontoma, v Pedunculated spongy exostosis, Ivory exostosis of the skull, Section from an ivory osteoma, Osteoma of the .muscular attachments Vessels from a plexiform angioma Mesh-work from a cavernous angioma, Tissue of granulation-sarcoma, Tissue of glio-sarcoma, Tissue of a spindle-celled sarcoma, Giant-cells from a sarcoma, Giant-celled sarcoma with cysts, Cell-globules from a sarcoma, Mucous tissue from a myxosarcoma, Mucous tissue from an adenomyxoma, Alveolar sarcoma from the deltoid muscle, Alveolar sarcoma from the tibia, Central osteosarcoma of the ulna, Section of Fig. 140, Central osteosarcoma of the lower jaw, Section of Fig. 142, Compound cystoma of the thigh, Periosteal sarcoma of the tibia, . Section of 145, ..... From an adeno-sarcoma of the female breast, 2 xviii LIST OF WOODCUTS. FIG. 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 carcincma 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, . PAGE 629 633 636 638 652 652 653 654 655 659 662 662 663 664 664 665 666 667 671 672 674 675 SURGICAL PATHOLOGY AND THERAPEUTICS. LECTURE I. INTRODUCTION. Relation of Surgery to Internal Medicine.—Necessity of the Practising Physician being acquainted with both.—Historical Remarks.—Nature of the Study of Sur- gery in the German High-schools. Gentlejien : 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. 2 INTFvODUCTION 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 wiU 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 lie deeply hidden, more is demanded from a surgical diagnosis and prognosis, and even in the treatment, than from the therapeutic action of internal medicine. I do not deny that in many respects internal medicine may hold a higher rank, just on account of the difficulties it has (and often so brilliantly overcomes) in localizing and recognizing disease. Very fine operation of the mind is often necessary to come to a proper conclusion, from the combination of symptoms, and the results of the examination. Physicians may point with pride to 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 rio-ht 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. 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 xeiP an(l zoyov, 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 JEs- culapius, a son of Apollo, and a scholar of the Centaur Chiron. Many temples were built to yEsculapius, 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 ^Esculapides, 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 wall 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 y 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. fi 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 Celsus (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 S INTRODUCTION. have been written so clearly by any one who had no practical knowl- edge of his 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 his have come down to us. Galen re- turned ag'ain 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, Antyllus (in the third century), Oribasius (326-403 a. d.), Alexander of Tralles (525-605 a. d.), Paulus of^Egina (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 athenaeum, scientific institutions where medicine also was INTRODUCTION. 7 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. JRhazes (850-932), Avi- cenna (980-1037), Albucasis (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 3 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 Luzzi (1314) differs very little from that of Gfalen, 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 (f 1300), Guido of Cauli- 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 Ji 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. Come," 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 about ten years since the distinction was done away with in almost all the German states and neither chirurgi puri nor medici puri were made, but only physicians 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 apothecary-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. 10 INTRODUCTION. 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 (1532-1562), and Fus- tachio (f 1579), were the founders of our present anatomy ; their names, like those of many others, are known to you from the appellations of certain parts of the body. The celebrated Bombastus 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-physiological foundation on which the whole structure now moves, and which forms a strong protection against all philosoph- ical medical systems. Even this anatomical direction, however may be pushed too far and too exclusively. We shall speak of this hereafter ' Now we will turn our attention to the scientific development of surgery from the sixteenth century to our times. It is an interesting feature of that time that the advance of practi- cal surgery depended more on the surgical societies than on the learned professors of the universities. German surgeons had to seek their knowledge mostly in foreign universities, but part of it they worked out for themselves independently: Heinrich von Pfolsprundt a German friar (born the beginning of the fifteenth century) Hieron- ymus Brunschwig (born 1430), Hans von Gersdorf (about 1520), and Felix Wurtz (fl576), surgeons at Basel, are first amono- 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 Pare (1517-1590) is most prominent; originally only a barber, from his great services, he was made a member of the So- ciety of St. Come; he was very active as an army surgeon, was often called from home on consultations, and at last resided in Paris. Pare advanced surgery by what was for those times a very sharp criticism of treatment, especially of the enormous use of problematical remedies; some of 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. Desault (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 Heister (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 Got- tingen; some of Bichter'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. Cooper's 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 JYep. Bust, of Berlin (1775- 1840), Philipp von Walther, of Munich (1782-1849), Carl Ferd. von Graefe, of Berlin (1787-1840), Conr. Joh. Martin Langenbeck, 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 cono-ressexs 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), Civiale (J1867), 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 Middledorpf (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 came from Boston the first news that Morton the dentist, at the suggestion of his friend Dr. JacJcson, had, in extracting teeth, em- ployed inhalations of sulphuric ether, pushed to complete anaesthesia, with perfect success. In 1859, Sirnpso?i, 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 Hunter 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 attamed 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 would be a long, tedious labor, and only a very gifted, industrious man would learn any thing in this way. After having made numerous errors, we must not place too great a value on " experience " and " observation," if by these 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 bv any means intend to say that you must be theoretically acquainted with all medicine before studying it practically, but you should brino- 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 goino- 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 topographica. 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 Langenbeck, 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 couwe in operations in the sixth or seventh semestres, along with their special surgery, so that I may give them the opportunity of oc- 3 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 WOUNDS OF THE SOFT PABTS. 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 Haemorrhage; Arterial, Venous.—Entrance of Air through Wounded Veins.—Parenchymatous Haemorrhage.—Haemorrhagio Diathesis.—Haemorrhage from the Pharynx and Rectum.—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 wrounds 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. A perfectly blunl body rarely 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 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, when one falls on the crest of the tibia, and it divides the skin from within outward. As may be readily understood, sharp splinters of bone perforating the skin may also make wounds with smooth surfaces. Lastly, the open- ing of exit of a bullet-wound, i. 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 thi£ 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, wre leave such wounds out of consideration; their mode of recovery and treatment is just the same as that in contused wounds, unless they can be artificially converted into simple incised wounds by paring off the jagged edges. The various directions in which the cutting instrument enters the body generally makes little difference, unless the direction be so oblique that some of the soft parts are detached in the form of a more or less thick flap. In these fiap-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 Dr 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 ariy 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, tins 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, ivhen 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 pain- ful operation, she did not once cry out, although several branches of the trifacial nerve were divided. Women generally stand suffering bet- ter and more patiently than men. But the necessary exercise of psychical strength not un frequently causes subsequent fainting, or excessive physical and psychical relaxation, of longer or shorter du- ration. I have seen strong men of powerful will bear severe pain without a grimace, but soon fall to the ground fainting; still, as previ- ously stated, I believe that some persons suffer pain much less acutely than others. You will certainly meet persons who, without any exer- cise of will, show so little pain from severe injury that we can only believe that they really feel pain less aputely than others ; I have ob- served this most in flabby sailors, in whom all the sequelae of the in- jury 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, particularly in dividing the skin. The feeling in the wound, immediately after its reception, is a pe- culiar burning. It can scarely be termed any thing but the feeling of being wounded ; there are a number of provincialisms for it—in North- ern 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 immediately after the injury; if these do not soon cease spontaneously,, or after exami- nation of the wound, and removal of the local cause, or, if this is im- possible, or inefficacious, they should be arrested by the exhibition of some internal remedy; otherwise, they will induce and keep up a state of excitement in the patient that may increase to maniacal delir- ium. To avoid the pain in operations, we now always use chloroform. The method of administering this article, as well as the prophylaxis and treatment of the dangers that may arise from it, you will learn much sooner, and remember better afterward, in the clinic, than if I gave you a prolix account of it here. Local anesthetics, which have for their object temporary blunting of the pain, in the part to be op- erated on, by application of a mixture of ice and saltpetre or salt have been again abandoned, or rather they have never been o-enerally received. Recently, these attempts have again acquired a o-eneral interest, as it seemed that a suitable method of local anaesthesia had at last been found. An English physician, Bichardson, constructed a small apparatus, by which a stream of pure ether [or, better rhifn> SYMPTOMS—HEMORRHAGE. 21 line] spray is for a time blown against one spot in the skin, and Buch 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 Liebreich, 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 ma}r 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, Immorrhage 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, sucli 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 haemorrhage 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 haemorrhage, 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 rjarenchymatous 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 haemorrhages; 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 hcemophilen. 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 wTounds, 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 are 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 symptoms 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 wTe 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 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. 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 orv(p(o, to contract). 1. The ligature may be applied in three ways, viz., as ligature of the isolated bleeding vessels, as mediate ligature of the latter with the surrounding soft parts, or as ligation in the continuity, i. e., liga- tion of the vessel at some distance from the wound. These varieties of ligation apply almost exclusively to arrest of arterial haemorrhage. Venous haemorrhages rarely require ligation—it is only occasionally indicated in the large venous trunks; we avoid it whenever we can, as its results may be dangerous. We shall here- after inquire in what this danger consists, and at present speak only of the ligation of arteries. Let us suppose the simplest case; a small artery spurts from a wound: you first seize the artery, as much isolated as possible, best transversely, between the branches of a sliding forceps; then fasten the slide, and the bleeding is stopped. The sliding forceps are best made of German silver, as it rusts less readily than iron. There are many different varieties of these forceps, which are all so arranged that when closed they remain fixed in that position; the mechanism accom- plishing this closure varies greatly; the more simple it is, the better. It is interesting to follow the phases of development of this instru- ment since the days of Ambrose Par'e, before it attained its present simple completeness. Of late small spring clamps are not unfre- quently employed to compress the bleeding arteries; these are very serviceable, if strongly made. Besides these pincettes, we may also use small curved sharp hooks [BromfieW s artery-hook) to draw out the artery, but this is not so good a way, for of course the blood would continue to spurt during the subsequent ligation. Having seized the artery securely, the next thing is to close it permanently; this is done by the ligature. But satisfy yourself first that you have not included a nerve with it, for the coincident ligation of a nerve may not only induce continued severe pain, but even dan- gerous general nervous affections. For ligating arteries we use silk thread of .various thickness, according to the size of the artery; it must oe good, strong silk, so that it shall not break when firmly tied; and it 28 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. should not really absorb fluids. Have the forceps, which hang from the end of the artery, held up, then from below place the silk around the artery, making first a simple knot and tying it tightly just in front of the forceps, then tie a second knot. Now loosen the forceps; if the ligature is rightly applied, the bleeding must be arrested. The tight- ening of the knot must be accomplished by pushing the silk forward and stretching it with the points of both fingers. If the silk be good, two simple knots, one over the other, will suffice. Some surgeons, how- ever, prefer to make first a so-called surgeon's knot and then a simple one. The surgeon's knot is made by passing both ends of the thread through the loop. You should first try these little manipulations on the cadaver or on living animals. When the ligature is firmly applied, cut one end off short and lead the other out of the wound the shortest way. It is not always possible to take up the spurting artery and ligate it by itself; occasionally it contracts so strongly into the tissue, es pecially into the muscles or dense cellular tissue, that its isolation is impracticable. Under such circumstances it is difficult to complete the ligation securely; we are very apt to include the blades of the forceps in the ligature, as it is difficult to push the ligature fare nough for- ward. Such cases are proper ones for mediate ligation. After hav- ing pulled forward the bleeding part with forceps or a hook, pass a curved needle, held in a needle-holder, around the artery, then tie the ligature so as to encircle the entire end of the artery; tie the knots tightly, as above directed; thus, while closing the mouth of the artery, you will enclose some of the surrounding tissue. Mediate ligation is only to be regarded as an exceptional proceeding, for the ligated tissue dies or the ligature suppurates through very slowly, so that the sepa- ration of the latter is much impeded; of course we must guard against including any visible nerve-trunk near the artery in the ligature. In the percutaneous mediate ligation of Middledorpf, we proceed even more summarily; we pass a strongly-curved large needle through the skin, under and across the bleeding artery, and again out through the skin; the thread is tied, and, besides compressing other parts, compresses the artery; the thread remains two or three days. I do not recommend this method; it should only be employed in cases of necessity, and as a provisional haemostatic. Whenever the bleeding artery can be seen in the wound, the haem- orrhage is to be arrested by ligature;. but, in those cases where the arteries of the periosteum or bone spurt out blood, ligature is impos- sible, and other methods, such as compression, come into play. * If you have to deal with large bleeding arteries, the proceeding is just the same, only you must be doubly careful in isolating the artery: seize the bleeding end and scrape back the surrounding TREATMENT OF HEMORRHAGE—COMPRESSION. 29 tissue with a small scalpel, then ligate carefully and accurately; in most cases, when you have the central and peripheral ends exposed in the wound, you should ligate both, for the anastomoses in the arterial system are so free that, if the peripheral end does not bleed at once, it may do so later. The wound from which a copious haemorrhage comes may be very small, as a punctured or gun-shot wound. From your anatomical knowledge you should know what large vessel may be injured by such a wound. If, from the free haemorrhage or its frequent recurrence after compression, you are satisfied that ligation is the only certain remedy for the bleeding, you have the following alternatives: either enlarge the existing wound by careful, clean incisions, and seek for the vessel m the wound while the artery is compressed above, and ligate the divided ends of the artery; or else, while you have the bleeding vessel compressed in the wound, you seek the central part of the vessel above the wound, and then ligate in the continuity. Both op- erations demand accurate anatomical knowledge of the positions of the arteries, and practice. Which of these two operations you shall choose depends on how you can soonest prudently attain your object, and on which of them will require the smaller new wound. If you think you can expose the artery in the wound without enlarging it much, choose this method as the more certain; but if you consider this very difficult, if at the seat of the wound the artery lies deep under muscles and fascia, especially in very muscular or fat persons, make a regular ligation of the artery above (toward the heart from) the wound. I shall not here discuss the points chosen after years of trial, on theoretical and practical grounds, for the ligation of arteries. In op- erative surgery, in the text-books on surgical anatomy, and especially in the operative course, you will be instructed on this point, and must attain practice in certainly finding, neatly exposing, and carefully ligating, the artery, in doing which, you cannot accustom yourself to too much pedantry and technicality. Although the value of the ligature is recognized by all surgeons of the present day, still attempts have been constantly made to find simpler substitutes which should be just as safe. Some have con- sidered it (unjustly, as it seems to me) a great evil to leave in the wound a silk thread and a portion of ligated vessel to die and be- come putrid. I pass over the attempts and proposals made for allow- ing the ligature to heal in the cicatrix, and merely mention torsion of the bleeding artery as a mode of closing the vessel mechanically till its walls grow together. The bleeding vessel is seized with strong, accurately-closing forceps, drawn forward half an inch, and twisted on its axis five or six times ; I usually draw it out as far as 30 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. possible, and twist till it breaks off. In this way I have twisted ves- sels from the smallest size to that of the brachial, so as to securely arrest the bleeding. If branches leave the artery just above the bleeding-point, it will not be movable enough to make the torsion securely; hence I have never tried torsion for the femoral; but other surgeons have done so successfully. 2. Compression.—Pressure on the bleeding vessel with the finger is such a simple, apparent method of arresting haemorrhage, if we may caU it a method, that it is strange the laity do not resort to it at once; any person that has seen one or two operations would instinc- tively hold his finger on the bleeding vessel; still how rarely people do this in a case of accidental wound! They prefer resorting to all sorts of home remedies; spider-webs, hair, urine, and all sorts of filth, are smeared over the wound, or else they run for some old woman who can arrest the bleeding by magic. And no one around thinks of compressing the wound. Methodical compression may be made for one of two purposes, as provisional or permanent. Provisional compression, which is used till we can determine how the bleeding may be best arrested permanently, may either be made by pressing the bleeding vessel in the wound against a bone, if possible, or by pressing the central part of the artery against the bone at some distance from the wound; the former, as we have al- ready stated, is to be done when we propose to ligate the trunk ; the latter, when we wish to tie the bleeding end of the artery, or to ex- amine the wound more carefully. Where shall we compress the artery, and how shall we do it most effectually? To compress the right carotid, you would place your- self behind the patient, and lay the tips of the second, third, and fourth fingers of the right hand along the anterior border of the sterno-cleidc-mastoideus muscle, about the middle of the neck, and press firmly against the spine, while you pass the thumb around the neck, and with the left hand bend the patient's head gently to the wounded side and somewhat backward. You should distinctly feel the pulsation of the carotid artery. Firm pressure here is quite pain- ful for the patient, for the vagus nerve is unavoidably compressed, and the tension of the parts necessarily acts on the larynx and trachea. From the free anastomoses of the two carotids, the effect of compres- sion of one of them, in arresting bleeding from an artery of the head or face, is not generally very great, and perfect compression of both vessels requires so much space, that we must generally be satisfied with diminishing the volume of the arteries by incomplete compres- sion. Compression of both carotids is always a very painful and tor- TREATMENT OF HEMORRHAGE—COMPRESSION. 31 rifying operation for the patient, especially on account of the strong secondary pressure made on the larynx and trachea; hence it is rarely employed. Compression of the subclavian artery may be more frequently i\ quired, especially in wounds of this artery in Mohrenheirn's fossa and in the axilla. In this operation also you may best stand behind the recumbent or half-sitting patient; with your left hand incline the head of the patient toward the wounded (right) side, and push your right thumb firmly behind the outer border of the clavicular portion of the relaxed sterno-cleido-mastoid muscle, so that you may firmly compress the artery against the first rib, at the point where it passes forward between the scaleni muscles. Here also pressure is painful, from the liability of the brachial plexus of nerves to be included in the com- pression ; still, by employing sufficient force, we may completely com- press the artery so as to arrest pulsation of the radial. But the thumb soon grows tired and loses sensation; hence various aids have been de- vised—instruments by which the compression may be made certainly. One of the most convenient means is a short thick key whose wards are wrapped in a handkerchief and the handle held firmly in the palm of the hand; you place the wards of the key over the artery, and compress it firmly against the first rib. But this cannnot fully replace compression by the finger of a skilled assistant, for with the instrument you of course cannot feel if the artery slides away from the pressure. From its position the brachial artery may of course be readily compressed ; in doing this, you place yourself on the outer side of the arm, take the arm in your right hand, so as to lay the second, third, . and fourth fingers along the inner side of the belly of the biceps, about the middle of the arm or a little above it, surround the rest of the arm with the thumb, and press against the humerus with the fingers; the only difficulty here is. to avoid simultaneous compression of the median nerve, which at this point almost covers the artery. By com- pressing the brachial artery, we may readily arrest the radial pulse, and we may employ this compression with great advantage if we de- sire to ligate either the radial or ulnar artery on account of wounds, or to amputate at the forearm or the lower part of the arm. In haemorrhages from the arteries of the lower extremities we com- press the femoral artery at its commencement, that is, immediately below Pouparfs ligament. Here, where it lies just in the middle be- tween the tuberculum pubis and anterior inferior crest of -the ileum, the artery should be pressed against the horizontal branch of the pubis. The patient should be recumbent; compression should be made with the thumb, and is easy, because at this point the artery is superficial. As far down as the lower third of the thigh, the femoral artery may 4 32 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. be compressed against the femur, but this can only be done certainiy by the finger in very thin persons; in most cases we employ for this purpose a special compress called a tourniquet. By a tourniquet we mean an apparatus by which we press an elongated oval piece of wood or leather, a pad, against an artery, and this against the bone, by means of a twisting, screwing, or buckling mechanism. Since a long compression of the brachial or femoral ar- teries is very fatiguing, we may advantageously call it to aid in com- pressing these arteries. The form of instrument that we now employ is the screw tourniquet of Jean Louis Petit. The pad, which is mov- able on a band, is to be applied exactly over the point corresponding to the artery, and opposite the screw, under which a few folds of linen are to be placed, to prevent too great pressure on the skin. Then buckle the band around the extremity, and by means of the screw and band draw the pad tighter till the subjacent artery ceases to pulsate. In an amputation-wound, if we do not at once see the mouth of the artery, we may loosen the screw slightly and permit a little blood to escape from the artery, which at once shows its position; then screw up the tourniquet at once, and ligate the artery. This is the great ad- vantage of the screw. When the apparatus is well made and careful- ly applied, it is of excellent service. It is true, the band around the limb unavoidably compresses the veins, especially the subcutaneous veins; nevertheless, on account of the pad, it acts chiefly on the artery. With a piece of broad bandage and a round block of wood, or a roller of bandage and a short stick, you may readily improvise such a tour- niquet ; still, if this improvised apparatus does not secure the artery very firmly-and securely, I should advise more certain modes of com- pression, of which I shall speak immediately. The facility of check- ing even considerable haemorrhages by means of the tourniquet, might delude us into leaving it on for a long while, until the bleeding stopped of itself, and we should thus escape the trouble of ligating. This would be a great error. If the tourniquet remains on half an hour, the extremity below it grows blue, swells, loses sensation, and circulation in the part may be entirely arrested, and it will die; through your whole life you would blame yourself for such an error, which might greatly endanger the life of your patient. Hence, application of the tourniquet is only admissible as a pro- visional haemostatic. It is almost impracticable to compress a laro-e artery with the finger till the haemorrhage shall be certainly arrested spontaneously. Still, cases may arise where compression with the finger is the only certain mode of arresting bleeding from smaller ar- teries, as in haemorrhages from the rectum or deep in the pharynx when other means have failed; here, compression with the fingei TREATMENT OF HEMORRHAGE—COMPRESSION. 33 must sometimes be continued half an hour to an hour, or longer, for ligation of the internal iliac in the former case, and of the carotid in the latter, are as dangerous as they are uncertain for a permanent ar- rest of the bleeding. Quite recently the genial surgeon and obstetrician, Simpson, of Ed- inburgh, whom you already know as the introducer of chloroform, has recommended a method which I cannot recognize as a perfect sub- stitute for ligation, but which is in many cases of practical use; this is the compression of the bleeding artery by a needle—acupressure. Acupressure may be made in various ways. For instance, in an am- putation-flap, you introduce a long insect, or sewing-needle, nearly vertically through the skin and soft parts to within one-quarter or one-half an inch of the artery; turn the needle horizontally, bring its point close over or under the artery, and at about the same distance from the artery you push it into the soft parts, and pass it out through the skin nearly vertically, so that the artery shall be compressed be- tween the needle and the soft parts, or, still better, against a bone. Should this compression not act perfectly, as it would rarely be likely to in large arteries, if the first needle was applied above the artery, pass a second one below it, and so compress the artery between the two needles, or else press the artery against the needle by means of a wire loop. In amputations I prefer acupressure by torsion; I pass the needle transversely through the artery, which is drawn forward, and with the needle make a half or whole rotation in the direction of the radius of the surface of the flap, until the bleeding is arrested, and then insert the point of the needle into the soft parts. The needles may be removed after forty-eight hours, -without renewal of bleeding. The extensive experience of English surgeons in the suc- cess of this bold operation first gave me courage to try it, and I must acknowledge that in several amputations, even of the thigh. I have seen no objection to it. I cannot quite believe that acupressure will altogether displace ligation, as Simpson prophesied. In this opera- tion, to which I have resorted in most of my amputations for several years, I employ long golden needles with large heads, because other metals rust easily, and silver is too soft, and platinum too expensive. Quite recently Von Bruns has applied small ligature rods, with which loops of silk are applied around and retained against the artery, previously drawn out. These, like acupressure-needles, are re- moved after forty-eight hours. I have just tried this procedure with perfect success On the femoral artery in an amputation of the thigh. In venous haemorrhage, or bleeding from numerous small arteries, especially in so-called parenchymatous haemorrhage, a regular tampon must be applied, by means of bandages, compresses, and charpie. 34 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. If you have a haemorrhage from the arm or leg, that you wish to wrest by compression—if, for instance, large quantities of blood are being poured out from a dilated diseased vein, or if there be bleeding from numerous small arteries—you may apply a bandage firmly from the lower to the upper part of the extremity, having previously covered the wound with a compress and charpie, and after applying several thicknesses of linen along the course of the chief artery of the extremity. For the latter purpose you may also employ the graduated compress, which you will learn to make in the course on bandages. To this, which is called Theden's dressing, it is well to add a splint, to keep the extremity perfectly quiet, for the bleeding is readily renewed by muscular contractions. These graduated compresses, carefully made, are particularly serviceable on the battle-field, in gun-shot and punc- tured wounds; by their aid we may arrest haemorrhage from the radi- al, ulnar, anterior and posterior tibial, and even from the brachial and femoral arteries. In the former or smaller arteries, by leaving the dress- ing on six or eight days, we may arrest the bleeding permanently, but in the latter it only acts as a provisional haemostatic ; it must be followed by ligation, if we wTish to be at all sure of avoiding a recur- rence of the bleeding. We may also employ compression in haemor- rhages from the thorax, as in case of parenchymatous haemorrhage after removal of a diseased breast; here we may dress the wound with compresses and charpie, and retain them in position by bandages around the thorax. But, for such a bandage to be efficacious, it must be very annoying to the patient; on the whole, it is better to ligate the bleeding arteries, even if there should be many of them; by so doing, both you and your patients will be better off, for you will not be worried and disturbed by the secondary haemorrhages followino- these operations as a result of hasty ligation and insufficient compres- sion. In some parts of the body you cannot employ compresses, as in bleeding from the rectum, vagina, or posterior nares. Here the tam- pon (from tampon, plug) is serviceable. There are many varieties of tampons, especially for haemorrhage from the vagina or rectum. One of the simplest is as follows: Take a four-cornered piece of linen about a foot square; placing the middle of this over two, three or five fingers of your right hand, pass it into the vagina or rectum, and fill the space left by the removal of your hand with as much charpie as you can get in, so that the vagina or rectum will be fully distended from within, and thus strong pressure tie made on its walls • when the haemorrhage is arrested, leave the tampon in till the next day, or lono-er if necessary, then remove it by gentle traction on the linen, which TREATMENT OB HEMORRHAGE—STYPTICS. 35 serves as a sac for the charpie. You may also make a ball of charpie or linen by wrapping a string around it, and leave a long string hanging out by which to remove it; as such a tampon may be either too large or too small, I prefer the first method, in which we may fill the linen sac to the extent we desire. If the bleeding come from the portio vaginalis uteri, after an operation, for instance, a more certain way is to hold back the poste- rior wall with a large Sims''s speculum, thus bringing the portio vagi- nalis into view, and press a tampon firmly against the bleeding part; for it requires an incredible quantity of charpie to fill the vagina of a woman who has borne many children, so that no blood can pass through, and it causes great pain. In profuse bleeding from the nose, which mostly comes from the posterior part of the inferior meatus, and not unfrequently from the posteriorly-situated cavernous tissue of the lower turbinated bone, plugging the nose from the front proves inefficacious and useless; the b^eding continues, and the blood either passes into the pharynx or flows out of the other nostril, as the patient presses the velum pen- dulum palati against the wall of the pharynx, and shuts off the upper part of the pharyngeal cavity. Hence, we must be prepared to plug the posterior nares; we may do this by the aid of Belloc's sound. This exceedingly convenient instrument consists of a canula about six inches long and slightly curved at one end; in the canula is a steel spring of much greater length, with a perforated button-head at one end. You prepare beforehand a thick plug large enough to fill the posterior nares, and have a thread attached to it. (You may make this plug by lay- ing threads of charpie side by side and tying them tightly together in the middle with a silk thread.) You apply this plug by passing the instrument, wTith retracted spring, through the inferior nasal meatus, then pushing the spring forward till it appears below the velum in the mouth. Pass the thread attached to the plug through the eye in the head of the spring, tie it there, and draw both canula and spring out of the nose ; the thread attached to the latter and the plug fast to this must follow, and if you draw tightly on the thread the plug is pressed firmly into the posterior nares; if the bleeding be now arrested, as it usu- ally is, if the plug (which should not be long enough for its end to reach the larynx) was not too small, you cut loose the thread, leave the plug in till the next day, then withdraw it by the thread left hanging from the mouth; this is usually easily done, as the plug is generally covered with mucus and is consequently smooth. As this instrument is not always at hand, we may use an elastic catheter or a thin slip of whale- bone for the same purpose, introducing it through the nose, seizing it 3G SIMPLE INCISED WOUNDS OF THE SOFT PARTS. with the finger behind the velum, and bringing the end out of the mouth to tie the thread to it. But the employment of this substitute requires more dexterity than is necessary for Belloc's sound. 3. Styptics are remedies which act partly by causing contraction of the tissue, partly by inducing rapid and firm coagulation. The num- ber of remedies recommended is immense; we shall only mention those that have a proved reputation under certain circumstances. Cold not only irritates the arteries and veins to contract, but also makes the other soft parts contract and thus compress the vessels; the current of blood is gradually more obstructed, and may even stagnate entirely, when the part is completely frozen. It seems to me, however, that the recommendation of cold as a haemostatic is often carried too far; I advise you not to rely on it too much. Cold may be employed as follows: first, we may squirt ice-water against the bleeding wound, or into the vagina, rectum, into the bladder through a catheter, into the nose or mouth—here the mechanical irritation of a strong stream of water is added to that of the cold; or you may lay pieces of ice on the wound, or introduce them into the cavities, or have them swallowed in gastric or pulmonary haemorrhage; or, lastly, you may fill a bladder with ice and apply to the. wound, to be left on for hours or days. The absolute quiet to be observed in all haemorrhages and the dim- inution in size of the arteries as a result of the bleeding that has already occurred, may often have more effect in arresting the haemor- rhage than ice has, while it receives all the credit. I will not dissuade you from using cold in moderate parenchymatous haemorrhages, but do not expect too much from it in bleeding from large arteries, and do not waste too much time over it, for time is blood—blood is life. The same is true of the common local remedies, vinegar, solution of alum, etc., which also contract the tisues and thus compress the vessels; they are very good for arresting capillary haemorrhages from the nose, but you must not expect any thing wonderful from them. The hot iron, ferrum candens causticum actuale, acts by charrino- the ends of the vessels and the blood, and the escape of the blood is arrested by the resulting firm slough. You only need to hold a rod of iron with a wooden handle at one end, and at the other a small iron head heated to a white heat, close to the bleeding spot, to form a black crust instantly; indeed, the tissue occasionally blazes up even from the radiated heat. A red-hot iron pressed on the bleeding spot has the same effect, but is apt to cling to the resulting eschar and pull it off again. This iron rod (cautery iron) is usually heated to the proper degree in a furnace with bellows. Under some circumstances the hot iron may be very convenient for arresting haemorrhage; formerly be- TREATMENT OF HEMORRHAGE. 37 fore ligation was known, it was the most celebrated styptic. The Arabian surgeons usually heated their amputating knives red hot a proceeding that even Fabricius Hildanus extolled, although he pre- ferred burning the bleeding arteries separately with fine-pointed cau- teries, in which he must have had an enviable expertness. Quite recently a similar method has been invented, namely, the use of platinum heated by the galvanic battery. This is the so-called galvano-caustic introduced into Germany by Middledorpf, which may/ sometimes be employed with advantage. As you may readily under- stand, in practice we have not always at hand an iron properly shaped for arresting haemorrhage, such as you see in the surgical clinics. Dieffenbach, the most talented German operator of this century, who was at the same time a most original man, once, lacking other means, being alone in a poor dwelling, arrested a haemorrhage following the extirpation of a tumor from the back, by means of the tongs which he heated in the stove. A knitting-needle, stuck in a piece of wood or a cork, and heated at the lamp, may answer the purpose of the hot iron. A remedy which not only equals, but occasionally surpasses, the hot iron in its effects, is liquor ferri sesquichlorati • this forms with the blood such a leathery, adherent coagulum, that it acts excellently as a styptic. To apply it, you press a piece of charpie, moistened with it, firmly against the wound; after having washed off the blood with a sponge, hold it there from two to five minutes; you will thus be able to arrest quite free arterial haemorrhage. If the first application does not succeed, try it a second or third time; this remedy will rarely fail you; but it makes a slough, behind which there is often sanious sup- puration mixed with gas-bubbles; hence we should not employ this styptic needlessly. The application of punk and blotting-paper to bleeding wounds is an old popular remedy; the punk sticks fast to the blood and the wound, if the bleeding be not excessive; in haemorrhages at all free it is useless without simultaneous compression ; occasionally it is very efficacious, and is highly praised by some surgeons. Dry charpie pressed firmly on the wound has the same effect, according to my experience. Other haemostatics are oil of turpentine and aqua Binelli, in which the creosote is chiefly efficacious; concerning the former alone have I any experience, and I recommend it strongly; when I studied in Gottingen, it was also specially recommended by my preceptor, Baum, and I used it once with such striking benefit in a doubtful case that I have a certain devotion for it. It is, however, an heroic remedy, not only because application of turpentine-oil to a wound induces severe pain, but also because it excites severe inflammation in the wound and its vicinity. I will relate the case where I employed it ',6 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. A young, feeble woman suffered, after confinement for many months, from an extensive suppuration behind the right breast, between the mammary gland and the fascia of the pectoral muscle; numerous inci- sions had already been made through the breast, and about its circum- ference, to give free access to the pus which formed in such quantities; but the openings soon closed again, and new ones had to be made, as the wound did not heal from below. From one such incision, which I made quite extensive, severe haemorrhage resulted, blood welled up from the depth of the abscess, and I was unable to find the bleeding vessel; it flowed continuously, as if from a spring. First, I filled the cavity with charpie and applied a bandage; the blood soon oozed through this dressing; I removed it and injected ice-water into the various openings; the bleeding moderated. I again made firm compres- sion, and the haemorrhage seemed arrested. I had scarcely reached my room in the hospital when I was called by the nurse, because the blood again oozed through the dressing; the patient had fainted, was pale as a corpse, and the pulse was very small. The bandage had to be removed at once. I now thrust pieces of ice through the different openings into the cavity under the breast; still the bleeding was not arrested. The patient wTent from one fainting-fit into another, the bed flowed with blood and ice-water, the patient lay unconscious, with cold limbs and upturned eyes, the nurses constantly trying to resuscitate the patient by holding ammonia to the nose, and rubbing the forehead with Cologne water. At the commencement of my surgical life, unaccus- tomed to quiet and presence of mind in such scenes, caused by my own act, I shall never forget this situation. I thought it would be abso- lutely necessary to amputate the breast at once, to find and ligate the bleeding artery, but determined to make one more attempt with oil of turpentine. I soaked a few wads in this substance, introduced them into the wound, and the bleeding was instantly arrested. The patient soon revived; the turpentine, which was left in twenty-four hours, caused intense reaction in the abscess cavity, whose walls be- came detached. Subsequent active granulation induced in three weeks a cure which had for months been patiently and perseveringly sought in vain by physician and patient. I cannot explain to you how bleed- ing is arrested by oil of turpentine and creosote; they do not cause particularly firm coagulation of the blood; probably the intense irrita- tion they induce excites a peculiarly energetic contraction of the di- vided capillaries. You will rarely see styptics employed in the surgical clinic; they are rather favorites of the practising physician, who is not accustomed to ligate arteries. Where we can ligate or compress, we should not TRANSFUSION OF BLOOD. 39 use styptics. In parenchymatous bleeding from the face, neck, or perinaeum, we may resort to styptics with advantage, if it makes'no difference whether the wound suppurates subsequently; but, if the haemorrhage be considerable, and styptics fail, subsequent ligation is much more difficult, as the wound is often terribly smeared up by the previous applications. In surgery you have nothing to expect from the internal adminis- tration of remedies recommended as styptics. Absolute quiet, keeping cool, narcotics, purgatives, may occasionally be of great assistance in congestive haemorrhages, but their action is far too slow for the bleed- ing that we have to deal with in surgery. The general debility from profuse haemorrhage will, of course, be most effectually combated by arresting the bleeding; but, while doing this, you may have the assistants, not otherwise employed, try to resuscitate the patient by smelling-salts, sprinkling with water, etc. You should not yourself join in these attempts, till the bleed- ing is stopped; then you may give wine, rum, or brandy, warm coffee, or soup; cover the patient up warmly ; let him take a few drops of spir- its of ether or acetic ether, and smell ammonia, etc. I have never had a patient bleed to death under my hands, but have met two cases where the patients died, two and five hours after extensive operations, with dyspnoea and spasmodic contractions, apparently as a result of the great loss of blood; these cases have decided me, under similar circumstances, to inject the blood of a healthy person into the veins of the bleeding one. This operation, which is called Transfusion, is quite ancient; it originated in the middle of the seventeenth cen- tury. After the world had been for a time astonished at its boldness, it was laid aside and derided, but, toward the end of the last century, it was again drawn from the shade of oblivion by English physicians, es- pecially the obstetricians. After Dieffenbach had made some attempts again to introduce transfusion into Germany without success, Mar- tin has of late the credit of again calling attention to it as a mode of saving life, while Panum has exhaustively treated the subject in physiological experiments. Statistics show that the operation was favorable in the great majority of cases, and was very easy to per- form. Although formerly lamb's blood was successfully injected into man's veins, it is best and most natural to choose blood from a young, healthy, and strong human being. The instruments required are a knife, forceps, scissors, a fine canula,.and a 4-6 oz. glass syringe to fit it. We open the vein of a healthy, strong young man, in the man- ner hereafter to be described, and receive first about four ounces of the blood in a rather high bowl, standing in a basin full of blood-warm water; the blood, flowing into the bowl, is beaten with a twirling 40 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. stick, till the fibrine is separated. While this is being done, the most perceptible subcutaneous vein at the bend of the elbow of the patient is to be exposed by an incision through the skin; then two silk threads are to be passed under it, the lower one is drawn on without closing it, so that no blood may escape by the subsequent fine oblique incision made in the vein by the scissors. The canula is passed up into the now gaping opening in the vein, and the upper thread is crossed over it without being tied ; some blood should escape through the canula, so as to fill it and drive out the air. Meanwhile, the as- sistant has completed the venesection and filtered the whipped blood through a fine cloth; then the previously-warmed syringe is to be filled with the blood inverted and the air forced out, placed firmly in the canula, and the blood injected very slowly. Experience has taught that it is not advisable to inject more than four to eight ounces of blood, and that this is enough to recall life. We should never empty the syringe entirely, and cease at once if the patient has dyspnoea. When the injection is completed, we remove the ligatures and canula, and treat the wound as after venesection. There has been much dis- pute, as to whether or not it is necessary to remove the fibrine from the blood to be injected. PanunrCs experiments have clearly proved that fibrine is not necessary in resuscitation by transfusion, and that, even with the greatest care, it may act injuriously by clotting. The active element in this operation appears to be the introduction of blood-cor- puscles as bearers of oxygen. Possibly, transfusion has a still wider future; at all events, it might be worth while to try it in excessive anaemia, resulting from other, sometimes unknown, causes, even al- though, according to Panum's excellent observations, the blood itself does not nourish, but is only the bearer and forwarder of nourish- ment. The experiments made by NeudOrfer, during the last Italian War, on the wounded wrho had become anaemic from profuse suppura- tion, had no brilliant results, it is true, but further trials should be made of this operation, which with proper care is not dangerous. Hueter has studied transfusion most thoroughly of late; he recom- mends injecting beaten and filtered and filtered venous blood into an artery (such as the radial or posterior tibial) in a peripheral direction, just as was once done by Von Graefe. As Hueter has demonstrated that this arterial transfusion is easier than the venous, it deserves the preference, because by it we avoid the danger of pulmonary emboli. No abnormal symptoms occurred where Hueter operated on the hands and feet; but I doubt if it would often be possible to introduce a canula into these small arteries in a patient bleeding to death • in such a case we should have to choose the brachial artery. The enormous increase of bodily temperature, the occurrence of GAPING OF THE WOUND. 41 bloody urine, and other symptoms, following this operation, show that it has a very decided influence on the physiological action of the organism. As this operation has always been performed in vain by myself and my assistants, I am much less in favor of it than formerly, wheti I only knew it from the accounts of others. I cannot here enter on the treatment of the later results of con- siderable haemorrhages; it will be evident to you that, in general, the chronic effects, the deficient formation of new blood, must be com- bated by strengthening and nourishing diet and medicines. LECTURE 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. After entirely arresting the haemorrhage from a wround, cleaning its surface with cold water, and satisfying yourself of its depth, and of the character of the parts divided, in doing which you must notice whether a "joint, or one of the cavities of the body, has been opened, a large nerve divided, or a bone exposed or injured, etc., you will turn your attention to the third symptom in the fresh wound, that is, its gaping. On division, skin, fascia, and nerves, will separate, partly from their own elasticity, partly because they are attached to the mus- cles, which, from their contractility, shrink together immediately after being divided, and whose cut surfaces, consequently, especially in transverse wounds, are more or less separated. At first we shall consider only those incised wounds where there has been no loss of substance, but only a simple division of the soft parts. . For such a wound to heal quickly, it is desirable that the two edges should be brought exactly together, as they were before the injury; to accomplish this, we make use of strips of adhesive plaster or of sutures. In wounds where the cutis is scarcely divided, as so often happens in the common incised wounds of the fingers, we may use isinglass- plaster with advantage. It consists of a solution of ichthyocolla in water, mixed with a little spirits of wine, painted over a thin, firm silk stuff or paper; the back is often painted with tincture of benzoin, which gives the plaster a pleasant odor. As the plaster readilj lo-is 42 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. ens under moist compresses, it is often advisable to paint it with col- lodion, after it has dried. Collodion is a solution of gun-cotton in a mixture of ether and alcohol. If this fluid be painted over the plaster and the skin immedi- ately adjacent, the ether quickly evaporates, and a fine membrane in- soluble in water remains, often puckering up the skin. A further therapeutic use may be made of this contractile action of collodion, by painting it on the inflamed skin, either directly, or, still better, after covering the part with a thin, coarse-meshed cotton-cloth (gauze); this causes moderate, even pressure. When you use collodion to fasten the plaster, avoid applying it directly to the wound; this not only causes unnecessary pain, but may also induce inflammation and suppuration of the wound, which should be particularly avoided. If the cutis be divided, and the plaster must resist any considera- ble tension in keeping the edges of the wound together, ichthyocolla- plaster proves insufficient, and adhesive plaster must be employed. Of this we have two varieties, besides innumerable modifications, from attempts to make it cheaper and better. Emplastrum adhaesivum, emplastrum diachylon compositum, our common adhesive plaster, con- sists of olive-oil, litharge, resin, and turpentine. While it is fluid from heat it is painted on linen, and it is generally used in strips, which are laid over the wound, and hold its edges together. When fresh, this plaster adheres excellently, but loosens after a time, if'moist com- presses be applied over it. Very sensitive skins are irritated by this plaster if it is frequently applied; then we may resort to the other adhe- sive plaster, the emplastrum cerussm (emplastrum adhaesivum album), which is prepared from olive-oil, litharge, and white lead, with hot water. This plaster adheres less firmly, but has the advantage of smearing the lips of the wound less than the yellow plaster. A mix- ture of equal parts of the two plasters lessens the objections and com- bines the advantages. In large wounds we now avoid the use of adhesive plaster more than formerly, and in its place employ the suture more commonly. When we wish to unite wTounds by the suture; we generally choose between two varieties, the interrupted (sutura nodosa) and the twisted suture (sutura circumvoluta). There is some truth in the assertion that, by the introduction of a foreign body, such as a thread or needle, we maintain constant irritation in the edges of the wound but this cannot equal the great advantage obtained by the certainty of ad- justment of the edges of the wound by means of sutures. Hence, except adhesive plaster, almost all substitutes for the suture in which ancient and modern surgery has exhausted itself, after beino- fashion- UNION OF WOUNDS—SUTURES. 43 able for a time, have been thrown aside. The suture has not yet been dropped, and probably never will be, any more than ligation. There are certain parts of the body, as the scalp, hands, and feet where we try to avoid sutures, because there certain inflammatory processes, which have often been ascribed to the suture, readily assume a dangerous character; but I think there is a good deal of prejudice in this. Wounds of the head are especially prone to cause inflamma- tions of the skin and subcutaneous tissue; extensive statistics have never shown whether this tendency is particularly increased by the irritation from sutures. There are many articles of faith handed down from preceptor to pupil, from one text-book to another; many of them are a sort of Hippocratic traditions, full of practical truth ; to these I pay full respect; others are based on accidental observations and consequent judgments ; among the latter, I class the objection to sutures in scalp-wounds. Reviewing my own experience, I remember more cases of inflammation following wounds where no sutures were introduced than where they were. It is very important, however, at once to recognize inflammations beginning in the head, and to remove the sutures. The amount of gaping and the forms of the wound (e. g., a flap-wound or not) at once show the necessity for sutures. One would never take any unnecessary trouble in introducing sutures, un- less urged by excess of surgical zeal; but where, for the reasons above given, adhesive plaster will not answer, we should employ sutures. For the interrupted suture we use surgical needles and silk thread or wire. Surgical needles differ from ordinary ones, in having a lance- shaped, ground point, which pierces the .skin more readily than the round point of a sewing-needle; they are also of somewhat softer steel than English sewing-needles, so that they do not spring so much. Their thickness and length vary greatly, according as we wish to apply a strong thread deeply where the edges of the wound are tense, or only to use a fine thread to bring the edges together ex- actly. All needles should, however, have a good-sized eye, so that we may not, like a tailor, lose time in threading them, but do so readily and quickly. The needle may be either straight or curved. The curve should vary with the locality where we wish to sew; for in- stance, very fine, strongly-curved needles are required for sewing about the inner canthus of the eye; large, strongly-curved needles are needed for sewing up a perinaeum, ruptured during labor, etc. The curvature may either be in the whole needle or only at the pointed end; for instance, for certain operations, it is shaped like a fish-hook ; the variety is very great. For sewing such wounds as usually present themselves in practice, you need only a few fine and coarse straight and variously-curved needles. 44 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. The thread is usually of silk, whose coarseness corresponds to the size of the needle. Formerly I always sewed with the red German silk, which has long been used for this purpose; but in England I found a sort of undyed, strongly-twisted silk, which, even when very fine, is so strong that, with thread as fine as a hair, we may sew up wounds and draw them together. Moreover, this silk imbibes so little moisture that it may lie for days in the wound without swelling or ir- ritating. Now I use only this so-called Chinese silk. Another mate- rial for sutures has been lately used in England and America, viz., silver or iron wire. It must be very fine and soft; the iron wire for this purpose is well annealed. The trial of this material was first induced by the long-known fact that, when metals were introduced under the skin or anywhere in the body, they usually excited no suppuration, but the parts often healed over them. Hence, it was thought that the inflammations often occurring at the points of suture might be avoided by using metal instead of the animal substance silk. In truth, it cannot be denied that this suppuration is less apt to occur from metal than from silk thread, still experiments of Simon have shown that the suppuration from sutures depends greatly on the thick- ness of the thread. From my own experience I can affirm that fine silk threads cause as little suppuration along the course of the suture, and may heal in, just as well as metal ones. We come now to the application of the interrupted suture. You do it as follows : with a toothed forceps you first seize one lip of the wound; pass the needle through the skin, about two lines from the edge, as deep as the subcutaneous tissue, and bring it out through the wound; now seize the other lip of the wound with the forceps and pierce it from the wound up towTard the skin, exactly opposite the first point of entrance, then draw the thread through and cut it off, leaving both sides long enough to tie readily in a knot. Now make a simple, or, if the tension of the borders of the wound be great, a surgeon's knot, and draw it tight, seeing that the edges of the wound are in exact apposition; then make a second knot, and cut off both threads, close to the knot, so that no long ends of thread may get in the wound. Should you desire to use wire, you thread it as you do the silk on the needle, draw a short portion through the eye and bend it then make the suture as above described. When the wire is very soft we can tie a knot with it nicely, just as with a silk thread- still the whole of this manipulation is much less pleasant with wire than with silk thread, and on closing the knot the border of the skin is readily displaced, or there may be twists, that render the hold less secure • UNION OF WOUNDS. 45 this is especially apt to happen with our German wire, which has not yet attained the softness of the English. The pleasantest wires are those made of a mixture of gold and silver and of platinum, of which very fine, pliable, and, at the same time, firm wire may be made. [Very nice wire is made of lead, and it is supposed by some to be an advan- tage that this will break if the parts should swell excessively.] Still, how ridiculous it would be to try to substitute these expensive articles for ordinary silk, by which millions of wounds have been healed excel- lently, and will be in future ! I pass over the many newly-recommend- ed modes of fastening the wire by knots or twisting; they show that even those who advocate metallic sutures have found some trouble in fastening the knot. I first make a simple knot, draw it together, make two or three short twists, and cut off the ends close to the twisted part. Wire cuts the edges of the wound, just as silk does, if it be very fine. I have rarely found the little objections to silk sutures sufficiently annoying to make me often replace them by metal sutures. I only consider the latter preferable exceptionally; of this we shall speak more in individual cases in the clinic. Formerly great pains were taken to replace silk by other substances, such as fine catgut, horse- hair, etc., but these attempts met with little success; hence, for the present, we will be satisfied with silk. Straight needles may be best introduced with the fingers; but curved needles, especially when they are small or the wound deeply seated, are introduced better and more certainly by means of a needle- holder. There are numbers of these; I am in the habit of using DieffenbacKs. It consists of a forceps with short, thick blades, be- tween which we hold the needle firmly and securely, and introduce it through the skin in the direction of its curvature. This perfectly sim- ple instrument suffices for almost all cases, and in good hands is sur- passed by no instrument for security in holding and introducing the needle. Complicated instruments are especially suited for unskilful surgeons, says Dieffenbach, in the unparalleled introduction to his Ope- rative Surgery; not the instrument, but the hand of the surgeon, should operate. Practice and habit render this or that instrument indispen- sable. Thus some find it complicated and inconvenient to seize the lips of the wound with forceps, as I taught you, although this is bet- ter than holding them with the fingers; for me, the latter would be very inconvenient. In this matter any one may do as his habits and inclination lead him. When I have to sew some deep part—as the velum, rectum, or vagina—I always use needles with handles. Of course the number of sutures to be applied depends on the 43 SIMPLE INCISED WOUNDS OF THE SOFT PAKTS. length of the wound; generally sutures half-an-inch apart suffice, but where perfect apposition and small cicatrices are very desirable, as in wounds of the face, they must be closer, and should alternate between coarse ones at a distance from the edge of the wound, and fine ones enclosing but a small portion of the edge. The second variety of suture, twisted or hare-lip suture, is made by passing a long pin with a lance-shaped point through the flaps of the wound, and passing a strong cotton or silk thread around it, as I now show you. You take the thread in both hands, lay it parallel to and immediately over the pin, that is, transversely to the wound, pass it under the two ends of the pin from above, and draw on it, so as to approximate the edges of the wound exactly (this is the so-called Nulltour) ; now you change the threads to the other hands, and, with the right thread in the left hand, pass around the left end of the pin from above downward, and, with the left thread in the right hand, do the same for the right end of the pin; you change the threads again and make four to six similar, so-called figure of eight turns; then tie a double knot and cut the ends off close; then cut off the ends of the pin to a proper length, so that they may not press on the skin, but not so short as to prevent their being readily withdrawn subsequently. There are a great number of other sutures, which for the most part are only of historical interest, and which we here pass over; some peculiar forms of suture will be treated in special surgery, under wounds of the different parts, as in wounds of the intestine. Where are the advantages of the twisted over the interrupted suture ? and when do you employ it ? These indications may be re- duced to two factors, so that you will consider the interrupted suture as the simpler and more common. The twisted suture is preferable— 1. When the flaps of the wound are very tense; 2. When the skin- flaps to be united are very thin and without support—in short, where the lips of the wound have a tendency to roll in. The needle, remain- ing in position in both cases, renders the suture more secure and firm; the needle serves as a sort of subcutaneous splint for the edo-es of the skin ; they are supported by it, and are also held more securely by the folds of thread on the outside. In many cases, in apply in o- sutures in the face, the interrupted and twisted sutures are applied alternately • the latter serve as supports and to resist tension, the former to in- duce more exact union of the edges of the wound. y^ When the bleeding has been stopped and the wound united all ^ has been done that is at first necessary. Now let us observe what takes place in the closed wound. UNION OF WOUNDS. 47 Immediately after being united, the edges of the wound are Gener- ally white, from the pressure exercised by the sutures as they com- press the capillaries; rarely the borders of the wound are dark blue • this always indicates great impediment to the return of blood throuo-h the veins, due to a loss of part of the blood-vessels. It is evident that the communication between arteries and veins may be greatly disturbed by the division of a large number of capillaries, so that at some point in the border of the wound the vis a tergo of the venous stream shall be insufficient. On the whole, this dark-blue color of the flaps of the wound is rare; it either disappears spontaneously or a small portion of the lip of the wound dies, a symptom to which we shall return when speaking of contused wounds, in which it is quite common. Even after a few hours you find the borders of the wound slightly swollen and occasionally bright red; this redness and swelling are often absent (especially where the epidermis is thick), but occasionally, according to the extent and depth of the wound and tension of the skin, it spreads from two or three lines, or to as many inches, around the wound ; the usual so-called local reaction about the wound takes place in this space. The wound pains slightly, especially on being touched. All this may be best seen in children and women with delicate skin. About wounds of the face, especially of the eyelids, we often notice extensive oedema in twenty-four hours; this fre- quently terrifies the friends, but is usually free from danger. In a considerable number of cases, if the sutures be not too tightly applied, the edges of the wound appear unchanged not only at the time, but till the cure is complete. But often enough the wound shows the cardinal symptoms of inflammation; pain, redness, swell- ing, and increased heat, of which you may satisfy yourself by placing your finger on the parts about the wound, then on a distant part of the body. The process going on at the wound, and ending in the union of its edges, comes under the combination of morphological and chemical metamorphoses comprised by the name inflammation, and, in the case under consideration, would be termed traumatic inflam- mation, that is, an inflammation caused by an injury (rpavua). As a rule, these focal symptoms have reached their height in twenty-four hours; if by that time they have not exceeded the above bounds, you consider the process as taking a normal course. It is a marked peculiarity of traumatic inflammation,that,in a pure form, it is strictly limited to the borders of the wound, and does not extend without special cause. It is not unusual for these symptoms to remain at the same height the second or even the third day ; but by the third or fifth day, the redness, swelling, pain, and increased temperature. 5 48 SIMPLE INCISED WOUNDS OF THE SOFT PARTS should have disappeared mostly or entirely. If the symptoms still increase the second, third, and fourth days, or if some of them, as se- vere pain, and great swelling, recur at this time, or if they remain at the same point to the fifth or sixth day, it is a sign that the course differs in some way from the normal. This will be especially evident from the general condition of the patient. The whole body reacts to an irritation of one part of it, not in a perceptible manner, in small wounds, it is true. We shall refer to this general reaction at the close of this chapter. At present, we shall consider exclusively the condi- tion of the wounded part. The third day, often indeed on the second, you may carefully re- move the pins of the twisted suture, provided you have also applied interrupted sutures; this is best done by seizing the needle with Dieffenbach?s needle-holder, and rotating it gently, while fixing the twisted threads with one finger. The threads usually remain as a sort of clamp on the wound, to which they are attached by dried blood; they subsequently loosen spontaneously; by forcibly detach- ing the thread, you would unnecessarily strain the wound, and possi- bly tear apart the freshly-united edges. If at this time we carefully feel the edges of the wound—if the oedema has subsided—we find them rather firmer than parts around; this state of firm infiltration sooner or later disappears. When you have applied many stitches, you may remove some of them, that have little to hold, on the third day; others, on the fourth and fifth. At the tensely-stretched parts of the skin it is well to leave a few threads for eight days or more, or even leave them till they cut through the flaps of the wound, provided it can do any good to hold together the edges of the wound, which may be gaping open. Should the inflammation quickly exceed the normal amount, we must remove the sutures earlier, so that they may not increase the irritation ; not unfrequently blood, that is decomposing or mixed with pus, at the bottom of the wound, is the cause of the unusual irritation. In removing the interrupted suture, you should take the following precautions : cut the thread on one side of the knot, where you can most readily introduce the thin blade of the scissors without stretching the wound; then seize the thread at the knot with a dissecting for- ceps, and draw it out toward the side where it was divided so as not to separate the edges of the wound by the traction. Should you think that, after removing the suture, the union of the wound is still too weak to prevent its gaping, you may, by applying strips of ichthyocoUa-plaster transversely over the wound between the points where the sutures were, and fastening the ends (not the part UNION OF WOUNDS. 49 over the wound) with collodion, give support enough to prevent ten- sion of the flaps of the wound, such as unavoidably occurs in changes of expression in the face. In from six to eight days, most simple incised wounds have adhered firmly enough to require no further support; indeed, in many cases, this is the case by the second or fourth day. If, in the course of the following days, the dry blood about the wound be carefully washed off, the young cicatrix appears as a fine red stripe, a scarcely visible fine line. This process of healing is called healing by first intention. In the course of the subsequent months, the cicatrix loses its red- ness and hardness, and finally becomes perceptibly whiter than, and as soft as, the skin ; so that for years it may be recognized as a fine white line. It often disappears almost entirely after some years. Some of you, who left the university with many still visible cicatrices on the face, may hope that they will be scarcely visible in six or eight years, when the Philistine visage will become you less than it does the stu- dent. Tempora mutantur et nos mutamur in illis. LECTURE 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. Gentlemen : You are now acquainted with the changes, visible to the naked eye, that take place in the wound while it is healing; let us now try to see what occurs in the tissues from the time of wound- ing till the formation of the cicatrix. For a long time, attempts have been made to study and know these changes more thoroughly, by making wounds in .animals, and examining them at the different stages; but it is only the most exact microscopic examination of the tissue, and the direct observation of the changes after wounding, that have enabled us to give a description of the process of healing. I shall attempt to give you a brief resume of the result of these investi- gations, which, until recently, I have made my special study. The interesting results thus arrived at have in a great measure brought it about that by " inflammation " we now mean generally the series of changes which we perceive on microscopic examination. Of .ate we are accustomed to consider these morphological processes as 50 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. the essential part of the inflammation, and to term their occurrence and typical course the " inflammatory process." I would not weaken your interest in these things at the outset; but the prevailing tenden- cies render it necessary for me to call your attention to the fact that (as in all organic growth, and in each transformation of the tissues of the body) form is always the product of chemical or physical power inherent in the material supplied; the inflammatory, like every other physiological process, is chemico-physiological; this we never see, even with the best microscopes; we merely perceive the results of its action. These results, destruction and new formation of tissue, have something peculiar in their typical course; but they vary as widely as life and death; the tissue may die suddenly or not for years ; of two neoplasia of the same structure, one may form in a few days, the other may require months; very different causes may induce very similar new formations. But I dread confusing you, if I enter further into the difficulties always arising when we speak of inflam- mation in general. So let me go at once into detail; and we will hereafter return to the general question of inflammation. The changes after injury of the different tissues are particularly seen in the vessels, in the injured tissue itself, and in its nerves. The influence of the latter on the process is, however, so obscure, that we shall not consider it. We shall at once dismiss as unanswerable the question, whether the finest nutrient (vasomotor) nerves, which lose themselves in the different tissues (for the question can only arise con- cerning these), have any direct influence on the changes occurring in the tissues, and in the vessels themselves; and the rather so, as the ends of the nerves have only been certainly recognized in a few parts of the body, while for other parts it is entirely unknown how the nu- trient nerves act, and what relation they have to the capillary vessels. You will have already had your attention called to the imaginable pos- sibilities and probabilities on this point, in the lectures on physiology and general pathology. Hence, if we say but little about the nerves in what follows, it is because we know little of their action in this special process, not because we wish to deny their influence. Let us first consider the simplest tissue; let us suppose a vertical section, through the connective tissue, with a closed capillary system at the surface of the skin, magnified 300-400 times. Here you have a diagram of such a system. Let there be an incision down through the tissue; the capillaries bleed, the bleeding soon ceases, the wound is accurately united. Now what takes place ? The blood coagulates in the capillaries as far as the next branches, UNION OF WOUNDS. 51 to the next points of intersection of the capillary net-work. Some co- agulated blood/usually remains also between the flaps of the wound; Fig. i. Diagram of connective tissue, with capillaries. Magnified 300-400. we have omitted this in Fig. 2, so as to have the simplest possible rep- resentation of the changes. Of the channels for the circulation in our diagram, some have become impassable; the blood must accommodate itself to the existing by-paths—of course this takes place under a heavier arterial pressure than previously; this pressure is greater the greater the obstruction to the circulation, and the less numerous the by-paths (of the so-called collateral circulation). The result of this increased pressure is the distention of the vessels (which, however, is usually much greater than could be represented in the diagram), hence the redness about the wound, and to some extent also the swelling. But the latter also has another cause: the more the capillary walls are distended, the thinner they become ; if under the ordinary press- ure, with normal thickness of their walls, they permit blood plasma to pass to nourish the tissues, now under increased pressure, more plasma than normal will pass through the walls, which saturates 52 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Fig. 2. Diagram of incision.—Capillaries closed by blood-clot Collateral distention. Mag- nified 300-400. the injured tissue, and which the latter absorbs by its power of swelling. This is a brief explanation of the perceptible changes in the borders of the wound, the redness and increased heat caused by the rapid development of the collateral circulation, by which more blood flows through the vessels nearer the surface; the swelling is caused by the distention of the vessels and swelling of the tissues, wdiich again induces slight compression of the nerves, and this excites some pain. This, as it seems to me, very simple mechanical explanation, would be much more valuable, if it fully explained the whole subsequent course, and could be applied to all inflammations, which are not of traumatic or'mechanical origin. But this is not the case. Neithei the great vascular distention that occurs some time after injury, that bIiows itself in extensive redness around the wound, nor the capillary dilatation that exists from the first in idiopathic inflammations, can be referred to purely mechanical causes. * UNION OF WOUNDS—IRRITATION. 53 If the disturbance of circulation through the incision be not ex- tensive, it passes off very rapidly; these so-called passive hyperopias are not exactly inflammations ; their extent accurately corresponds to the mechanical conditions, while in regular inflammations the redness often extends far beyond the point where the circulation is mechani- cally impaired. We do not call it inflammation till irritation of the tissues accompanies, or in fact arises from, the capillary distention. Such irritations, causing dilatation of the capillaries, are numerous; we shall here speak only of the mechanical ones. You now see my ocular conjunctiva of a pure bluish white, like that of any normal eye. Now I rub my eye till it weeps, and the conjunctiva becomes reddish; perhaps with the naked eye you may see some of the larger vessels —with a lens you will also see the finer vessels, full of blood. After five minutes at most, the redness has entirely disappeared. Look at an eye where a small insect has accidentally gotten under the lid, as so often happens ; the person rubs, the eye weeps, and becomes quite red; if the insect be removed, in half an hour you will probably see nothing noticeable about the eye. Here you have the simplest obser- vation how vessels dilate on irritation, and empty again soon after the cessation of the irritation. What is the immediate cause of this symptom ? Why do not the vessels contract instead of dilating ? These questions are as difficult to answer as the observation is easy to make, and to repeat innumerable times, with the same result. The fact itself has been known as long as man has observed; the old say- ing " ubi stimulus ibi affluxus " refers to this. The increased flow of blood is the answer of the vascular part to the irritation. Of late, the process inducing this redness is called active hy- peremia or active congestion. Virchow took up the old name, and made "fluxion and congestion " again popular. Assisted by your knowledge of general pathology, you will now perceive that it is desirable to give a theoretical explanation of symptoms which, through all time, have formed one of the most im- portant objects of consideration in medicine, particularly as the pro- cess of inflammation is always considered as closely allied to this ac- tive congestion, or indeed even considered as always a sequent of the latter. Astley Cooper, a celebrated English surgeon, whose works you will read with pleasure, when you take up the study of mono- graphs, a thoroughly practical surgeon, begins his lectures on sur- gery in the following words: "The subject of this evening's lec- ture is irritation ; which, being the foundation of surgical science, you must carefully study, and clearly understand, before you can expect to know the principles of your profession, or be qualified to practise it oreditably to yourselves, or with advantage to those who may place themselves under vour care." 54 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. This will show you what part the questions to-day under con- sideration, which you might regard as a superfluous exercise of the mind and imagination, have played at various times; you will here- after learn, from the history of medicine, that entire systems of medi- cine, of the greatest practical importance, are based on hypotheses that were formed for the explanation of this symptom in the vessels, of this irritability and of irritability of the tissues generally. This is not the place to enter into a thorough historical considera- tion of this question; I will only call to mind a few hypotheses which have been advanced lately, under the already-existing knowledge of the vessels and parts visible to the naked eye, concerning the occur- rence of vascular dilatation from irritation. From histology and physiology, you know that, until they pass into capillaries, the arteries and veins have transverse and longitudi- nal muscular fibres in their walls, and that in general these are more scanty in veins than in arteries, although this varies greatly. Now, although it may be very difficult to make direct observations of the effect of irritation on these smallest arteries and veins, it is very simple to see its effect in the intestine, where we have essentially the same conditions, namely, a tube provided with longitudinal and transverse muscular fibres. But, irritate the intestine as you may, you will never induce dilatation at the constricted part, but only a shortening or con- striction and a consequent motion of the contents of the intestine, whose rapidity will depend on the frequency of the repetition of the contractions. But can dilatation of the capillaries be induced by such increased rapidity of motion of the vessels and blood ? Certainly not. In the general pathology of Lotze, the celebrated medical philosopher of Gottingen, you find some remarks which are so apt, and, like all the chapters on this subject, so well show the brilliant genius and critical acumen of the writer, that I shall make use of his expressions. He says : " Pathologists who seek to explain congestion by increased con- traction of the arteries, assume the thankless task of the Danaides; they cannot show the stopper that prevents the escape of the blood that is pumpel in with so much difficulty. Over-fulness results if more is introduced and the same amount escapes, or if the same quantity is introduced but less escapes. If we suppose a portion of a vessel to contract more actively and rapidly, it will have as little ten- dency to induce increased afflux or diminished efflux of blood as the stamping of a person in a river would to regulate the amount of water." This refuted hypothesis, of the dilatation of the capillaries depend- ing on more rapid and energetic contraction of the arteries was at least based on known observations ; but Lotze's explanation on the contrary, is so far from all analogy, I might almost say so metaphysi- UNION OF WOUNDS—IRRITATION. 55 cal, that we cannot attach any value to it. Lotze asserts that there is no objection to the supposition that capillaries are affected differently from arteries by irritation; by nervous influence they may expand ac- tively on irritation, by their molecules separating. But this view ia pure hypothesis, which not only has no analogy, but is even opposed to recent observations. It is well known that, with the microscope, we can follow the circulation in the smaller arteries and veins, as well as in the capillaries of the web in the foot, in the mesentery and tongue of the frog, or in the wing of a bat; but the immediate effect of a mild chemical or mechanical irritant does not at once show in the capillaries, but first in contraction of the smaller arteries, occasionally also of the veins ; this is very evanescent, of scarcely a second's dura- tion, indeed, it often escapes observation, and we then suppose that its duration and grade are too slight for us to measure. This brief contraction is followed by the dilatation, whose immediate cause is indistinct even on microscopical observation. We shall soon see that this is insufficient, that the fluxion is the result of paralysis of the ves- sels, active as the symptom appears. Even the recent very interest- ing observations of Golubew, who had the kindness to show me that the capillaries of the nictitating membrane of the frog contract trans- versely, as the result of strong electrical shocks, did not appear to me, on thinking the matter over, to apply perfectly to the question of fluxion. Virchow appears to think that the irritation, which is certainly the immediate cause of the contraction, is followed by quick fatigue of the muscles of the vessels; that after a tetanic contraction there is a relaxation, just as in irritated nerves and muscles—a view which may find some support in a communication from Dubois-Beymond about the painful tetanus of the muscles of the vessels in the head as a cause of headache on one side, so-called hemicrania, since this sup- posed tetanus of the muscles of the vessels, induced by strong excite- ment of the cervical portion of the sympathetic, was certainly followed by their relaxation and great distention of the vessels, and shortly by symptoms of cerebral congestion. But, in this view (by which a relaxation or temporary paralysis of the walls of the vessels and a consequent decrease of their resistance to the pressure of the blood would, it is true, be explained as a se- quent of their contraction), we must not forget that it is by no means proved that the muscles of the vessels, once irritated and excited to rapid contraction, are indeed paralyzed, while in other muscles this fatigue usually occurs only after repeated irritation. It is necessary arbitrarily to assume that the muscles of the vessels very readily be- come fatigued, which is directly refuted by experiment. From physi- 56 SIMPLE INCISED WOUNDS OF THE SOFT PARTS ology you know that Claude Bernard has proved that the contrac- tions and dilatations of the arteries of the head are under the influ- ence of the cervical portion of the sympathetic nerve, as I have al- ready indicated. If we irritate the upper cervical ganglion of this nerve, the arteries contract; if we divide the nerve, there is dilatation (paralysis) of the arteries and capillaries. This experiment of irri- tating the muscles of the vessels may be often repeated, without their becoming quickly fatigued, unless the electrical current be too strong; hence we might imagine that there is little probability in the hypoth- esis of immediate fatigue after a single irritation. Schiff, however, like Lotze, assumes that active dilatation of the vessels is possible; he thinks that this necessarily follows from certain experiments; but this is perfectly incomprehensible to me, for there are no muscles that could actively dilate the vessels. If the veins alone contracted on being irritated, filling of the cap- illaries would doubtless follow the obstruction, and there would then be no difference between venous (passive) hyperaemia and fluxion. But this supposition is quite untenable; it is perfectly incomprehensi- ble that the veins alone should contract on inflammatory irritation. That the veins contract on mechanical irritation, you may see in the femoral vein of an amputated thigh, to which Virchow has called particular attention, and this irritability lasts even longer in the walls of the vein than in the nerves. Henle already advanced the view that the symptom of distention of the vessels from irritation was directly caused by paralysis of their walls; when Lotze, in opposition to this, says that it is not supposable that there should be paralysis of the muscles in a man who is exces- sively irritated and has his muscles tense and his face glowing, his objection is not perfectly tenable. Nor does the other objection of the usually acute Lotze appear to me correct when he says, " What shall we think of paleness, of the contraction of the vessels that results from fright and terror ? Does that look as if due to great muscular action, if redness in anger and shame is induced by paralvsis ? " I say this proves nothing. Fright may throw the muscles into a tetanic state, which is usually quickly followed by fatigue of the muscles of the vessels; immediately after a great fright, we generally feel the blood pour into the cheeks, as soon as we begin to breathe and re- cover from the shock; we soon grow red again, at first indeed redder than we often like; not unfrequently the paling from fright is often overlooked, and only the succeeding redness perceived. Still, apart from these objections, how can we imagine the paralvz ing action of an irritated nerve ? We actually know such phenomena from physiology ; the obstruction of the heart's action by irritation of UNION OF WOUNDS—IRRITATION. 57 the vagus nerve, of the movements of the intestines from irritation of the splanchnic nerve, etc. Here a vaso-motor nerve-system is sup posed which arrests the contraction of the muscles; could not such a vaso-motor nerve-system also be supposed for the vessels—nerves irritation of which lessens the tone of the muscles of the vessels and thus renders the walls less capable of resisting the pressure of blood ? The doctrine about vaso-motor nerves is so difficult to explain, that even a brief exposition of the probable possibilities of the process would lead us too far; hence I must content myself with having called attention to the analogous physiological processes. Virchow and Henle agree in the view that the symptoms of fluxion are due to paralysis of the vessels, although they refer this paralysis to different causes; on the whole, most credence is attached to the view that the muscles of the vessels, like those of the heart, are partly under the influence of sympathetic, partly of cerebro-spinal nerves, and that the former cause the rhythmical (automatic) contractions of the vessels, and the latter act as regulators or obstructors of these contractions. Irri- tation of the sympathetic filaments would increase the contractions of the vessels, dividing them would result in paralysis of the mus- cles of the vessels and their consequent dilatation; but the latter might also be caused by irritation of the cerebro-spinal obstructive nerves. The discovery by Achy, Eberth, and Aucrbach, that the blood- capillaries are entirely composed of cells, might excite new hypotheses about the irritability of the capillary cells and their influence on dila- tation and contraction of the capillaries, although even this would not solve the mechanical difficulty which opposes the idea of an active vascular dilatation. In the action of local irritation and entirely local dilatation of the vessels we have the choice of considering that irritation of the nerves of the vessels (or of the living cell-substance of the capillary walls) directly disturbs their function, or that this dis- turbance is due to reflex irritation. You have now material enough for meditation. None of the hypotheses advanced can claim to fully explain the symptoms of fluxion, although some of them perhaps contain the germ for future perfect development. Still the recognition of this truth, the dis- tinction of hypotheses from observation, is useful; it does not limit the onward progress of experiment, but constantly reanimates it. Congratulate yourselves that it is permitted to you and the coming generation to clear up this point. We shall now leave this question, and the next hour shall again return to the field of certain observation, to study the effect of the wounding on the tissue itself. 58 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. LECTURE VI. . Changes m the Tissue during Healing by the First Intention.—Plastic Infiltration.— Inllammatory New Formation.—Retrogression to the Cicatrix.—Anatomical Evi- dences of Inflammation.—Conditions under which Healing by First Intention does not occur.—Union of Parts that have been completely separated The dilatation of the capillaries and the exudation of blood-serum that usually accompanies it, which we have found as the first effect of the wound, and which is most readily seen in the living tissue, as above mentioned, cannot of course by itself cause two flaps that are brought in apposition to unite organically—changes must take place on the surfaces of the wound, by which the latter are to a certain ex- tent dissolved and melted into each other; just as you render two ends of sealing-wax soft by heat, to fasten them together, so here the sub- stance itself must become the means of union, in order that it should be firm and intimate. In fact, this is the final result of the healing process, both in the soft parts and in the bone. Let us keep in mind the above diagram (Fig. 2), and suppose that only connective tissue and vessels have been wounded, and that their reunion is the question for consideration. As you already know, con- nective tissue consists of cellular elements and filamentary intercellular substance. The cellular elements are partly the stable, fixed, long- known connective-tissue corpuscles, i. e., flat, nucleated cells, with long processes, which adhere to the connective-tissue bundles, partly the wandering cells discovered by Becklinghauscn, which are identical with white-blood and lymph cells, in form, species, and vital peculiar- ities, are probably formed for the most part in the lymphatic glands, through the lymphatics enter the blood, from the capillaries and veins, occasionally wander into the surrounding tissue (as discovered by Strieker), there become fixed tissue-cells, or again (as observed by Hering) enter the lymphatic or blood vessels, or undergo metamor- phoses not yet discovered. If we examine the tissue of the flaps of the wound a few hours after the injury, we shall find it full of wandering cells. These in- crease enormously from hour to hour; they infiltrate the fibrous tissue, already softened by swelling, and even wander from one flap of the wound to the other. During this cell-activity, and probably on ac- count of it, the connective-tissue intercellular substance gradually changes to a homogeneous gelatinous substance, which gradually disap- pears as the cells increase, possibly being consumed by them; so that there is a time when the surfaces of the wound in apposition consist PLASTIC INFILTRATION. gg almost entirely of cells, held together by a very slight quantity of gelatinous intermediate substance (which subsequently becomes firmer and finally fibrous). In the sketch below (Fig. 3), a sequel to the above diagram, you Fig. 3. see a section of the wound now united by newly-formed tissue, which once for all we shall term inflammatory new formation or primary cellular tissue. Virchow calls it granulation tissue, Bindfleisch germ- tissue. The inflammatory new formation results from an earlier state in which the still filamentary connective tissue is infiltrated with innu- merable wandering cells, a state which may readily return to the nor- mal by atrophy of these cells. This stage of cellular or plastic infiltra- tion, in which the tissue feels firmer than in watery edematous infiltra- tion, is almost always at some distance from the edge of the wound, bo that in any such specimen of a recent wound we may follow the development of the inflammatory new formation from the plastic (cellular) infiltration, if we make microscopical examinations from the 10 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. normal tissue toward the wound. The injury represents an inflamma- tory irritation, whose action may extend somewhat beyond the imme- diate vicinity of the irritation, but then rapidly diminishes. In the great majority of cases there will be at least a slight layer of coagulated blood between the flaps of the wound; this also extends somewhat into the interstices of the tissue of the flaps of the wound. This blood-clot may sometimes interfere with the healing, as when, from its size or other causes, it decomposes or turns to pus, but it may also become cicatricial tissue and perfectly disappear with the new formation in the flaps of the wound; this must take place for union by the first intention to occur. We shall hereafter speak of the changes that take place in the clotted blood during this process. We must now attend to the question, Whence come the innumera- ble wandering cells that infiltrate all inflamed tissues immediately after their irritation, as they here do the flaps of the wound ? Of late, this question has received the following wonderful explanation, which ten years ago would have been considered as the fancy of a madman: Cohnheim made the following remarkable observation: he introduced finely-powdered analin blue into the lymph-sac in the back of a frog, then irritated the animal's cornea with caustic, and found that numbers of wandering cells (lymph-pus cells) containing anilin gradually col- lected at the cauterized point; hence the conclusion, at an irritated point white-blood corpuscles wander from the vessels into the tissue; these white-blood corpuscles constitute the inflammatory cellular in- filtration. Cohnheim then confirmed, by direct observation on the mesentery of a living frog, the discovery already made by Strieker on the nictitating membrane that had just been removed, that under some circumstances the white-blood cells wander through the walls of the vessels into the tissues, and showed also that this occurred to a still greater extent in dilated capillaries and veins. Although it was afterward shown that an English experimenter, Aug. Waller, had several years previously made similar observations on the mesentery of the toad and the frog's tongue, the works of the German observers, Strieker, Von Becklinghausen, and Cohnheim, were quite independent of his, and Cohhneim has the undivided honor of having correctly interpreted his observations on inflam- mation, which have constantly advanced to the present time, and of having presented them in a form to greatly affect all modern pathology. It is difficult for you, gentlemen, to imagine the immense impression made on all histology by these new discoveries, which I have just imparted to you as simple facts, because you are not acquainted with the former point of view from which the origin of inflammatory new PLASTIC INFILTRATION. 61 formations, and that of complicated organized growths, was regarded. From previous observation, our idea of the affair was about as follows: It was supposed that the cells of the connective tissue, of which only one variety, the fixed, was known, increased greatly by division as a result of irritation, and cellular infiltration thus resulted. Imao-ine yourselves back a few years in a time when nothing was known of the vital peculiarities of young cells, of their amSboid and locomotor ac- tion, and we only knew how to deduce the course of the pathological process, from various stages of the diseased, but not dead tissues, as is still the case in the normally-developing layer; then you will readily understand that it was decided without hesitation that the cells lying packed together in the inflamed tissue were formed out of one another. Even this was a great advance, which was only possible after the overthrow of the generatio osquivoca; for, not long before, the development of cells and tissue from lymph, coagulated blood, and fibrine, was firmly believed in. The first observations on cell-division as a result of abnormal irritation were made on cartilage by Bedfern in England; then followed the observations of Virchow and Heis on in- flamed cornea. In both cases it was seen that after cauterization with nitrate of silver, or after introduction of a seton, the tissue was filled with young cells ; in the original tissue-cells, biscuit-shaped, then double nucleii were seen, from which a division was decided on; young cells were seen grouped together, and their origin from the tissue-cells seemed indubitable. Hence arose the idea that inflammation was a process in the tissues, which, entirely independent of the vessels, was associated with a rapid luxuriant proliferation of tissue-cells, and par- tial softening and disintegration of the intercellular tissue. Von Becklinghausen's discovery of the two varieties of cells found in con- nective tissue, as well as his discovery of the varied movements of pus-cells, might well have given rise to the question whether the pro- liferation of the cells, on irritating the tissue, started from the fixed or movable connective-tissue corpuscles, but failed to do so. But now observation is piled on observation; and we are driven to the supposi- tion that all young cells which in inflammation toe find abnormally in the tissue are wandering white-blood cells. Observers, who have recently investigated this point, do not all agree; some still ascribe to the stabile cells of the connective tissue a part in the inflammatory process. On this question Cohnheim is very reserved ; Von Becklinghausen is obstinately conservative; while Strieker, in his latest publications, is reactionary ; he maintains that on irritation the stabile tissue-cells are filled with neoplasma and increase by segmentation; but he does not deny the wandering of white blood-cells. Observations on this point are so tedious that we 62 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. cannot wonder at the delay in elucidating a question apparently so simple. Of Course, from the various errors to which we are liable in inter- preting the significance of what has been observed, we should be very careful about announcing general principles. In regard to the in- flammatory changes in connective tissue, however, as far as my obser- vation and criticism extend, I would maintain the above statements. In cartilage alone, nothing has been observed different from for- mer appearances. As the hyaline cartilage-substance has no canals passable for cells, so far as we at present know, there is little left except to suppose that the increase of cells in the cartilage-cavities after irritation results from division of the protoplasm of the cartilage- cells ; of this I shall hereafter show you preparations ; still hyaline cartilage has never yet been watched for days in a living and irri- tated state, and consequently this observation must give place to the studies on living connective tissue. If there be no longer any doubt that all young cells that infiltrate the inflamed tissue, and sometimes, as we shall hereafter see, escape from it in the shape of pus, are white-blood corpuscles, or, briefly, wandering cells, we have two questions to answrer, namely, Why do so many cells wander into the inflamed tissue, and how come these num- bers of wandering cells in the blood; where do they originate ? There are two chief opinions regarding the passage of the wandering cells through the walls of the vessels: some believe that they pass at the points where the cells forming the capillary walls separate, that is, through fine openings formed for them ; others think that the capil- lary walls consist of a soft protoplasm, through which the wandering cells thrust themselves. There is also some doubt whether the passage of the wandering cells is to be regarded as due to their own act or as the result of intravascular pressure. It would lead me too far to discuss fully the pros and cons of this question. My own view, sub- ject to future observations, is as follows: the first change that we see in irritated living tissue is dilatation of the vessels; the immediate re- sult of this is retardation of the flow of blood, increased transudation and a collection of white-blood cells in the periphery of the calibre of the vessels; the wall of the vessel gradually grows softer, possibly from the long contact with the white-blood cells, which graduallv en- ter and finally pass through the wall. Retardation of the circulation, and softening of the wall of the vessel, appear to me the necessary requirements for the extensive wandering of the cells. Whence come the quantities of white-blood cells that escape durino* inflammation is a physiological question, and must be answered by the physiologists. Lymphatic glands and the spleen are the organs to which we first turn HEALING BY FIRST INTENTION. 63 as the source. Although it cannot be regarded as absolutely proved that, with the extensive escape of cells, new lymph-cells are also formed extensively, still this is very probable; and, as we know from clinical experience that the lymphatic glands near the seat of an in- flammation are almost always swollen, it is most natural to assume these as the source of the abnormal quantity of wandering cells. In spite of most zealous efforts, I have been unable to discover any thino- about the morphological changes in this cell-formation. I must mention one other point, which is, that in inflammation red blood-corpuscles also not unfrequently pass through the walls of the vessels; according to Cohnheim''s experiments, this is greatly influ- enced by the increased intravascular pressure. Let us now return to our wound and see what becomes of the tis- sue infiltrated with cells, of the inflammatory new formation, how the cicatrix develops from it while the cell-infiltration extends slowly and sluggishly at some distance from the wound: the cells in the surfaces of the wound, which already adhere loosely, gradually assume a spin- dle shape, the intercellular tissue then becomes firmer, the spindle- cells change to fixed connective-tissue cells, and finally the young cicatricial tissue assumes more and more the form of normal, fibrous connective tissue. That is, the white blood-cells become fixed con- nective-tissue cells, as probably takes place even in the embryo. Here, again, we are met by various questions. The newly-formed, adhesive interlacing tissue soon becomes firm, especially in healing by the first intention; even after twenty-four hours we find its intercellular sub- stance quite stiff and fibrinous, the borders of the wound are also more or less infiltrated with this stiff substance; it is only the early harden- ing of the intercellular connecting substance, formed of transuded serum and softened connecting tissue, that explains why the union is so firm, even the third day, that the flaps of the wound hold* together without sutures, for without such connective substance the young cel- lular tissue could not be so coherent. This stiffening connective-tissue substance (Fig. 8) is most probably fibrine, which consists of the trans- udation coming from the vessels under the influence of the extrava- sated blood-corpuscles, possibly also of the wandering cells. From the excellent experiments of Alexander Schmidt it is known that most exudations contain the so-called fibrogenous substance, which forms fibrine as we know it in the coagulated state, by combining with the fibro-plastic substance of the blood and other tissues. Very accurate proportions of fibrogenous and fibrino-plastic substance are required to form fibrine; these favorable requirements occur in many inflamma- tions. Schmidt considers it probable that all firm fibrous tissue is formed and maintained by the fibrogenous substance from the blood 6 64 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. being precipitated in a certain manner around the tissue-cells, because they contain a fibrino-plastic substance in a firm shape. Under this hypothesis we must suppose a specific cell-action, which would cause the coagulating product to assume the form of muscular striae in one place and in another of connective tissue. In our case this is a very probable view, for we see filamentary connective tissue gradually form from the intercellular coagulated fibrine. It is true the amount of in- tercellular substance in the new formation is not great, but there is little doubt that the small spaces between the cells are filled by it. A short time subsequently the young cicatricial tissue appears still to consist chiefly of spindle-cells closely pressed together (Fig. 9); but then the spindle-cells diminish greatly by flattening, many are even destroyed, and we have now a filamentary, connective-tissue substance, which is to be considered partly as a product of secretion, partly as metamorphosed protoplasm of the spindle-cells; the cicatricial tissue finally remains stable in this state. Thiersch, who quite recently has again carefully studied the healing of wounds, maintains that the ap- parently fibrinous intermediate substance is not fibrine, but only meta- morphosed connective tissue. I will not deny that there may be an immediate union of the soft- ened edges of the wound, although it must be very rare. Quite recently I had Dr. Gussenbauer make a new series of accurate obser- vations on healing by the first intention with especial reference to Thiersch's views. He could not confirm the latter's observations, but he, as well as Gilterbock, arrived at results which in the main corre- spond with the above views, which I arrived at from my own studies. Meantime, what has become of the closed ends of the vessels ? The blood-clot in them is reabsorbed or organized; the walls of the vessels send out shoots which communicate with the vascular loops of the opposing border of the wround, and with each other. In this way, however, only the rather scanty union of the opposing vascular loops, which is at first slight, is accomplished; these were already formed by extensive tortuosities and windings of the vessels, which had loop- shaped terminations after the injury (Figs. 12-14). This is not the place to go into the details of this interesting development of the vas- cular loops; their development is not due solely to dilatation, but very much to interstitial growth of the walls of the vessels. The original, formerly-existing vascular union is thus replaced by a newly-formed vascular net-work which is at first far richer. As a result of the restoration of circulation through the young cica- trix, the circulatory disturbances caused by the injury are removed, the redness and swelling of the borders of the wound disappear ; from the numerous vessels, the cicatrix appears as a fine red stripe. Now HEALING BY FIRST INTENTION. the consolidation of the cicatrix must take place : this is accomplished on the one hand, by the partial disappearance of the newly-formed vessels, whose wralls fall together, and they thus become solid, fine, connective-tissue strings ; on the other hand, by the intercellular sub- stance becoming firmer and containing less water, as above mentioned, the cells assume the flat form of connective-tissue corpuscles, or disap- pear ; possibly some of them remain as wandering cells, and return again into the lymphatics or blood-vessels. To this condensation and atrophy is due the great contractile power of the cicatricial tissue, by means of which large, broad cicatrices may occasionally be reduced to half their original size. At the first glance, it might appear to you contradictory, that an apparently excessive capillary net-work should be formed in the young cicatrix, and should subsequently be for the most part obliterated. We cannot explain this apparent excess, still there are plenty of analogies in embryonal development; I only need to remind you that there is a period in foetal development when, even in the vitreous body, there is a capillary net-work, which, as you know, disappears, leaving scarcely a trace. Not to fatigue you with so-called theoretical subjects, I leave this field for a short time, and, before leaving healing by the first inten- tion, as a point fully understood, I shall make a few remarks on the causes that may prevent this mode of healing, even when the flaps of the wound are in apposition. Healing by first intention does not take place : 1. When the edges of the wound are brought together by plasters, or sutures, but their tension or tendency to separate again is very great. Under these circumstances, either the plasters do hot keep the wound accurately closed, or the sutures cut through the flaps; perhaps also the tension of the tissues obstructs the flow of blood in the capillaries, and thus disturbs the cell development and formation. How great this tension must be, and what means we have for relieving it, you can only learn in the clinic. 2. A further obstruction to healing is, a large amount of blood poured out between the edges of the wound ; this interferes with the process of healing, partly as a foreign body, and partly, if it decom- poses, by the influence of the process of decomposition. 3. Other foreign bodies, as sand, dirt, alkaline urine, faeces, etc., also retard the healing, partly mechanically, partly chemically. Hence these substances should be carefully removed before uniting the wound. In wounds of the urinary bladder, it is not usual to attempt the clos- ure of the skin-wound; the urine would force its way into the sub- cutaneous cellular tissue, or into the peritoneal sac, and excite terrible 36 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. injury. Here, under some circumstances, it would be a decided fault to unite the wound, although of late the views on this particular point differ somewhat from those of former days. 4. Lastly, from a contusion, whose effect on the flaps of the wound we may fail to observe, there may have been an extensive disturbance of circulation and destruction of minute tissue, which has induced the partial death of certain parts or of the whole surface of the wound. Then, as there is no cell-formation in the edges of the wound, but only where the tissue is still living, we have small tags of the destroyed tissue lying as foreign bodies between the edges of the wound; these must prevent healing by first intention. If this mortification attack only minute particles, these may possibly quickly undergo molecular disintegration and absorption ; this may occur not unfrequently. We shall speak more extensively of this mortification of the tissue, and of its detachment from the healthy parts, when treating of contusions. Experience, arising from many observations in judging of wounded surfaces, will hereafter enable you in most cases to say whether heal- ing by first intention may be expected or not, and you will also learn when it may be useful, even in doubtful cases, to try to aid this union by applying dressings. You will occasionally hear of wonderful cases where parts of the body, completely separated, have again become united. This appears to be actually the case. I have never had the opportunity of making any observations on such cases; still, even in late days, very trust- worthy men have asserted that they have seen small portions of skin again unite after being removed from the fingers by a blow or cut, then carefully replaced and fastened on with adhesive plaster. For- merly I contended against the possibility of this healing, but must now admit it, also on theoretical grounds, after it has become imaginable that, through the movements of the cells, the detached portions, if not too great, may soon be restored to life again by the entrance of wan- dering cells. That we may successfully transplant a twig, cut from one tree, into another one, is well known ; but, as the circulation in plants is not by pumping, but the sap runs simply by cellular force, the anal- ogy is not very close ; it Avas more remarkable, it is true, that a cock's spurs could be transplanted to his comb, but between birds and men the differences in the formative process are also very oreat and any immediate transfer of observations is inadmissible in practice. When treating of the cicatrization of wounds with loss of sub- stance, we shall investigate the discovery of Beverdin that we may cause epidermis to grow on granulating surfaces. HEALING BY GRANULATIONS. 67 LECTURE VII. Changes perceptible to the Naked Eye in Wounds with Loss of Substance.—Finer Pro- cesses in Healing with Granulation and Suppuration.—Pus.—Cicatrization.—Ob- servations on "Inflammation."—Demonstration of Preparations illustrative of the Healing of Wounds. It now remains for us to inquire what becomes of the wound, if, under the above circumstances, it does not heal by first intention. Then, as the flaps gape, we have an open wound before us; and the circumstances are the p.ame as if the gaping wound had not been closed, or as if a piece had been cut out, as in a wound with loss of substance. Accurate observation of such wounds, which are usually covered with some unimtating body, as with a fold of linen dipped in oil, with oiled or dry charpie, etc., shows the following changes—if we examine it daily, thia is not necessary, it is true, and may even be in- jurious : after twenty-four hours, you find the borders of the wound slightly reddened, somewhat swollen, and sensitive to the touch ; the same symptoms as in closed wounds. As in healing by first inten- tion, these symptoms may be very insignificant or entirely absent, as in old, relaxed, flabby skin, also in strong skin with thick epidermis. We observe these symptoms best in the skin of healthy children. An extensive and increasing redness, swelling, and pain about the wound, make us suspect an abnormal course; just as, with the same symptoms in a wound healing by first intention, various individual circumstances are to be considered, and the vibrations from the normal to the abnor- mal are so numerous, that the dividing line is often difficult to deter- mine. After the first twenty-four hours, the surface of the wound has changed but little ; all over it you can still recognize the tissues quite distinctly, although they have a peculiar gelatinous, grayish appear- ance ; you also find a considerable number of yellowish or grayish-red small particles over the surface; on close examination, you find these to be small fragments of dead tissue, which still adhere, however. The second day, you may already notice a trace of reddish-yellow, thin fluid over the wound, the tissues appear more regularly grayish red and gelatinous, and their boundaries become more indistinct. The third day, the secretion from the wound is pure yellow, somewhat thicker, most of the yellow dead particles are detached and flow off with the secretion; the surface of the wound becomes more even and regularly red—it cleans off, as we say technically. If you had not bound up the wound (a stump from amputation, for instance), and had received in a basin the secretion that formed, the first and second day you would find it bloody, brownish red, then of a gelatinous dirty gray, 68 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. then dirty yellow: at the points where the secretion flows from the wound, fibrine not unfrequently stiffens in drops. If you examine care- fully with a lens, even the third day, you will see numerous red nod- ules, scarcely as large as a millet-seed, projecting from the tissue —small granules, granidations, fleshy warts. By the fourth or sixth day these have greatly developed, and gradually join into a fine, granu- lar, bright-red surface—the granulating surface ; at the same time, the fluid flowing from this surface becomes thicker, pure yellow, and of creamy consistence ; this fluid is pus, and, when of the quality here described, it is good pus, pus bonum et laudabile of old authors. Of this normal course there are many varieties, which chiefly de- pend on the parts injured, and the mode of injury; if large shreds of tissue from the surface of the wound die, the wound is longer in clean- ing off, and then you may sometimes see the white, adherent shreds of dead tissues still clinging for days to the surface, most of which is al- ready granulating. Tendons and fasciae are particularly apt to have their circulation so impaired, even by simple incised wounds, that they die to an unexpected extent from the cut surface, while there is little loss of loose cellular tissue or muscle. This is undoubtedly due partly to deficient vascularity of the tendinous parts, partly to their firm- ness, wThich does not permit rapid collateral dilatation of the vessels; the same is true in injuries of bone, especially of the cortical substance, where there is often death of the injured bone-surface, that requires a long time for detachment. Other obstacles to active development of granulations are constitutional conditions; for instance, in very old or debilitated persons, or badly-nourished children, the develop- ment of granulations will not only be very slow, but they will look very pale and flabby. Hereafter, at the close of this chapter, I will give you a short review of those anomalies of granulation which are daily occurrences in large wounds, and, to a certain extent, may be regarded as normal or at least customary. But, to return to the observation of the normally-developing layer of granulations, with the continued secretion of pus, you perceive that the granulations become more and more elevated, and sooner or later attain the level of the skin, and not unfrequently rise above it. With this process of growth, the individual granules become thicker, and more confluent, so that they can hardly be recognized as separate nodules; but the entire surface assumes a glassy, gelatinous appearance. Occasionally the granulations remain for a long time at this stage, so that we have to use various remedies to restrain the proliferating J&W neoplasm within bounds that are requisite for recovery; on the periphery, particularly, the granulations should not rise above the level of the skin, for the cicatrization has to commence at this point. CICATRIZATION. 69 The following metamorphoses now gradually occur: the entire surface contracts more and more, becomes smaller; on the border, between skin and granulations, the secretion of pus diminishes; first, a dry, red border, about half a line broad, forms and advances toward the centre of the wound, and, as it progresses and traverses the granular surface, it is followed closely by a bluish-white border, which passes into nor- mal epidermis. These two seams result from the development of epidermis, wiiich advances from the periphery toward the centre; cicatrization begins; the young cicatricial border advances half a line or a line daily; finally, it covers the entire granulation surface. The young cicatrix then looks quite red, and is thus sharply defined from the healthy skin; it feels firm, more so than the cutis, and is still very intimately connected with the subjacent parts. In the course of some months, it gradually grows paler, softer, more movable, and finally white ; in the course of months and years, it grows still smaller, but often remains whiter than the cutis all through life. The strong contraction in the cicatrix often causes traction on the neigh- boring parts, an effect that is occasionally desirable, but sometimes very unwelcome, as, for instance, when such a cicatrix on the cheek draws the lower eyelid down, causing ectropion. You will occasionally see it asserted that the cicatrization of a granulating surface may sometimes begin from several patches of epidermis forming in its midst. This is only true of cases where por- tions of cutis with rete Malpighii have remained in the midst of the wound, as may readily happen in gangrenous wounds, as the caustic agent may penetrate unequally deep. Under such circumstances, epi- dermis again forms from some remaining portion of the papillary layer, that has the slightest possible covering of cells of the rete Mal- pighii ; at these points we have the same circumstances as when we have raised a vesicle on the skin by cantharides, inducing by the rapid exudation an elevation of the epidermis from the mucous layer of the skin; this is followed by no granulations, if you do not continue to irritate the surface, but horny epidermis again forms at once over the mucous layer. But, if there be no such remnant of rete Malpighii, we never have these islands in the cicatrix,*the formation of epidermis only takes place gradually, from the periphery of the wound toward the centre. I believe this so firmly, that I think surgeons, viio say they have seen otherwise, must be mistaken in some way. The transplantation of epidermis after Beverdin's method also ap- pears to me to favor the view that epithelium is only developed from epithelium. After having considered the external conditions of the wound, the development of granulations, of pus, and of the cicatrix, we must 70 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. now turn again to the more minute changes by which these external symptoms are induced. It will be simplest for us, again, to represent a relatively simple capillary net-work in the connective tissue: suppose a crescentic piece to be cut out of it from above; first, there will be bleeding from the ves- sels, which will be arrested by the formation of clots as far as the next branches. Then, there must be dilatation of the vessels about the wound, which is due partly to fluxion, partly to increased press- ure ; an increased transudation of blood serum, or an exudation, is also a necessary result of the capillary dilatation, from causes above given; the transuded serum contains some fibrogenous substance, which, by the influence of the newly-formed cells in the most super- ficial layers, coagulates to fibrine, while the serum, mixed with blood plasma, flows off. The vascular net-wrork would assume the following shape: Diagram of a wound, with loss of substance. Vascular dilatation, magnified 300-400 times. In most cases, from insufficient supply of blood-plasm, at the sur- face of the wound, more or less particles of tissue will die; as the stoppage of vessels must, of course, deeply affect the nutrition of tis- sues not very vascular, and, where the tissues are very stiff, dilatation GRANULATION TISSUE. 71 of the vessels will be interfered with. Let us suppose that the upper layer, shaded in the diagram, is dead from the changes in the circula- tion. What will now take place in the tissue itself? Essentially, the same changes as in the united edges of a wound; wandering of white-blood cells through the walls of the vessels, their collection in the tissue with the secondary action they induce; plastic infiltra-lo- tion, and inflammatory new formation. But, since there is no oppos- "''-° ing wounded surface, with which the new tissue can coalesce, then to be quickly transformed to connective tissue, the cells, escaping from the vessels, remain at first on the surface of the wound; the exuded fibrinous material on the surface of the wound becomes soft and gelatinous; at the same time, the infiltrated tissue of the surface of the wound assumes the same peculiarities ; the soft connective tissue, into which the young vessels shortly grow, even if only present in small quantities, holds together the cells of the inflammatory new for- mation, which constantly increase in number. The granulation tissue is thus formed; this is, therefore, a highly-vascular inflammatory new formation. At first, it grows constantly, the direction of its growth is from the bottom of the wound toward the surface; the tissue is, however, of different consistence in the various layers, its superficial surface especially is soft, and most superficially of fluid consistence, for here the intercellular substance becomes not only gelatinous, but fluid; this uppermost thin fluid layer, which is constantly flowing and being constantly renewed from the granulation tissue by cell-exu- dation, is pus (Fig. 6). Hence, pus is fluid, as it were melted, dissolved inflammatory new formation. Where pus is present in quantity it must have come from some sort of granulation tissue or from some other highly-vascular and usually highly-cellular source; this source need not always be a surface, as in the present case, but may lie deep in the tissue and form a cavity; the centre of an inflammatory new formation anywhere in the tissue may break down into pus; then we have an abscess. We shall frequently have occasion to speak of this relation of pus | and granulations to each other ; hold fast to the idea of granulations being tissue (not granules), and of pus being fluid inflammatory new formation, and you will hereafter readily understand many processes, especially chronic inflammations, whose variable appearance you would otherwise find incomprehensible. Let us now say a few words about pus itself. If left standing in a vessel, it separates into an upper, thin, clear layer, and a lower yel- low one; the former is fluid intercellular substance, the latter contains chiefly pus-corpuscles. On simple microscopic examination these are round, finely punctated globules, of the size of white-blood corpuscles; 72 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. they contain three or four dark nuclei, which become quite distinct on addition of acetic acid, because it dissolves the pale granules of the protoplasm, or at least swells them so that they become transpar- ent. The nuclei are not soluble in acetic acid ; the entire globule is readily dissolved in alkalies. Fig. 5. Pus-cells from fresh pus, magnified 400 times, a. dead without addition : b, the same cells after addition of acetic acid; c, various forms that living pus-cells assume in their amOboid movements. At a and b we see the pus-cells as they usually appear when we cover a drop of pus with a thin glass, and without any addition ex- amine it under the microscope. The above-mentioned observations of Von Becklinghausen have shown that only the dead cells have this round shape; if we observe the pus-cells in the moist chamber on a warmed object-table (according to M. Schultze), we see the amOboid movement of these cells most beautifully. These movements, which only go on slowly and sluggishly at blood-heat, become more rapid at a higher temperature, and less so at a lower. The number of pus- cells in pus is so great, that in a drop of pure pus, under the micro- scope, the fluid intercellular substance is not at all perceived. Chemi- cal examination of pus is difficult, first, because the corpuscles can- not be completely separated from the fluid, also, because the large quantities of pus obtainable for chemical examination had already been a long time in the body, and may have changed morphologically and chemically ; and lastly, because chiefly protein substances are con- tained in pus, whose perfect separation hitherto has not always been possible. If we let pus from a wound stand in a glass, the clear, bright-yellow serum usually occupies more space than the thick, straw- yellow sediment, which contains the pus-corpuscles. Pus contains ten to sixteen parts of firm constituents, chiefly chloride of sodium; the ashy constituents are about the same as those of blood-serum. Recent examinations of pus have shown that myosin, paraglobulin, protagon, fatty acids, leucin, and tyrosin, are constant constituents. Pus collected in the body does not readily undergo acid fermenta- tion ; pure fresh alkaline pus soon becomes sour, however, if it is left standing for a time even in a covered glass. Let us now return to the granulation layer, where we have still an important point to consider, namely, the numerous vessels, winch GRANULATION TISSUE. 7.3 give its red appearance. The extensive vascular loops that must form on the surface of the wound, and which in the diagram (Fig. 6) are too small and too few, commence, with the growth of the surround- ing granulation tissue, to elongate and become more tortuous; tow- ard the fourth or fifth day new vessels develop as fine lateral capil- lary communication, as in healing by first intention, and the tissue is soon traversed by an excessive number of vessels, which have so much effect on the appearance of the entire granulation surface that it is hardly recognizable on the cadaver, where the fulness of the ves- sels is wanting, or is at least less marked than during life, and the tissue consequently appears pale, relaxed, and much less thick. The question arises, Whence come these remarkable, small, gradually-con- fluent red nodules, which are visible to the naked eye ? Why does not the surface look even ? Indeed, this is frequently the case; the granules are by no means always distinctly defined; but it is not easy to explain the cause of their form. It is usually assumed that the granules are to be regarded as imitations of the cutaneous papillae; but, independent of the fact that it is incomprehensible why such structures should be imitated in muscle and bone, and that the gran- ules are usually ten times as large as the cutaneous papillae, this is no real explanation. The appearance of the granules, doubtless, de- pends on the arrangement of the vascular loops into tufts, on certain boundaries betw-een the different groups of vessels. Hence we might suppose that the vascular loops acquire this form without known cause. Still, it seems to me natural to compare them to the circum- scribed capillary districts, already formed in the normal tissues, of which we have numerous examples, especially*in the skin and in fat. You know that every sweat and sebaceous gland, every hair-follicle and fat-lobule, has its nearly-closed capillary net-work, and, by the enlargement of such capillary net-wrorks, the peculiar closed vascular forms of the granules might arise. In fact, in the cutaneous and fatty tissue you will find the individual fleshy growths, particularly sharply and clearly defined, while this is more rarely the case in muscle, where these bounded capillary districts do not occur. It can only be decided by artificial injections of fresh granulations, whether this explanation is correct; till then, it remains simply an attempt to refer this pathological new formation to normal anatomical con- ditions. The following sketch, in which, on account of the great enlarge- ment, and the small injured district, nothing can be seen of the granu- lar layer, may serve you as a diagram of the development of the gran- ulation tissue with its vessels, and of its relation to pus and to the subjacent matrix, as it has developed from Fig. 4. With the for- n SIMPLE INCISED WOUNDS OF THE SOFT PARTS. mation of this rich new course of circulation, the redness of the edges of the wound, caused by the collateral circulation, disappears, the symptoms of fluxion having previously ceased soon after the injury. It has already been stated that pus is inflammatory new formation which has become fluid; strictly speaking, this is only the case in purulent melting down of infiltrated tissues, in formation of granula- tions and abscess. The secretion of pus from the granulating surface, in which the latter loses no substance by giving off pus, is to be regarded as the continual escape of numerous pus-cells on the surface of the granulations, in part directly from the granulation tissue, partly from the vascular loops. Thus the secretion of pus on the granulation surface becomes quite analogous to the secretion on the mucous and serous membranes, and particularly to the increased secretion from mucous membrane in catarrh. This also fully shows the difference between secretion of pus and progressive suppurative softening of tissue (suppuration and ulceration). Fig. 0. Diagram of granulation of a wound; the layer of pus-cells is represented ae having been acted on by acetic acid, to distinguish the pus-cells in the figure more accurately from the erann- lation cells. Magnified 30CMOO diameters. b RESULTS OF GRANULATION. 7.5 If the growth of the granulations was not arrested at some point, a constantly-growing granulation tumor would be formed. Fortu- nately, this is never or very rarely the case. You already know, from the representation of the external conditions, that when the granula- tions have reached the level of the cutis, or even sooner, they cease to grow and are coated with epidermis, and retrograde to a cicatrix. The following changes occur in the tissue: At first, in the granula- tion tissue, as in the edges of the wound in healing by the first inten- tion, there are numerous cells which are destroyed. Not only the millions of pus-cells on the surface, but also cells in the depths of the granulation tissue, disappear by disintegration and reabsorption; it is very probable that cells from the granulation tissue may pass back un- injured into the vessels, as we shall see, when treating of the organi- zation of thromboses of the vessels. As the cells retrograde, fine fat Fig. 7. Fatty degeneration of cells from granulations. Granulation-cells. Magnified about 500 diameters. granules gradually form in them, not only in the round but also in the spindle-shaped ones; such cells, which are composed of very fine fat-globules, are generally called granular cells (Kcrnchenzellen); they often occur in the granulations, as above described. When the gran ulation tissue is thus diminished by atrophy, and escape of the cells, and at the same time the new formation of cells ceases, something im- portant must happen,- that is, the gradual consolidation of the gelat- J inous intercellular tissue to striated connective tissue, which is. brought about by the steadily-increasing loss of water, that is carried off by the vessels and evaporated from the surface ; then the remain- ing cells at once assume the shape of the ordinary connective-tissue corpuscles. According to the view of other observers, the original intercellular substance entirely disappears, and its place is supplied by the protoplasm of granulation cells which transforms into fibrous tis- sue. With these changes which take place from the periphery tow- ard the centre, the secretion of pus on the surface ceases; at the very 73 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. circumference of the wound on the condensing granulation tissue epidermis forms and quickly separates into hard epidermic and mucous layers ; according to J. Arnold, this formation takes place by the di- vision of a protoplasm, at first entirely amorphous, in the immediate vicinity of the existing border of epidermis. Lastly, the superfluous capillaries must be obliterated; few of them remain to'keep up the circulation through the cicatrix. With their obliteration the tissue be- comes drier, tougher, contracts more and more, and often the cicatrix does not acquire its permanent form and consistence for years. The whole process, like all these modes of healing, contains much that is very remarkable, although recent investigations have explained many of the more minute morphological changes. The possibility, nay, the necessity, under otherwise normal circumstances, of arriving at a typical termination, is the chief characteristic of those new forma- tions that are induced by an inflammatory process. If this natural course of healing does not take place, it is because either constitu- tional or local conditions indirectly or directly interfere, or because the organ attacked is so important to life, the disturbance to the entire body so severe, that there is death of the organ, or of the individual, or that the functional disturbance of the former causes the death of the latter. Every new formation, due to inflammation, always has the tendency to reach a certain point, to retrograde, and pass into a sta- ■ tionary state, while other new formations have no such natural termi- nation, but usually continue to grow. Different as healing by the first and second intentions appears, at the first glance, the morphological changes in the tissue are in both cases the same ; you only need to divide Fig. 3 at a, to have the same picture as in Fig, 6. Observation teaches in the simplest manner that this is actually so; if a wound almost healed by first intention, but not yet consolidated, be torn open, we have a granulating wound which soon suppurates. You will hereafter be frequently convinced of this in practice. The above process of healing by immediate adhesion and by gran- ulation we have termed traumatic inflammation, and have found it identical with some other forms of inflammation; it has also been stated that a marked peculiarity of traumatic inflammation is, that in it, without some further cause, the irritation in the tissue does not extend beyond the immediate vicinity of the injury. I beg you i carefully to remember this limitation. As we know nothino- ac- curately about the chemical changes and nerve-actions in the in- flamed tissue, while we do know the morphological processes very accurately, we naturally attend most to the latter if we wish to de- fine and generalize the term " inflammation." I will briefly take up RESULTS OF GRANULATION. 77 the previous views on this subject (p. 48). " Inflammation" is a modification of the normal physiological processes in the different tissues of the body, a " disturbance of nutrition" (Virchow) whose histopoetic results you now know and of whose destructive, deleteri- ous actions you will hereafter hear. Any part of the body was said to be " inflamed " when it was hot and red; as it is then generally swollen and painful also, this name is applied to processes where the above symptoms occur. The word inflammation originated when there were no true pathologico-anatomical ideas ; even the oldest ob- servers understood that something unusual was going on in the tissues, that they were much heated (inflammatio), and from the first this process has been regarded as an intense increase of the vital processes. As they could not understand the process itself any bet- ter than we do, they considered the symptoms and the results of the process, just as we do; so that doubts often arose if it were proper to speak of inflammation when one or other symptom was absent or not well marked, just as it is to-day. We now know that inflammation is not an existence outside of the body, which makes its way into some part and there grows, and must be expelled like Beelzebub, and we know why " tumor, rubor, calor, dolor," are caused by in- flammation, but although any one usually recognizes an acute inflam- mation as such and designates it correctly, it still remains difficult as well clinically as anatomico-pathologically to give an exact definition of " inflammation." There is no difficulty in distinguishing an oak from an ass; but, if you attempt to generalize and give a sharp defi- nition between plants and animals, you will have the greater difficulty the more you know of the details of botany and zoology. The word "inflammation" is in use, and so accurately designates those pro- cesses to which it was first applied, that it would be useless to try to root it out. By it we understand the above-described combination of .processes in the tissues, which in the present case arise from a purely mechanical irritation (wound) acting only once. How much hyperaemia, exudation, and new formation of tissue is required before we can term the process inflammation cannot be stated absolutely. It seems to be agreed by surgeons and anatomists to designate as "inflammatory" the purely regenerative processes, that is, the neo- plastic tissues, which directly or indirectly replace the loss of sub- stance. If we consider the process in the modern histological sense,, it cannot be accurately defined from the inflammatory, slight as it may be occasionally. From a purely clinical point of view, the distinction is easier, as we often meet cases without any of the four cardinal symptoms on the edges of the wound; and still the difference be- tween a slight redness, swelling, and sensitiveness of the borders of 78 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. the wound to an intense, progressing inflammation over the entire affected portion of the body is only one of degree. Custom has here made a distinction; when a wound heals without any symptoms of so-called reaction we do not call it inflammation of the wound, but only apply this term when the symptoms of inflammation are very prominent at the part injured. I deemed it necessary to speak to you of these general consider- ations on inflammation, so that you might early learn some of the difficulties of the subject. In these lectures it will always be my ob- ject to explain to you, as clearly as is now possible, the anatomico- physiological disturbances, and at the same time to show you histo- logically the origin of the clinical descriptions and expressions now in use. This is the only way we can truly ground our knowledge ; without understanding this you would always be feeling around the outside of symptoms, and by clinging to certain ones fall into in- curable dogmatism, winch in a country doctor the world calls " nar- row-mindedness," in the eminent city physician " infallibility." As the great majority of men are stupid in physical matters, you are sure even with the latter peculiarities of attaining great practical success, but you must then renounce all idea of appreciating or ad- vancing the progress and development of society. It is not the object of these lectures to show you on preparations, step by step, the morphological microscopical changes in wounded tissue— you will see these, in the practical lessons on pathological histology— b.ut I will show you a few points, so that you may not think that the pro- cesses of which I have spoken can only be demonstrated on diagrams. The cell-infiltration of tissue, after irritation by an incision, is best seen in the cornea. Four days ago I made an incision, with a lance- shaped knife, in the cornea of a rabbit; yesterday the incision was visible as a fine line with milky cloudiness. I killed the animal care- fully, cut out the cornea, and let it swell in pyroligneous acid, till this morning; then made a section through the wound, and cleared it up with glycerine. Now, at a a (Fig. 8), you may see the connecting substances be- tween the edges of the wound, in which there has been a considerable collection of cells, between the lamellae of the cornea, where the cor- neal corpuscles lie. These cells are not so evident in the method em- ployed as in that where carmine is used, still the intermediate sub- stance between the edges of the wound is very distinct. As you see, it consists almost entirely of cells; the cells alone would not, however, render the union sufficiently firm, if they were not glued together by a fibrinous cement. The young cells probably come out of the edges of the wound from the fissures between the corneal lamellae, and prob- ably do not originate in the connective substance between the edges PREPARATIONS SHOWING HEALING OF WOUNDS. 79 of the wound; on the contrary, the latter is finally formed from them. Let me remark incidentally, these fine corneal cicatrices subsequent- ly clear up, so as to leave scarcely a trace. All the cells that you here see in the preparation come from the vascular loops of the con- junctiva ; the normal stellate corneal cells are not visible here. I have chosen this specimen because the intermediate substance is broad and very rich in cells. In very small incisions, made in the cornea with a very sharp knife, the intermediate substance is so slight, that it is seen with difficulty; then, too, the changes on the edges of the wound are slighter than here, and so slight a scar is not visible to the naked eye. Here (Fig. 9) you have a transverse section through a twenty-four- Corneal incision three days old; a a, the uniting substance between the two sides of the incis- ion. Magnified 300 diameters. hour old, freshly-united wound in the cheek of a dog. The incision is well marked at a a; the edges of the wound are separated by a dark, intermediate substance, which consists partly of white cells, partly of red corpuscles—the latter belong to the blood, escaped between the edges of the wound, after the injury; the connective-tissue fissures crossed by the wound, in which the connective-tissue cells lie, are already filled with numerous newly-formed cells, and these cells have already pushed into the extravasated blood between the edges of the wound. The preparation has been treated with acetic acid, hence you no longer see the striation of the connective tissue, but see the young cells more distinctly. Look particularly at certain strings, rich in cells, that extend from the wound toward both sides (b b b); these are blood-vessels in whose sheaths many cells are infiltrated; this is apparently because here many white-blood cells have passed through r 80 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Fia. 9. Incised wound twenty-four hours old, in the cheek of a dog. Magnified 300 diameters. the walls of the blood-vessels, or are about to do so. About the transformation of the coagulated blood betwreen the edges of the wound, the wound thrombus, we shall hereafter speak more fully when treating of cicatrices of the vessels at the end of this chapter. This preparation (Fig. 10) shows a young cicatrix, nine days after the injury. Pig. 10. a. Cicatrix nine days after an incision through the lip of a rabbit, healed by first intention Magni- fied 300 diameters. • • » The connective substance (a a) between the edges of the wound consists entirely of spindle-cells pressed together, which are most inti- mately connected with the tissue on both sides of the wound. PREPARATIONS SHOWING HEALING OF WOUNDS. 81 Fine sections cannot be made of granulation tissue, just taken from a wound; it is generally a very difficult subject for fine prepara- tions. If you harden the granulation tissue in alcohol, color the sec- tion with carmine, then clear it up with glycerine, you have a speci- men like Fig. 11. Fig. 11. Granulation tissue. Magnified 300 diameters. The tissue appears to consist solely of cells and vessels, with very thin walls ; the whole tissue is shrunken by the alcohol, so that we here see nothing of the mucous intercellular substance which is al- ways present, even if only in small quantities, in healthy, fresh granu- lations. We see the tissue of the young cicatrix particularly well in the following preparation (Fig. 12), which was taken from a broad cica- trix, following granulation and suppuration, in the back of a dog, about four or five weeks after the injury. Fig. 12. Young cicatricial tissue. Magnified 300 diameters. 82 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. The preparation has been treated with acetic acid, to show the ar- rangement of the connective-tissue cells, that have formed from the granulation tissue; a a a are partly obliterated, partly still permeable blood-vessels; the connective-tissue cells are still relatively large, suc- culent, and distinctly spindle-shaped, still the intercellular substance is richly developed. To study the state of the blood-vessels in the wound, we must make injections; this is quite difficult, and quick success often depends on a lucky chance. Fig. 13. *& a Horizontal section through the tongue of a dog, near the surface, made with a broad knife. Frontal section through the tongue after injection and hardening, ibrty-ei"ht hours after the injury. Magnified 70-80 diameters'; after Wywodzoff—a a, intermediate substance between the edges of the wound (consisting of filamentary-looking adhesive material and extrava- sated blood). The section has passed through two layers of muscle crossing each other. Looping of the vessels with dilatation in both borders of the wound; commencing elonga- tion of the loops into the connective substance. On this subject we have the recent works of Wywodzoff and Thiersch, whose results in the.main agree partly with one another partly with my investigations on this subject. Wywodzoff, who op- orated on dogs' tongues, gives a series of representations of the con- PREPARATIONS SHOWING HEALING OF WOUNDS. 83 dition of the blood-vessels in various stages of healing of the wTound, a few of which I shall demonstrate to you, without, however, going into the more minute details of the formation of vessels. Fig. 14. Similar section of a dog's tongue as in Fig. 13.—Cicatrix (a) ten days old : everywhere anas- tomoses of the vessels from the two edges of the wound. Magnified 70-80 diameters: after Wywodzoff. Fig. 15. lllar section oi a aoe 8 tongue as m rur. 10.—<^iuaui.\ \,ui sm.mccm uoy= vm. •*"-. 1» already greatly diminished and atrophied. Magnified 73-83 diameters : after Wywodzoff. 84 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. This (Fig. 16) is a preparation of granulations from a human bo ing, where the vessels were tolerably filled by natural injection ; the vascular loops are very close together and complicated at the surface; leep down the vessels run nearly parallel. Fig. 16. Granulation vessels. Magnified 40 diameters. In conclusion, here is a preparation of injection of the lymphatic vessels of a dog's lip. You see that the young cicatrix, on the seventh day, when it still consists almost exclusively of cells, has no lymphatic Seven-days-old wound in the lip of a dog. Healing by the first intention. Injection of the lymphatic vessels: a, mucous membrane; b, young cicatrix. Magnified 20 diameters. vessels; these cease immediately at the young cicatrix; they do not form in the cicatrix till the fibrillar connective-tissue bundles form. The granulation tissue also has no lymphatic vessels; where the in- SURGICAL FEVER. 85 flammatory new formation, where the primary cellular tissue forms the lymph-vessels are mostly closed, partly by fibrous coagulations, partly by new cell formations. These observations have also been confirmed quite recently by Losch, of St. Petersburg, by examinations of trau- matically inflamed testicles. LECTURE VIII. General Reaction after Injury.—Surgical Fever.—Theories of the Fever.—Prognosis.— Treatment of Simple Wounds and of Wounded Persons.—Open Treatment of Wounds. Gentlemen: You now know the external and internal minute processes in the healing of wounds, so far as it is possible to follow them with our present microscopes. Of the wounded person we have not yet spoken. If you have crit- ically examined his condition, you will have noticed changes, which may not be explained by cell-knowledge (mit Zellenweisheit), and perhaps not at all. Possibly even the first day the patient may have been restless toward evening; he may have felt hot, thirsty, with no appetite, some headache, wakeful at night, and dull the next morning. These sub- jective symptoms increase till the evening after the next day. If we feel the pulse, we find it more frequent than normal, the radial artery is tenser and fuller than before; the skin is hot and dry; we find the bodily tempertaure elevated; the tongue is coated and readily becomes dry. You already know what ails the patient—he has fever. Yes, he has fever; but what is fever ? whence comes it ? what connection is there between the different remarkable subjective and objective symp- toms? But do not ask any more questions, for I can scarcely answer those already proposed. By the name " fever " we designate the combination of symptoms which, in a thousand different shapes, almost always accompanies in- flammatory diseases, and is generally apparently due to them. We know its duration and course in various diseases; still, its nature is not fully understood, although it is better known than formerly. The different fever symptoms appear with very variable intensity. Two of these symptoms are the most constant, viz., the increase of pulse and bodily temperature; we can measure both of them, the first by counting, the latter by the thermometer. The frequency of the heart's beat depends on many things, especially on psychical excite- ment of all sorts; it shows slight differences in sitting, lying, standing, 86 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. walking. Hence, there are many things to which we must attend, if we would avoid error. However, we may avoid these mistakes, and for centuries the frequency of the pulse has been used as a measure of fever. Examination of the pulse also shows other things important to be known: the amount of the blood, tension of the arteries, irregu- larity of the heart-beat, etc.; and it should not be neglected even now that we have other modes of measurement of the fever. This other, and in some respects certainly better, mode of measuring the amount and duration of the fever is determination of the bodily temperature with carefully-prepared thermometers, whose scales are divided, accord- ing to Celsius, in one hundred degrees, and each degree in ten parts. The introduction of this mode of measurement into practice is due to Von Bdrensprung, Traube, and Wunderlich / it has the advantage of graphically presenting the measurements, which are usually made at 9 A. M. and 5 p. m., as curves, and making them at once easily read. A series of observations of fever in the normal course of wounds shows the following points: traumatic fever occasionally begins imme- diately after an injury, more frequently not till the second, third, or fourth day. The highest temperature attained, although rarely, is 104.5° F.-105.50; as a rule it does not rise much above 102°-103°. Simple traumatic fever does not usually last over a week; in most cases it only continues from two to five days; in many cases it is en- tirely absent, as in most of the small superficial incised wounds of which we spoke above. Traumatic fever depends entirely on the state of the wound; it is generally of a remitting type; the decline may take place rapidly or slowiy. From these observations we should naturally suppose the fever would be the higher the more severe the injury. If the injury be too insignificant, there is either no fever or the increase of temperature is so slight and evanescent as to escape our modes of measurement. It has been thought that a scale of injuries might be constructed, according to which the fever would last a longer or shorter time, and be more or less intense, in proportion to the length and breadth of the wound. This conclusion is only approximately correct, after making very considerable limitations. Some persons become feverish after very slight injuries; others do not, even after severe ones. The cause of this difference in the occurrence of traumatic fever depends partly on whether the wound heals with more or less inflammatory symptoms, partly on unknown influences. We cannot avoid the supposition that purely individual circumstances have some influence : we see that, from similar injuries, one person will be more disposed to fever than an- other. Before going on to examine how the state of the wound is related ELEVATION OF TEMPERATURE IN INFLAMMATION. 87 to the general condition, we must examine the latter a little more carefully. The most prominent and physiologically the most remark- able symptom of the fever is the elevation of the temperature of the blood, and the consequent increase of the bodily temperature. All the modern theories of fever turn on the explanation of this symptom. There is no ground for supposing that in fever any absolutely new element must be added to the requirements acting for the preservation of a constant temperature in the body, but it is probable that the fever temperature is caused by some change of the normal requirements of temperature, which vary readily with circumstances. When you re- member that men and animals in the varied temperatures of summer and winter, in hot and cold climates, have about the same temperature of the blood, you will see that the conditions of production and giving off of heat are susceptible of great modification, and that within these conditions there may very possibly be abnormities of the resulting bodily temperature. It is evident a priori that an increase of bodily temperature may depend either on diminution of the amount of heat given off, the production remaining the same, or on increased produc- tion, the loss of heat remaining the same (other relations of these factors to each other* are possible, but I shall pass over them, to avoid confusing you on this difficult question). The decision of this cardinal question does not seem possible at present; it would be possible by determining and comparing the quantity of heat produced in fever and in normal conditions, by the so-called calorimetrical experiments on men and large warm-blooded animals; but hitherto there have been great difficulties in the way of these experiments. Liebermeister and Leyden have invented methods of calorimetry, that seem to me cor- rect; but the methods and conclusions of Liebermeister have been energetically combated by Senator. Hence, in regard to the above questions, we are still, to a great extent, thrown on probability and hypothesis. As the production of heat depends chiefly on oxidation of the constituents of the body, increase of the latter would necessarily be followed by increase of the former if the loss of heat remained the same. Now, since the amount of urea is regarded chiefly as the result of the burning up of the nitrogenous bodies, and as the amount of urea excreted in fever is usually increased, and the weight of the body rapidly decreases, as appears from the experiments of 0. Weber, Lieber- meister, Schneider, and Leyden, this, with the above-mentioned calori- metric experiments, is considered strong proof that in fever the con- sumption is greatly increased, and that consequently more warmth is really produced than in the normal state, more than can be disposed Df by the body in the same time. Traube gives another view of the occurrence of fever-heat: he asserts that every fever begins with ener- 88 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. getic contraction of the cutaneous vessels, especially of the smallei arteries, and that thus the giving off of heat to the air is decreased, and more heat collected in the body, without its actually producing more. Although this hypothesis is advanced by its author with wonderful ability and acuteness, and is apparently supported by the work of Senator, I, with most pathologists, cannot agree with it, especially as the premises, the contraction of the cutaneous vessels, can only be ac- knowledged in the cases begining with chill; but this chill is by no means a constant symptom in the fever. Hence, in what follows, we shall start from the point that in fever there is increased production of heat. Then arises the question, How does inflammation generally, and traumatic inflammation particularly, effect the increase of bodily temperature ? This question is answered in various ways: 1. At the point of inflammation, as a result of the lively interchange of tissue, heat is produced; the blood flowing through the inflamed part is warmed more, and distributes the abnormal amount of heat here acquired, to the whole body. That the inflamed part is warmer than the non-inflamed is readily proved, especially in superficial parts, as in the skin, but this does not prove that more warmth is produced here than is usual, but is probably simply due to the circulation of more blood through the dilated capillaries ; if the inflamed part be not warmer than the blood flowing to it, it is not probable that it should produce heat. The investigations on this point are numerous and contradictory. The tbermometrical measurements of 0. Weber and Hvfschmidt have given various results; usually the temperature in the wound and in the rec- tum (which has about the warmth of arterial blood) were equal; occa- sionally the former was higher than the latter, sometimes the reverse; the difference was never great, not being more than a few tenths of a degree in any case. Recently 0. Weber has hit on a new method of measurement, the thermoelectric: by his very difficult investigations the question seemed to be decided that the inflamed part is always warmer than the arterial blood; indeed, that the venous blood coming from the seat of inflammation is warmer than the arterial blood going to it. Quite recently these investigations were repeated in Konigsberg by H. Jacobson, M. Bernhardt, and G. Laudien, with the final re- sult of showing no increase of warmth in the inflamed part. From the contradiction of the results of observation it is impossible to form a judgment on this point. Nevertheless it seems certain that in the in- flamed part there is not enough heat produced to elevate the tempera- ture of all the blood in the body several degrees. 2. The irritation induced by the inflammation on the nerves of the inflamed part might be supposed- as advancing to the centres of the vasomotor (nutrient) nerves ; the excitement of the centres of these ELEVATION OF TEMPERATURE IN INFLAMMATION. 89 nerves would induce increase of the general change of tissue and con- sequent increase of the production of warmth. This hypothesis which is supported by some facts, such as the great difference in febrile irri- tability, and which I formerly maintained, no longer appears to me tenable; it is opposed by the experimental researches of Breuer and Chrobak, which prove that fever occurred even when all the nerves were divided, by which there could be any conduction from the periph- eral injury to the nerve-centres; the recent investigations of Leyden also oppose this hypothesis, since they prove that there is no constant re- lation between the loss of nitrogenous material, or consumption, and development of warmth. 3. Since, from the nature of the process, in the inflamed part some of the tissue is destroyed, while some new tissue is formed, it is not improbable that some of the products of this destruction enter the blood, partly through the blood-vessels, partly through the lymph- vessels ; such material acts as a ferment, excites change in the blood, as a consequence of which the entire amount of blood may be warmed. We might also admit a more complicated mode of development of warmth, which, by including the nervous system, might in some re- spects be more serviceable theoretically; the blood changed by taking up the product of irritation might prove irritant to the centres of the vaso-motor nerves, and thus induce increased production of warmth. The decision between these different hypotheses is difficult; they are all about equally justifiable, and all have the common factor of pollu- tion of the blood by material from the seat of inflammation or the wound, which is recognized as having an effect on the production of heat; these substances must have the effect of exciting fever (apyrogenous action). This was to be proved. It has been proved by experiments of 0. Weber and myself, which I can notice only briefly here. In most open wounds, especially in contused wounds, shreds of tissue are always decomposed; in many idiopathic inflam- mations, the circulation is arrested at different points in the inflamed tissue, and there is partial decomposition of these dead portions. Decomposing tissue, then, was an object to be examined in regard to its pyrogenous action. If you inject filtered infusions of this substance into the blood of animals, they have high fever, and not unfrequently die with symptoms of debility, of somnolence, with coin- cident bloody diarrhoea. The same effect is induced by fresh pus in- jected into the blood; a weaker effect follows the employment of juice and pus serum pressed out of the inflamed part. Hence the products of decomposition, as well as those of new formation, have a pyrogenous action in the blood. These products are of a very complicate^and variable nature; some of the chemical substances in them have been independently tested in regard to their fever-exciting qualities: Ave 90 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. may induce fever by injecting leucin, sulphuretted hydrogen, sulphides of ammonium and carbon, and other chemical sub- stances resulting from the decomposition of tissue, or even by injecting water; decomposing vegetable matter also has a fever- exciting effect. Hence there are no specific fever-exciting sub- stances, but the number of pyrogenous materials is innumerable. A considerable amount of them is usually contained in the inflam- matory foci. 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. There is still something to be said about the course of the fever 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 doo- 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 PROGNOSIS OF SIMPLE INCISED WOUNDS. 9] again; by repeated injections of putrefying material we may kilf 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 may ao-ain 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 in- flammation 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 only often impairs the function of the joint, but is often dangerous to life from its secondary effects. External circumstances, the constitution and temperament of the patient, 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 hereafter speak in a separate chapter. You must for the time being content your- selves 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 92 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 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 all rational therapeutics, here it is most important: 1. To prevent injurious influences that may interfere with the normal course; 2. Carefully to watch the occurrence of deviations from the normal, and to combat them at the right time, if possible. If we, first 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 naif 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 nor- mal 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 lay 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 band- age over it. We are somewhat more careful in open, non-united wounds. After the bleeding is arrested, most surgeons cover the surface and cavity of the wound with dry charpie. In large wounds, it is better to apply first a piece of linen full of holes (a so-called fenestrated com- press), and over this the charpie ; this has the advantage that with the compress you may at once remove all the charpie, while otherwise pieces of it would stick in places and require the removal of the indi- vidual particles. The blood drying and the first secretion from the wound cause the charpie first applied to adhere firmly to the TREATMENT OF SIMPLE INCISED WOUNDS. 93 wound, and you rarely need to remove it before it becomes loose, which is usually the third or fourth day, when plenty of pus appears on the wound. Should the wound have bled subsequently, and the charpie, saturated with decomposed blood, smell badly, you may moisten it with water, and remove it carefully without stretching the woun d and hurting the patient. Should th e wound prove tolerably clean after the removal of the charpie, it is subsequently simply necessary to dress it daily with charpie, after previously cleansing it of pus. If, after removal of the first charpie, the wound is found covered with de- composed blood, and numerous shreds of necrosed tissue are scattered over it, you may advantageously dip the charpie, subsequently ap- plied, in chlorine-water, or solution of chloride of lime (one drachm of chloride of lime to a pint of water), then wring it out and apply moist. Usually this will quickly arrest the process of decomposition in the wound, which is rarely of much importance in simple wounds. Continue this dressing till the wound granulates actively, and sup- purates. How often you must renew the charpie on a suppurating wound, depends on the quantity of pus secreted; sometimes it must be twice a day, again only once in two days. For syringing of the wound, we may either use a simple wound-syringe, or Es- march's wound-douche, which consists of a vessel ten inches high, and four and a half inches in diameter, in the bottom of which there is a hole with a short tube through it, to which a rubber tube with a syringe-nozzle is attached; as the vessel is elevated by a nurse, the apparatus acts as syringe or douche. As just remarked, I have recently become convinced that it is better not to apply dressings to fresh wounds or to those suppurating freely, but to take precautions for the blood, pus, and sanies, to flow into vessels placed beneath. Thus we make the unexpected discovery that the blood and serum at first escaping has no smell of its own, when cold, nor has pure pus; and, moreover, that, at the ordinary tem- perature of the room, this secretion may stand for twelve or twenty- four hours without developing stinking gases. This is surprising, be- cause we know that every dressing, saturated with blood or pus, smells worse when removed from the wound, and that this odor can only be overcome by keeping the wound constantly covered with so- called antiseptic or disinfectant solutions. The reason of this is, that, when the secretion flows off, it cools so quickly that it decomposes far less readily, while the same secretion decomposes very quickly when on the wound at a temperature of 101°-104° F., and the water cannot evaporate from it on account of the thick dressing. It is also possible that the minute organisms, which induce the decomposition, have a more favorable soil when the secretion impregnates the dress- 94 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. ing than when it is received in a vessel or dries into a scab on the wound; we shall notice this in the development of these small organ- isms, which occasionally give the pus a blue-green color: of this more hereafter. Clinical observation, as well as experiments, shows that the reabsorption of putrid and purulent secretion is greatly favored when the evacuation or escape of the secretion is mechanically opposed; on this ground also we cannot sufficiently urge that the escape of the se- cretion from the wound should be perfectly free. It is true that in this way crusts form, and the wound does not look so well; but this objection is slight as compared with the advantages of the open treat- ment of wounds. If the wound granulates perfectly, cicatrization begins, and the secretion grows less, we may dress the wound as usual without injury. In freely-suppurating wounds, applications of charpie have the advantage of absorbing the pus ; but this is a doubt- ful advantage, if we bear in mind the possibility of more ready decom- position of the pus in the charpie. Many surgeons dress only with small rags of linen or cotton, many with wadding; blotting-paper and other articles have also been employed. It does not make so much difference what the material of the dressing is, if it only be soft and somewhat bibulous. In hospital service I prefer fresh wadding to charpie, which is made by the patients or nurses, with dirty fingers, from badly-washed bits of bandage ; if it be necessary to use the lat- ter, it is best to dip it in some disinfecting fluid beforehand. For this purpose dilute chlorine-water, solutions of chloride of lime, and of per- manganate of potash, alcohol, solutions of sulphurets of the alkalies (Polli), lead-w^ater, acetate of alumina (alum 3 j, acetate of lead 3 j, water § viij, Burow), are very good. In many cases nothing more is necessarj^; the wound heals without further treatment. 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 healing is arrested; for days the process of cicatrization does not advance, and the granulating surface assumes a flabby appearance. Under such circumstances it is advisable to change the dressing, to irritate the granulating surface by new remedies. These temporary ar- rests of improvement occur in almost every large wound. Under such circumstances you may order fomentations of warm chamomile- 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 HEALING OF WOUNDS. 95 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. rosae § 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 Beverdin. 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 plaster, 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 for 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 Beverdin, and still more so by Amabile. Czerny has shown that 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 8 96 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 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 epidermic 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 in- jury, the patient should not overload his stomach, but, as long as he has fever, must live on low diet. This he usually does spontaneously, 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, rasp- berry-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 dissolved 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 physi- cian should know as much about the cellar and kitchen as about the apothecary-shop, and it is even well for him to have the reputation of being a gourmand. v- 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, wiiich occur so frequently 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 HEALING OF WOUNDS. 97 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. In the same way it not unfrequently happens that the deep part of the wound heals by first intention, while after removing the sutures the cutaneous edges separate, and afterward heal by suppuration; or, on the other hand, the cutaneous surface unites by first intention, while pus oozes up from the depth of the wTound, and the cutaneous edges, which have become adherent, again partially separate. These two latter cases occur particularly in amputation-stumps of the ex- tremities, when the wound is united by suture. Why, in such cases, even perfectly smooth incised wounds do not always heal, can scarcely be certainly decided in every special case. However, when you consider how complicated the conditions of this process, how much they depend on the nature of the injured tissue, on the arrangement of the vessels, on the tension of the edges of the wound, and their more or less perfect apposition, on rest of the parts, on the cleanliness of all instruments and dressings employed, on the general health of the patient, and, finally, on many things that we do not exactly understand, we cannot be astonished that such disturb- ances occur in the process of healing, and would be delighted if noth- ing worse could happen to the patient than failure of healing by the first intention, which, in simple incised wounds, except in plastic opera- tions, is really only important from the time lost. The histological conditions, when a wound at first closed subsequently opens partly or entirely, may be readily understood from the description I have given you; the whole difference in the healing is essentially that the inflam- matory new formation in the one case is transformed directly to con- nective tissue, and in the other case must pass through the stage of granulation tissue. 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 formation 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 bv 98 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 granulation* 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 Bindfleisch also discovered collections of Virchow's mucous tissue, fully developed. The development of vessels may bo very prolific ; the fragile tissue often bleeds on the slightest touch; occasionally the granulations are of a very dark blue. In orhcr 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 yellowifh, gelatinous appearance, in very anaemic persons, often also in younr^ 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 OF THE GRANULATIONS. 99 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 100 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 hyoscjramus-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. 101 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. 102 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 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 winch the epidermis formed exceptionally. You know it is the custom to pierce the ear-lobes of little girls, so that they may subse- quently wTear 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. 103 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 104 SIMPLE INCISED 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 his 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- Fig. 19. Ends of divided muscular fibres from the biceps muscle 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 earcolemma drawn out 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; «, the same with youno-, free muscle-cells; f, 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.] Gussenbauer 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 slightly, 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. 105 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 Gussenbauer. 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 106 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. stump. From these cells, just as in the embryo, new nerve-fibrillae develop upward and downward ; the filaments, which are at first very pale, subsequently acquire a sheath, and then cannot be distinguished from ordinary nerva-filaments. Fig. 31. Fig. 22. Regeneration of nerves. Fig. 21, from a rabbit fifteen days after division ; young spmdle-cells in the eud 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. Magnified 300 diameters, after Ejett.. The most recent investigations as to the significance of wandering cells in new formation of tissue, as well as the special studies over the formation of nerves in portions of tadpoles' tails regenerated 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 into young nerve-filaments, and that the elongated spindle-cells, which undoubt- edly 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. 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 REGENERATION OF NERVES. 107 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 Brown-Sequard 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 . cicatrices, 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 108 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Fio. 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 6 i9poju/3oc, 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 Bave the patient's life. FORMATION OF THROMBUS. 109 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. 22) 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. 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 110 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 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 showrs a transverse section of a recent throm- bus in a small artery; 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- r"-/<^^^^^^^S>C5k\\lll Mil mine); next comes the tunica intima, t^j^ g§L^ «^\W////. ]aid together in regular folds, in which the blood-clot clings; then the tunica muscularis; then the tunica ^w^^^^^^^^^Mimt^kWr 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. FORMATION OF THROMBUS. Ill 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. a thrombus six days old. 300 diameters. Fio. 27. ?en-day-old thrombus, a. Organized thrombus; b, Tunica intima; c, Tunica muscularie; d, Tuuica adventitia. 300 diameters. 112 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 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 nunimum, a fate which it shares with many new formations resulting from inflammation. Fig. 28. Domp.etely-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 ; d, 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- FORMATION OF THROMBUS. 113 stantly-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 114 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. Fig. 30. 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. Becklinghausen 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 thai 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 Bubnoff 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 coapula- FORMATION OF THROMBUS. 115 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 Bubnoff'}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 wiience 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. 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-vasculai 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, 116 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 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 Kocher 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, wiiich 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. 31. Carotid artery of a rabbit, Carotid artery of a goat, injected injected 6 weeks after 35 months after ligation. Al- ligation. After Porta. %ex Porta COLLATERAL CIRCULATION. 117 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 FlQ- 83. 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 Porta, 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 months after ligation. After Porta. 118 SIMPLE INCISED WOUNDS OF THE SOFT PARTS. 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 Frame'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 PECTJLIABITIES OF PUNC TUBED WOUNDS. LECTURE X. As 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 120 SOME PECULIARITIES OF PUNCTURED WOUNDS. 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. B. von Langenbeck 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, wilich 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-caecal 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, NEEDLE WOUNDS. 121 something could be said against all these hypotheses. After a few days the reddened skin became very thin, the abscess pointed about the beight 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 Dieffenbachs 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 wTas 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. 122 SOME PECULIARITIES OF PUNCTURED WOUNDS 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. PUNCTURED WOUNDS OF ARTERIES. 123 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 XVIII.). 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 haemorrhage, any more than there is always escape of faeces from 124 SOME PECULIARITIES OF PUNCTURED WOUNDS. 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-34- by layers of new fibrine from the circulating blood, depositing on the part of the plug projecting into the calibre of the vessel, and ,1 i •, -i i , c • Arterv wounded on the side, with clot, four thus Closing it by a Clot, tormillg a day8 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 perceptibly 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 avevpvvetv, 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 ANEURISM FROM PUNCTURED WOUNDS. 125 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- FlG- m- 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 traumaticum of the brachial artery; after Froriep, " Surgical Copperplates." Bd. IV., Plate 483. 126 SOME PECULIARITIES OF PUNCTURED WOUNDS. 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 witb 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 Fia. 36. Varix nneurismaticus. a, Brachial artery; after Bell. Froriep, "Surgical Copperplates." v Bd. III., Taf. 263. ° vv v ANEURISM FROM PUNCTURED WOUNDS. 127 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. Aneurisma varlcosnm. a, Brachial artery; 6. median vein. The aneurismal sac is cut open; after Dorsey. Froriep, " Surgical Copperplates." Bd. III., Taf. 263. We call this aneurisma varicosum. 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- 128 SOME PECULIARITIES OF PUNCTURED WOUNDS. 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; while in other text-books you will 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, while 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 VENESECTION. 129 veins appear in the bend of the elbow. You choose, for openino- 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. CONTUSION'S OF THE SOFT PABTS WITHOUT WOUNDS. LECTURE XI. Causes of Contusions.—Nervous Concussion.—Subcutaneous Rupture of Vessels.—Rup- ture of Arteries.—Suggillations.—Ecchymoses.—Reabsorption.—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 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 CONCUSSION. 131 in wounds, but pain of a duller, more undefined character, althou°-h 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 trembhng, 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. Xow, as we do not know what specially takes place in the nerves, we 132 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 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 hemorrhage 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 coao-ulation of the blood; for Brixcke has proved that a living, healthy intima of the CONTUSIONS OF BLOOD-VESSELS. 133 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 haemorrhages, even when from a large vessel of the extremities, are very seldom instantly dangerous to life. Of course, it is different in haemorrhages 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 haemorrhages 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, haemorrhages 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 airo and ttXtjooo), 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 haemorrhages in contusions are from rupture of the subcutaneous veins. These effusions of blood 134 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 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 striae (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 haemorrhagic 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- eumscribed 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 CONTUSIONS OF BLOOD-VESSELS. 135 have to deal with a tumor of firm consistence, or with one containinc fluid. You will be showrn in the clinic how it is best to make this examination in different cases. Some of these effusions of blood have received particular n imes according to the localities where they occur. Thus those coming on the heads of the newly-born, between the various coverings of the skull and in it, are called cephalhematoma (from Kt^akr\, head, and ai\iarbu>, 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 episiohema- toma or episiorrhagia (from kixtiatov, the external genitals). Effu- sions of blood in the pleura and pericardium have also special desig- nations : hematothorax, hematopericardium, 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 Bkin, and if Ave have the opportunity of examining blood extravasa- 136 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 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—hematoidin. As in the thrombus, this is partly granular, partly crystalline; in a pure state it is orange-colored, and Fig. 38. if scanty gives the tissue a yellow- ish color, if plentiful a deep orange J*oQ «o. A hue. y \/ «9.'wvi'/^.f/ Beabsorption of the extravasa- &f .- ^•Vf*°* vi^P®*'''9' **on almost always takes place in 0$9 »0° *».0«° •*»,»^»» diffuse suggillations, as the blood *?'•»*. j"'."' vT^ °»^fei»*wA is very widely distributed through *»^*'«' ^ '9'vA^*°a **ie tissucs> and the vessels that *".':*$*''* 00o J/* have to accomplish the reabsorp- * " tion have not been affected by the Granular and crystalline hasmatoidin, partly __4. • •x-j.i i. j • l 1 orange, partly ruby-red in color. Magni- 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 SUPPURATION OF EXTRAVASATIONS. 137 often quite thick. Here we have the same conditions as in laro-e fibrinous exudations in the pleura; there also the fibrous deposits op 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- caWed fibrous tumor is thus formed; in the cavity of the uterus, also, such fibrous tumors occasionally develop. Some haematomata 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 oriighter 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 exactly of this L38 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 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 fasciae, 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. TREATMENT OF BLOOD-EXTRAVASATIONS. 139 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 behoves in arnica, an- other in lead-water, a third in vinegar, as the potent external reab- sorbed. 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. 140 CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. 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 wTas 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 wh^i 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 LACEBATED WOUNDS OF THE SOFT PABTS. LECTURE 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 Rapid 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 wpunds 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 142 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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. Lacerate! 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 wround 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, fasciae are torn, the skin, for some distance around the wound, is no't 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; wiiile 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 HEMORRHAGE FROM CONTUSED WOUNDS. 143 the injury and crushing of the parts. This is readily explained by the nerves in the wound being 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 was absolutely no primary haemorrhage. It is true, this is rare; in many cases wiiere 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 haemorrhage 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. 144 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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 wras 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 departed 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 haemorrhage 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 ecrasement, the instrument he calls an ecraseur. It con- sists of a strong metallic ligature, composed of small links, which HEALING OF CONTUSED WOUNDS. 145 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 wround. 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 146 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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 wTere 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 vexpog, dead), gangrenous (from i] yayypaiva from ypaivu, 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. HEALING OF CONTUSED WOUNDS. 147 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 oi 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. Fig. 39. Diagram of the process of detachment of dead connective tissue in contused wounds. Magni fled 300 diameters; a, crushed necrosed part; 6, living tissue; c, surface of the wound. 148 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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, fasciae, 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 fasciae; 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. HEALING OF CONTUSED WOUNDS. 149 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, 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 following case : A girl about ten years old caught her right hand between two rollers of a spinning-machine ; she drew her arm quickly back, so that it might not be entirely mashed betwreen the rollers. The hand came out again, but the skin from the wrist to the ends of the fingers re- mained between the rollers ; the skin was torn right around the wrist, and then drawn off like a glove. When the patient was brought into the hospital, the injured hand looked like an anatomical preparation ; you could see the tendons play in their sheaths on every motion of flexion and extension, which were unimpaired ; no joint was opened, no bone broken: what was to be done here ? Considerable experience in these injuries by machinery had shown me that fingers which are entirely deprived of their skin always become gangrenous ; here there remained a very strange stump of a hand, which in the most favor- able case would present an immovable cicatricial clump ; it was even doubtful if a permanent solid cicatrix would form; many months would be wasted, trying to obtain such a result; under such circum- stances it would be better to amputate close above the wrist; this was done, and in four weeks the patient returned home ; her employer had an artificial hand, with simple mechanism, made for the patient, to overcome the injury as far as possible. 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 the hand that every line, more or less, is of im- portance, 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- 150 CONTUSED AND LACERATED WOUNDS OF TnE SOFT PARTS. made artificial hand ; for the foot and lower extremity there are other considerations, of wiiich 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 preserve 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 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, 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 dirty 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. This is most remarkable in hthotomy : if, for the purpose of removing a stone, you open the bladder, whether by the perineal or upper sec- tion, the urine, which in such cases is usually alkaline, naturally escapes directly from the bladder through the opening made; the en- tire surface of the wound almost universally becomes gangrenous, but only to a slight depth, perhaps half a line to a line. In favorable cases, after six or eight days, the white necrosed tags fall spontane- ously ; beneath them appear strong, wTell-suppurating granulations, although the urine continues to flow ; the wound contracts, and usually heals entirely in from four to six weeks. Should the urine not escape, but be pressed deeper and deeper into the cellular tissue (as is the case in so-called infiltration of urine, as when an opening is suddenly formed in the bladder or urethra, without simultaneous injury of the skin), all would become gangrenous with wiiich the alkaline urine comes in contact. If you compare the state of contused wounds, on which shreds of tissue are decomposing, you find an analogy to the mrcumstances in lithotomy; the sanies flows from the tissue, hence the gangrene only extends to a certain depth. Even this is not HEALING OF CONTUSED WOUNDS. 151 always the case, as in most of the shreds of tissue long hanging on the wound, such as tendons, fasciae, or skin, from the natural dryness of these tissues, the putrefaction comes on slowly and at a time when the healthy tissue is already bounded by cell infiltration and granu- lation. 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. On the borders of the inflammatory new formation the lymphatic vessels are closed; on the granulating surface there are no open lymphatic ves- sels, hence no reabsorption takes place there. The latter view is much disputed; it has been especially con- tended that the putrid matters could only act in solution, and that there was no reason why they should not then permeate the walls of the capillaries and veins just as readily as those of the lymphatics. I can acknowledge the justness of this reflection without thereby entire- ly giving up the above explanation of the generally-known observa- tion. For it is not correct that only the putrid substances in solution affect the wound injuriously; foul air is always associated with the development of minute elementary organisms belonging to the lowest vegetable species, microscopic fungi and algae. These are sometimes minute globules (micrococcus, from p,iKpbg, small, and 6 kohkoq, the kernel), sometimes minute rods (bacteria, from to (3attTrjpiov, the rod), which are found isolated, in pairs or in groups of four to twenty, or they are often united into irregular spherical or cylindrical forms by an exuded mucous substance (coccoglia, from KOKKog, and rj yXia, or yXoia, glue). These elements differ greatly in size, varying in diame- ter between that of the pale globules, scarcely perceptible with the strongest magnifying power, and that of a pus-globule; they are mov- able or at rest; they are /always present, to some extent, in the gan- grenous shreds adherent to the wound before it is completely cleansed. To these small fungi are ascribed the chief part in the occurrence of that form of decomposition termed putrefaction, and characterized more particularly by the development of badly-smelling gases. In putrefaction they play the same part as the ferment-fungus does in the fermentation of the juice of the grape and many other fruits: they are the so-called ferments which induce putrefaction of the juices of the body. I pass over the theories advanced for the explanation of this strange process of living action, as well as the objections to the correctness of the assertion that putrefaction can only be induced by 152 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. the above-mentioned organisms, and content myself with telling you that since the patient investigation of Pasteur on spontaneous gen- eration, fermentation, and putrefaction, it appears proved absolutely that all the processes which we class together as putrefaction and fer- mentation, can only be caused by vegetable organisms, which, of course, is not denying the occurrence of other forms of decomposition without fermentation, which may also be accompanied by the devel- opment of offensive gases. Granting this, it follows that these organ- isms would more readily enter open lymph-vessels than traverse the walls of blood-vessels. The decomposition induced by these organ- isms is accompanied by the development of ammonia, butyric acid, lactic acid, and some other substances, which are proved, by experi- ment, to have an injurious, phlogogenous action on the tissues, as well as a poisonous effect on the whole body. Hence the entrance of these organisms, whose mechanical irritation is very slight from their very small size, is dangerous, and becomes more so as they increase. For this increase, besides various other things, plenty of water is requisite. 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. HEALING OF CONTUSED WOUNDS. 153 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. We 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 againf 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 wiiich, 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. 154 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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 Avho knows anatomy thor- oughly, and has employed his time well in the operative courses. Anatomy, gentlemen 1 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 hemorrhages. 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, SECONDARY HAEMORRHAGE. 155 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 fewT of these parenchymatous haemorrhages. The latter explanation sounds very plausible ; so far as I know, it originates with Stromeyer. 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.—Prophylaxis against Secondary Inflammations.—Internal Treat- ment of those severely Wounded.—Quinine.—Opium.—Lacerated Wounds : Sub- cutaneous Rupture 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 wrere 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 cedematous; on the surface the granulations are smeary, yellow, swollen, and spongy. When we press in the vicinity of the wound, the pus flows 156 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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 wiiole 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 INFLAMMATION OF CONTUSED WOUNDS. 157 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 158 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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, Avhich cannot be accurately defined, a sudden change of temperature induces inflammations, especially in a locus minoris resistentie of an individual; in a wounded person the wound is always to be considered as a locus minoris resistentie. 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 INFLAMMATION OF CONTUSED WOUNDS. 159 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 the 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 12 L60 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. from the wound itself, may be a disputed point, so far as we at present know. We shall return to this point wiien 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, wiien 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. From these considerations, 3-ou will be much terrified about the fate of the wounded, as absolute prevention of such injuries seems impossible. I must state at once, for your comfort, that all molecular organisms, millions of which are contained in the atmosphere, are not taken up' by the wound, nor do they all induce inflammation. Just as certain fungous germs, under certain condi- tions, sometimes very limited, are necessary to induce fermentation in certain fermentable fluids, so it is not every animal or vegetable germ that can excite inflammation in the wround. 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 in- flammation 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 substances 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, INFLAMMATION OF CONTUSED WOUNDS. 161 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.'1'' 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." 162 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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, Traube 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 Jochmann 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, bui 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- TREATMENT OF CONTUSED WOUNDS. lo J matic and inflammatory diseases, which you may regard as a continu- 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. Baum, 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. 164 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. I have seen all these modes of treatment in practice. Here is my 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 TREATMENT OF CONTUSED WOUNDS. 165 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 wrater 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 wound after the simple rules already given. 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 water, 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 water-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 L66 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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 «oon 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 wrounds. 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, TREATMENT OF CONTUSED WOUNDS. 167 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 hyperaemia, and so the increase of 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 (Potfs 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. 168 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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!" 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. 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, every thing that drives the blood and lymph more strongly into the vicinity of the wound, may eventually prove injurious. Of late, I rarely see contused wounds do so well as compound fractures of the extremities, where plaster dressings are at once applied; hence wTe have a strong hint to compel absolute rest of an extremity with a large contused wound without fracture, by applying a fenestrated plaster-spint. The cases where I have done this did remarkably well; even after amputations of the hand and foot, where the patient was very restless, I have ap- plied the plaster-spint with excellent result, and think that this mode of treatment, which we shall describe more fully under compound fractures, may be more extensively used than hitherto. TREATMENT OF CONTUSED WOUNDS. 169 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, en 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, Volkmann 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. 92). 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. 93), 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. In the treatment of secondary inflammation, most careful prophy- 170 CONTUSED AND LACERATED WOUNDS OF THE SOFT TARTS. 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 {he patient. The bleeding of the wound on dressing should be avoided by carefully syringing it with Fsmarchs 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 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, of permanganate of potash. Lister has recom- mended 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. These different modes of application, under the name of "Lister's dressing," have been regularly tried, and it is a good thing for the profession 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 antiseptic, but have not found it to possess any special advantage over the remedies and modes of treatment above men- tioned. 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 sus- picious, it should be quickly rubbed with cleaning powder. In order to carefully observe all these precautions, you must be perfectly satis fled of their necessity. TREATMENT OF CONTUSED WOUNDS. 171 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, perhaps, 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 medicines; you must espe- cially avoid liberality with opium, when it is not required, for it is con- stipating. 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; 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 externus 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, 172 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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 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; from the roof of the house against which the scaffold rested, there hung 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 great, 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 inflamma- tion 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 wrar it is not very rare for arms and legs to TREATMENT OF CONTUSED WOUNDS. 173 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 scaoula Fig. 40. Fig. 41. Fie. 42. >ntral end of a torn brach- ial artery. Torn-out middle finger, with all its tendons. Arm torn out, with scapula and clavicle. I 74 CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. 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 usually quickly fatal CHAPTER V. SIMPLE FB AC TUBES OF BONES. 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 alwrays 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 nature 13 176 SIMPLE FRACTURES OF BONES. 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 " fragilitas 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 bones 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 bo'th 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. 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. 177 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 multiple 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 178 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 js 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. 179 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, howrever, that it cannot be rooted out, and every one knows what it means. An edu- jated 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 Ave 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 lotus / 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 adperipheriam / 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 180 SIMPLE FRACTURES OF BONES. 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 aftei FORMATION OF CALLUS. 181 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. Longitudinal section oi' a fracture of a rabbit's bone, four daj's old; a, ex- travasated blood; b, swollen soft parts external callus; c, periosteum. ~~ct Diagram of a longitudinal section of a fii'teen-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 too great, 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 182 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 (b), 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, wiiich represents the periosteum (d). The j7ouug 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 tommenced 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. 183 Fig. 45. Longitudinal section of a fractured bone from a rabbit, after twenty- four weeks. Progressive reab- sorption of the callus. Restora- tion of the medullary cavity, natural size ; after Qurlt. Except the regeneration 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 opportunity 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, the same reabsorption and condensation 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 184 SIMPLE FRACTURES OF BONES. together. The larger the circle of irritation from the dislocated frag- ments, 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. Fig. 46. Fig. 47. 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 dimin- 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 c.ises, so disappear in the course of months and years, that in their place there is only left some dense, compact, cortical substance. Fracture of the tibia of a rabbit, with great dislocation, with extensive Formation of callus, after 27 days. Natural size, after Skutsch. (GurlVs Fractures, vol. i., p. 270.) FORMATION OF NEW BONE. 185 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 extravasated 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, arid 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 Fig. 4S. Diagram of a longitudinal section through the cortical substance of a long bone, o, surface. 0. Haversian canals, with blood-vessels and connective tissue; c. periosteum. Magnified 40!) diameters. 186 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): Fig. 49. Diagram of inflammatory new formation in the Haversian canals, a, surface; b 6, 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. 18? 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 probably 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 hav« 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 hvre no solid bone formed, but a 188 SIMPLE FRACTURE OF BONES. connective-tissue union, pseudarthrosis (from ipevdrjg, false ; ap&puoig, 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 Haver- eian 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. 189 As previously remarked, the periosteum is used up in the neopla« jia 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; b, boue. Magnified 20 diameters. Fig. 52. 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 the bone through the young callus. The 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. 52). Lastly, observe the following prepa- ration. It is an eight-day-old, already ossified, external callus on the surface of the tibia of a door, mag-nitied 250 Artificially-injected transverse section of the tibia of a dog, from the immedi- 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 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, 190 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. 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 J. Wolff, render it very probable that they increase in all directions by interstitial deposit of young osseous tissue, and hence that growth by apposition through the epiphyseal cartilages and perios- teum can no longer be regarded as the sole source of increase in length and thickness; such a mode of growth is placed beyond a TREATMENT OF FRACTURES. 191 doubt by Wegner's excellent work on the osteoplastic action of phos- phorus on growing bones. I will not conceal from you that the view which I have obstinately maintained, that the bone-cells in new osseous formations do not pro- liferate, but remain quite passive, is much disputed; since Cohn- heim has shown the passiveness of the stabile connective-tissue cor- puscles in inflammation, there does not seem so much strangeness about my view, which was advanced years ago, and was founded on numerous observations; still, the explanation of the preparations in question is not simple enough to permit only one view. Recently, by very careful investigations about the histological changes during the transformation of provisional into definitive callus, Lossen has tried to show that the bone-cells in the former take an active part in the formation of vascular canals in the latter by enlarging and changing position. I can agree with this entirely without abandoning the above views, for the provision-callus is like the young osteophytes of calcified connective tissue, like certain boundary-layers between car- tilage and bone. I have no doubt that the cells of this " osteoid car- tilage " ( Virchow), like the cells of hyaline cartilage, proliferate to true bone. But this is not the place to enter more deeply into the histological details, which, great as is their intrinsic interest, have no essential influence on the definitive formation of the new development of bone. / LECTURE XV. Treatment of Simple Fractures.—Reduction.—Time for applying the Dressing, its Choice.—Plaster of Paris and Starch Dressings, Splints, Permanent Extension.— Retaining the Limb in Position.—Indications for removing the Dressings We shall pass at once to the treatment of simple 01 subcutaneous fractures, especially fractures of the extremities, for these are by far the more frequent, and they particularly require treatment by dressings, while those of the head or trunk are to be treated less by dressings than by appropriate position, as is taught in the lectures on special surgery and in the surgical clinic. The indications we have to consider are, simply to remove any dislocations and to keep the fractured extremity in the correct ana- tomical position till the fracture is healed. First, the fragments are to be replaced; sometimes this may 14 192 SIMPLE FRACTURE OF BONES. be unnecessary, as when there is no dislocation, for instance, in some fractures of the ulna, fibula, etc. In other cases it is very difficult, and cannot always be done perfectly. The obstacles to the reposition may be in the position of the fragments themselves ; one fragment may be wedged into another, or a small fragment lies between the chief ones, so that the latter cannot be brought together accurately; fractures of the lower articular extremity of the humerus are very obstinate in this respect, for small fragments may be so dislocated that neither flexion nor extension of the elbow-joint can be performed perfectly; hence its functions remain permanently impaired. Muscular con- traction forms a second obstacle to the reposition of the fragments; the patient involuntarily contracts the muscles of the broken limb, thus rubs the fragments together or presses them into the soft parts, causing severe pain; this muscular contraction is occasionally almost tetanic, so that, even by great force, it is hardly possible to overcome the opposition. Indeed, formerly these difficulties were, to some ex- tent, insurmountable; and, although attempts were now and then made to attain the object by dividing tendons and muscles, it was often only possible to attain an imperfect reposition. All these diffi- culties were at once removed by the introduction of chloroform as an anaesthetic. Now, in all cases where we do not readily succeed in reposition, we anaesthetize the patient with chloroform, till his mus- cles are perfectly relaxed, and we can then usually place the frag- ments in position without difficulty. Some surgeons go so far as to use chloroform in almost all cases of fracture, partly for the examina- tion, partly for the application of the dressing. This is unnecessary, and may even prove very unpleasant, for some persons, especially those in the habit of drinking, at a certain stage of the anaesthesia are affected with spasmodic contractions of the extremities, so that, in spite of being carefully held by strong assistants, they rub the frac- tured ends against each other with fearful force, and we must be very careful that a sharp fragment does not pierce the skin. This should not frighten you from using chloroform in fractures, when it is neces- sary, but simply warn you against being too free with it. The meth- od of reposition is usually as follows : The fractured part is grasped by two strong assistants at the joints above and below the point of fracture, and regular, quiet traction employed, while the surgeon holds the extremity at the point of fracture, and, by gentle pressure, attempts to force the fragments into position. All sudden, impul- sive forced traction is useless, and should be avoided. Here you have to notice two technical expressions; we term the traction on the lower part of the extremity, extension, that on the upper part, counter-extension. In fractures, these are both made by the hands, TREATMENT OF FRACTURES. 193 while in dislocations we must occasionally resort to different mechan- ical appliances. By the above method accurate reposition will only be impossible when, from excessive swelling or from peculiarly un- favorable dislocation of the fragments, we are unable to correctly recognize the variety of the displacement. From our present ideas, which are based on a large number of observations, the sooner reposition is made after the occurrence of the fracture, the better; we then at once apply the bandage. This was not always the belief, but formerly the adjustment of the frac- ture and the application of the dressing were delayed till the disappear- ance of the swelling, which almost always occurs if a dressing is not at once applied. It was feared that under the pressure of the dress* ing the extremity might mortify, and the formation of callus would be hindered; with certain cautions in the application of the dress- ing, the former may very readily be avoided, and there is little truth in the latter belief. Regarding the choice of the dressing also, surgeons have of late reached an almost unanimous opinion. It may be regarded as a rule, that a solid, firm dressing should be applied as early as possible in all cases of simple subcutaneous fractures of the extremities / this may be changed altogether two or three times, but in many cases does not need renewal. This mode of dressing is called the immovable or fixed, in contradistinction to the movable dressings, which must be renewed every couple of days, and are only provisional dressings. There are several varieties of firm dressings, of which the most serviceable are the plaster of Paris, starch, and liquid glass. I shall first describe the plaster dressing, and show its application, as it is the one most frequently used, and.answers all requirements in a way that can scarcely be improved. Plaster of Paris Bandage.—After adjustment of the fragments, the broken limb is extended and counter-extended by two assistants, then one or more layers of wadding applied over the point of fracture, and over parts where the skin lies directly over the bone, as over the crest of the tibia, the condyles, and malleoli. Now it is best to en- velop the limb with a new fine flannel roller-bandage, so as to make regular pressure on it, and cover all parts that are to be surrounded by the plaster-bandage. In hospital and poor practice, where we can- not always have flannel, we may use soft cotton or gauze bandages. Now comes the application of the plaster-bandages prepared for the purpose; the plaster-bandage that I here have is cut from a very thin gauze-like stuff; it is prepared by sprinkling finely-powdered plaster (modelling plaster) over the unrolled bandage and then rolling it. In private practice a number of these bandages of various sizes may be 194 SIMPLE FRACTURE OF BONES. prepared beforehand and kept in a well-closed tin box. Here in the hospital, where these plaster-bandages are much used, they are pre- pared two or three times a week. This bandage you place in a basin of cold water and let it soak through, then apply it like any roller- bandage to the extremity prepared as above described. Three or at most four thicknesses of this plaster-bandage suffice to give the dress- ing the requisite firmness. In about ten minutes good plaster be- comes stiff enough for us to lay the extremity loose on the bed; in half an hour or an hour, the dressing becomes as hard as stone and quite dry; the time required for hardening depends partly on the quality of the plaster, partly on how much you have moistened the bandage. After many comparisons with other modes of applying the plaster-bandage, I have found this the most practical; but I must mention some modifications of the way of handling the plaster and of the material of the bandage. For instance, we may rub the plaster into the common muslin or flannel bandages, which makes the dress- ing somewhat heavier and firmer; but this is not necessary and the loose gauze is very much cheaper than muslin-bandage. If the band- age does not appear sufficiently firm, we may apply a layer of plaster- paste over the dressing; this plaster-paste is to be made with water, and spread on the bandage very quickly with the hand or a spoon ; it should not be prepared till we wish to use it, as it stiffens very quick- ly. The plaster-dressing as made with roller-bandages was first in- troduced by a Dutch surgeon, Mathysen / this method was first pub- lished in 1832 ; but it has only become well known since 1850; it has been spread through Germany chiefly by the Berlin school. A differ- ent mode of applying the plaster-dressing is by different strips of bandage; Pirogoff first hit on this method from lack of bandages in the army; all kinds of material were cut into the shape of splints, then drawn through thin plaster-paste and laid on the broken limb, then the whole was coated with plaster-paste and a firm capsule was thus made. Subsequently the same surgeon made a special method of this; he cut old coarse sail-cloth into certain patterns for each limb, and applied it in the above manner. Lastly, the so-called many-tailed bandage of Scultetus was used in the same way as a plaster-bandage. The foundation of the bandage has also been modified in various ways; it has even been used without wadding or any under-bandage, the whole limb being simply covered with oil so that the plaster- bandage, being applied directly, might not adhere to the skin by the fine hairs. Others have employed thick layers of wadding without any under-bandage. Lastly, thin wooden splints or strips of tin have been lately used in it, as we shall hereafter see; this may have certain advantages in fenestrated bandages. TREATMENT OF FRACTURES. 195 I have intentionally represented all these modifications of the plaster-bandage as only exceptionally useful, all of them having cer- tain objections as compared with the method first described. A more careful criticism of these modifications here would lead us too far. For persons unskilled in the matter, the removal of the plaster- bandage is quite difficult, but you may see that any of my nurses will do it with astonishing quickness. It is simply done as follows: with a sharp, strong garden-knife we divide the plaster-bandage, not per- pendicularly but rather obliquely, as far as the under-bandage, then remove the bandage entire, like a shell; we may also employ the plaster-scissors proposed by Szymanoioski or those of Bruns. We use this capsule in some other cases as a provisional dressing. Starch-Bandages.—Before plaster-bandages were known, we had in the starch-bandage an excellent material for the immovable dressing. The starch-bandage was perfected and introduced chiefly by the Belgi- an surgeon Seutin (f 1862); it is only during the last twelve years that it has given place to the plaster-dressing, but it is still used oc- casionally. The application of the wadding and under-bandage is the same as in the plaster-dressing, but then we apply splints, cut from moderately thick pasteboard and softened in water, to the limb, and fas- ten them on with bandages thoroughly soaked in starch-paste; we now apply wooden splints till the dressing has hardened, which at the ordi- nary temperature requires about twenty-four hours. Compared to the plaster-dressing this has the disadvantage of hardening much more slowly ; we may improve this somewhat if we use gutta-percha splints instead of pasteboard, these may be softened in hot water, and adapted to the extremity. Gutta-percha bands, such as are used in factories, are very useful as splints. It cannot be denied that the introduction of gutta-percha into surgery is to be regarded as a great advantage ; but it is too costly to be used in practice for every simple fracture, although thick splints of this material harden even quicker than plaster. The dressing with roller-bandages prepared with plas- ter is so cheap and firm that it will certainly not be displaced again by starch-bandages, now that it has been introduced into practice. Instead of plaster, solutions of dextrine, pure white of egg, or simple mixture of flour and water, were formerly employed; they have all gone out of use, but it is well for you to know the usefulness of these substances, which are in every house, and which we may well employ as provisional dressings. Liquid-glass Dressings.—Instead of starch, we may employ the liquid glass of the shops (silicate of potash). On applying the dress- ing, we paint this on the muslin-bandages with a large brush, after having made a substratum of wadding as above described. The liquid 19C SIMPLE FRACTURE OF BONES. glass dries quicker than starch, but not so soon as plaster, nor does it become as hard as the latter; this dressing does for fractures with no tendency to displacement; if we wish to fix dislocated fragments of bone by the liquid-glass dressing, we must strengthen it by applying splints. I doubt not the time will soon come when every country physician will always keep a few plaster-splints ready prepared; in spite of them, provisional dressings remain useful. These consist of band- ages, compresses, and splints, of various materials. You may make splints of thin boards, shingles, cigar-boxes, pasteboard, tin, leather, firmly-plaited straw, the bark of trees, etc., and, for bandages, must often content yourselves with old rags, muslin, torn into strips and sewed together; hence, in the practical courses on bandaging, it is necessary for you to learn to make use of the most varied materials. It is not our intention here to introduce to you every thing that may be used in the way of dressing, but I must still speak briefly of a few things. As may be readily seen, the object of the splints is to make the bone immovable by supporting it firmly on various sides; this may be attained by external, internal, anterior, and posterior, narrow wooden splints; we may, however, employ hollow splints, so-called gutters. Hollow splints are only good when made of plia- ble material, as leather, thin sheet-iron, wire-gauze, etc.; an absolutely stiff, hollow splint would only do for certain persons. Besides these mechanical aids, there is another method of keeping broken limbs in position, namely, permanent extension. This is particularly indicated in cases where there is great tendency to shortening, to dislocatio ad longitudinem. Attempts have been made to attain this extension by attaching weights by various mechanical contrivances, by continued traction made by weights hung to the injured limb, by the double- inclined plane, where the weight of the leg is used as the extending weight. Since, during the past two years, I have unexpectedly seen such excellent effect from permanent extension with weights in pain- ful contractions at the hip and knee joints, I am compelled to believe that this method may also eventually prove very serviceable for the gradual adjustment of dislocated fragments of bone. Amono- the arrangements of this nature with which I am acquainted, V. Dum- reicher's so-called railroad apparatus best fulfils the object of perma- nent extension, but it is too costly and complicated to come into extensive use in private practice; it is, doubtless, the intention of the inventor to employ it chiefly in cases where the dislocation is difficult to overcome. [Dr. Gurdon Buck's apparatus for fractured thio-h is about as efficacious and much simpler.] The double-inclined plane, represented by a thick roller-cushion applied under the hollow of the TREATMENT OF FRACTURES. 197 knee, may occasionally be employed as a suitable fixation apparatus in fracture of the neck of the femur in old persons. We must still mention some auxiliary appliances which we have to employ to keep the broken limb in good position after it has been dressed; for the upper extremity, in most cases, a simple, properly- applied cloth, a mitella, or sling, in which the arm is laid, suffices. Patients with fractured arm or forearm may be permitted to go about with a plaster-bandage and a sling during the entire treatment, with- out interfering with the favorable healing. For keeping broken lower extremities in position, there are a number of mechanical aids, of which the following are the most serviceable: sand-bags, narrow sacks filled with sand, about the length of the leg; these are placed both sides of the firm dressing, so that the limb may not move from side to side ; for the same purpose we may use long, three-sided pieces of wood, cut prismatically, which are laid together, so as to form a gutter. For some cases a sack, loosely filled with chaff or oats, is sufficient; we make a hollow in it length- wise, and the leg is to be placed in this. If we desire firmer supports, we use fracture-boxes, narrow, long, wooden boxes, open at the upper end, so that the leg may be placed in them; and the sides are made to turn down, so that the extremity may be carefully inspected, without moving it; the elevation of these fracture-boxes may be suited to the convenience of the patient. Lastly, we must mention the swing, which is usually made with a gallows, or strong bow, that is brought over the foot of the bed, and to which the limb is suspended in any sort of a fracture-box, or hollow splint [or Dr. Nathan Smiths anterior splint], so that it may swing about; in restless patients especially, this has certain advantages. All these apparatuses, which, although more rarely employed than formerly, are still occasionally useful, you must learn to apply; you will have opportunity for this in the surgical clinic. Of late we rarely apply these apparatuses in the lower extremity, as my former assistant, Dr. Bis, who has brought the application and elegance of the plaster-bandage to an extraordinary state of perfection, applies a well-padded wooden splint, three or four inches wide, to the under side of the leg, making it reach somewhat below the heel and as high as the knee, or, in fractures of the thigh, as high as the middle of the thigh. The hmb lies firmly on this board, if the mattress be not too uneven ; if we wish to attain still greater firmness, we may lay a board the width of the bed over the lower third of the mattress, and on this place the Hmb, with its plaster-dressing and supporing splint. In the numerous double fractures of both lower extremities that came to the Zurich hospital, this supporting apparatus did excellent service. 198 SIMPLE FRACTURE OF BONES. The old form of plaster-moulds has been recently strongly advo- cated again by Dr. M. Mailer; we have tried it again, but it bears no comparison with the plaster-bandage. Seutin tried to increase the advantages of firm dressings by giving aids that might enable patients with fractured lower limbs to go about to some extent. For instance, a patient with a broken leg may have a broad leather strap passing over the shoulder, and buckled just above the knee, so that the foot will not touch the floor, and then let him go on crutches. But I advise you not to carry these experi- ments with your patients too far; at all events, I only allow my patients to make such attempts three weeks after the occurrence of the fracture, otherwise oedema readily occurs in the broken limb, and some patients are so clumsy in the use of crutches, that they are apt to fall, and, although this may only cause slight concussion of the limb, it is still injurious. Lastly, we have to discuss how long the dressing should be left on, and the causes that might induce us to remove it before the cure is complete. The decision as to whether a dressing is too tightly applied is entirely a matter of experience; the following symptoms must guide the surgeon: If there be swelling of the lower part of the limb, as of the toes or fingers, which are usually left exposed, if these parts become bluish red, cold, or even senseless, the dressing should be removed at once. If the patient complains of severe pain under the dressing, it is well to remove it, even if we can see nothing to cause it. In judging of the exhibitions of pain, we should know the patients; some always complain, others are very indolent, and show their feelings but little; however, it is better to reapply the bandage several times uselessly than once to neglect its removal at the right time. I cannot too strongly urge you always to visit, with- in twenty-four hours at most, every patient to whom you apply a fixed dressing; then your patient will certainly not come to grief, as un- fortunately too often happens, from the carelessness and laziness of his surgeon. A series of cases has been published where, after the application of a firm dressing, the affected limb mortified, and re- quired amputation; from these cases it was decided that firm dress- ings were always improper, while the fault was chiefly due to the surgeon. Just think how little trouble we have in treating fractures now, compared to former times, when the splints had to be renewed every three or four days ; now you need only apply a dressing once. But you must not think you have got rid of all trouble in the appli- cation of dressings. The application of the firm dressing requires just as much practice, dexterity, and care, as did dressing with splints. If you are first called to a fracture when it is two or three TREATMENT OF FRACTURES. 199 days old, when there is already considerable inflammatory swelling, you may even then apply the firm dressing, but must apply it more loosely, and with plenty of wadding. This dressing will be too loose, and should be renewed in ten or twelve days, when the swelling has left the soft parts. It will chiefly depend on the looseness of the bandage, and the greater or less tendency to dislocation, when and how often the dressing should be removed during the treatment. Swelling, if not accompanied by considerable contusion, is no contra- indication to a carefully-applied firm bandage ; nor do large or small vesicles, full of clear or slightly-bloody serum, present any great ob- jection ; such vesicles result not unfrequently from contused fractures with extensive rupture of the deep veins, since, from obstruction to the flow of venous blood, the serum readily escapes from the capilla- ries, and elevates the hard layer of the epidermis into a vesicle; we puncture these vesicles with a needle, gently press out the fluid, and apply some wadding, and they soon dry up. It is the same with slight superficial excoriations of the skin ; we are only rarely obliged to remove the dressing and apply another, when new vesicles form, as wre may know by the pain. The length of time that a firm dressing must remain on for the different fractures you will learn partly in the clinic, partly from spe- cial surgery ; I simply mention here, as the limits, that a finger may require a fortnight, a thigh sixty days, or more, for healing. If you apply the plaster-dressing immediately after the fracture, dislocation having been completely removed, the provisional callus will always be less, and hence firmness result later, than where there is some dis- location and the dressing is applied later; but this has no effect on the formation of definitive callus, and the actual union of the frac- tured ends of the bone. CHAPTER VI. OPEN FBA CTUBES AND S UPP UBA TION OF B ONE. Difference between Suhcutaneous 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 Fragments. We shall now pass to complicated or open fractures. When we speak simply of complicated fractures, we usually mean only those accompanied by wounds of the skin. Strictly speak- ing, this is not exact, because there are other complications, some of them much more important than wounds of the skin. If the skull be fractured, and part of the brain-substance crushed, or some ribs broken and the lung wounded, these are also complicated fractures, even though the skin should remain uninjured. But, since in these cases the complications themselves are more important for the organism than the fracture is, we usually term such cases contusion of the brain, or injury of the lung, with fracture of the skull or ribs. But we shall not here enter on the subject of injuries of internal organs by frag- ments of bone, because very complicated states of disease are occa- sionally induced in this way, whose analysis you would not now un- derstand. For the present let us limit ourselves to fractures of the extremities, accompanied by wounds of the skin, which we shall call open fractures, and which will give us trouble enough in their course and treatment. In speaking of the course of simple contusions without wounds, and of contused wounds, I have already shown you how readily reab- sorption of extravasated blood and the healing of contused parts go on, as long as the process is subcutaneous, but how much the condi- tions change if the skin also be destroyed. The chief dangers in such cases are, as you may remember, decomposition in the wound, exten- sive necrosis of crushed or dead parts, progressive suppuration, and accompanying protracted, exhausting fever, while we have scarcely PROGNOSIS IN OPEN FRACTURES. 201 mentioned the severe general diseases, erysipelas, putrid-blood poison- ing, pyaemia, tetanus, and delirium tremens. The difference between contusions and contused wounds is even more strongly marked in simple and compound fractures, as regards course and prognosis. While in many cases we can scarcely call a person with simple frac- ture sick (we have not spoken of fever there, for it rarely occurs), and under the present convenient treatment such an injury is rather an inconvenience than a misfortune, a compound fracture of a large bone of an extremity, or sometimes even of a finger, may induce severe, and too frequently fatal, disease. But, not to alarm you too much, I will at once add that there are many grades of danger even in open fractures, and, moreover, that their treatment has been much improved of late. It is very difficult and important, but not always possible, to make a correct prognosis about an open fracture at once. The life or death of the patient may occasionally hang on the choice of the treatment the first few days, so that we must study this subject more accurately. The symptoms of an open fracture are of course essentially the same as of the subcutaneous, except that discoloration from extravasated blood is often wanting, because at least part of the blood escapes through the wound. The fractured ends not infrequently project from the wound, or lie exposed in it, so that a glance may suffice for the diagnosis of an open fracture. But this is not enough. We must do our best to ascertain how the fracture was caused, whether by direct or indirect force, and how great the force; if it was accompanied by crushing and twisting; whether arteries and nerves have been torn; if the patient lost much blood, and what is his condition at present. There are cases where we can say, at the first glance, healing is im- possible ; amputation must be resorted to. When ■& locomotive has run over the knee of an unfortunate railroad hand, when a hand or forearm has been caught in the wheels or rollers of machinery, when a premature explosion in blasting stone has crushed or torn off a limb, or hundred-weights have completely mashed a foot or leg, it is not difficult for the surgeon to decide at once on primary amputation, and usually in such cases the state of the limb is such that the patients also, though with a sad heart, quickly consent to the operation. These are not the difficult cases. And in other cases it may be just as easy to foretell, with considerable certainty, the probability of a favorable cure. For instance, if fracture of the leg from indirect force has fol- lowed too great bending of the bone, the broken pointed end of the crest of the tibia may puncture and force through the skin; in such a case there is no contusion, but simply a tear through the skin. When a pointed body strikes forcibly against a small portion of a 202 OPEN FRACTURES AND SUPPURATION OF BONE. limb, and injures bone and skin, the whole extremity may be greatly shaken; but the extent of the injury is not great, and most of such cases terminate favorably under suitable treatment. The question- able cases lie between these two extremes. In cases where there is some contusion, but only a slight amount evident, and the skin is only injured at a small spot, it will be very difficult to decide whether healing should be attempted or amputation be resorted to, and the peculiarity of the individual case alone can settle the question. Of late the tendency is increasing rather to try to preserve the limb in these doubtful cases than to amputate one that might possibly have been saved. This principle is certainly justified on humane grounds; but it cannot be denied that this conservative surgery may be prac- tised at the cost of life, and that we cannot with impunity vary too much from the principles of the older surgeons, who generally pre- ferred amputation in these doubtful cases. Besides mode of origin of the injury, and the amount of accompanying contusion, the impor- tance in any given case depends on whether we have to deal with deep wounds, with fractured bones lying far down among the muscles, or with bones lying near the skin, as the danger of suppuration de- pends greatly on the depth and extent of the bone-injury. Thus, an open fracture at the anterior part of the leg is of more favorable prognosis than a similar injury of the arm or forearm. Open fractures of the thigh are the most unfavorable; indeed, some surgeons always amputate for such injuries. Large nerve-trunks are rarely torn in fractures, and, when they are, it does not seem to have much effect on the cure; and experiments on animals, as well as observations on man, show that bones may unite normally in paralyzed limbs. Injury of large venous trunks, as of the femoral vein, causes haemorrhage, which may be readily checked by a compressing-bandage, it is true, but may prove dangerous when the blood effused between the muscles and under the skin begins to decompose. Rupture of the arterial trunk of a limb occasionally leads at once to considerable arterial. haemorrhages; but this is not a necessary sequence; for, as previously shown, a thrombus quickly forms in the crushed artery, so that we do not always have extensive haemorrhage. But, if, from the nature of the haemorrhage, we recognize the rupture of an artery, according to principles already laid down, we should either attempt to ligate the artery at the wound, or else at the point of election. Rupture of the femoral artery with fracture of the femur is found by experience to be followed by gangrene, and is an imperative indication for ampu- tation ; in a corresponding injury of the arm, recovery may result or gangrene may follow. In fractures of the forearm or leg, even if one or both arteries be ruptured, recovery may take place. Lastly, PROGNOSIS IN OPEN FRACTURES. 203 in the question as to whether we shall try for union, or proceed to amputation, we must consider how useful the limb can be if unioi* results and all unfavorable chances have been overcome. In compli- cated fractures of the foot and lower part of the leg this question may be particularly important, and it has frequently been necessary to amputate a foot because of the change of form and position result- ing after union of an open, comminuted fracture, which rendered it useless for walking. The same thing is to be considered when, in a case of moderately extensive gangrene of the foot, we wish to decide if it should be amputated or not. The dead portion of the foot may be detached in such an inconvenient shape that the remaining stump is neither useful for walking nor for the adaptation of an artificial hmb. In such cases we should amputate, for all our methods of am- putating are designed for the future application of artificial limbs. Since the nature of the subject has led us directly to the indica- tions for amputation in injuries, I shall at once proceed to the sub- ject of secondary amputations. In the question as to whether a complicated fracture should be amputated or not, you might readily satisfy yourself with the idea that it might be done at any future time if the fears of an unfavorable course should be realized. On this point attentive observation shows that there are two periods for this secondary amputation. The first danger threatens the patient from an acute decomposition about the wound and the consequent putrid intoxication of the blood. The question as to this danger is settled during the first four days; if it arises, and you then amputate (this must be done far above the point of putrefaction), it is just at the most unfavorable period for the operation, for you will very rarely succeed in saving your patient. Somewhat more favorable, but still unfavor- able as compared with primary amputations (those made within the first forty-eight hours), are the results of amputations made from the eighth to the fourteenth day; they are particularly unfavorable if the symptoms of acute purulent infection, pyaemia, are distinctly present. If the patient has survived two or three weeks, and profuse exhaust- ing suppuration or other local indication for amputation arise, the results are again relatively favorable. When some surgeons have asserted that secondary amputations give better results than primary, they have almost exclusively considered these later secondary ampu- tations. But, if we bear in mind how many patients with open frac- tures die during the first three weeks, that is, how few of them live till the favorable time for secondary amputations, it seems to me we can have no doubt about the decided advantages of primary amputations. Up to the present time I have rarely found indications for late second- ary amputations. 204 OPEN FRACTURES AND SUPPURATION OF BONE. An open fracture may unite in various ways. The skin-wound, aa well as the deeper parts, occasionally heals by first intention; this is the most favorable case. Under modern treatment this occurs more fre- quently than formerly, although, from the nature of the case, the re- quirements for this result are not often present. Far more frequently (and this is also favorable) the wound only suppurates superficially, and not between and around the ends of the bone, but union of the bone takes place as in simple subcutaneous fracture. The cases where the wound only affects the skin, and does not communicate with the fracture, should not be counted among complicated fractures; but the limits are difficult to trace. The process of cure must of course differ greatly from the above, if the skin-wound be large, the soft parts greatly contused, so that fragments are detached from them; if the suppuration extends deep between the muscles and around the bone, and even into its medullary cavity; if the fragments are bathed in pus; if half-loose pieces of bone lie about, and longitudinal fissures extend into the bone. The activity of the soft parts will remain essentially the same as in subcu- taneous fractures, except that in this case the inflammatory new forma- tion does not directly become callus, but, after detachment of the crushed, necrosed shreds of tissue, granulations and pus are formed, the former of which are transformed to ossifying callus. The form of the callus will not be much changed, except that, where the open suppurating wound exists for a long time, there will be a gap in the callus-ring till it is closed by the after-growth of deep ossifying granu- lations. Hence the process will terminate far more slowly than in subcutaneous fracture, just as healing by suppuration takes longer than healing by first intention. Now, what becomes of the ends of the fragments which, partly or entirely denuded of periosteum, lie in the wound ? What becomes of pieces detached from the bone, and only loosely attached to the soft parts ? As in the soft parts, so here one of two things may happen, according as the ends of the bone are living or dead. In the first and most frequent case, granulations grow directly from the surface of the bone. In the latter, as in the soft parts, plastic activity in the bone occurs on the borders of the living; interstitial granulations and pus form ; the bone melts away ; the dead end of the bone, the sequestrum, falls off. The extent to which this process of detachment goes natu- rally depends on the extent to which the bone is dead, or, expressed more physiologically, on the extent to which the circulation has ceased from stoppage of the vessels. This extent may vary greatly : it may possibly extend only to the superficial layer of the injured bone: and, since the whole process is called necrosis, this superficial detachment UNION OF OPEN FRACTURES. 205 of a plate of bone is termed necrosis superficialis, while that of the whole fractured end of the bone may be called necrosis totalis ; but the latter term is more usual for indicating that the entire diaphysis of a long bone, or at least the greater part of it, is detached, and the opposite of this is necrosis partialis. The opposite of the above- mentioned necrosis superficialis, which is also termed exfoliation, is properly necrosis centralis, that is, detachment of an inner portion of bone. Necrosis superficialis and necrosis of the broken ends and partly-detached fragments of the bone are so often combined with sup- purating fractures, of which we have to treat here, that we must treat of them in this place. It will at first seem strange to you that vascu- lar granulations should spring from the hard, smooth cortical substance of a long bone. From what has already been said, it will seem pos- sible that, under the influence of this plastic process, the hard osseous tissue should be so dissolved that there may be a spontaneous solu- tion of continuity between the dead and healthy bone. We shall now study more exactly these processes of formation of granulations and of suppuration in bone. You will remember, from the full description of traumatic suppu- ration of the soft parts, that in traumatic inflammation the process chiefly depends on free suppuration and extensive formation of new vessels, as well as on direct cell-infiltration from the blood, while the intercellular substance assumes a gelatinous or fluid consistence. Both of these processes can only take place to a slight extent in bone, especially in the firm cortical substance of a long bone, because the firm osseous substance prevents much dilatation of the capillaries which are enclosed in the Haversian canals. I may at once call your attention to the fact that, from this slight distensibility of the vessels in the osseous canals, portions of bone may more readily die than would be the case with the soft parts, because, in case of coagulation of blood, even in the smaller vessels, the nutrition can be only imper- fectly kept up by collateral circulation. Moreover, the connective tissue and the vessels in the Haversian canals may be entirely de- stroyed by suppuration, so that necrosis at the ends of the fragments will be inevitable. Should a vascular granulation-tissue develop on the surface of the bone or in its compact substance, this can only occur as previously described, after the osseous substance (lime-salts as well as organic matter) has disappeared at the point where the new tissue is to appear; hence there must be solution and atrophy of the bone- tissue, just as there are of the soft parts under similar circumstances (see Fig. 39). The whole difference appears chiefly in the difference of time, for the development of granulations on and in the bone takes much longer than in the soft parts. I have already stated that the 200 OPEN FRACTURES AND SUPPURATION OF BONE. same process requires much longer in the tendons and fasciae, which have few vessels, than in the connective tissue, muscles, and skin; in the bone it requires even more time than in the tendons. The con- stitutional power of the individual, and the consequent so-calleri vitality of the tissues, are also to be taken into consideration. LECTURE Xvl. 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.—Antiphlogistic Remedies.—Immersion.—Rules about Bone-splinters.—After-Treatment. When a denuded portion of bone begins to throw out granula- tions on its surface (which in complicated fractures we can only see when the ends of the fragments are exposed by a large skin-wound, on the interior surface of the leg, for instance), we recognize this with the naked eye by the following changes: For the first eight or ten days after being denuded of periosteum, the bone mostly preserves its pure yellowish color, which, even during the last day of the above period, changes toward bright rose-color. If we then examine the surface of the bone with a lens, we may notice numbers of very fine red points and striae, which a few days later become visible to the naked eye also; these rapidly increase in size, grow in length and breadth, till they unite and then present a perfect granulating surface which passes immediately into the granulations of the surrounding soft parts, and subsequently participates in the cicatrization, so that such a cicatrix adheres firmly to the bone. If we follow this process in its finer histological details, which must be chiefly done experimentally, by aid of injected bones de- prived of their lime, we have the following result: If the circulation in the bone is maintained near to the surface, there is a rich infiltra- tion of cells into the connective tissue accompanying the vessels in the Haversian canals; this tissue grows, with the vascular loops de- veloping toward the surface, out of the bone at the points where the Haversian canals open externally. The development of this young granulation-mass laterally results at the expense of reabsorbed bone. If we macerate one of these bones with superficial granulations, its surface will appear gnawed and rough; in the living bone, granulation tissue fills the numerous small holes, which all communicate with the Haversian canals. The surface of the bone does not, however, remain UNION OF OPEN FRACTURES. 207 in this state, but, while the osseous granulations on the surface con- dense to connective tissue and cicatrize, in the deeper parts they ossify quite rapidly, so that at the termination of the process of heal- ing the surface of the injured bone does not show a deficiency, but appears denser from deposit of new bone. You see that here too the circumstances are exactly the same as in subcutaneous development of the inflammatory neoplasia. If you look at Fig. 49, and suppose the periosteum removed from the surface of the bone, the new formation (in this case as granulations) will grow fungous-like out of the Haver- sian canals. You will understand this better if we now follow more carefully the process of detachment of necrosed portions of bone. Let us re- turn to what we see with the naked eye, and let us suppose Ave have before us a portion of the parietal bone denuded of soft parts; then, if no granulations, as above described, grow from the bone, we shall have the following symptoms: While the surrounding soft parts and the portion of bone still covered with periosteum have already pro- duced numerous granulations and secrete pus, the dead portion of bone remains pure wiiite or becomes gray or even blackish. It re- mains some weeks, sometimes two months or more; most proliferant granulations grow around it; cicatrization has already begun in the periphery of the wound, and we cannot decide how the case will ter- minate, for in the sixth week the surface of the bone may look just as it did the day after injury. Some day we feel the bone and find it Detachment of a superficial piece of a flat bone (as of one of the cranial bones), which has been ex- posed by an injury and become necrosed. Necrosis superficialis; «, the granulations arising from the living portion of the bone undermine the dead portion, the sequestrum (shaded vertically); b, the lower side of the sequestrum has been considerably eaten away by the granulations, which have perforated it at various points. Diagram, natural size. 15 208 OPEN FRACTURES AND SUPPURATION OF BONE. movable; after a few attempts one blade of the forceps may be intro- duced under it and we lift off a thin plate of bone, under wiiich we find luxuriant granulations ; the under surface of this plate is very rough, as if eaten away. Now healing goes on rapidly. It is often long before the cicatrix becomes permanent and solid enough to re- sist all injuries, such as pressure and friction, but healing often termi- nates favorably. This is the process that we term necrosis superfi- cialis or exfoliation of bone. We are already acquainted with this process in the soft parts; during the first week large shreds of tissue fall from the contused wound, since on the border of the healthy tis- sue there is an interstitial development of granulation, by which the tissue is detached; the process is the same here. In a bone deprived of its lime we may readily examine these processes anatomically. The inflammatory neoplasia, or granulation tissue, develops on the mar- gin of the healthy bone in the Haversian canals. The accompanying flgure (Fig. 55) may represent to you the details of this process. If you have fully understood what has been said, it only requires a slight stretch of imagination to see how the same process of detach- ment of a fragment may extend through the entire thickness of bone; that is, how (and here we come back to complicated fractures) a vari- able length of the fractured end of a bone may be entirely detached, when it is incapable of living. When the bone in question is thick, this process requires sev- eral months; but at last we may find even large pieces of bone movable in the wound, and remove them as we would a su- perficial bony plate. As regards splinters entirely detached from the bone, and only attached to the soft parts, their future fate, as regards living or not, depends on how far their circulation is preserved. If they are not capable of living, they at last become entirely detach- ed by suppuration of the soft parts attached to them, and of- ten, as foreign bodies, keep up Diagram of detachment of a necrosed portion of . ., ,. n ,. /? ,1 bone. Magnified 300. a, necrosed portion o( irritation and Suppuration Ol tne bone; 6, living bone; c, new formation in the j re i.u „ „ „„,™VI,> ^e Haversian canals, by which the bone is de- wound. If they are capable ol tached. compare Fig. so. living, they produce granula- Fig. 55. imm DETACHMENT OF THE SEQUESTRUM. 209 tions on the free surface; these subsequently ossify and unite with the other callus, forming around the fractured ends. To represent the relation of the formation of callus to this process of detachment of the necrosed ends of the fractured bone, I present the following figure (Fig. 56). The fragments of the broken bone are not accurately adjusted, but displaced somewhat laterally; the ends of the fragments have both become necrosed, and nearly detached by interstitial proliferation of granulations on the borders of the living bone. The whole wound is lined with granulations, which secrete pus that escapes at d. In both fragments, an inner callus (b b) has formed, which, however, from suppuration of the fractured surfaces, has not yet been soldered to- gether. The outer callus (c c) is irregular, and interrupted at d, be- cause the pus escapes here from the first. When the granulations grow so strongly as to fill the entire cavity, and subsequently ossify, healing is completed, and the final result is just the same as in the healing of subcutaneous fractures. For this to take place the necrosed portions of bone must be removed, for experience shows they cannot heal up in the osseous cicatrix. This elimination of the sequestrated Fig. 56. Diagram of fracture of a long bone with external wound, longitudinal section. Natural size, ee, bone; ////, soft parts of the limb; a a a a, necrosed ends of bone. The darkly-shaded part repre- sents the granulations, which line (d) the wound that opens outwardly, and secrete pus; bb, internal callus in the two dislocated ends of bone; cc exter- nal callus. Fig. 57. Amputation stump of the thigh, with necro- sis of the sawed sur- face. 210 OPEN FRACTURES AND SUPPURATION OF BONE. fragments takes place either by reabsorption or by artificial removal outwardly; the former is the more frequent in small, the latter in large sequestra; but union will not result as long as the sequestrum remains between the granulations of the fragments. Since the open- ing at d may be much contracted by the development of externa] callus," the operative removal of the necrosed ends is often very diffi- cult. We find, by examination with the probe, whether such seques- tra in the deeper parts really existed, and if they are detached. If you suppose the sequestrum, a a (Fig. 56), removed from the wound, there is no obstacle to the filling of the wound with granulations and to their subsequent ossification. Such sequestra in complicated frac- tures are frequently the cause, not only of new exacerbations of the acute suppurative inflammation, but also of subacute and chronic peri- ostitis, with protracted firm oedema of the extremity and annoying eczematous eruptions on the skin, as well as of long-continued bone fistulae and ulcerations of the ends of the fragment. The action ol this sequestrum combines the double effect of a foreign body and that of local or general purulent infection. We may speak here of conditions as they exist in the bone after amputation. Imagine Fig. 56 divided transversely at the point of fracture and the lower half removed, then the condition will be just the same as after amputation. Granulations either grow directly from the wounded surface, or a portion (the sawed surface) is necrosed to a greater or less extent (Fig. 57). Let this be as it may, in the medullary cavity, as well as on the outside of the bone, a neoplasia (a half callus) is formed; this subsequently ossifies; if you examine an amputation stump several months old, you will find the medullary space in the stump of the bone closed by osseous deposits, as well as external thickening of the bone. We may here remark that the name callus is used almost exclusively for the bony new formation in frac- tures, Avhile the young bony formations on the outside occurring in various ways are called " osteophytes " (from dareov, bone, and