particularly in those individuals who are habitually addicted to the
use of ardent liquors: they seem to arise from, at least they follow,
disorder of the digestive organs. Their seat is in the skin and
subjacent cellular tissue.
They generally occur in those parts which are possessed of little
vitality, as in the back, buttocks, shoulders, the posterior part of
the neck, &c. They are seldom single, are often numerous, and vary in
size from a pea to a pigeon’s egg.
A boil is of a conical form, elevated above the surface of the body;
its base is hard and firm, whilst its apex is acute, soft, of a white
colour, and exceedingly painful; the pain experienced in the tumour
is severe and burning. From the comparatively trifling nature of the
affection, the assistance of the surgeon is seldom required, and hence
the apex of the tumour generally gives way either spontaneously, or
in consequence of being scratched by the patient, or rubbed by the
clothes; the purulent matter, which is generally small in quantity, and
mixed with blood, is thus discharged. This, however, is attended with
but little relief in bad forms of the affection; for at the lower part
of the cone is situated a considerable quantity of mortified cellular
tissue, which must be evacuated before the cavity can heal.
In this unhealthy species of inflammation, resolution cannot be
expected; on the contrary, suppuration is the natural termination of
the disease, and must be hastened by poultices and fomentations. A
simple or crucial opening, according to circumstances, must afterwards
be made in the apex of the tumour, so that the sloughs of the cellular
tissue may be permitted to escape readily. In the advanced stage, the
sloughs are the irritating cause by which the inflammatory action is
prolonged, and on their removal the cavity contracts speedily.
If there is much derangement of the digestive organ, it may frequently
be found necessary to administer an emetic. If the bowels are slow
and the liver torpid, calomel and antimony are highly useful, or
other mercurial preparations may be given, in combination with
active purgatives; if the state of the secretions is more natural,
these medicines may be administered in alterative doses. The mineral
acids are often usefully administered, with the view of removing the
disposition to the formation of boils. Twenty minims of the aromatic
sulphuric acid may be given twice or thrice a day in any convenient
vehicle. Anodynes are occasionally required.
[Illustration]
_Anthrax_ or _Carbuncle_ maybe considered as a severe form of boils.
It occurs in the plague, and is a characteristic symptom. It appears
in the same parts, and apparently from the same causes, as the boil.
The tumour is of a more flattened form, slightly elevated above the
surface, and frequently of great extent; the base is deeply-seated,
hard, and unyielding. The integuments are at first of a bright colour,
but afterwards assume a dark-red or reddish-brown hue. The pain is
violent and burning. The process of suppuration is very tedious, and
the matter that is formed is small in quantity. If the tumour is not
interfered with, ulceration occurs in its surface, producing various
apertures, through which the matter is evacuated, the discharge is thin
and unhealthy, excoriating the neighbouring surface; and the mortified
cellular tissue, remaining at the base of the swelling, keeps up the
irritation. The extent of a carbuncle is frequently great, both as to
width and depth; on the back, or buttocks, it not unfrequently attains
an immense size. In one instance, the whole posterior part of the neck
was involved; the cellular tissue, muscles, and tendons, sloughed;
and the vertebræ were ultimately exposed. In another case, the whole
occiput, the posterior and lateral parts of the neck, and the space
betwixt the shoulders, exhibited one continuous mass of carbuncle. By
making free incisions, procuring early separation of the sloughing
parts, and supporting the strength of their constitutions, both
patients recovered, though considerably advanced in life.
It seldom occurs in the face or head, and when it does, it generally
proves fatal. In a male patient in the Edinburgh Royal Infirmary,
aged forty-eight, a carbuncle of the size of a very large orange
was situated in the centre of the forehead; by active local and
constitutional treatment, he soon got well.
The affection is sometimes attended with typhoid symptoms, rigors,
profuse perspiration, nausea, vomiting, disordered bowels, loss of
appetite, anxiety, restlessness, difficult respiration, palpitations,
faintings, pale-white tongue, low pulse, pale or turbid urine,
headache, giddiness, drowsiness, and, in severe cases, with delirium.
In old or exhausted patients, the prognosis is unfavourable.
An early and free incision must be made into the tumour; if the
swelling is large or extensive, the preferable form of incision is
the crucial; the ill-formed matter is thus evacuated, the slough
exposed, and more readily allowed to escape. If the mortification
of the cellular tissue be extensive, and the sloughs prove firmly
adherent, the free employment of the caustic potass will be found of
much service, the half-dead cellular substance being thereby completely
destroyed, and the surrounding parts stimulated to a new and superior
degree of action, necessary for the removal of the mortified parts, and
reparation of the breach of surface. Poultices and fomentations may
afterwards be employed, followed by the warm-water dressing, medicated
or not. The stomach and bowels must be put into proper order by the
exhibition of suitable medicines; and the vis vitæ may be still farther
supported by the administration of tonics and stimulants. If, after the
separation of the sloughs, the exposed surface shall assume an indolent
or debilitated action, stimulating dressings, such as turpentine
liniment, or elemi ointment may be employed.
Such practice will be found sufficient to procure a speedy and
favourable termination of the disease, in this country, where we have
not to combat any of those malignant diseases with which carbuncle is
accompanied in other climates.
OF INFLAMMATION OF THE MUCOUS MEMBRANES.
Mucous Membranes and the skin are analogous in structure, somewhat
similar in function, and sympathise closely with each other in
health and in disease. Both are endowed with that peculiar degree of
sensibility which enables them to bear with impunity the impressions
of foreign bodies; and both are protected from the influence of these
bodies by an inorganic covering; the cutis and rete mucosum by the
epidermis; the corium of mucous membranes by a laminated epithelium.
They are the seat of all excretions, and by them all substances are
introduced from without into the system. The capillary portion of
the vascular system appears to have somewhat the same arrangement
in both; the distribution of blood to the mucous membranes being,
however, more copious. At the commencement and extremity of the
alimentary canal, they insensibly pass into each other by means of
an intermediate structure, of which the prolabium may serve as an
example. In particular circumstances, they change into each other,
both in appearance and in function. Thus, in prolapsus of the gut or
of the vagina, the discharge from the protruded mucous surface after
a time subsides, the rugæ disappears, the membrane becomes thickened
and indurated, and gradually assumes an appearance exactly resembling
that of the skin. In natural paraphymosis, the delicate membrane
which, in the healthy state of parts, lines the internal surface of
the prepuce, becomes converted into a cuticular covering. In neglected
and long-continued excoriation of the nates, the raw surface, which
was at first tender and irritable, and discharged a serous fluid,
becomes villous, less sensible, and discharges a fluid similar to a
mucous secretion. In sinuses also of long duration, the secreting
surface becomes changed, so as to resemble a mucous membrane, and the
discharge, from being purulent or gleety, becomes mucous, or at least
resembles a mucous fluid,
A mucous surface, when inflamed, has for a short time, perhaps,
at first, its functions suspended; it then furnishes a secretion,
increased in quantity, and but little changed in appearance from the
healthy fluid; afterwards the discharge resembles purulent matter, and
is termed muco-purulent. When, however, the inflammation is violent,
the discharge becomes bloody, or is altogether suppressed, and the
membrane is thickened. Inflammation of a mucous membrane is very
apt to spread with great rapidity, in this respect resembling the
corresponding affection of the skin. It is attended with a sense
of itching, and a burning pain. This pain is much increased by the
muscles surrounding the parts being thrown into action, as in expelling
their contents, more especially if these be of an acrid quality.
The membrane is thickened, and of a spongy appearance; its surface
is red, and sometimes covered with flakes of lymph; occasionally it
is much softened, and coated with a viscid adherent mucus; and it
would appear, in many instances, that, in acute inflammation, the
membrane is generally softened, whilst it becomes indurated from
chronic inflammatory action. When the inflammation is violent, and
consequently rapid, considerable quantities of lymph are effused either
on the surface of the membrane, or into the submucous tissue: and the
lymph subsequently becoming organised, the membrane is much thickened,
and a contraction is the consequence. The functions of a part lined
with mucous membrane are more or less deranged, in consequence of the
vitiation of the secreted fluid.
In inflammation of this tissue, metastasis is also apt to occur, from
one part of the membrane to another, and from the membrane to the
external surface. Cynanche, for instance, often follows upon erysipelas
of the face and scalp, and _vice versâ_.
The passages, the internal surfaces of which are invested by a mucous
membrane, are those subservient to respiration, nutrition, generation,
and the urinary secretions; in other words, the mucous surfaces are the
Pneumogastric and the Genito-urinary. Their particular diseases will be
treated of hereafter.
OF INFLAMMATION OF THE SEROUS MEMBRANES.
On such an extensive subject it is unnecessary to enter fully; not that
the inquiry is uninteresting, or that a knowledge of the diseases of
the internal cavities, and the mode of treating them, is not required
of the surgical practitioner before he can enter into practice, with
safety to his patients and comfort and satisfaction to himself, but
we have a very important class of diseases to bring under review in
a limited space, and it is properly the province of others to treat
of internal disorders, and to describe the best mode of alleviating
or curing them. It is, however, the duty of the surgeon to treat
the inflammatory affections of some of the serous membranes, and
the consequences of inflammatory action in most of them; and it is
therefore highly necessary that he understand the symptoms, progress,
and consequences of such actions. The affections of the serous
membranes are principally under the management of the physician; but
they not unfrequently follow wounds and surgical operations, and the
diseases of several of them are purely surgical. Inflammation of a
serous membrane is attended with heat and pain, aggravated by motion
of the parts and by pressure; the natural secretion is increased
in quantity, the process of exhalation being incited, and that of
absorption weakened; the serous fluid accumulates. The secretion
becomes altered in quality, and assumes a milky appearance; lymph
is effused, generally mixed with purulent matter, and floats in the
fluid, or adheres to the surface of the membrane, which is rough and
flocculent. The adherent lymph becomes organised, being penetrated
by numerous bloodvessels; and thus the original membrane is, in many
instances, much thickened, chiefly from the addition of new matter,
though also from enlargement of its bloodvessels and opening out
of the primitive tissues, principally the subserous cellular. When
inflamed serous surfaces, which have been altered, both in texture and
function, in consequence of inflammatory action, remain for a short
time in contact with each other, lymph is effused and penetrated by
bloodvessels from each surface; thus the new deposit is organised, and
forms a medium of connection. By this process the parts are intimately
united to each other, and consolidated into one mass; or are merely
approximated, and joined, at one or more points, by portions of lymph,
in some cases thin and narrow, in others extensive and of considerable
thickness; the adhering bands either extend in a straight direction,
from one surface to another, or interlace, forming a sort of network.
After adhesions of various kinds have been formed, they are often
lengthened and attenuated in consequence of the motion of the parts,
as is particularly the case with adhesions between the pleura costalis
and pulmonalis. When they have been of considerable duration, they
often resemble the original membrane from which they were deposited,
becoming thin and transparent, smooth on their external surface, and
furnishing a serous secretion. Not unfrequently, inflammatory action
in this tissue terminates in suppuration; and the pus, secreted by
the membrane, accumulates in the most dependent part of the cavity.
By collections of matter, whether serous, sero-purulent, or purulent,
within a serous cavity, the functions of the contained viscera are
deranged, much impeded, and in many instances morbid actions are
excited in them. The inflammation, whether it terminates in resolution,
or proceeds to serous effusion, adhesion, or purulent secretion,
is attended with constitutional disturbance, and the symptoms are
proportioned to the original intensity of the action, and the extent
and kind of its termination. The effusion of lymph, and consequent
adhesion, is, however, in many circumstances, a highly salutary
process, as in wounds and injuries of the hollow viscera: effusion of
their contents being thereby prevented, and the patient being saved
from the danger attending violent inflammation of those cavities and
their coverings, caused by the escape of a greater or less quantity
of irritating extraneous matter. Purulent collections also, in the
solid internal viscera, are thus allowed to discharge themselves
externally. The nature, symptoms, and consequences of inflammation of
serous membrane, will be more fully considered under the diseases of
particular parts.
OF INFLAMMATION OF TISSUES COMPOSING THE ARTICULATIONS.
Inflammation of the synovial surface occurs in consequence of wounds,
bruises, or sprains, and often from exposure to cold; from the latter
cause, the knee and elbow joints most frequently suffer, as they are
generally more exposed to its influence, and not so well covered with
muscular substance as the others. Constitutional diseases, such as
certain fevers, are followed sometimes by effusion of serous fluid into
joints. Purulent matter is also deposited in joints during certain
forms of suppurative fever; and this is attended by rapid change of
structure.
There is heat, throbbing, pain, and swelling of the part, sometimes
redness of the surface, and great constitutional disturbance; the
symptoms and appearances, however, vary much, according to the extent
of the joint which is involved. When part of the capsule is affected,
the inflammation spreads rapidly over all the surface; the synovial
membranes resembling the serous in this respect, as well as in healthy
structure and function. Like the serous, too, they are shut sacs, are
smooth on their surface, and furnish a secretion, the synovial, for
facilitating the motion between opposing surfaces; it is, however,
somewhat more glairy than the serous. Neither, in their healthy
state, are possessed of much sensibility, nor are ligaments, tendons,
tendinous sheaths, and bursæ, which two latter textures resemble in
every respect the synovial; when inflamed, they become most exquisitely
sensible. The incited action of the bloodvessels is followed by
increased discharge, which is less glairy and albuminous, partaking
more of the serous character. When the incited action soon terminates,
and the activity of the absorbents is diminished, the fluid accumulates
within the joint, producing _Hydrops Articuli_. This accumulation of
fluid in joints may take place without being preceded by any apparent
inflammation, and may remain a long time without any visible change
of structure in the membrane. The knee is more frequently the seat of
dropsy than any other joint.
When the action is more violent, and is not actively opposed, lymph
is effused on the inner surface of the membrane, or is deposited
amongst the ligamentous and cellular tissues external to the joint,
in consequence of which, the membrane and external ligaments become
thickened, and of an almost cartilaginous consistence. Serum is
effused into the more superficial cellular tissue, filling up the
hollows around the joint, concealing the protuberances of the bones,
and producing a globular swelling. The articulating surfaces become
ulcerated, and matter forms within the capsular ligament; or the
pus is deposited exteriorly to the joint, and gradually approaches
the surface. But although ulceration is so prone to occur in the
cartilages, the synovial membranes do not readily take on this action,
unless from the progress of matter, formed within the joint, towards
the surface. The synovial lining of the bursæ and sheaths of the
tendons are extremely indisposed to ulcerate; and it may be remarked,
that, while suppuration without ulceration is common in the synovial
membranes, the cartilages, on the other hand, afford frequent instances
of ulceration without suppuration, of which more particular mention
will be made in the sequel. The cartilage is occasionally swelled and
softened where the disease has long existed.
Along with ulceration of the cartilage, a portion of it may become
dead, or either state may occur separately; and in many cases, the
substance of the bone also becomes affected, of which two classes of
cases may occur, viz., great inflammation on the articular surface of
the bone, with separation of the cartilage by the ulcerative process
in this situation; and inflammation of the medullary web, leading to
atrophy of the cancelli, collections of pus therein, or even death of a
portion of the spongy texture of the bone, as will be more particularly
treated of in the chapter on diseases of the osseous tissue. These
changes often compose the primary disease, and to them the affections
of the synovial membrane and other parts succeed.
Such occurrences are attended with alarming disturbance of the
constitution, with fever, and even with the most threatening and
dangerous symptoms, such as delirium and coma. If the patient survive,
and the matter be evacuated from the joints by openings into its
cavity, hectic fever is almost certain to supervene.
An opinion has been broached lately by Mr. Key, that the ulceration
of cartilage was consequent upon the increased vascularity and
thickening of the synovial membrane, that the cartilage, in fact,
was removed by the action of the vessels ramifying in the membrane,
and the prolongations or fringes from it in its diseased condition.
Occasionally these fringes correspond, in a remarkable manner, to the
breach of surface in the cartilage; but again, ulceration is frequently
met with far removed from the membrane. It is also seen, in cases
where an opportunity is afforded of making the examination in the
earlier stage of disease, that ulceration exists to some extent whilst
the synovial membrane is unaffected. And certain cases, in which the
cartilage is affected with hypertrophy, and the common form of atrophy
of this part in old people, are altogether adverse to Mr. Key’s views.
When ulceration takes place at a point removed from the attachments
of the synovial membrane, it appears to proceed more frequently from
the attached than from the free surface of the cartilage; then the
adventitious membrane occupying the rugged spaces, and which under the
microscope appears highly vascular, is connected apparently with the
medullary web.
In acute inflammation of the synovial membrane, and in cases where the
cartilage is ulcerated, the pain is very intense, and the spasms of
the limb most distressing. This happens when the surface is ulcerated,
and perhaps to no great extent. We know that in the horse an ulcerated
hollow in the cartilaginous covering of the navicular bone, not so
large as to contain a grain of barley, will cause such lameness and
suffering as to render the animal so affected perfectly useless. If he
is not destroyed at this stage, as many valuable animals have been,
the mischief extends, and terminates in extensive disease of that
and the neighbouring bones and articulations. It is different if the
disease commence, as it sometimes does, in the human subject, in the
cancelli of the bone, and on the attached surface of the cartilage,
the free surface remaining some time entire and smooth. When the
synovial membrane is primarily affected by chronic disease, the pain
is in general trifling, often not complained of, and swelling of the
part, from effusion, into the joint or neighbouring bursæ, first
attracts attention, after it has existed, perhaps, in a slight degree,
for a considerable time. The joint is stiff, and pain is experienced
from extensive motion; on this account the patient is disinclined to
use it, and it is soon tired by the slightest exertion. The swelling
becomes more solid, though still remaining elastic, and the feeling of
fluctuation diminishes. Effusion of lymph follows that of serum, the
latter having been absorbed; the motion of the joint is still further
impeded, and the articulation is distorted; the patient keeps the limb
in the most easy position, generally that of partial flexion, in which
it becomes almost immovably fixed. The cause of the flexed position,
which is almost pathognomonic of knee disease, being preserved, seems
to be that the limb is insensibly brought into it in order to take the
pressure off the interarticular apparatus, the ligamenta mucosa and
alaria,—these swell—the muscles of the hamstrings get contracted from
habit, and a difficulty, even after the disease is completely subdued,
is often enough experienced in procuring complete extension. The
muscles, from disuse, shrink, the adipose substance is absorbed, the
shafts of the bones also are diminished in size, get into an atrophied
state, as the phrase is, and thus the whole limb is rendered slender
and wasted, so as to make the swelling of the diseased articulation
still more conspicuous. The bones are softened, and the muscles are
of a white colour, as in the limbs of the paralytic or bedridden,
and resemble more cellular than muscular tissue. The wasting of the
muscles and loss of power often precede the appearance of disease; this
is frequently observed in the shoulder-joint, the deltoid shrinking,
and almost disappearing, before any disease in the articulation
is suspected by the patient. Not unfrequently, also, this wasting
occurs without obvious cause, or any affection of the joint. When the
disease is advancing, the patient may feel no acute pain, but merely
a reluctance to use the limb; and from this, if long continued, the
muscles, and afterwards the bones, become wasted. Wasting of the limbs
in children, often of one of the lower, frequently arises from disorder
of the bowels, and the irritation and debility attendant on teething.
This must be distinguished from the wasting accompanying diseased
joint. The history of the case, the period at which the weakness of the
limb was observed, and its appearance, will lead to a correct diagnosis.