consequences from the absorption of animal matter. The absorbents
leading from the wounded part become swelled and painful, and in
slight cases there are shivering and general indisposition for some
days. The more violent symptoms arise from examining bodies which are
rather recent, and in which putrefaction is just commencing, and very
frequently from inspecting the bodies of females who have died of
puerperal diseases. The absorption may take place from punctures made
by scissors, the point of a knife, or spiculæ of bone, or from old
scratches, or chops by the side of the nail or on the hand. There is
little or no danger from an open and bleeding wound, as by the flow
of blood the part is completely cleaned; it is generally from slight
punctures that untoward symptoms need be apprehended. Effects similar
to those resulting from wounds in dissection often occur in nurses
and others who have pricked themselves with pins while washing foul
clothes, or from handling poultices or dressings removed from bad,
putrid, or sloughing surfaces. The symptoms already mentioned are soon
followed by others more severe: shivering continues, and the patient
is seized with vomiting; the part affected, and often the greater
part of the arm, becomes red and much swollen; the cellular tissue
is infiltrated with serum often dark and putrescent, abscesses form
at various points along the limb to the axilla, and purulent matter
is diffused throughout the unhealthy cellular tissue, which in many
instances sloughs, and gives rise to extensive sores. Typhoid symptoms
soon appear, and in the more aggravated cases speedily prove fatal.
When such local and constitutional symptoms arise, it will generally be
found that the patient was of a broken-up constitution previously to
the infliction of the wound; did they solely depend on the inoculation
of virus, they would be of very common occurrence, considering that
wounds are so frequently received during dissection; but it is seldom
comparatively that any unpleasant symptoms follow such an accident. In
all cases, however, it is prudent to adopt measures in order to prevent
absorption of the virus. With this view, the wound is made to bleed
by means of pressure or suction, and by the latter method the exposed
surface is most effectually purified; afterwards nitrate of silver
maybe applied to deaden the surface, and protect it by an eschar. If
such means be unavailing, the after symptoms must be encountered as
they appear, local inflammation subdued, tension relieved, abscesses
opened, sloughs removed, &c. General bleeding is seldom admissible, but
purgatives and antimonials will prove beneficial at the commencement;
afterwards the strength is to be supported, and, if the patient be much
reduced, stimulants are to be liberally administered.
We shall next treat briefly of gunshot wounds; under this head are
included the contused and the lacerated, caused by splinters, &c.
The vitality of the injured surface is generally destroyed at once,
whence bleeding seldom occurs, even after whole limbs have been shot
away; in some cases, however, hemorrhage is profuse, as when a large
artery has been wounded by small shot. The effects on the system are
extremely various; some persons are affected with tremors, anxiety,
and depression from slight wounds; while the most severe injuries
are often unaccompanied by any disturbance of the nerves. The shock
is generally of short duration, disappearing soon, on the patient’s
being reassured and encouraged, or after his taking a little wine or
opium. In gunshot wounds, those inflicted from a distance or close
at hand can in general be readily distinguished. In the latter, the
wound is large and lacerated, portions of the wadding are impacted,
and the skin around is marked with grains of gunpowder. In the former,
the wound is small and clean. When a ball passes through a fleshy
part, the opening at its entrance is small and depressed; whilst that
by which it escaped is open, with everted edges. When it follows a
superficial course, its track is marked by a wheal, or elevation of the
skin with discoloration. At one time, it was believed that the most
serious consequences resulted from a ball passing close past the body
without even touching it—that in this way violent concussion of the
brain, proving instantly fatal, was produced; but this notion has been
disproved by experience; part of the head accoutrements, of the hair,
of the nose, and of the ears, have been shot away by cannon-balls, and
yet no disturbance of the brain has followed either immediately or
consecutively. The opinion originated from the circumstance of soldiers
having been found dead without any evidence of injury; but bones are
often broken and comminuted by an indirect blow, or by a spent ball,
without any breach of surface or external sign remaining; internal
injuries indeed—rupture of viscera—more than sufficient to cause
instant death, are thus inflicted without any apparent external læsion.
The course of a ball in the body is often very strange, depending
on the force with which it is projected, or the resistance which is
opposed to it, and on the position of the struck part. Balls often pass
under the integument almost completely round the head or chest, having
first struck the bone at a very oblique angle. Frequently they remain,
lodged along with part of the clothing which they thrust before them.
In such cases, they may be immediately removed, their exact situation
being previously ascertained by external examination, or by means of a
probe. They can generally be extracted through the aperture by which
they entered; but if situated superficially, and at a distance from the
opening, this will be more readily accomplished through an incision
made upon them; if allowed to remain, suppuration will occur in the
neighbourhood, the surrounding cellular tissue will be condensed, an
abscess will be formed containing the foreign body, and by the process
of absorption proceeding in the parts external to the abscess, the
ball will at last reach the surface, and be discharged. The track is
often so extremely tortuous, as to render it impossible to ascertain
the situation, or even the existence of the foreign body, which greatly
impedes the operation; and, in other instances, it may be necessary to
allow the ball to remain undisturbed, on account of its being placed
near important parts, which might be injured by any attempt at removal.
Foreign bodies often remain lodged in fleshy or membranous parts for
years, having become enveloped in a dense cyst, and having ceased to
produce any great irritation. In consequence of the force with which
they have been projected, and the resistance which has been opposed
to their progress in the body, musket-balls, when extracted, either
immediately after the infliction of the injury, or after a considerable
time has elapsed, are seldom found to retain their globular form, but
are flattened and ragged, and not unfrequently completely divided by
the bones on which they have impinged. A bullet may be divided into
numerous fragments on a bone, and part may enter into the osseous
substance, whilst other portions penetrate in all directions into the
soft parts, and, though sharp and irregular, may remain long in the
dense cellular cyst which forms over them, without producing pain or
inconvenience. There will necessarily be suppuration, and generally
discharge of dead matter, from gunshot wounds, in consequence of the
bruising of the parts by the ball, which may be expected to injure
the superficial layer of parts in its tract so severely, that it must
slough more or less.
Besides, the bones are often splintered by the force with which they
are struck, and loose portions of them lodge amongst the muscles; then
they are the cause of much mischief, for, on account of their long,
sharp, and irregular form, they occasion great irritation, suppuration
ensues in various parts, sinuses form, and the cure is rendered very
tedious. In other cases, the bone is split in a longitudinal direction,
and, in the cylindrical bones, these fissures are often of great extent.
Considering the nature of the body which inflicts the injury in a
gunshot wound, and the velocity with which it is impelled, it is
evident that the cure must be in all cases tedious, in consequence of
the sloughing and suppuration which is induced, particularly at the
aperture through which the ball passed. The foreign body ought always
to be removed as early as possible, provided it can be accomplished
without much violence, or injury to the parts. Dilatation of gunshot
wounds is now had recourse to only to facilitate the removal of balls,
splinters, &c., and even with this view, it ought to be employed but
to a very slight extent, if at all; for foreign substances, when
deeply seated, can be much more easily taken out when the sloughs are
separating, and the parts relaxed by suppuration; then, too, they can
be more readily reached through a counter-opening, when their situation
renders this expedient. In short, the surgeon is not justified in
cutting for balls, unless they are easily felt, and not deeply lodged.
In order to discover the foreign body, probes will sometimes be
required; the finger often answers the purpose best, unless when the
wound is of considerable depth. If, on examination, the ball cannot be
discovered, and if there is reason to think that it has followed an
indirect course, the surgeon will, sometimes, be assisted in his search
by placing the patient in that position in which he received the wound,
and then judging of the circumstances most likely to affect the foreign
body in its passage. In many cases, extraction can be accomplished
by means of the finger alone; in others, forceps and scoops, various
in length and size, are indispensable. Afterwards, light dressings
are to be employed; and in the first instance, cold applications
may prove advantageous in keeping down the inflammatory action; but
when inflammation has commenced, and to encourage suppuration, warm
fomentations and poultices are to be preferred; they will in many
cases be both more grateful to the patient and more beneficial in
their results, when used even from the commencement. Afterwards,
it will be necessary to afford sufficient support to the parts by
bandaging, and to change the applications according to the particular
circumstances:—soothing, if the wound be irritable, stimulating, if
inert, and gently escharotic, if the granulations be exuberant.
In severe injuries of the limbs, the surgeon must be guided by the
state of the part, and of the constitution, by the circumstances in
which he is placed, as to accommodation, and mode of transportation,
&c., in deciding on the removal of the part by amputation,—or on
making an attempt to save it, by trusting to, and assisting, the
processes of nature. The question whether to amputate immediately,
and on the spot, merely allowing the shock, if any exist, to pass
away, or to delay till suppuration occur, is now scarcely a matter of
dispute. When it is evident, from the extent, violence, and nature
of the injury, that there is danger of speedy mortification, or of
extensive and severe inflammation and suppuration, amputation is to
be instantly performed,—delay is inadmissible. In comminution of the
hard, with contusion and laceration of the soft parts—where limbs have
been shattered and completely detached, or nearly so—in lacerations of
parts, including the principal bloodvessels and nerves—fractures of
the heads of bones, with openings into the joints—and in bad compound
fractures, more especially of the thigh (for all compound fractures
of the upper part of the thigh are dangerous), amputate at once.
When the limb has been retained, and gangrene arises in consequence
of the external injury, and when there is no reason to suppose that
any internal cause is also in existence; or when the violence of
inflammatory action has subsided, and the patient is become hectic,
with profuse purulent discharge, and with disunited bones, then
amputate. But, in this latter case, the chance of recovery is not
so great, and the proportion of recoveries small; whereas, in the
immediate or primary operations, the very reverse holds true. Such is
the experience of the greater number of military surgeons. In civil
practice, the results are somewhat different; a greater proportion of
primary amputations are unsuccessful, and the secondary turn out more
favourably than the statements of military surgeons would lead one to
believe. In all cases, the judgment of the surgeon must guide him in
his determination. The circumstances of the case, and the probable
contingencies, must be all duly considered, and he must not proceed
with his knife where there exists even a slight chance of preserving
the limb.
Paralysis occasionally follows wounds of the arm, forearm, face, &c.,
inflicted by accident or operation, and this arises from an important
nerve, or set of nerves, being divided. In cases of simple division,
without much separation of the parts, reunion of the nerves may take
place, and their functions be restored. If the limb remains paralysed,
after cicatrisation of the wound, tepid effusions, friction, dry
or with liniment, stimulating applications, &c., may sometimes be
advantageously employed.
TETANUS
Is a disease which occasionally follows a wound, but rarely in this
country. It is a spasmodic contraction, with rigidity, of the voluntary
muscles, in some cases involving the whole body, in others the upper
part of it only, and in some it is confined to a certain class of
muscles. When the extensors are affected, the disease is termed
opisthotonos; when the flexors, emprosthotonos. Complete tetanus is
said to exist when the flexor and extensor muscles exactly balance
each other, and the body is thereby kept straight and rigid. But when
the affection is confined to the muscles of deglutition, and chiefly
to those moving the lower jaw, it is called trismus. The disease has
besides been divided into acute and chronic, and into traumatic and
idiopathic; the one following wounds, the other arising from internal
causes, or circumstances not connected with the læsion of the surface.
The disease supervenes at various periods; sometimes, though rarely,
not long after the infliction of the injury, in other instances after
the lapse of eight or ten days, and often when the wound is healing,
or nearly cicatrized. In warm climates, where it is of very frequent
occurrence, it occasionally seems to be caused by exposure to damp
and changeable weather; in children, it supervenes on the slightest
irritation. It is often induced by the presence of splinters, or
rather bodies of an irritating nature, and by the partial division of
nerves. Not unfrequently it occurs after clean wounds, as amputation
or venesection; in the former it may perhaps arise from a nerve being
included in the same ligature with an artery, in the latter, from a
nervous twig being partially divided. The more prominent symptoms are,
stiffness of the back of the neck, and contraction of the features;
difficult deglutition supervenes, and the efforts to accomplish it
are attended with violent spasms of the muscles of the pharynx and
œsophagus. Spasms of the injured limb often precede those of the
muscular system generally; the muscles of the lower jaw become rigid
and spasmodically contracted, and by a continuance and increase of
the spasmodic action, the mouth is at last completely and immovably
shut. The muscles of the trunk and limbs become affected, and there
are violent spasms of particular sets of them, most generally of those
situated posteriorly; thus the body is bent violently backward, so
that its whole weight is supported on two points only, the heels and
the occiput. These symptoms are not constant; relaxation occurs,
and the patient enjoys a cessation of the malady: but this is only
temporary; the painful feelings and the spasms soon return. A symptom
of the most distressing nature is pain and spasmodic twitching of
the diaphragm, impeding respiration, and imparting a shock to the
whole system. Occasionally, emprosthotonos occurs, but, so far as my
experience goes, the body is much more frequently bent backward; the
muscles are sometimes ruptured by the violence of their own action.
The circulating system and sensorial functions are often not much
disturbed; but during the whole course of the disease, the bowels
are much constipated. In most cases of traumatic tetanus, after four
or five days, all the symptoms become aggravated; the countenance is
horribly distorted, the spasms of the diaphragm are more frequent and
violent, and the patient dies convulsed. Sometimes, though rarely, the
fatal termination does not take place till the eighteenth or twentieth
day. On dissection, the pharynx is found contracted, and bearing marks
of acute inflammation. In one case, which fell under my observation,
there was ultimately great difficulty in breathing and expectorating;
and on examination, the trachea, as well as the pharynx, bore evident
marks of inflammation, and were filled with a viscid mucus. In some
instances, there are evident marks of inflammation of the spinal
chord; the vessels, more especially at the lower part, are found
enlarged, tortuous, and engorged with blood; portions of lymph are seen
deposited on the arachnoid covering, and a serous fluid is effused,
not unfrequently mixed with blood. Such appearances, however, are not
observed in every case of fatal tetanus, and therefore it cannot be
asserted as a fact, that the disease is dependent on a morbid condition
of the spinal chord, though in certain cases the two affections
coexist. By some it has been supposed, that in consequence of the
distended and engorged state of the spinal arteries, the origins of
the nerves are stimulated, and that a morbid affection of them ensues,
giving rise to the tetanic symptoms; but want of uniformity in the
morbid appearances prevents such a cause from being generally set down
as the origin of tetanus.
This disease is one of the most intractable with which the surgeon
has to contend. In the acute form, time is scarcely allowed for
remedies; and in the advanced stage, it is with much difficulty that
medicine can be received internally. Of course all irritations must be
removed, both local and general, as far as that can be accomplished.
If the patient be robust, and if the tetanic symptoms be ushered in
with arterial incitement, general depletion ought certainly to be
practised; and if the symptoms be such as to render the propriety of
general bleeding dubious, blood may be abstracted locally, from the
back of the head, or along the spine; and this may be followed by such
counter-irritants as act rapidly. At the same time, powerful purgatives
must be given, so as to bring the bowels into a better state; for, as
already observed, obstinate constipation is a constant attendant on
this disease. But the most important indication is to alleviate and
prevent, if possible, the spasms; and for this purpose, opium is to be
administered in large doses, either by itself, or combined with camphor
or other antispasmodics. By such means, the disease has in some cases
been arrested, but in the majority it has proceeded unabated. Some
practitioners recommend and employ cold affusion and immersion, whilst
others prefer the warm bath; and the latter appears to be the safer
application, though neither can be considered as efficacious. Great
relief and benefit seem to have accrued from the frequently repeated
use of a warm bath, with some drachms of the tart. antimonii dissolved
in it. I have had only two opportunities of trying this practice; one a
chronic ease, where, after the division of the nerves proceeding from
the wound, this remedy, with others, seemed to allay the spasms in a
very remarkable manner: the patient recovered. In the other, a very
acute case, after the extraction of a splinter from betwixt the thumb
and forefinger, the bath was tried; the patient felt much comforted by
it; but suddenly expired in a violent convulsion, whilst being replaced
in bed. Great relaxation follows this remedy, profuse perspiration,
and subsidence of the rigidity and convulsive action of the muscles.
The practice was recommended to my notice by my excellent friend Dr.
Stevens, Professor of Surgery at New York. In some cases, it would be
worth trial to produce instant vesication by the acetic solution of
cantharides or ammonia, and then try the effect of the application
to the blistered surface of some of the alkaloids, such as morphia,
aconitine, &c., or belladonna might be applied.
Some practitioners have used mercurial frictions along the spine, or
on other parts of the surface; while others administer stimulants,
and enemata with tobacco and turpentine. When there is reason to
apprehend that the symptoms arise in consequence of laceration or
partial division of a nervous trunk, it has been recommended to
complete the division of it; and the practice is worthy of adoption,
as in some cases it appears to have been successful. Little good can
result from scarification of the wound. Amputation of the wounded
member has also been proposed, particularly in chronic cases, and
in one or two it has succeeded. I have made trial of it in but one
instance, and in that it failed. Acute tetanus had followed a lacerated
wound betwixt the thumb and forefinger; amputation of the forearm
was performed, and immediately after the operation the spasms abated;
but they soon returned, notwithstanding the free use of opium, and
other remedies, and the patient died. In this case, the branch of the
median nerve was found partially divided, and its cut extremities were
thickened and inflamed. During the operation, I wished to abstract
a considerable quantity of blood, but the arteries seemed to be so
spasmodically contracted, as to permit the flow of a small quantity
only. On examination after death, the median nerve was of its natural
appearance, excepting at the bend of the arm, where it was of a
bright-red colour. No change could be perceived in the brain or spinal
chord, though the examination was conducted with the utmost care.
OF ULCERS.
By ulcer is generally understood a breach of continuity in the soft
parts of the body, with secretion of purulent or other fluid. But as
suppuration may be independent of ulceration, so may we occasionally
see a loss of substance like an ulcer on the surface of parts,
without the production of pus, or any other morbid secretion, of
which some instances are noted in the remarks on Atrophy of Articular
Cartilage. Mr. Burns, in his excellent volume on the Principles of
Surgery, has extended the term to the reparative process, as well
as the destructive; this, if adopted, would lead to confusion and
misapprehension.
Ulcers vary much in disposition and appearance, follow wounds,
abscesses, sloughing, eruptions, &c., and often occur without any
previous læsion of the surface. Those most generally met with are
comprehended in the following classes:—1. The simple purulent ulcer,
or healthy or healing sore. 2. The weak or sluggish ulcer,—a sore
with undermined integuments and an unhealthy state of the cellular
tissue. 3. The indolent ulcer,—a sore with hard elevated edges, and
presenting little or no appearance of reparation. 4. The irritable
ulcer,—a sore with over-action, and generally affecting only the mere
surface of the true skin. Besides these, there are sores connected with
diseases of the bones, and others arising from specific action; some
are complicated with a varicose state of the veins: the former have
been already treated of; the latter are reserved for consideration.
Ulcers change their characters, as from simple to irritable, and from
indolent to inflamed; the change depends on situation, on the state of
the constitution, and on the treatment which they receive.