vessels, secrete a substance which is transformed into a set of minute
capillaries, and these also, assuming a secretive action, produce an
arterial or venous tube, similar to that nourished by the original
vasa vasorum. By this process the lymph becomes well supplied with
bloodvessels, those from the opposite surfaces meeting, and freely
inosculating with each other. These bloodvessels, as already stated,
have been produced from arteries possessing different powers, and hence
the newly-formed assume actions similar to those of the primary, and
thereby interstitial matter is deposited of its proper kind and in
its proper place, a cuticular membrane superficially, then cellular
tissue, afterwards muscular, and so on according to the primary tissues
which had been divided; these parts do not at first resemble exactly
the corresponding natural tissues, but, by the continued action of
the new vessels and capillaries, they are moulded and prepared for
the due performance of their respective functions. If the degree of
action necessary for the accomplishment of these processes increase to
inflammation, adhesion is interrupted till the action be lowered to its
previous standard.
From this view it is evident, that, besides a certain excitement of
the bloodvessels, it is necessary that the raw margins be in close
apposition, and carefully retained so, for, by ever so slight movement
of the parts, the recent and delicate bond of union will be ruptured;
and, if this motion be allowed to continue, adhesion may be at divers
times begun, but can never be perfected. Whereas, if the necessary
precautions are adopted, union is often completed in thirty or forty
hours, sometimes sooner, seldom later. From a knowledge of the
astonishing powers of nature in repairing injuries, many and important
improvements have of late years been made in the practice of surgery.
In the majority of instances it is also requisite that the parts be
brought in contact soon after division, otherwise granulation will have
commenced in the different parts of the wound, and the surfaces then
approximated will not so readily adhere: pus is formed, and, having
lodged between the surfaces, acts as an extraneous substance, keeping
them apart, and separating them still farther by its accumulation.
All foreign bodies in the wound must be removed before adhesion can
occur; and, on the same principle, care ought to be taken that no
effused blood be interposed. In many cases the margins of the wound
can be accurately adjusted by careful attention to the position of
the part, or by the application of a few strips of adhesive plaster;
but the latter, from indiscriminate use, often prove the source of
much irritation, and totally frustrate the end for which they are
designed. When employed, they ought to be narrow and few. If such means
be considered insufficient, recourse must be had to a few points of
interrupted suture, and these are not productive of bad consequences
which have been by some attributed to them. When neatly applied, they
can produce but little irritation, more especially if removed as soon
as their presence is unnecessary, that is, as soon as adhesion has
fairly commenced, and the natural bond of union is of such strength
as to need no artificial assistance. By these the edges of the wound
are more neatly and suitably placed than by any other means; they meet
easily, without the puckering or overlapping of each other; and, from
the circumstance of sutures obtaining a more just coaptation, they can
be sooner discontinued. In most wounds no other dressing is required;
but in some a combination of sutures, adhesive plaster, and compress,
is necessary.
Of late, I have greatly dispensed with stitches and the common adhesive
plaster, using, instead of the latter, slips of glazed riband smeared
with a saturated solution of isinglass in brandy, which is much less
irritating and more tenacious than the common adhesive compost. The
parts are fixed temporarily with a single stitch, or two at most, and
cloths dipped in cold water are placed over the wound; the ribands are
not applied till the adhesive substance has partly congealed, and the
oozing of blood ceased. The divided margins being approximated by the
fingers of an assistant, the ribands are laid gently over, and held for
a few seconds. Soon after a sufficient number have been applied the
stitches are withdrawn, being no longer necessary. No other dressing
is required unless suppuration occur; the ribands will adhere firmly
till the completion of the cure, and thus the pain and irritation
caused by frequent dressing is avoided. Even the largest wounds, as
after amputation, are treated in this manner with the most satisfactory
results. Of late years a plaster, made by coating oiled silk with a
solution of isinglass, has been used instead; the glazed surface of
the slips is moistened, and applied as here directed.
If at any part adhesion fail, suppuration and granulation must follow.
The adhesion may be prevented by any of the circumstances already
mentioned, or by an unfavourable state of the constitution, the nature
of the wound, exposure to bad air, the occurrence of fever, or of a
flux natural or not. The wound may contain foreign matter; blood or the
contents of canals may be effused into it, and many other obstacles
may exist to retard, or prevent adhesion. Notwithstanding, in all
cases, though the chance of union be but small, the parts should be
approximated. A great point is gained if certain parts only are brought
to adhere, for by their natural attachments the opposite surfaces are
preserved in more direct contact than they could otherwise be, and
thereby but little space remains to be filled up with granulations.
If, on the contrary, the surfaces are not approximated, the flap is
diminished in size, and when afterwards placed in contact with the
surface from which it was detached, it is found not to correspond,
leaving considerable deficiency to be repaired by the comparatively
slow process of granulation. Whereas, if it had been early replaced,
partial attachments would probably have been formed by adhesion, the
flap thereby retained in situ, and prevented from shrinking, so that
but little new matter would be required.
Sometimes union does occur, and that speedily, after the flap has
remained separate for a considerable time; and in such cases it may be
doubted, whether union is accomplished by adhesion, strictly so called.
Most probably it is by this process that the rapid union occurs in such
circumstances: the divided parts have assumed an excited action, and
effused lymph; during their state of separation, the lymph will become
organised when it is connected with the original parts, just as well
as if the surfaces had been in contact; and when they are at length
so placed, they will be agglutinated to each other by the outer part
of the effused lymph, which still continues soft and unorganised. If
motion be then prevented, organisation, which has already commenced
in the connecting medium, will proceed undisturbed, converting the
agglutination of soft unorganised lymph into firm and permanent union
by means of organised tissue. In these circumstances, it is not to
be wondered at if adhesion should be completed in a shorter time
than when the surfaces are brought together immediately after their
division; in each instance the process is the same, only in the one
it has to proceed from its very commencement, whilst in the other it
is previously all but perfected, and after the parts have been put
together, the last stage only requires completion. It is only in a
particular stage of a granulating surface, that adhesion will take
place speedily, when the discharge is diminished, but healthy, and the
granulations florid and firm.
When a wound is to heal by granulation, the exposed surface at first
is dry, painful, and slightly swelled, and afterwards a thin discharge
of bloody serum is poured out, with relief to the painful sensations;
the surface is at this time covered by a thin layer of coagulated
lymph, and the parts, if approximated, are in the most favourable
state for adhesion. Soon, however, the vessels assume a different mode
of action, and secrete a fluid which becomes purulent; the effused
lymph has been organised, forms a living part of the surface from which
it was deposited, and is covered and protected, in its yet delicate
condition, by the purulent fluid. This new matter is disposed in
numerous small conical projections of a florid colour; and these, by
their own power, form others similar to themselves, at the same time
discharging purulent matter; so that, in a healthy constitution, the
cavity is soon filled by the granulations, which come to the same level
as the surrounding integument. Sometimes they are exuberant, soft, and
spongy, and in this state possessed of little sensibility, and but ill
supplied with bloodvessels. At others, they are slow in approaching the
surface, and then often morbidly sensible. In all cases, the new matter
is very apt to be absorbed, either from the state of the patient’s
health, or from the nature of the applications; and foreign substances,
in a state of solution or minute division, are more readily taken into
the system from the raw surface than from the sound skin. When, then,
the granulations approach the skin, the sore contracts, the newly
formed parts being modelled into a more firm and dense condition by the
action of the absorbents. Sometimes, in superficial sores, the skin is
seen spreading from several parts near the centre; but at these points
portions of the original skin must have remained uninjured, though
the others were destroyed, and have formed cutaneous matter as soon
as they were on the same level with the surrounding granulations; for
these insulated portions of skin are not a product of granulations, as
some suppose, but of a substance similar to themselves. Skin is formed
from skin. Thus, where a part of the integuments has been completely
removed by operation, or destroyed by accident, no islands of skin are
observed during the cure, but the sore is uniformly covered by skin
proceeding from its margins. The margins of a healing sore are of a
white colour, and adherent to the subjacent parts; but in an unhealthy
one the margins are often unsupported, the subjacent granulations are
absorbed, and their place is occupied by thin purulent matter; the
new skin is unable to maintain its independent existence, continues
of a dark colour, perhaps for a long period, then wastes away or
sloughs. The recent cutaneous matter covering a sore contracts, and the
neighbouring old skin is extended; the new surface is thus diminished;
it assumes a slightly puckered appearance, and is termed cicatrix. This
is at first pretty vascular, the vessels running straight; after a time
they contract and become invisible, and scarcely admit fine injections.
Frequently the scar is so far absorbed after some time, as to leave
only a firm line, whiter and more dense than the surrounding integument.
If union by the first intention does not take place, then all the
application to procure it must be abandoned, all sutures, plasters,
compresses, &c., must be dismissed, for they now can do no good, and
may be productive of harm; the attention, on the contrary, must be
directed to effecting union by granulation; with this view, other means
are to be chosen, so that to continue those which were formerly used
to promote adhesion would be absurd, when adhesion can no longer be
expected. The stitches must then be taken out, when inflammation has
gone off, and œdema remains, the parts are to be supported; and by
attention to position, and gentle bandaging, the size of the wound
will be diminished. Inflammation must be subdued by the usual means,
and suppuration encouraged by fomentation and poulticing, or warm
water dressing. After inflammation has subsided, tension disappeared,
purulent discharge occurred, and granulations formed, the edges of the
wound are to be gently brought together, so as to render the quantity
of new matter requisite for filling up the cavity as small as possible.
Nature will then accomplish the union in her own way, and we can only
assist and minister to her; for who thinks now of healing wounds by
pure force of surgery? The dressings ought to be light, the ointment,
if any is used, scanty; in some cases the application may be dry; but
in many cases various lotions will be found of much advantage. These
latter are used of different qualities, according to the nature of the
sore; and these can be of little avail unless evaporation be prevented,
by a piece of oil-silk laid on the outer surface of the dressing. In
most granulating wounds, they require to be of a mildly stimulating
nature, and the one which I have most frequently employed is a weak
solution of the sulphate of zinc. The integuments round the wound may
be occasionally washed, to prevent excoriation, but no good can accrue
from washing the sore; its natural discharge is its best protection,
and if superabundant, it can be removed by means of dry lint or tow
from the surrounding parts.
From bruised and lacerated wounds there is little or no hemorrhage, but
in proportion to the severity of the bruise, is the bleeding slight,
and the danger great. The bloodvessels are so torn and twisted as to
permit the spontaneous and temporary suppression of hemorrhage to
occur almost immediately; and the larger arteries may escape entirely,
owing to their elasticity. Sometimes after bruised wounds, such as
those inflicted by gunshot, the large vessels bleed instantly and
violently; often, however, hemorrhage occurs only after the sloughs
separate, many days after the infliction of the injury, and then it is
generally very profuse; in some instances, limbs are torn, bruised,
or shot away, without hemorrhage occurring to any great degree, or at
any period. Frequently the vitality of the parts surrounding the wound
is much diminished; and the whole limb is apt to become gangrenous,
either immediately, on account of the extreme violence of the injury,
or consecutively, from greatly excited action going on in parts whose
power of resistance has been much impaired: it often arises also from
constitutional peculiarity. The gangrene extends often rapidly, in
consequence of the infiltration of putrid serosity into the cellular
tissue. In the treatment of bruised wounds, the position of the parts
must be carefully attended to; they must be placed in a state of
relaxation. In general, it is unnecessary to retain the margins of the
wound in contact, for adhesion cannot occur—suppuration must ensue,
and is to be desired—and the dead and dying parts must be loosened and
discharged before union can take place. Sometimes, as when a large
flap has been detached, and the parts not much injured otherwise,
approximation ought to be accomplished, for the reasons already
mentioned. In almost all cases, and most certainly in those in which
the mechanical injury has been severe, and its effects extensive,
violent inflammatory action is to be dreaded, and measures must be
taken to ward it off: notwithstanding the prophylactic treatment,
violent inflammation often comes on, and then recourse must be had to
the means proper for the subduing of it. Blood is to be taken from
the part, if necessary, and soothing applications used, in the form
of fomentation and poultice. The main indications are to prevent
extravasation into the substance of the limb, and strongly excited
action. When the sloughs begin to separate, emollient poultices promote
the suppuration and discharge of dead matter, and afterwards the
sore must be dressed, according to the nature of the case, with the
applications most fit for granulating sores in their different degrees
of action and advancement. During the after treatment, the sides of the
sore ought to be well supported, so as to prevent, as much as possible,
suppuration from extending along the neighbouring cellular tissue; but,
at the same time, the dressing must not be so tightly applied as to
cause irritation. When abscesses have formed in the neighbourhood, the
cavities should be freely exposed by incision; thus a free discharge
will be given to the matter, and the cavity brought to granulate from
the bottom. During the suppurating stage, the patient’s strength must
be maintained by generous diet.
Punctured wounds are dangerous, from the deep and internal effusion of
blood and serum which usually attends them. The effusion, which in open
wounds is poured out externally, and moderates and prevents the excited
action from exceeding what is salutary, is, in punctured wounds, poured
into the substance of the limb to its detriment. It is followed by
severe inflammatory action and profuse suppuration. In order to prevent
these untoward results, it was formerly the practice immediately to
dilate the wound; but this is hurtful, for if the wound be deep, as it
generally is, dilatation of its whole extent is a proceeding severe in
itself, and in its consequences; whilst, if the external part only of
the wound is dilated, the operation will entirely fail to effect what
is intended. The knife will be used in great good time where a foreign
body is found to be lodged in the wound, when tension has occurred, or
matter has formed. Sometimes the wound heals throughout its whole track
by adhesion, without any bad symptoms being so much as threatened.
Setons, recommended in this class of wounds, are of no service. It is
not the narrowness of the external opening, as is sometimes supposed,
that is the cause of all the mischief, but the injury and consequent
inflammation of deep-seated parts.
Poisoned wounds are rare in this country. Wounds by the stings of
certain trifling insects produce considerable swelling in some
constitutions, and when the injury has been inflicted on a loose
texture. In some parts of this country, the bite of a small adder
causes pain, swelling, and unhealthy suppuration of the part, with
some constitutional disturbance, but the results are seldom serious,
and never fatal. In warmer climates, the bites of some snakes are
followed by the most violent symptoms; in some cases proving fatal
in a few hours, in others after a day or two. Great swelling occurs
almost immediately, attended with excruciating pain, and extends upward
along the limb; vision becomes impaired, the patient lies in a state
of stupor, and ultimately succumbs under convulsions and delirium; the
symptoms vary in particular instances according to idiosyncrasies and
the state of the constitution when the injury is inflicted.[22] In this
country, the bites of rabid animals are more dangerous than those of
animals naturally poisonous. Rabies most frequently occurs in dogs,
and others of that species, such as wolves, foxes, &c. They become
dull, sluggish, and irritable; have unnatural appetites and cravings,
devouring their excrement and urine; the stomach is generally found
full of chopped straw, pieces of wood, &c. Derangement of the cerebral
functions is not complete,—they know and obey their master. They are
often not afraid of water, but lap it and go into it readily. From them
the disease is communicated to the human subject, and to the lower
animals, such as cats, sheep, cattle, and even fowls; the virus is not
communicable, except by the deposition of the saliva on an abraded
surface, or into a wound. It is not produced by eating the flesh of a
rabid animal. During the first days of the attack, pustules are, it is
said, observed under the tongue, but there is no apparent change in the
glands. The symptoms of hydrophobia in man seldom appear before the
twentieth day after the infliction of the wound, and in some instances
they have not presented themselves till after the lapse of months. The
most prominent are great restlessness, much irritability and anxiety,
and convulsions of the muscles concerned in deglutition, produced
either by attempts to swallow, or by fluid being presented to the
patient. Ultimately, the spasms become general, are induced by the most
trifling exertions or noises, and prove fatal in a few days. Frequently
the patient retains his senses throughout, and is fully aware of his
lamentable situation; in other instances, he soon becomes delirious,
raves, and threatens his attendants. For this horrible disease we
are unacquainted with any cure. In general, profuse bleedings are
employed, and large quantities of opium given internally; every
powerful antispasmodic, as well as every violent medicine, has been
made trial of, but in vain: some certainly mitigate the symptoms, but
none cure the patient. It has been even proposed to suspend or destroy
the function of the nervous system for a time, by the employment
of the Wourali poison, keeping up at the same time respiration by
artificial means, under the expectation that thus the impression
on the system might be got over. The morbid appearances usually
observed after death are marks of inflammation of the pharynx and
air-passages, and of the mucous surface of the stomach and intestines.
It is evident that the disease ought to be prevented if possible, and
for its prevention the most efficient measure is timely excision of
the affected parts; and they should be cut out a long period before
the constitutional affection comes on: when excision is dangerous,
or wholly impracticable, and when the patient does not apply soon
after the accident, the injured parts may be destroyed by some active
caustic, as the potassa fusa. The nitrate of silver has been strongly
recommended and extensively employed by Mr. Youatt, whose experience in
this disease is very great. This application should scarcely be trusted
to alone. The removal of parts wounded by snakes, even after violent
symptoms have appeared, has proved successful, ammonia having been
at the same time administered internally. In some instances, arsenic
has been found efficacious when given in large doses, and frequently
repeated.[23]