Part 18
“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.
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.