ELEMENTS OF SURGERY:
BY
ROBERT LISTON,
SURGEON TO THE NORTH-LONDON HOSPITAL, PROFESSOR Of CLINICAL SURGERY,
ETC., ETC., ETC.
FROM THE SECOND LONDON EDITION,
WITH
COPIOUS NOTES AND ADDITIONS,
BY
SAMUEL D. GROSS, M.D.,
PROFESSOR OF SURGERY IN THE LOUISVILLE MEDICAL INSTITUTE, SURGEON
TO THE LOUISVILLE MARINE HOSPITAL, ETC., ETC.
Illustrated
WITH NUMEROUS ENGRAVINGS.
Philadelphia:
ED. BARRINGTON & GEO. D. HASWELL.
NEW YORK—J. & H.G. LANGLEY: CHARLESTON, S. C.—WM. H. BERRETT:
RICHMOND, VA.—SMITH, DRINKER & MORRIS:
LOUISVILLE, KY.—JAMES MAXWELL, JR.
1842.
[Entered, according to Act of Congress, in the year 1842, by BARRINGTON
& HASWELL, in the Clerk’s office of the District Court for the Eastern
District of Pennsylvania.]
TO
WILLARD PARKER, M. D.,
Professor of Surgery in the College of Physicians and Surgeons
in the City of New York,
THIS EDITION OF MR. LISTON’S WORK
Is Inscribed,
AS A TESTIMONIAL OF RESPECT
FOR HIS UNTIRING ZEAL IN SURGICAL PURSUITS,
AND OF ESTEEM FOR HIS PRIVATE VIRTUES,
BY HIS FRIEND AND FORMER COLLEAGUE,
THE EDITOR.
PREFACE
TO THE AMERICAN EDITION.
The character of Mr. Liston’s work is too well established to render it
necessary for me to say anything in commendation of it. As an outline
of surgical science, which is all that can be claimed for it, it is
unrivalled in the English language. Written in a bold and graphic
style, the distinguished author never hesitates to express his opinion,
frankly and fearlessly, of what his judgment and experience have led
him to disapprove. In this, as well as in some other particulars, he
reminds one forcibly of that great and eccentric surgeon, John Bell.
There is no cringing to this man or that, no doubtful or equivocal
sentiment, no attempt to theorise or speculate; on the contrary, he
comes right out, and clearly tells us what he means. His work, full
of vigour and freshness, contains more originality than any other
similar publication that has been issued for a long time from the
British press. The hand of a master is discernible in every page; and,
notwithstanding an occasional incongruity, or _outré_ expression, it is
impossible to read it without feeling that it is the production of a
great mind, thoroughly acquainted with the subject on which he treats.
Such a work is invaluable to the student; for, independently of
imparting sound surgical knowledge, it does more to form his judgment,
and to qualify him for the practical duties of his profession than all
the compilations in Christendom. Velpeau, with all his learning and all
his patience, has never furnished anything equal to it. His "_Medicine
Operatoire_" is nothing but a vast storehouse of research, to which
pompous doctors may resort for ancient lore, and prosing teachers for
materials for instruction. It details with endless minuteness the
operative methods of every surgeon, great or little, from the age of
Hippocrates to the present period, with their various modifications
and improvements, not forgetting the "appreciations" and labours of
the able professor himself. Such productions are well enough in their
way; they serve to give us an idea of the rise and progress of surgery,
and form good books of reference. Beyond this, however, they are of
comparatively little utility; the great mass of the profession is no
more benefited by them than if they had never been written; few read
them, and still fewer understand them. This attempt at erudition
pervades, if I mistake not, almost every recent publication on surgery
in the French language. Dupuytren is alone free from it. His writings
breathe throughout a different and more independent spirit: he speaks
like one accustomed to act and to think for himself; and the result
is, that he has accomplished more for French surgery than any other
Frenchman since the days of Ambrose Paré.
The first edition of the present Treatise was published at Edinburgh
in 1831, some time prior to the author’s removal to London. It was
originally comprised in three volumes. A second impression, of which
this is a reprint, appeared at London in 1840, in a revised and
improved form. The favourable reception which the publication has met
with in this country, and the desire I have felt to introduce it into
the school with which I am connected, as a text-book, have induced
me to prepare it for the American press with particular care. Among
the additions, properly so called, is an article on Strabismus, and
another on Club-foot; two subjects, the former of which was entirely
omitted in the English edition, and the latter discussed in a manner
altogether incommensurate with the existing state of our knowledge in
regard to it. The notes are designed to serve as further illustrations
of the text, or to supply deficiencies in relation to certain topics
which have been passed lightly over by the author. They might have
been extended to almost any number, and it would have afforded me no
ordinary gratification, had it been consistent with the views and
interests of my publishers, to present what might be considered as a
tolerably fair outline of American surgery. For such an object ample
materials are extant, highly valuable in themselves, and eminently
calculated, when they shall be properly embodied, to reflect credit
upon the talents, enterprise, and dexterity of our surgeons.
It need hardly be added, what is self-evident, that the editor of a
work is responsible to the public only so far as his own labours are
concerned. He adopts only in a general manner, without endorsing all,
the views and opinions of his author.
S. D. GROSS.
Louisville Medical Institute,
May, 1842.
PREFACE.
The rapid advancement made in the pathology and treatment of surgical
diseases demands a perpetual revision and correction of the systematic
works devoted to this department of the healing art.
Accordingly, text books, various in merit and extent, have emanated
from the different schools. Several of these have, by successive
editions, kept pace with the science; whilst others have fallen into
disuse.
In this part of Britain, the systems of Latta, B. Bell, and Allan,
occupied the field; but it being now vacant, I venture to supply the
deficiency, by reducing the heads of my lectures into a compendium, or
guide, for those students who resort to this city.
It must appear superfluous to preface such a work by anatomical
descriptions, anatomy being now studied more generally, and with
greater zeal, than heretofore. Pathology also is more attended to,
and better understood. To which circumstances are to be ascribed the
improvements in surgical science, as well as in the art of operating.
The functions and structure of parts are more frequently preserved
uninjured—mutilation is more rarely required—and operations are
dispensed with. The wider the extension of pathology, the fewer the
operations will be—thus affording the best criterion of professional
attainment. Who will question, that there is more merit in saving one
limb by superior skill, than in lopping off a thousand with the utmost
dexterity?
To treat surgical diseases as they ought to be treated, the
practitioner must be thoroughly acquainted with the healthy and morbid
structure; he must also have a mind vigorous and firm from nature, well
instructed in the best precedents, and matured by observation.
Years are not the measure of experience. It does not follow, that the
older the surgeon is, the more experienced and trustworthy he must be.
The greatest number of well-assorted facts on a particular subject
constitutes experience, whether these facts have been culled in five
years or in fifty.
It is only from experience, directed and aided by previous study, that
accuracy of diagnosis and celerity of decision can be acquired. Besides
knowing in what manner to proceed, the surgeon must know well wherefore
he acts, and also the precise time at which he should interfere. With
knowledge and confidence derived from experience, he will perform such
operations as are indispensable for the removal of pain and deformity,
or for the preservation of life, with calmness and facility—with safety
to his patient, and satisfaction to those who assist in, or witness,
his proceedings.
Attention to the apparatus is necessary. It should be in good order,
simple, and ample. The young surgeon should note down, previously to
an operation, whatever, on reflection, can possibly be required. "For
in most capital operations, unforeseen circumstances will sometimes
occur, and must be attended to; and he who, without giving unnecessary
pain from delay, finishes what he has to do in the most perfect manner,
and that most likely to conduce to his patient’s safety, is the best
operator."
It is seldom necessary to employ much preliminary treatment. From the
usual preparative course of bleeding, purging, cooling diet, etc.,
patients about to undergo capital operations, as lithotomy, suffer more
than they can gain.
It is of the utmost importance to attend to the state of the patient’s
mind and feelings. He ought not to be kept in suspense, but encouraged
and assured; and his apprehensions must be allayed. If this cannot be
effected—if he is dejected and despondent—talks of the great risk,
and of the certainty of his dying, it is better that the operation be
abandoned, or at least delayed. If, on the contrary, he is confident
in the resources of his constitution, and in the ability of his
attendant, and looks forward to the advantage to be derived from his
own fortitude, then should there be no delay.
A mild laxative may be given, when an empty state of the bowels is
desirable, or when they, by acting too soon afterwards, might put the
patient to inconvenience or pain, or interrupt the curative process.
Attention to after-treatment is of much greater importance. The
practitioner is not to rely on success, however well the manual part
has proceeded. He must consider his labour only begun, when the
operation has finished; the patient is yet to be conducted, by kindness
and judgment, through the process of cure.
It is thus only that difficult and unpromising cases can be brought to
a happy conclusion, and favour and lasting reputation gained.
In the present work an endeavour has been made, in the first place,
to lay down, correctly and concisely, the general principles which
ought to guide the practitioner in the management of constitutional
disturbance, however occasioned.
The observations introduced to illustrate the doctrines inculcated are
given as briefly as is consistent with an accurate detail of symptoms
and results. The descriptions of particular diseases have been sketched
and finished from nature; and, it is hoped, with such fidelity, that
their resemblance will be readily recognised.
To describe all the methods recommended and followed, in the different
surgical operations, would occupy more space than can be allotted in an
elementary work—would, without answering any good purpose, lead into
the wide range of the history and progress of surgery.
Such modes of operating are described as have been repeatedly and
successfully performed by the Author.
If by clear and simple description of the phenomena attendant on morbid
action, and of the changes which it produces,—if by plain rules for
the treatment of the diseases, and performing the operations for their
alleviation or cure,—he contribute to the progress of surgery, and the
consequent diminution of human misery, he will consider himself fully
rewarded for the time and the labour spent on this production.
CONTENTS.
PART FIRST.
Page
INFLAMMATION 13
Signs 14
Irritation 20
Termination of Inflammation 25
Adhesion 25
Suppuration 29
Mortification 43
Erysipelas 55
Furunculus and Anthrax 62
Inflammation of Mucous Membranes 65
Serous Membranes 66
Joints 67
Hypertrophy and Atrophy of the Articular Cartilages,
with Eburnation 75
Scrofulous Disease of Joints 77
Neuralgic Affections of Joints 78
Growths from the Synovial Membrane and Loose Substances
in Joints 79
Affections of Bursæ 80
Coxalgia 81
Alterations of Form in the Head of the Femur 86
Inflammation and Diseases of Bone 94
Suppuration in Bone 96
Caries 96
Necrosis 103
Fragilitas Ossium 110
Mollities Ossium, Rachitis, &c. 110
Arterial System, Affections 116
Aneurism 118
by Anastomosis 127
Inflammation of Veins 130
Tumours 134
Adipose 137
Fibrous 138
Encephaloid 139
Melanoid 142
Carcinomatous 142
Fungus Hæmatodes 147
Painful Tubercle 149
Polypus 150
Encysted Tumours 151
Tumours of Bones 153
Osteosarcoma 154
Spina Ventosa 157
Aneurismal 158
Osseous 158
Hydatic 161
Wounds 164
Tetanus 183
Ulcers 186
Hospital Gangrene 191
Sloughing Phagædena 191
Malignant Pustule 193
Ulcers on the Genital Organs, with their Consequences 195
Scalds and Burns 211
PART SECOND.
Injuries of the Head 215
Wounds of the Scalp 215
Wounds of the Temporal Artery 216
Concussion 218
Compression 226
Fractures of the Cranial Bones 227
Wounds of the Brain 232
Hernia Cerebri 233
Perforation of the Cranium 234
Inflammation of the Scalp 238
Thickening of the Scalp 239
Tumours of the Scalp 243
Diseases of the Eye and its Appendages 245
Inflammation and Abscess of the Lachrymal Passages 245
Inflammation of the Lachrymal Sac 246
Fistula Lachrymalis 248
Encanthis 252
Encysted Tumours of the Eyelids 253
Closure of the Eyelids 253
Ectropion 254
Entropion 255
Trichiasis 255
Pterygium 256
Diseases of the Eyeball 257
Ophthalmia 257
Purulent Ophthalmia 260
Staphyloma 261
Inflammation of the Cornea 261
Pustular Ophthalmia 263
Ulcers of the Cornea 263
Leucoma 264
Hernia of the Iris 264
Albugo 264
Nebula 264
Ophthalmia Tarsi 265
Staphyloma 266
Hydrophthalmia 266
Exophthalmia 266
Internal Ophthalmia 272
Iritis 272
Hypopium 273
Choroiditis 274
Amaurosis 275
Glaucoma 277
Cataract 277
Artificial Pupil 287
Wounds of the Eyeball 288
Orbital Inflammation 290
Tumours in the Orbit 290
Strabismus 292
Nasal Polypi 301
Malignant Polypi 303
Nose, and Nasal Cavities, Inflammation, &c. 308
Noli me tangere 310
Ozœna 310
Rhinoplastic Operations 312
Inflammation of the Antrum Maxillare 317
Lips, Ulcers 319
Congenital Deficiencies 322
Palate, Congenital Deficiencies 322
Soft Palate, Tonsils, &c., Inflammation, &c. 326
Tongue, Ulcers 331
Inflammation 332
Division of Frænum 334
Salivary Ducts, Diseases 335
Ranula 335
Gums, Diseases 337
Teeth, Diseases 338
Extraction of 340
Lower Jaw, Diseases 341
Disarticulation 345
Wounds of the Face and Neck 347
Larynx and Trachea, Diseases 354
Foreign bodies 363
Tracheotomy 364
Pharynx, Diseases 368
Foreign bodies 371
Œsophagotomy 372
Ear, Diseases of 373
Foreign bodies 375
Polypus 375
Deafness 375
Bronchocele 377
Glandular Tumours in the Neck 379
Hydrocele of the Neck 381
Distortion of the Neck 382
Venesection in the Jugular Vein 384
Ligature of the Carotid Artery 385
Arteria Innominata 387
Subclavian Artery 387
Axillary Artery 392
Brachial Artery 392
Humeral Artery 394
Wounds of the Palmar Arches 395
Paronychia or Whitlow 396
Onychia 399
Collections in Thecæ 401
Ganglia 401
Venesection, bend of the arm 403
Mamma, Diseases 405
Encysted Tumours 406
Affections of the Chest 409
Hydrothorax 410
Empyema 410
Wounds 411
Affections of the Abdomen 412
Hernia 412
Congenital Scrotal Hernia 413
Hernia Infantilis 414
Inguinal 415
Crural or Femoral 416
Ascites 435
Ovarian Dropsy 436
Bruises of the Abdomen 438
Lumbar Abscess 441
Spina Bifida 444
Affections of the Rectum and Neighbouring Parts 445
Hemorrhoids or Piles 445
Distinct Varieties 445
Inflammation of the Rectum 447
Fistula 449
Stricture 450
Schirro-contracted Rectum 452
Prolapsus Ani 453
Pruritus of the Rectum 460
Neuralgia of the Rectum 460
Affections of the Mucous Membranes of the Urinary
and Genital Organs 461
Gonorrhœa 462
Hernia Humoralis 467
Inflammation of the Bladder 469
Irritable Bladder 470
Stricture of the Urethra 470
Fistula in Perineo 472
Retention of Urine 478
Incontinence of Urine 489
Gonorrhœa Præputialis 490
Phymosis 491
Paraphymosis 491
Hypospadias and Epispadias 495
Chimney-sweeper’s Cancer 495
Hydrocele 496
Cirsocele 501
Hæmatocele 503
Sarcocele 505
Castration 507
Calculus Vesicæ 508
Lithotrity 517
Lithotomy 519
Calculus in the Female 530
Gonorrhœa in Females 531
Gonorrhœal Lichen 532
Retention of Urine in Females 533
Vesico-vaginal Fistula 534
Imperforate Vagina 535
Contracted Vagina 535
Inflammation of Vagina 536
Polypus Vaginæ 537
Diseases of the Uterus 538
Ligature of the Common Iliac Artery 539
Internal Iliac 539
External Iliac 540
Femoral 541
Aneurismal Varix in the Thigh 542
House-Maid’s Knee 543
Cartilaginous Bodies in the Knee-joint 544
Distortion of the Feet 545
Varus 547
Valgus 548
Pes Equinus 548
Calcaneal 549
Exostosis of Distal Phalanx 551
Fractures 552
of the Cranium and Face 558
Spinal Column 560
Thorax and Upper Extremity 564
Pelvis and Lower Extremity 574
Disunited Fracture 586
Dislocations 588
Lower Jaw 591
Upper Extremity 592
Lower Extremity 600
Sprain 607
Bruise 610
Amputation 612
Excision of Portions of Diseased Bones 632
Excision of Joints 634
ELEMENTS OF SURGERY.
PART FIRST.
OF INFLAMMATION.
There are few accidents or diseases, to which the human body is liable,
which are not preceded or followed by incited action, increased
circulation, and accumulation of blood in the capillary vessels of
the part affected; and these phenomena require to be very attentively
studied, and correctly understood, by all who propose practising the
healing art. As all the salutary as well as diseased processes which
occur in the human body are more or less attended or affected by this
action, and as its regulation forms a principal part of the duty of the
surgical practitioner, this work cannot be more properly commenced than
by treating of its nature, consequences, and management.
Inflammation may be defined to be, an unnatural or perverted action
of the capillary blood vessels of an organ or part of the body,
attended with redness, throbbing, swelling, pain, heat, and disorder of
function, as well as with more or less disturbance of the system.
Every part of the body is liable to inflammation; and some writers have
divided this action into different kinds, according to the particular
tissue which it chiefly involves. But it appears to be always of the
same character, though modified by various circumstances, such as the
tissue in which it occurs, the state of the constitution, the exciting
cause, and the intensity of the action.
The usual division of the subject, into _Acute_ and _Chronic_, is that
which it is here proposed to adopt. The term Chronic Inflammation is
more properly applicable to a consequence of the Acute: but it is at
the same time true, that morbid actions proceed more slowly in some
constitutions, and in some parts of the body, than in others; and that
changes of structure and morbid products, such as generally result from
inflammatory action, even occasionally occur, without the prominent
symptoms of inflammation being experienced by the patient or detected
by the practitioner.
The term _Morbid_ is used in contradistinction to what is called
_Healthy_ Inflammation; but inflammatory action is generally connected,
more or less, with a diseased or disordered state of some part of
the body. In many circumstances it is highly necessary that a certain
degree of incited action of the vessels should occur, and continue for
a certain time; as during the uniting of fractures, the adhesion of
wounds, and the healing of some sores—and thus far it is healthful:
when, however, the action becomes excessive, it must, for this
reason, be considered morbid, as it frustrates the natural reparative
process; if the action, in fact, proceeds farther than is necessary
for reparation, it becomes a disease, and leads to absorption or
destruction of parts. In animals possessing the greatest powers of
reparation, inflammation, it appears, does not take place at all, or is
very slight, and scarcely ever proceeds to suppuration.
_Redness_ is the first sign of inflammation to be considered; this is
observed, in the living body, on the surface, or at the extremities
of those canals which terminate externally. The inflamed conjunctiva
affords a conspicuous example of this appearance. In a subject that
has suffered from an internal inflammatory attack, a good opportunity
is frequently afforded of observing the enlarged and injected state
of the vessels on which the red colour depends. But inflammation may
have existed to a certain degree, and yet the parts may be pale, from
the capillaries having emptied themselves into the veins immediately
after the patient’s death. The paleness may be also in part caused by
the influx of the red globules being impeded immediately after death,
or when the patient is in articulo mortis, in consequence of the
contraction of the vessels, which is well known to occur at that period.
It has been said that redness is not essential to inflammation; for
serous vessels may be altered in size and function by this action,
and yet not be sufficiently dilated to receive the red globules of
the blood. And, again, that serous vessels may be enlarged so as to
admit the red globules; and a part that is colourless when in the
healthy state may, in consequence, assume a highly red hue when in an
inflamed condition. This may be observed in the cornea lucida, which,
when violently inflamed, is pervaded by numerous vessels, visible to
the naked eye, distended with red blood, ramifying over the whole of
it, and freely inosculating with each other. Some have even supposed
that these vessels are newly formed, in consequence of inflammatory
action. This opinion is, however, erroneous; as the vessels existed in
the cornea previously, and are only increased in size, so as to admit
of the accumulation of a sufficient number of red particles to render
the vessels visible. The speedy, and, in many cases, instantaneous,
appearance of red vessels where they could not previously be observed,
decidedly overturns the opinion that new vessels are in such a case
formed. New vessels are seldom formed, unless after a breach of
structure, or in cases where morbid deposits become vascular. There is
no proof of the existence of mere serous vessels in the human body,
as any one may ascertain who is accustomed to examine the capillaries
with a good microscope. Vessels which are so small as to admit only a
very few, say one, or at most two rows of globules, would, of course,
appear colourless, and these are what have been called serous vessels.
The globules of blood are so small as to be invisible to the naked eye;
and vessels carrying only one series of them would appear colourless.
No vessels belonging to the sanguiferous system have ever been observed
less in character than a blood globule; and this, so far as I have
been able to observe, is, as nearly as possible, 1/3000 part of an
inch. They appear to be flattened discs; and whether those of the human
body have a central nucleus or not, seems, as yet, very doubtful. The
globules are here shown upon a scale of 1/4000 part of an inch, linear,
and in different positions. They are represented, as seen in the
greater number of microscopes, having a central nucleus. Whether, in
the blood of mammiferous animals, or not, this is an optical deception,
is not very clearly made out; but in that of reptiles the nucleus is
easily demonstrable. The redness then is not from error loci, or in
consequence of red particles flowing where none flowed before, but from
the capillaries becoming distended and dilated with an unusual quantity
of blood, which is stagnated in the central part of the inflamed
neighbourhood, the inflammatory focus.
[Illustration]
_Throbbing_, to a greater or less degree, is always felt in an inflamed
part by the patient; and it is frequently so distinct as to be readily
perceived by an attentive examination. This arises, probably, from
the stagnation of blood in the vessels of the part over-excited, and
principally affected by the disease or injury, causing an increase in
the collateral circulation; and it is this rapidly increased action
around that gives rise to the signs and symptoms, and constitutes,
in point of fact, what is known and recognised as inflammation. The
sensation of throbbing is not, however, produced entirely by the action
of the capillary vessels, but in consequence, also, of the larger
trunks in the neighbourhood sympathising with these capillaries,
and so having their action increased also. The obstruction of the
capillaries in the early stage of inflammation must necessarily cause
a greater force of the heart to be expended on the trunks leading to
such capillaries; hence the greater impulse and velocity of blood in
the circumferential and patent vessels. In fact, when the inflammatory
action is extensive or severe, or when the part affected is of much
importance to life, the whole circulating system is disturbed, and thus
arises the sympathetic excitement of the constitution.
The incited action of those vessels in the more immediate vicinity of
the inflamed part is well marked in cases of Paronychia. There the
digital, the radial, and ulnar arteries, with their branches, beat more
violently than usual; and with much greater force, though not more
rapidly, than the vessels in other parts of the body.
_Swelling_ is caused by the enlarged and overloaded vessels relieving
themselves by effusion of part of their contents into the surrounding
cellular texture. The effusion varies in extent and consistence,
according to the degree of inflammatory action, and the species of
resistance offered; at first it is serous, then mixed with fibrin,
and consequently spontaneously coagulable. _Cæteris paribus_, the
greater the resistance, the less the effusion, and the more violent
the inflammatory action; the chance of its speedy and favourable
termination is also more diminished. Even the enlargement of the
blood-vessels produces a certain degree of intumescence previous
to effusion. The relief to the vessels by effusion giving rise to
swelling, when it occurs in loose cellular tissues, may be considered
as a beneficent provision of nature. But in vital organs it may be
productive of the most serious consequences; as in these, very slight
effusion will often endanger the structure of the organ, destroy its
functions, and not unfrequently be attended with fatal consequences.
The nature of the effused fluid varies according to the degree of
violence and advancement of the action, and is also modified by the
texture in which that action occurs. It may consist of serum, lymph,
blood, or pus. In inflammation, in short, exhalation, though at first
diminished, is soon much increased, whilst the powers of the absorbent
vessels are diminished, or at least do not maintain their usual
relation to those of the exhalants.
_Pain_ is the next symptom enumerated. Here the very common error of
supposing that where there is pain there must always be inflammation
may be noticed. Some diseases attended with the most acute pain, as Tic
Douloureux and Cramp, are generally unattended with inflammation. Many
chronic diseases, too, are accompanied with violent and long-continued
paroxysms of pain, without excited circulation of the part.
This erroneous opinion often gives rise to highly prejudicial
proceedings, as—the exhausting, by copious depletions, the vital powers
of patients, already enfeebled by continued disease or treatment—the
consequent aggravation of the urgent symptoms—and, the then only
termination of the disease and of the practice, death.
Again, it is true that we must bleed, in some cases, with the view
of preventing the occurrence of inflammation; yet the prophylactic
treatment may be carried too far, as in cases of violent injuries, or
after severe operations. In these instances, the immediate abstraction
of blood, so far from being beneficial, expedites the dissolution
of the patient, or at least greatly retards the cure. Pains arising
from local irritations are often treated in a similar way, whilst the
removal of the cause would be much more likely to restore the natural
action of the parts.
Though inflammation does not always accompany the sensation of pain,
yet the latter, in a greater or less degree, attends inflammatory
action; and, perhaps, it is fortunate that it does so. Because, were
it not for the occurrence of pain, the patient’s attention would not
be directed to the disease; he would continue to use the part as if
in health, and the affection would thus be much aggravated. Whereas,
according to the existing provision of nature, pain is felt at the
commencement of the action, the presence of which the patient is
thereby made aware of; and he is compelled to employ such measures
for its removal as reason naturally dictates, of which none is more
effectual than disusing the affected part. The nerves are thus the
safeguards of the various parts of the body in health—their nurses
in disease. A part deprived of sensation may be used, even to the
destruction of its texture, without producing any impression on the
sensorium, and consequently without the animal being conscious of it.
The presence of pain, as a symptom of inflammation, may be easily
explained. The connexion of the vascular with the nervous system
is very constant and intimate. Their ramifications accompany each
other, and are contained in the same cellular sheath; and without the
reciprocal influence of each, neither could perform its functions
perfectly. By injecting a limb soon after its separation from an
animal, and before its vital heat has departed, spasms of all muscles
are sometimes produced; showing the intimate connexion between these
two systems. This, however, is distinct from the contractions of the
muscular fibre produced by the application of stimuli. In the former
case, the contractions are universal, and induced through the medium of
the nerves. In the latter, the irritability of the fibre is excited.
When the circulation is excited, the nerves accompanying the affected
vessels are unusually compressed, and over-stimulated by the
circulating fluid, in which, probably, some change takes place, and in
this manner unnatural impressions are produced; the nerves themselves
are likewise the seat of disease, in consequence of the enlargement
of the minute capillaries which permeate them. Over-distension of the
coats of the vessels may also be supposed to give rise to painful
feelings, independently of any affection of the accompanying nervous
trunks.
The degree of pain is generally in proportion to the sensibility of
the part when in health; it also depends upon the distensibility
of the parts affected, and on the intensity of the inflammatory
action. When bones, tendons, &c., which in their uninflamed state are
nearly insensible, become inflamed, the pain and suffering are most
excruciating, owing to the resistance opposed to the dilatation of the
vessels, and the prevention of the effusion by which they naturally
relieve themselves.
The kind of pain also varies, in consequence of different modifications
in the action causing different impressions on the sensorium. Pain
is not always increased in proportion to the natural sensibility of
the part; for in some instances the sensibility is rendered much more
intense, while in others it is much obtunded.[1]
The last, and, according to some writers, the only unequivocal symptom
of inflammation, is _Heat_. In extravasation of blood into the cellular
texture, as under the conjunctiva, there is redness, swelling,
and occasionally pain; but at first, and unless the action of the
bloodvessels be excited, there will be neither heat nor throbbing.
In many internal inflammations heat is much complained of; and in
Enteritis it has been considered a pathognomonic symptom.[2]
The signs, symptoms, and consequences of inflammation—and amongst
others, heat—are modified by the distance of the affected part from the
centre of circulation. All actions, healthy as well as morbid, proceed
with more vigour in the superior extremities—in the head, the neck, and
the trunk, than in the more remote parts of the body; for to the former
the blood is transmitted more speedily, if not in greater quantity, and
is not so liable to be impeded in its return. Hence an arm may bear up
under a severe injury, which, to an inferior extremity, would prove
inevitable destruction. The heat, however, of an inflamed part, is
generally supposed to be much greater than it really is. The sensation
of heat is considerable to the patient, as well as to any observer,
whilst the absolute increase of temperature is very slight indeed.
It has been proved by the most decided experiments of Mr. Hunter, on
the mucous canals of animals, first when in health, and again after
violent inflammation had been excited, that little or no variation of
temperature can be observed. The elevation of temperature is probably
constant, though only amounting to a degree, or even less. As the blood
is the source of heat, wherever an increased quantity is circulated,
there should, to some extent, be increased heat.
The effects of an incited action of the vessels on the system at
large must now be adverted to; or, in other words, that general
disturbance in the system which attends inflammatory incitation, and
which occurs in a degree proportioned to the power of the exciting
cause, and the kind of texture primarily affected. The functions both
of the sanguiferous and nervous systems are deranged, producing a
state termed Symptomatic or Sympathetic Inflammatory Fever. From some
observations of my friend Mr. Gulliver, it is probable that this state
is frequently, if not generally, dependent on changes in the blood
consequent on inflammation. A sort of decomposition of part of the
fluid and vitiation of the remainder; the fibrin being separated and
effused into the injured part for the purposes of reparation, while the
blood globules are converted into pus in the capillaries, and mixed
with the circulating fluid. Thus the presence of pus in the blood may
become the proximate cause of fever; but if an outlet to the matter be
established, if it be discharged by the occurrence of suppuration in
a cavity or on a surface, the case is benefited and the constitution
relieved. This points to an important principle in practice. Nature
puts it in operation in small-pox, for example—how favourable it is for
the pustules to come out, and to what danger is not the patient exposed
if they are repelled.
During the paroxysm of inflammatory fever all the secretions and
excretions are diminished or suppressed; and hence the hot dry state
of the skin, the thirst with foul and dry tongue, the scanty and high
coloured urine, and the constipation of the bowels. This last symptom,
however, though it may arise partially from the diminished secretion
of mucus, yet is often dependent on disturbance of the functions of
the brain and nerves. The pulsations of the arteries become rapid and
strong, the sanguiferous system being unable to relieve itself by
effusion, in consequence of the obstruction of the exhalants.
If the extreme vessels are in any way obstructed, and the general
circulation in consequence much accelerated, the internal viscera
become oppressed, and are interrupted in their functions; and relief is
experienced only when relaxation occurs in the vessels upon the surface
of the body. Thus, in any violent and continued exertion, there is a
sense of oppression in the chest, and the functions of the encephalon
are somewhat disordered, but as soon as perspiration breaks out the
relief is instantaneous, and the animal can, without difficulty,
persevere in its exertions.
In inflammatory fever, the breathing is often difficult, and the
appetite declines; the patient is restless and watchful, and when he
does sleep, he is not thereby refreshed. In the more violent cases,
the sensorial functions are much disturbed; even delirium supervenes,
with violent muscular exertion and convulsions, and may be followed by
coma, should the local affection not subside. The delirium attendant
on violent diseases and accidents may often be considered a beneficent
effect of nature’s operations; for the patient, frequently losing all
consciousness of his situation, seems to be under the influence of the
most pleasing hallucinations, and is freed from the more lamentable
state of severe mental as well as bodily affliction.
Writers on Inflammation have expatiated at great length on
_Sympathies_; and these have been divided into, 1st, The Partial—the
Remote, the Continuous, and the Contiguous;—Remote, when parts
sympathise, though situated at a considerable distance from each
other;—Contiguous, when the sympathetic action seems to be produced, in
separate parts, merely from juxtaposition;—Continuous, when the action
extends in parts which are of similar texture, and conjoined with that
which is primarily affected.—2d, Universal, where the whole system
suffers along with parts of it. For instance, the whole system is often
disturbed by a deranged state of the alimentary canal, and, conversely,
the bowels, or the skin, the brain, the osseous or any other of the
textures, may suffer from a general disorder.
The system sympathises much more with some parts than with others;
and we accordingly find that disorder in one part will give rise to
alarming constitutional excitement, whilst in another, a much greater
derangement in function and structure will apparently be almost
entirely disregarded by the constitution.
_Irritation_ is an effect of sympathy, and differs from inflammation,
inasmuch as the functions of the nervous system, and not those of the
sanguiferous, are disturbed;—the latter frequently supervenes on the
former. Irritation is local, or constitutional. As examples of the
strictly local species, may be mentioned that peculiar and dreadfully
annoying sensation produced in the alveoli by the presence of a
diseased tooth, or the irritation caused by ascarides in the rectum, or
by stone in the bladder.
But, from this action being dependent on the nervous agency, irritation
is frequently produced in a part remote from the source of the action.
Thus, if an irritating cause of any kind be applied to the origin
of a nerve, the effects of the irritation may be evinced in a part
supplied by its extreme branches; while, if the cause is applied
to the termination of a nerve, a similar action is produced at its
commencement, and in parts supplied by nerves from the same origin.
Thus, disease of the hip-joint causes pain in the knee, whilst
dentition in children not unfrequently produces fatal effusion at the
base of the brain; and again, irritation at the neck of the bladder
frequently gives rise to pain in the feet.
Local impressions, injuries, or irritations, though apparently of
little importance, frequently produce irritation which affects the
whole system, and is therefore termed _constitutional_. Syncope
sometimes follows the passing of a bougie along the urethra. We meet
with too many instances of constitutional irritation following severe
injuries or operations, especially if attended with much hemorrhage.
In general, there is considerable prostration of strength; the patient
is anxious and restless; his sleep is disturbed; the pulse is weak and
fluttering, occasionally intermittent; the tongue is white and loaded;
the appetite is gone; the stomach rejects the little food which the
patient is able to take; he is startled and annoyed by the slightest
external impression. At this period of the disorder, rigors generally
occur, and are followed by a sense of heat, and by perspiration; then
the above symptoms gradually decrease, and the patient recovers; but in
certain instances his breathing becomes quick and somewhat oppressed,
attended with a peculiar spasmodic elevation of the nostrils; all the
secretions are diminished, the intellectual functions become impaired,
and there are occasional convulsive twitchings; coma supervenes,
preceded by a low muttering delirium, and followed by death.
This action, as well as every other, is much modified by the importance
of the part which is the source of the action, and by the constitution
of the patient. It is more severe in children than in adults. The
affection will be more fully detailed, when treating of local injuries,
and the management of patients after severe operations.
The _Causes_ of Inflammation come next to be considered; and first, of
the proximate cause or theory. The different states of the Vessels, in
their healthy and in their incited condition, have given rise to much
discussion. In the first place, considerable difference of opinion
exists as to the relative share which the heart, the larger arteries,
and the capillaries, have in propelling the circulating fluid in a
state of health. Some physiologists are inclined to attribute the
principal power to the heart, the blood being propelled and returned,
according to them, almost entirely by the vis a tergo; while they
suppose that the arteries possess merely a degree of elasticity or
tonicity. Considering the arteries as elastic tubes, performing an
indispensable part in the propulsion of the blood, we will now briefly
consider their state in inflammation.
Passing over the different theories of error loci, spasm, &c., which
have at various times been entertained, let us first examine the
condition of the capillary vessels, for these are primarily and
principally concerned. In inflammation, the balance of the circulation
is destroyed, but a diversity of opinion has existed as to the precise
nature of the change which occurs. It has been supposed, and perhaps
correctly, that the circulation is, in the first instance, much
accelerated in the capillary vessels of an inflamed part; but it has
been satisfactorily proved by experiment, that, after inflammation
is fairly established, the blood circulates more slowly than in the
healthy state of the vessels. There appears, in fact, to be, as
insisted upon by some writers on the subject, a state of excitement,
then of collapse, followed, if the life of the part is not destroyed,
by reaction. When a part is stimulated, the circulation is accelerated,
and a greater quantity of blood is transmitted by its vessels: if
the excitement is speedily removed, they recover themselves, though
perhaps a little dilated, and no inflammation ensues. If, for instance,
a foreign body of any kind gets entangled betwixt the upper eyelid
and the bulb of the eye, and it is permitted to remain a few moments
only, redness of the whole surface of the conjunctiva takes place,
but it is transitory, and disappears entirely some short time after
the extraction of the foreign body. If, however, it is permitted to
continue longer in contact with this sensible surface, the membrane
reddens more and more, and becomes thickened. Violent pain, with
discharge of tears, and alteration of the secretion from the mucous
surface, take place, ophthalmia is, in fact, established. If the
exciting cause is applied for a sufficient length of time, the extreme
vessels lose their contractility, they are weakened, become dilated,
and the contained blood circulates slowly. When inflammation is fairly
established in a part, the capillaries become considerably dilated,
and the blood is often completely stagnated in the inflammatory point.
In the circumference of this focus, it is accelerated as formerly
noticed: the blood is probably stagnated for two or three days in the
capillaries and in the contiguous cellular tissue, when the action
is at all violent. It, however, begins to move again; it loses its
colouring matter, while stagnated; the fibrin is assimilated to the
neighbouring parts, or rather effused, so as to cause the thickening,
and the blood globules have possibly undergone a change, and been
converted into those of pus. If the disease be of a limited extent,
and without breach of surface, they are carried into the circulation
very gradually, and in such small numbers as not to produce injury
to the health; otherwise the contamination of the blood by a large
quantity of pus causes inflammatory fever. It is probable that the
permanent dilatation occurs in consequence of the larger vessels in the
immediate vicinity being incited, and propelling more blood into the
minute capillaries than they can readily return into the corresponding
veins; and in consequence of so great a degree of distension being
produced, the vessels are incapable of again speedily contracting;
the blood, also, from being stagnant, becomes of a darker colour. The
larger trunks propelling blood into the distended and comparatively
inert capillaries, which are incapable of transmitting into the veins
the same quantity of fluid which they receive, will cause the throbbing
or pulsating sensation. The blood circulating in the parts around is
sometimes apparently changed in quality; it is redder, flocculi appear
floating in it, and the globules disappear. These last may have been
broken down, or partial decomposition may have taken place from a loss
of vital power in the vessels themselves.
The blood globules are, perhaps, merely compressed; for whenever motion
is produced in the fluid, they speedily reappear. Fresh globules
also find their way into the affected capillaries from neighbouring
vessels. The alteration in the component parts of the blood has been
supposed to depend upon the previous state of the inflamed vessels
in which it is contained: it is said soon to reassume its natural
appearance, when brought into a healthy vessel, and reference is made
to experiments on the web of the frog’s foot. When once altered, it
is, however, questionable if the blood ever reassumes its natural
appearance; of course the blood which takes the place of that which
was stagnated in the capillaries will be natural. If there have been
extensive inflammation, and therefore much altered blood, one of two
things will happen, viz., inflammatory fever and its consequences, or
the discharge of the offending matter (the altered blood) as pus. We
may also conclude that the blood of an inflamed part undergoes chemical
changes; for when the part becomes gangrenous, the blood then loses its
red colour, and assumes a yellowish-brown hue, from the absorption of
its colouring matter, which necessarily implies an alteration in its
chemical constitution. It seems not unlikely, that the change which is
early observed in the appearance of the blood of an inflamed part is
the commencement of a chemical process, which, if the vessels do not
regain their contractile power, terminates in the total destruction of
the ordinary properties of that fluid. It is probable that the more
modern speculators in medical science have paid too little attention
to the state of the fluids, and to the fact that, when diseased
action occurs in a part, its secretions and supplying fluid are very
considerably changed.