Chapter VIII: Part 8

|OPERATIONS. | |General total. | | |Primary operations. | | | |Died. | | | | |Remaining. | | | | | |Proportion of deaths | | | | | |to operations. | | | | | | |Secondary operations. | | | | | | | |Died. | | | | | | | | |Remaining. | | | | | | | | | |Proportion of deaths | | | | | | | | | |to operations. | | | | | | | | | | |Total remaining. | | | | | | | | | | | |Of these | | | | | | | | | | | |doubtful. | | | | | | | | | | | | |Transferred | | | | | | | | | | | | |to Antwerp. | | | | | | | | | | | | | |REMARKS. +---------+---+---+---+---+-------+---+---+---+------+---+--+--+--------+ |Shoulder-| | | | | | | | | | | | | | | joint | 8| 6| 1| 5|1 to 6| 12| 6| 6|1 to 2| 11| | | | |Hip-joint| 1|...|...|...|... ...| 1|...| 1|......| 1|..|..|A French| | | | | | | | | | | | | | |soldier,| | | | | | | | | | | | | | |who | | | | | | | | | | | | | | |recover-| | | | | | | | | | | | | | | ed. | |Thigh |148| 54| 19| 35|1 to 3| 94| 43| 51|1 to 2| 86| 9| 4| | |Leg | 93| 43| 7| 26|1 to 6| 50| 16| 34|1 to 3| 60|..| 4| | |Arm | 72| 21| 4| 17|1 to 5| 51| 13| 38|1 to 4| 55|..| 6| | |Forearm | 39| 22| 1| 21|1 to 22| 17| 5| 12|1 to 3| 33|..| 3| | |Carotid | | | | | | | | | | | | | | | artery | | | | | | | | | | | | | | | tied | 1|...|...|...|... ...| 1|...| 1|......| 1|..|..| | |Trephine | 2|...|...|...|... ...| 2| 1| 1|1 to 2| 1|..| 1| | | +---+---+---+---+-------+---+---+---+------+---+--+--+ | |Total |374|146| 32|104|... ...|228| 84|144|......|248| 9|18| | +---------+---+---+---+---+-------+---+---+---+------+---+--+--+--------+

LECTURE VIII.

CHARACTERS OF HOSPITAL GANGRENE.

164. This most destructive disease owes its names of hospital gangrene, phagedena, gangrenosa, _pourriture d’hôpital_, sloughing ulcer, etc. etc. to the different appearances the affected parts assume on different occasions, according to the intensity of the morbid poison applied, and possibly also to the state of constitution of the individual attacked. The peculiar nature of this poison has not yet been ascertained. Professor Brugmans says that in 1797, in Holland, charpie composed of linen threads cut of different lengths, which, on inquiry, it was found had been already used in the great hospitals in France, and had been subsequently washed and bleached, caused every ulcer to which it was applied to be affected by hospital gangrene; and the fact that this disease was readily communicated by the application of instruments, lint, or bandages which had been in contact with infected parts, was too firmly established by the experience of every one in Portugal and Spain to be a matter of doubt. Its character as a thoroughly contagious disease is indisputable. Its capability of being conveyed through the medium of the atmosphere to an ulcerated surface is also admitted, although some have thought that the infection was not always applied to the sore, but affected it secondarily, through the medium of the constitution. Brugmans says that hospital gangrene prevailed in one of the low wards at Leyden in 1798, while the ward or garret above it was free. The surgeon made an opening in the ceiling between the two, in order to ventilate the lower or affected ward, and in thirty hours three patients who lay next the opening were attacked by the disease, which soon spread through the whole ward. Our experience in Portugal and Spain confirmed this fact, and left no doubt on the mind of any one who had frequent opportunities of seeing the disease, that one case of hospital gangrene was capable of infecting not only every ulcer in the ward, but in every ward near it, and ultimately throughout the hospital, however large. The disease, as long as it remains unaltered by destructive applications, may be considered to be infectious as well as contagious.

This infection can penetrate the dressings so as to affect the ulcer through them, although requiring a difference of time in different parts of the body. Ulcers on the lower extremity experienced the influence of the morbid poison in general at an earlier period than those on the upper extremity; and a wound might be seen in a healthy state on the arm, while one on the leg had been evidently suffering from this disease for some days, if the complaint had become mild, or somewhat chronic. If the morbid poison were in its active state, then the deterioration of the ulcers on the arm was almost if not quite contemporaneous with that on the leg.

165. Mr. Blackadder has given the following account of the disease from inoculation in his own person, which is, therefore, more to be relied upon than any other:--

“While engaged in examining the stump of a patient who had died from this disease, I accidentally wounded one of my fingers with the point of a double-edged scalpel, but so slightly that not a drop of blood made its appearance, and on this account I did not consider any particular precautionary means necessary. In the course of about sixty hours, however, the wound had become inflamed, and I was attracted to it by an occasional smart, stinging sensation, which ultimately extended a considerable way up the arm. On the fourth day the inflammation had increased, and the stinging sensation was almost constant. Headache, nausea, and general indisposition followed, with frequent chills, which increased very much toward evening; but which, with the other symptoms, were considerably relieved by the use of neutral salts, the pediluvium, and warm diluents. A vesicle, having a depression in its center, and containing a watery fluid of a livid color, was now forming upon a hard and elevated base; the surrounding integuments became tumefied, of an anserine appearance, and extremely sensitive to the touch; at about the distance of the fourth of an inch from the base of the tumor, a very distinct areola, of a bluish-red color, made its appearance, and remained visible for several days. At this period, circumstances rendered it necessary for me to be exposed to wet, to undergo considerable fatigue, and immediately afterward to travel to a considerable distance. The inflammation, however, gradually subsided, but the stinging, accompanied by a burning sensation, still continued, and the sore had no disposition to heal; yet it did not enlarge externally, but was disposed to burrow under the integuments. This phagedenic disposition was ultimately got the better of by laying open the sore, and by repeated applications of caustic; but it was two months before a complete cicatrix had formed. The new cuticle remained for a length of time extremely sensitive to the touch; and it was upwards of six months before it had acquired the color of the surrounding integuments.”

166. M. Delpech was disposed to consider that the misfortunes and sufferings of the French army had a great depressing influence on the soldiers, from which at other times they would have been exempted, and that this aided the propagation of the malady; but many soldiers of the British army, free from these particular depressing causes, suffered in a similar manner. Dr. Tice, at Coimbra, says:--

“An uncommon depressing affection of the mind often exists among persons suffering from this disease, painful to witness--a morbid dejection, or apathy, which could scarcely be removed, and on which, in very bad cases, no impression could be made. In others, the humane solicitations of the medical officers have failed against the influence of oppressive gloom, amounting to despair. Expectation and hope seemed to be exiled from their minds by the dominion of painful despondency, which, prevailing in melancholy disorder, seemed uncontrolled or checked by the intrusive importunities of the present, or the consciousness of a future existence.”

A wound attacked by hospital gangrene in its most concentrated and active form presents a horrible aspect after the first forty-eight hours. The whole surface has become of a dark-red color, of a ragged appearance, with blood, partly coagulated, and apparently half putrid, adhering at every point. The edges are everted, the cuticle separating from half to three-quarters of an inch around, with a concentric circle of inflammation extending an inch or two beyond it; the limb is usually swollen for some distance, of a shining white color, and not peculiarly sensible, except in spots, the whole of it being perhaps edematous or pasty. The pain is burning, and unbearable in the part itself, while the extension of the disease, generally in a circular direction, may be marked from hour to hour; so that in from another twenty-four to forty-eight hours, nearly the whole of the calf of a leg, or the muscles of a buttock, or even of the wall of the abdomen, may disappear, leaving a deep, great hollow, or hiatus, of the most destructive character, exhaling a peculiar stench, which can never be mistaken, and spreading with a rapidity quite awful to contemplate. The great nerves and arteries appear to resist its influence longer than the muscular structures, but these at last yield; the largest nerves are destroyed, and the arteries give way, frequently closing the scene, after repeated hemorrhages, by one which proves the last solace of the unfortunate sufferer. I have seen all the largest arteries of the extremities give way in succession, and until the progress of the disease was arrested by proper means, the application of a ligature was useless. The joints offer little resistance; the capsular and synovial membranes are soon invaded, and the ends of the bones laid bare. The extension of this disease is, in the first instance, through the medium of the cellular structure of the body. The skin is undermined, and falls in; or a painful red, and soon black patch, or spot, is perceived at some distance from the original mischief, preparatory to the whole becoming one mass of putridity, while the sufferings of the patient are extreme. A complaint of this kind cannot be local, even if a local origin be admitted; the accompanying fever is usually dependent on the previous state and general constitution of the patient, modified by the season of the year, or the prevailing type of febrile disease.

This gangrenous disease does not always prevail in this, its most concentrated form; the destroying process assumes more of a sloughing than of a gangrenous character, whence Delpech has denominated it pulpous, rather than gangrenous. It is in its nature almost equally destructive, although not quite so formidable in appearance. It may attack the whole surface of an ulcer at once, or in distinct points, all, however, rapidly extending toward each other, until they constitute one whole. The red of the granulations becomes of a more violet color, and the change is accompanied by burning, a pain not usually felt in the part, while a layer of ash-colored matter is soon seen covering them, which adheres so firmly as not to be readily removed; or, if separated, shows that it is a substance formed upon the surface, and constituting a part of the granulations themselves, which are ultimately confounded with it.

About the end of the first week, and sometimes much later, this kind of ulcer becomes more painful, the edges or the circumference of the wound assume a browner hue, and the parts become somewhat pasty, the whitish color of the part particularly affected being opaque, gray, and soft. It may be said that the false membrane, having become very thick, has lost the little vitality it possessed, and become putrid; the discharge, which had been partly suppressed, now reappears, not as pus, but as a fetid ichor, exhaling the peculiarly offensive stench of this disease. This pulpy, yellowish, putrid substance becomes thicker, and extends deeply; it invades the whole substance of a muscle, under which a probe may be passed, and the instrument brought out through it, with the loss, perhaps, of some striæ of blood, from parts which are not yet actually destroyed; the mass is, however, adherent, although its extent diminishes by the putrefaction and wasting away of its surface.

There are two characters always peculiar to this disease, in which it differs from all other gangrenous ulcers from ordinary causes; these are, the circular form it assumes after a very few days, even in its slighter varieties, and its peculiar odor or stench.

167. If this disease were entirely a local complaint, caused by the application of a morbid poison, giving rise to the destructive changes described on the surface of an ulcer, it should be followed by febrile or constitutional symptoms at the end of several days only; and Delpech is disposed to think that in such cases these constitutional symptoms take place from and after the sixth day. If it were entirely a constitutional disease, giving rise to the destructive changes described as taking place on the surface of an ulcer, the febrile symptoms should precede the changes in the ulcerated surface. That the febrile symptoms do seem to follow the appearance of the local alteration, is in many cases indisputable; that they precede or accompany the local symptoms in many other cases, is indubitable; and that the disease in a mild state, although yet capable of committing much mischief, is neither preceded nor followed by febrile or constitutional symptoms, cannot be doubted. The febrile symptoms themselves differ essentially from each other when they do occur, generally partaking the character of the endemic fever prevailing in the country at the season at which they appear. The fever is sometimes inflammatory, sometimes typhoid, and occasionally resembles the bilious remittent of the summer and autumn in hot climates, and ends in typhus. It is probable that a want of attention to these circumstances decided the opinions entertained by different individuals as to the general character of the febrile symptoms, and of the treatment to be pursued for their removal. That this disease was generally considered a constitutional complaint, until nearly the end of 1813, must be admitted; and it was the very indifferent success which attended its treatment by constitutional means and simple detergent applications, which caused the surgeons of the British army to view it more as a local disease, capable of giving rise to severe constitutional symptoms--a change of opinion which was materially influenced by the knowledge that the French surgeons more generally considered, with Pouteau, that it was local in the first instance, and treated it by the actual cautery. In my hands, constitutional treatment, and every kind of simple mild detergent applications, always failed, unless accompanied by absolute separation, the utmost possible extent of ventilation, and the greatest possible attention to cleanliness; and not even then without great loss of parts in many instances. This induced me, at Santander, in November and December, 1813, to try the mineral acids, not as then generally used as stimulants or detersives, but as caustics. This proceeding was always, however, accompanied by a constitutional treatment, regulated by the nature of the symptoms, which at that station were never benefited by bleeding, although it had proved so effectual, without the local remedies, at the neighboring sea-port of Bilbao.

168. Dr. Boggie, the great advocate for constitutional treatment, says that under him, at Bilbao, in 1813, where caustic applications were not used, or only as detersives, the disease was arrested by blood-letting to the amount of one or two pounds, and, in some cases, to the extent of three or four. He admits, however, that bleeding must be resorted to with the greatest caution in persons of less robust constitutions, who may have lingered long in hospital, or suffered much from ill health; and that in some cases it is altogether inadmissible--an acknowledgment which is decisive, in my mind, that constitutional treatment is only auxiliary. He says he never saw the puncture made by the lancet affected by this disease; a convincing proof to me, who have seen it, that the virulence of the complaint, as an infectious disease, was subsiding at Bilbao when the treatment he introduced proved so effectual.

In one case at Santander, in which hospital gangrene in the hand and arm and tetanus existed together, they were both cured by venesection, which failed as signally in doing the least good in a case in the next bed, under nearly similar circumstances.

Dr. Boggie admits that “in that form of gangrene named phagedena, a very great destruction of parts may sometimes take place without the constitution being much affected by it. Now, if blood-letting be used in such a case, or even in the advanced stage of the true inflammatory gangrene, when disorganization has taken place, and the system is sinking under the consequent debility, the vital powers being nearly exhausted, the result must be obvious; but when it is used with caution, and in cases where it is really applicable, it will be found to be a most valuable remedy.” In all cases, Dr. Boggie, like every one else, had recourse to emetics, purgatives, and such other general treatment as the febrile symptoms appeared to indicate. As local applications, he recommends cold water, alone or mixed with a small portion of acetic acid, constantly applied and frequently renewed. Poultices and warm applications he objects to; and after the sloughs separate, he approves of dry lint and weak solutions of sulphate of zinc. Should the sloughs adhere after the inflammation has abated, warm, stimulating ointments, and sometimes weak solutions of the nitrate of silver or of the mineral and vegetable acids, may be had recourse to.

169. To Mr. Blackadder must be attributed the introduction of the use of Fowler’s solution of arsenic as an escharotic, in November, 1813, while he was at Passages; it answered remarkably well in arresting the progress of the disease, and was afterward found to be equally efficient in the hospitals at Antwerp. The only objection to its use that I am aware of is, that it caused in some few cases slight symptoms of its poisonous effect having taken place on the bowels, apparently from absorption,--an inconvenience which might become a serious evil, and which caused a preference to be given to the mineral acids, which act equally well without incurring a similar risk of evil. Mr. Blackadder, stationed on the same coast, within about forty miles of Dr. Boggie at Bilbao, took a diametrically opposite view of this complaint to the doctor; and believing the disease to be purely local in the first instance, considered venesection as almost always unnecessary, although he admitted that cases may occur in which the abstraction “of a small quantity of blood would be likely to be attended with more good than harm; but certainly,” he adds, “blood-letting is an operation which ought to be avoided as much as possible in gangrenous phagedena, particularly when the previous injury has been extensive, such as that of a penetrating gunshot wound.”

Dr. Walker, who served at Bilbao at the same time, concludes an able report in the following terms:--

“Lately, however, the disease put on a milder form, and the sloughing did not proceed with that rapidity that it did at first, nor was the fever so violent. And more lately still, since the setting in of the cold weather, the type of the fever seems to have changed entirely, and to have put on the inflammatory type, so as to require strong evacuants, and even bleeding, which has been used with the greatest success by Staff-Surgeon Boggie, who has for a considerable time had the more immediate care of the patients of this description at the Cordeleria Hospital.”

170. “When this disease does not proceed rapidly, and is confined to the ulcerative form,” Delpech says, “it may be removed by stimulant applications, such as vinegar, the vegetable and mineral acids, the Egyptian ointment, etc.” Of these he prefers vinegar applied on lint, after having rubbed or scraped off any false or pulpy membrane which appears to conceal the surface of the ulcer. “Some good effect,” he adds, “has been observed from the careful application of powdered charcoal to the whole surface of the sore, which,” he says, “ought not to be in the gangrenous, or pulpy, or putrid state, but merely ulcerative or phagedenic; and not even then, when this peculiar ulceration assumes a deeply hollowed-out form, rapidly filled with an abundant and tenacious discharge.” Of constitutional treatment he evidently thinks little; and, while he admits the propriety and necessity of treating every accompanying state of fever, whether it be inflammatory, catarrhal, bilious, remittent, etc., by its appropriate means, he does not seem to think they have much influence on the local disease, although he firmly believes that the suppression of the local disease materially assists in arresting, in a great measure, such constitutional symptoms as may be dependent on it, unless influenced by some peculiarity of constitution. His principal local remedy was the hot iron or actual cautery applied to every part.

He says (page 86) some surgeons of the Anglo-Portuguese army of Lord Wellington had assured him that the mineral acids, the hydrochloric, nitric, and sulphuric, had been frequently employed in the British hospitals in Spain with success; and he particularly mentions M. Guthrie, _Inspecteur au Service de Santé_, as the person from whom he especially received his information; thus establishing the fact that the use of the mineral acids in a dilute and concentrated state was known to, and had been essentially introduced into practice by, the surgeons of the British army during the war in Spain--a fact which admits of no dispute as to the origin of its use.

171. In India, Mr. Taylor, late surgeon 29th Regiment, now a deputy inspector-general in the medical department in the Crimea, reports:--

“Hospital gangrene appeared among the wounded of the 29th Regiment a little later than in the hospitals of other corps. The disease declared itself, on the 18th of January, in a stump case; and between that date and the 26th of the same month fifteen cases had come under treatment. At first I could tell, by the peculiar dark, florid countenance of the patient, that his wound had taken on the gangrenous affection; yet I cannot say that there was, in these cases, any marked inflammatory fever. Subsequently, in the prevalence of the disease, this dark-red color of the face was neither well marked nor by any means so constant. In many cases the disease seemed purely local; but in the great majority there was certainly much feverish constitutional disturbance accompanying the local affection, and often preceding it. My experience of the disease, as it occurred among the wounded at Ferozepore, does not enable me to determine, satisfactorily to myself, whether it be essentially a local or a constitutional affection. I am inclined to place it in the former category; and there is no doubt whatever in my mind that the essential means of treatment are local.

“In the treatment of this disease, I proceeded regularly on one plan, and found that so efficacious that I was not inclined to try any other. The plan adopted was, the application of the strong nitric acid, so as completely to cut off the diseased from the sound part, or part so far sound as only to be affected with inflammation. The acid, however, required to be rubbed in with the blunt end of the probe, so that it not only destroyed the cuticle, but killed the cutis vera, and probably the cellular membrane underneath. The narrow yellow ring of dead skin thus formed separated like a piece of leather, generally carrying with it the whole slough, and leaving a clean, healthy surface, as well as edges to the wound. I never attempted to apply the acid to the surface underneath the slough, neither is such an application necessary; the vital seat of the disease is in its circumference, however large the area. I must admit that the disease sometimes crossed the acid boundary, and a second, and even a third application of the remedy was required; but this was rare. Neither was constitutional treatment neglected, but this varied according to the state of the patient; emetics, purgatives, saline medicines, and low diet being sometimes required; while in other instances ether, ammonia, laudanum, and generous diet were administered.

“When speaking of the symptoms of this disease, I should have mentioned that a burning, gnawing sensation was sometimes loudly complained of. The application of the acid soon removed that pain, and the acid itself did not often seem to produce much suffering. In one instance, deemed a favorable one, I tried venesection, and I fear did mischief. Calomel and antimonials were useful. I did not try the arsenical solution. The change of air, which the march of the wounded, on their return to Kussowlee, occasioned, certainly had a very beneficial effect on all the gangrenous and sloughing sores.

“At the same time that hospital gangrene was prevalent at Ferozepore, some wounds took on a malignant fungous affection, which spread over the healthy surface like the hospital gangrene. The dirty, fibrous-looking, fungous growth rose considerably above the edges of the wound, partially overlapping them; these edges were inflamed, but not livid and vesicated as in the cases of gangrene; but here also the disease took the circular or oval form. The affection here noticed I observed only in wounds of the forearm and hand; Colonel Barr’s wound, which was of the forearm near the wrist, took on this disease. The application of nitric acid in the same way as for hospital gangrene eventually checked its progress.

“In no case that came under my observation did the gangrene directly prove fatal, though in many cases it contributed largely in bringing about an unfavorable termination.”

172. _Conclusions._ First.--Hospital gangrene never occurs in isolated cases of wounds.

Second.--It originates only in badly-ventilated hospitals, crowded with wounded men, among and around whom cleanliness has not been too well observed.

Third.--It is a morbid poison, remarkably contagious, and is infectious through the medium of the atmosphere applied to the wound or ulcer.

Fourth.--It is possibly infectious, acting constitutionally, and producing great derangement of the system at large, although it has not been satisfactorily proved that the constitutional affection is capable of giving rise to local disease, such as an ulcer; but if an ulcer should occur from accidental or constitutional causes, it is always influenced by it when in its concentrated form.

Fifth.--The application of the contagious matter gives rise to a similar local disease, resembling and capable of propagating itself, and is generally followed by constitutional symptoms.

Sixth.--In crowded hospitals the constitutional symptoms have been sometimes observed to precede, and frequently to accompany, the appearance of the local disease.

Seventh.--The local disease attacks the cellular membrane principally, and is readily propagated along it, laying bare the muscular, arterial, nervous, and other structures, which soon yield to its destructive properties.

Eighth.--The sloughing of the arteries is rarely attended by healthy inflammation, filling up their canals by fibrin, or by that gangrenous inflammation which attends on mortification from ordinary causes, and alike obliterates their cavities. The separation of the dead parts is, therefore, accompanied by hemorrhage, which, when from large arteries, is usually fatal.

Ninth.--The operation of placing a ligature on the artery at a distance, or near the seat of mischief, does not succeed, because the incision is soon attacked with the disease, unless it has been arrested in the individual part first affected, and the patient has been separated from all others suffering from it.

Tenth.--The local disease is to be arrested by the application of the actual or potential cautery: an iron heated red hot, or the mineral acids pure, or a solution of arsenic, or of the chloride of zinc, or of some other caustic which shall penetrate the sloughing parts, and destroy a thin layer of the unaffected part beneath them. If a sinus or sinuses have formed under the skin or between the muscles, from the extension of disease in the cellular or areolar structure, they must be laid open, and the cautery applied; for if any part affected be left untouched or undestroyed by the acid, the disease will recommence and spread from that point. The parts touched by the acids or cautery may be defended by cloths or other material, wetted with hot or cold water according to the feelings of the sufferers, and poultices of various kinds may be had recourse to, if unavoidable.

Eleventh.--After the diseased parts have been destroyed by the actual or potential cautery, they cease in a great measure to be contagious, and there is less chance of the disease being propagated to persons having open wounds or ulcerated surfaces. A number of wounded thus treated are less likely to disseminate the disease than one person on whom constitutional treatment alone has been tried.

Twelfth.--The pain and constitutional symptoms occasioned by the disease, considered as distinct from the symptoms which may be dependent on disease endemic in the country, are all relieved, and sometimes entirely removed, by the destruction of the diseased surface, which must, however, be carefully and accurately followed, to whatever distance and into whatever parts it may extend, if the salutary effect of the remedies is to be obtained.

Thirteenth.--On the separation of the sloughs, the ulcerated surfaces are to be treated according to the ordinary principles of surgery. They cease to eliminate the contagious principle, and do not require a specific treatment.

Fourteenth.--The constitutional or febrile symptoms, whenever or at whatever time they occur, are to be treated according to the nature of the fever they are supposed to represent, and especially by emetics, purgatives, and the early abstraction of blood if the fever be purely inflammatory, and by less vigorous means if the fever prevailing in the country be of a different character. Pain should be alleviated by opium, which should be freely administered.

Fifteenth.--The essential preventive measures are separation, cleanliness, and exposure to the open air,--the first steps toward that cure which cauterization will afterward in general accomplish.

Sixteenth.--If the sufferer be very young, or of a weakly habit, his strength will frequently require to be supported in the most efficient manner by a due administration of cinchona bark, wine, and a generous diet,--means often found essentially necessary after all severe attacks of debilitating diseases.

The formidable nature of this terrible disease, before the local application of caustic remedies was fully adopted, will be best understood by the following document.

RETURN _of the_ NUMBER OF CASES _of_ HOSPITAL GANGRENE _which have appeared at the Hospital Stations in the Peninsula between 21st June and 24th December, 1813_.

+---------+---------+-------+-----+----------+--------+------------+ | |No. |Dis- |Died.|Under |No. | | |STATIONS.|of cases |charged| |treatment.|operated|REMARKS. | | |occurred.|cured. | | |upon. | | +---------+---------+-------+-----+----------+--------+------------+ |Santander| 160 | 72 | 85 | 53 | 25 |Most of | |Bilbao | 972 | 557 | 387 | 28 | 183 |these cases | | | | | | | |were sent | | | | | | | |from | | | | | | | |Vittoria. | | | | | | | | | | | | | | | | | |Vittoria | 441 | 349 | 88 | 4 | 74 | | |Passages | 41 | 2 | 2 | | |Thirty-seven| | | | | | | |transferred | | | | | | | |to | | | | | | | |Santander. | | | | | | | | | | | | | | | | | |Vera | | | | | |Vera, being | | | | | | | |almost on | | | | | | | |the field of| | | | | | | |battle, had | | | | | | | |no case. | | | | | | | | | | | | | | | | | | | | | | | | | | +---------+-------+-----+----------+--------+ | | | 1614 | 980 | 512 | 85 | 282 | | +---------+---------+-------+-----+----------+--------+------------+

LECTURE IX.

ON WOUNDS OF ARTERIES, ETC.

173. The efforts resorted to by nature for the suppression of serious hemorrhages depend on the capabilities of the arteries as resulting from their structure, into which it becomes an object of importance minutely to inquire. With this view, the old division of an artery into three coats may be continued, the difference between ancient and modern anatomy being in their subdivision into different textures or layers. The annexed diagram shows the edge of a large artery, which has been divided circularly, and magnified so as to exhibit six layers in a distinct manner; each of the three ancient coats is divided into two. The _inner_ or old serous coat is shown to be separable into _two_: the epithelial, marked 1, and the fenestrated, marked 2. The _middle_ coat is also separated into _two_: the inner, or _muscular_, marked 3, and the outer, or _elastic_, marked 4. The _outer_ coat is divisible also into two layers, the _inner_, marked 5, and the _outer_, marked 6; number 5 being composed more of elastic fibers: number 6 more of areolar fibers, by which tissue, in a less condensed state, the arteries of the extremities are attached to their sheaths. Such may be considered to be the general composition of a large artery, each particular structure remaining to be examined.

OLD. MIDDLE. YOUNG.]

174. If a small portion of the inner coat of an artery be gently scraped with a knife, or if the inside of the cheek be treated in a similar manner, a little white soft substance is brought away on it, called _epithelium_, a name given to it by Ruysch, from the delicate layer of epidermis investing the female nipple, έπι, upon, θηλή, _a nipple_. The epithelium of the human body is divided into three kinds by microscopists--the _tesselated_, _pavement_, or _scaly_; the _cylindrical_, or _conical_; and the _spheroidal_, or _glandular_. The tesselated, as it exists in arteries, is represented in diagram No. 1, in three different stages--in the young person, in middle age, and in the very old person; one stage gradually degenerating or changing into the other, at each different period of life. It is composed of a single layer of nucleated cells, of a flat, oval, round, hexagonal, or polygonal form, and about 1/1400 of an inch in diameter, the nucleus in each cell containing within itself one or more nucleoli, and even several paler granules. The epithelium has a thickness proportioned to the friction or pressure to which it is exposed, particularly when covering the skin. In the arteries of the young, and in the mammalia generally, the epithelium is strongly marked; in older persons, all traces both of cells and nuclei have disappeared. It lines not only the internal surface of the arteries and veins, but the mouth with its mucous glands; the _conjunctiva_ of the eye; the pharynx and œsophagus; the vagina and cervix uteri; the entrance of the female urethra, and the serous membranes.

The _conical_ or cylindrical is composed of cells closely set together, of a conical, cylindrical, or pyramidal form, about 1/1200 of an inch long, each cell inclosing a flat nucleus, with nucleoli. It lines the urethra in the female, from the entrance where the tesselated ends, and extends inward to the urinary tubules of the kidneys; the greater part of the male organs in a similar manner; the digestive canal and gland-ducts, from the cardia to the anus.

The _spheroidal_ or _glandular_ epithelium consists of cells, more or less circular or spherical in figure, each having a large nucleus in its center. The epithelium is met with in all glandular organs, such as the liver, kidney, lachrymal, and salivary glands, and in these cells the proper secretion of the gland is developed. The tesselated and cylindrical kinds are, on the contrary, more or less protective.

The two first kinds are sometimes ciliated, by the addition, at their free extremities, of several fine, pellucid, blunt, and pliant hairlike processes or cilia, about 1/5000 of an inch long, which are, during life, in constant motion. This kind of epithelium, known as the ciliary, lines the whole respiratory track of mucous membrane; the _palpebral_ conjunctiva, as opposed to the tesselated on the eyeball; the ventricles of the brain; the posterior half of the uterus, and the Fallopian tubes.

The epithelium is placed upon the second layer of the internal coat, which, from certain appearances of apertures or windows, has been called the _perforated_ or _fenestrated_ layer. (See diagram No. 2.) It can be peeled off in small pieces only, and shows under a power of 250 diameters a series of well-marked fibers running in almost parallel lines upon a comparatively structureless membrane, resembling the inner layer of the cornea, as in the left-hand figure of the diagram, the fibers being arranged in the length of the vessel. They frequently bifurcate, and almost immediately join again, so that an oval space, resembling a hole, is perceived. This is not always a hole or perforation, as it is generally described to be, as may be seen and proved by the fact that the supposed opening is sometimes filled up by small bodies, like nuclei, as if the oval space were occupied by a cell. This fenestrated layer varies in thickness in different vessels, and is more strongly developed in the lower animals than in man; by some authorities it is not regarded as a distinct layer, but as the innermost layer of longitudinal fibers belonging to the middle coat. When this layer is very thick, the fibers which are yellow do not all run in the direction of the length of the vessel, for others crossing at right angles may sometimes be observed, as delineated in the right-hand figure of diagram No. 2. These two layers compose the ancient inner coat of an artery, and are frequently the seat of disease.

The middle coat, as it was termed, forms by much the greatest part of the thickness of an artery, and, generally speaking, is of a more or less yellow color. It appears fibrous to the naked eye, and can be peeled off not unfrequently in a series of circular layers; when examined microscopically, it is seen to be composed of _two_ sets of fibers arranged in a circular direction. The inner layer is composed principally of muscular fibers, of the organic or involuntary kind. (See line marked 3 on the circular diagram.) The outer layer, marked line 4 on the same diagram, is made up chiefly of elastic fibers, with a much smaller amount of the muscular or contractile element. These conjoined layers form the muscular coat of Mr. Hunter, the fibrous or contractile coat of later anatomists, who denied its muscularity from the supposed absence of fibrin--an error fallen into from chemical science being unequal at that time to its discovery, or rather of its more elementary part, called _protein_, the principal constituent both of albumen and fibrin, which two are now found to differ from each other in the addition only of three per cent, of sulphur. Mülder says, in his “Animal and Vegetable Chemistry,” (Part II. p. 307:) “The combinations of sulpho-phospho protein (_fibrin_ and _albumen_) and of sulpho-protein _casein_ with acids, alkalies, and salts are especially remarkable. Protein is soluble in weak alkalies. Since, therefore, the serum of the blood is always slightly alkaline, being a proteate of soda, with sulphur and phosphorus, it keeps the sulpho-phospho protein in solution. This property is the cause of the blood remaining in a liquid state--a chief requisite for animal life.

“If a weak alkaline solution of protein be neutralized by an acid, the solubility of sulpho-phospho protein is greatly diminished. The sulphuric and phosphoric acids, by not dissolving protein, stanch bleeding. Acetic acid, by which protein is dissolved, does not, neither does the hydrochloric.

“Protein, according to Mülder--although it is doubted by Liebig--is a complex substance, consisting of several heterogeneous organic compounds united into one whole, easily acted upon by strong reagents.

“If a protein compound be brought into contact with an alkali, ammonia is immediately disengaged, and the alkaline solution can hardly be made weak enough to prevent the disengagement of ammonia. If either fibrin or coagulated albumen be dissolved in a weak potash lye, ammonia is always perceptible. Protein, therefore, is always in a state of decomposition, as serum is alkaline.”

In diagram No. 3, fig. 3, the organic or _involuntary_ muscular fibers of the intestine are shown, consisting of more or less flattened bands, the fibers of which are soft, and marked with minute granules, sometimes exhibiting traces of nuclei. These purely muscular fibers are most abundant next to the inner coat of the artery, and diminish in number as they approach the outer layer, their place being occupied by firmer and more elastic fibers of a yellow color, seen collectively in the circular diagram, as line 4, and separately in diagram 3, fig. 4, and in diagram 4.

The _involuntary_ muscular fibers of an artery do not always form a continuous layer; they are often smaller than those found in the intestines, bladder, and uterus, and occur as fusiform cells, detached from each other, and having a large, club-shaped nucleus, as shown at fig. 6 in diagram 3.

The _voluntary_ muscular fibers differ from the _involuntary_, in having cylindrical fibers of much larger size, with transverse and longitudinal markings, unlike the flattened fibers of less size of the involuntary muscles, which have also a faintly granular appearance, instead of the more determined transverse and longitudinal lines of the voluntary muscles.

The _outer_ or _elastic_ layer of the ancient _middle_ coat, represented by line 4 in the circular diagram, contains muscular fibers, but it is formed principally of strong, elastic fibers difficult of separation, and, when torn across, have curled extremities, as shown in the diagram marked 4, differing only in size from those found in the ligaments of the spine, and in the ligamentum nuchæ of quadrupeds, as shown in the separate diagram marked 4.

The _external_ coat of an artery, divided also into _two_ layers, is shown on the circular diagram by lines 5 and 6. These two layers are composed of the yellow elastic fibers last noticed, and another set of fibers, _white_ in color and _in_elastic in structure, arranged in various directions; the _inner_ layer predominating in yellow elastic, the outer layer in white inelastic fibers, constituting a firm investment to all the other layers of which the artery is composed. The white inelastic fibers are shown in diagram No. 3, fig. 5, with a yellow elastic fiber curling round them. The constant crossing and recrossing of these two sets of fibers form certain spaces, which, when not in a compact form, become real spaces, meshes, or areolæ, constituting what is now called areolar tissue, rather than the cellular of the older anatomists, from the circumstance that the areolæ communicate, and that perfect cells in any tissue do not. These elements of areolar tissue can be readily distinguished by the action of acetic acid, under which reagent the white fibers will almost disappear, leaving only a slight trace of fibers containing oval nuclei, as seen and marked in diagram 3, fig. 5. It is seen when unraveled in _b_, diagram 5.

The inner layer of the middle coat, or muscular coat, as it may be justly termed, forms, it will be seen, the greatest part of the thickness of the wall of certain arteries, and in some instances, as in the anterior tibial artery, constitutes nearly the entire thickness of the vessel. The _internal_ coat in all is frequently seen puckered in a longitudinal direction.

175. The arteries are supplied with blood by vessels of small size, which do not come off immediately from the part of the artery they are destined to supply, but principally from neighboring vessels. They are called vasa vasorum. They are arranged precisely in the same manner as those of the areolar tissue. A few of these vessels penetrate as far as the middle or muscular coat, but do not reach the inner, which has no vessels, proximity to the circulating fluid being apparently sufficient for its nutrition.

Arteries are supplied with nervous influence by branches from the sympathetic system running in their walls, and through their connection by ganglions with the organs they supply with blood.

176. The cells, nuclei, and nucleoli alluded to are supposed to be thus produced. In a shapeless, consistent, sometimes almost gelatinous mass, to which the name of _cyto_-blastema or _formative substance_ has been given, containing the materials requisite for the production of cells, small, round grains or nucleoli are perceived in the act of formation. Around these grains a layer of granular matter is deposited, which continually increases in thickness, and constitutes the kernel or nucleus. This is oval shaped or round, almost always opaque, has a granular surface, and is considered to be a vesicle, a little cell itself. From the surface of this kernel a small, very thin transparent vesicle is raised, appearing as a segment of a sphere, which soon expands, and becomes so large, when full grown, that the kernel lies as a minute corpuscle upon its interior wall; the material for its formation being supplied by the cyto-blastema, it is converted into a vesicle by the kernel which is first formed, its embryo existing in the formative substance.

The first trace of organization is the production of a small, perceptible body, or nucleolus, which deposits on the surface a granular substance from the cyto-blastema, to give rise to a little producing organ, the kernel or nucleus. This further transforms the surrounding cyto-blastema into a granular surface, from which the vesicle is formed, raised, expanded, and filled with a liquid, in which vesicle thus enlarged the kernel remains inclosed and adhering to a certain spot of its wall.

If two nucleoli lie close to one another, they coalesce and become one solid mass, capable of producing one cell only, containing one kernel and two nucleoli. This view is that of Schleiden and Schwann, supported by Mülder, but not entirely approved by Henle; inasmuch as no kernel can be perceived in the cells of many cellular systems while in the act of formation. In the elementary parts of animals which have long since lost their cellular form, the remnants of kernels are frequently found, as has been demonstrated in the preceding diagrams. The manner, however, in which the elementary first-seen granules are formed in the cyto-blastema, science has not yet been able to discover. The chemists have proved that all elementary organic substances consist of carbon, hydrogen, oxygen, and nitrogen, susceptible of endless modifications of their respective forces, under which an organic molecule or ovum is produced, and after that, under certain circumstances, an animal such as man.

177. When the current of blood through the main trunk of the arteries of an extremity is cut off, the circulation is carried on by the collateral branches. This collateral circulation is more perfect, more active in young persons during the increase or growth of the body, than it is either at maturity or in the decline of life. The important point is not, however, alone referable to the time of life at which the continuity and permeability of the main trunk cease to exist, but to the nature of the disease or injury which has given rise to it.

When an aneurismal limb has been injected, on which an operation has not been performed, the collateral vessels have all been found larger and more fully shown than on the opposite side, although not to the same extent as in cases of a similar nature in which the operation has been done.

It is necessary that this enlargement of the collateral branches should lake place at an early period, because in many cases of aneurism the artery beyond or below the tumor is obliterated long before any operation is performed. The main supply of blood has been already cut off from the extremity, and the operation adds very little to the derangement of the circulation which has for some time taken place below the tumor.

When an operation has been successfully performed for aneurism, and the patient has died some time afterward, dissection has shown various arteries enlarged, both above and below the part where the trunk was obliterated by the ligature; and not only an enlargement of arteries, which, from their regularity have received names, but others have been developed not usually known to exist, or not of a size to be conveniently traced. These through their frequent anastomoses bring the blood at last into several large trunks, by which it is again conveyed to the original vessel below all and every obstruction which may have taken place; thus compensating by a circuitous route for the loss of the direct supply. The principal object of inquiry is, do these vessels always exist, or at what period of time do they begin to enlarge, so as to enable them to carry on the circulation, in the manner in which it is presumed to be done?--for few will assert that the enlargement of these particular collateral vessels was an accidental play of nature, and existed previously to the commencement of the disease or injury for which the operation was performed. On this point, the theory of the operation for aneurism and its applicability to wounded arteries appears to hinge; and, what is of more importance, on which the practice resulting from it depends.

Two distinct kinds of collateral circulation are at present acknowledged: one by direct large communicating arteries; the other through the direct medium of the capillary vessels inosculating with each other. Where direct communicating arteries exist, little subsequent change beyond enlargement takes place in them. It is otherwise with the indirect capillary vessels. When the radial or ulnar artery has been divided in the hand, the blood will not only flow readily from each end of the divided vessel, but equally red and arterial from both, the communication being through direct arterial branches from one vessel to the other. It will also be red and arterial if the division take place at the wrist, and may be so in the brachial; but if the femoral in the lower part of the thigh be wounded, the color of the blood issuing from the lower end of the artery, if any issue at all, will be _dark or venous_. It is so, because it has been obtained from the capillary arteries, which in this case being empty received blood by regurgitation from the veins, the valves of which when present do not prevent its reflux course. If a limb be injected and carefully dissected four or five days after a ligature has been placed during life high up on the principal trunk, the capillary vessels will be seen to be well injected; but few or none will be found large enough to admit of their inosculation being traced throughout. If another limb be injected and dissected, some sixty days after the ligature has been applied, a difference will be distinctly observed between the two preparations. In the latter, the capillaries will not appear to be so fully injected, but several larger and more tortuous vessels will be found in situations where they were not expected to exist; and the anastomoses of these one with another, generally by arches, may be traced to their communication with the principal trunk, both above and below the obliterated part. If an incision were made in the nearest pervious portion of the lower part of an artery in the thigh of a person who had undergone this operation, arterial blood would issue from it. The communication would have become direct by communicating branches, and the capillaries would have returned to their accustomed duties.

178. During the first twenty-four hours after the division of an artery such as the femoral, or the application of a ligature, the temperature of the limb is commonly diminished; after that period, and as the action of increase takes place, the temperature is usually from three to five degrees higher than in the opposite healthy limb. At the end of from eighteen to twenty-eight days, in a successful case, it is found to be equal in both.