Part 2

Injuries of the Head 215 Wounds of the Scalp 215 Wounds of the Temporal Artery 216 Concussion 218 Compression 226 Fractures of the Cranial Bones 227 Wounds of the Brain 232 Hernia Cerebri 233 Perforation of the Cranium 234 Inflammation of the Scalp 238 Thickening of the Scalp 239 Tumours of the Scalp 243 Diseases of the Eye and its Appendages 245 Inflammation and Abscess of the Lachrymal Passages 245 Inflammation of the Lachrymal Sac 246 Fistula Lachrymalis 248 Encanthis 252 Encysted Tumours of the Eyelids 253 Closure of the Eyelids 253 Ectropion 254 Entropion 255 Trichiasis 255 Pterygium 256 Diseases of the Eyeball 257 Ophthalmia 257 Purulent Ophthalmia 260 Staphyloma 261 Inflammation of the Cornea 261 Pustular Ophthalmia 263 Ulcers of the Cornea 263 Leucoma 264 Hernia of the Iris 264 Albugo 264 Nebula 264 Ophthalmia Tarsi 265 Staphyloma 266 Hydrophthalmia 266 Exophthalmia 266 Internal Ophthalmia 272 Iritis 272 Hypopium 273 Choroiditis 274 Amaurosis 275 Glaucoma 277 Cataract 277 Artificial Pupil 287 Wounds of the Eyeball 288 Orbital Inflammation 290 Tumours in the Orbit 290 Strabismus 292 Nasal Polypi 301 Malignant Polypi 303 Nose, and Nasal Cavities, Inflammation, &c. 308 Noli me tangere 310 Ozœna 310 Rhinoplastic Operations 312 Inflammation of the Antrum Maxillare 317 Lips, Ulcers 319 Congenital Deficiencies 322 Palate, Congenital Deficiencies 322 Soft Palate, Tonsils, &c., Inflammation, &c. 326 Tongue, Ulcers 331 Inflammation 332 Division of Frænum 334 Salivary Ducts, Diseases 335 Ranula 335 Gums, Diseases 337 Teeth, Diseases 338 Extraction of 340 Lower Jaw, Diseases 341 Disarticulation 345 Wounds of the Face and Neck 347 Larynx and Trachea, Diseases 354 Foreign bodies 363 Tracheotomy 364 Pharynx, Diseases 368 Foreign bodies 371 Œsophagotomy 372 Ear, Diseases of 373 Foreign bodies 375 Polypus 375 Deafness 375 Bronchocele 377 Glandular Tumours in the Neck 379 Hydrocele of the Neck 381 Distortion of the Neck 382 Venesection in the Jugular Vein 384 Ligature of the Carotid Artery 385 Arteria Innominata 387 Subclavian Artery 387 Axillary Artery 392 Brachial Artery 392 Humeral Artery 394 Wounds of the Palmar Arches 395 Paronychia or Whitlow 396 Onychia 399 Collections in Thecæ 401 Ganglia 401 Venesection, bend of the arm 403 Mamma, Diseases 405 Encysted Tumours 406 Affections of the Chest 409 Hydrothorax 410 Empyema 410 Wounds 411 Affections of the Abdomen 412 Hernia 412 Congenital Scrotal Hernia 413 Hernia Infantilis 414 Inguinal 415 Crural or Femoral 416 Ascites 435 Ovarian Dropsy 436 Bruises of the Abdomen 438 Lumbar Abscess 441 Spina Bifida 444 Affections of the Rectum and Neighbouring Parts 445 Hemorrhoids or Piles 445 Distinct Varieties 445 Inflammation of the Rectum 447 Fistula 449 Stricture 450 Schirro-contracted Rectum 452 Prolapsus Ani 453 Pruritus of the Rectum 460 Neuralgia of the Rectum 460 Affections of the Mucous Membranes of the Urinary and Genital Organs 461 Gonorrhœa 462 Hernia Humoralis 467 Inflammation of the Bladder 469 Irritable Bladder 470 Stricture of the Urethra 470 Fistula in Perineo 472 Retention of Urine 478 Incontinence of Urine 489 Gonorrhœa Præputialis 490 Phymosis 491 Paraphymosis 491 Hypospadias and Epispadias 495 Chimney-sweeper’s Cancer 495 Hydrocele 496 Cirsocele 501 Hæmatocele 503 Sarcocele 505 Castration 507 Calculus Vesicæ 508 Lithotrity 517 Lithotomy 519 Calculus in the Female 530 Gonorrhœa in Females 531 Gonorrhœal Lichen 532 Retention of Urine in Females 533 Vesico-vaginal Fistula 534 Imperforate Vagina 535 Contracted Vagina 535 Inflammation of Vagina 536 Polypus Vaginæ 537 Diseases of the Uterus 538 Ligature of the Common Iliac Artery 539 Internal Iliac 539 External Iliac 540 Femoral 541 Aneurismal Varix in the Thigh 542 House-Maid’s Knee 543 Cartilaginous Bodies in the Knee-joint 544 Distortion of the Feet 545 Varus 547 Valgus 548 Pes Equinus 548 Calcaneal 549 Exostosis of Distal Phalanx 551 Fractures 552 of the Cranium and Face 558 Spinal Column 560 Thorax and Upper Extremity 564 Pelvis and Lower Extremity 574 Disunited Fracture 586 Dislocations 588 Lower Jaw 591 Upper Extremity 592 Lower Extremity 600 Sprain 607 Bruise 610 Amputation 612 Excision of Portions of Diseased Bones 632 Excision of Joints 634

ELEMENTS OF SURGERY.

PART FIRST.

OF INFLAMMATION.

There are few accidents or diseases, to which the human body is liable, which are not preceded or followed by incited action, increased circulation, and accumulation of blood in the capillary vessels of the part affected; and these phenomena require to be very attentively studied, and correctly understood, by all who propose practising the healing art. As all the salutary as well as diseased processes which occur in the human body are more or less attended or affected by this action, and as its regulation forms a principal part of the duty of the surgical practitioner, this work cannot be more properly commenced than by treating of its nature, consequences, and management.

Inflammation may be defined to be, an unnatural or perverted action of the capillary blood vessels of an organ or part of the body, attended with redness, throbbing, swelling, pain, heat, and disorder of function, as well as with more or less disturbance of the system.

Every part of the body is liable to inflammation; and some writers have divided this action into different kinds, according to the particular tissue which it chiefly involves. But it appears to be always of the same character, though modified by various circumstances, such as the tissue in which it occurs, the state of the constitution, the exciting cause, and the intensity of the action.

The usual division of the subject, into _Acute_ and _Chronic_, is that which it is here proposed to adopt. The term Chronic Inflammation is more properly applicable to a consequence of the Acute: but it is at the same time true, that morbid actions proceed more slowly in some constitutions, and in some parts of the body, than in others; and that changes of structure and morbid products, such as generally result from inflammatory action, even occasionally occur, without the prominent symptoms of inflammation being experienced by the patient or detected by the practitioner.

The term _Morbid_ is used in contradistinction to what is called _Healthy_ Inflammation; but inflammatory action is generally connected, more or less, with a diseased or disordered state of some part of the body. In many circumstances it is highly necessary that a certain degree of incited action of the vessels should occur, and continue for a certain time; as during the uniting of fractures, the adhesion of wounds, and the healing of some sores—and thus far it is healthful: when, however, the action becomes excessive, it must, for this reason, be considered morbid, as it frustrates the natural reparative process; if the action, in fact, proceeds farther than is necessary for reparation, it becomes a disease, and leads to absorption or destruction of parts. In animals possessing the greatest powers of reparation, inflammation, it appears, does not take place at all, or is very slight, and scarcely ever proceeds to suppuration.

_Redness_ is the first sign of inflammation to be considered; this is observed, in the living body, on the surface, or at the extremities of those canals which terminate externally. The inflamed conjunctiva affords a conspicuous example of this appearance. In a subject that has suffered from an internal inflammatory attack, a good opportunity is frequently afforded of observing the enlarged and injected state of the vessels on which the red colour depends. But inflammation may have existed to a certain degree, and yet the parts may be pale, from the capillaries having emptied themselves into the veins immediately after the patient’s death. The paleness may be also in part caused by the influx of the red globules being impeded immediately after death, or when the patient is in articulo mortis, in consequence of the contraction of the vessels, which is well known to occur at that period.

It has been said that redness is not essential to inflammation; for serous vessels may be altered in size and function by this action, and yet not be sufficiently dilated to receive the red globules of the blood. And, again, that serous vessels may be enlarged so as to admit the red globules; and a part that is colourless when in the healthy state may, in consequence, assume a highly red hue when in an inflamed condition. This may be observed in the cornea lucida, which, when violently inflamed, is pervaded by numerous vessels, visible to the naked eye, distended with red blood, ramifying over the whole of it, and freely inosculating with each other. Some have even supposed that these vessels are newly formed, in consequence of inflammatory action. This opinion is, however, erroneous; as the vessels existed in the cornea previously, and are only increased in size, so as to admit of the accumulation of a sufficient number of red particles to render the vessels visible. The speedy, and, in many cases, instantaneous, appearance of red vessels where they could not previously be observed, decidedly overturns the opinion that new vessels are in such a case formed. New vessels are seldom formed, unless after a breach of structure, or in cases where morbid deposits become vascular. There is no proof of the existence of mere serous vessels in the human body, as any one may ascertain who is accustomed to examine the capillaries with a good microscope. Vessels which are so small as to admit only a very few, say one, or at most two rows of globules, would, of course, appear colourless, and these are what have been called serous vessels. The globules of blood are so small as to be invisible to the naked eye; and vessels carrying only one series of them would appear colourless. No vessels belonging to the sanguiferous system have ever been observed less in character than a blood globule; and this, so far as I have been able to observe, is, as nearly as possible, 1/3000 part of an inch. They appear to be flattened discs; and whether those of the human body have a central nucleus or not, seems, as yet, very doubtful. The globules are here shown upon a scale of 1/4000 part of an inch, linear, and in different positions. They are represented, as seen in the greater number of microscopes, having a central nucleus. Whether, in the blood of mammiferous animals, or not, this is an optical deception, is not very clearly made out; but in that of reptiles the nucleus is easily demonstrable. The redness then is not from error loci, or in consequence of red particles flowing where none flowed before, but from the capillaries becoming distended and dilated with an unusual quantity of blood, which is stagnated in the central part of the inflamed neighbourhood, the inflammatory focus.

_Throbbing_, to a greater or less degree, is always felt in an inflamed part by the patient; and it is frequently so distinct as to be readily perceived by an attentive examination. This arises, probably, from the stagnation of blood in the vessels of the part over-excited, and principally affected by the disease or injury, causing an increase in the collateral circulation; and it is this rapidly increased action around that gives rise to the signs and symptoms, and constitutes, in point of fact, what is known and recognised as inflammation. The sensation of throbbing is not, however, produced entirely by the action of the capillary vessels, but in consequence, also, of the larger trunks in the neighbourhood sympathising with these capillaries, and so having their action increased also. The obstruction of the capillaries in the early stage of inflammation must necessarily cause a greater force of the heart to be expended on the trunks leading to such capillaries; hence the greater impulse and velocity of blood in the circumferential and patent vessels. In fact, when the inflammatory action is extensive or severe, or when the part affected is of much importance to life, the whole circulating system is disturbed, and thus arises the sympathetic excitement of the constitution.

The incited action of those vessels in the more immediate vicinity of the inflamed part is well marked in cases of Paronychia. There the digital, the radial, and ulnar arteries, with their branches, beat more violently than usual; and with much greater force, though not more rapidly, than the vessels in other parts of the body.

_Swelling_ is caused by the enlarged and overloaded vessels relieving themselves by effusion of part of their contents into the surrounding cellular texture. The effusion varies in extent and consistence, according to the degree of inflammatory action, and the species of resistance offered; at first it is serous, then mixed with fibrin, and consequently spontaneously coagulable. _Cæteris paribus_, the greater the resistance, the less the effusion, and the more violent the inflammatory action; the chance of its speedy and favourable termination is also more diminished. Even the enlargement of the blood-vessels produces a certain degree of intumescence previous to effusion. The relief to the vessels by effusion giving rise to swelling, when it occurs in loose cellular tissues, may be considered as a beneficent provision of nature. But in vital organs it may be productive of the most serious consequences; as in these, very slight effusion will often endanger the structure of the organ, destroy its functions, and not unfrequently be attended with fatal consequences.

The nature of the effused fluid varies according to the degree of violence and advancement of the action, and is also modified by the texture in which that action occurs. It may consist of serum, lymph, blood, or pus. In inflammation, in short, exhalation, though at first diminished, is soon much increased, whilst the powers of the absorbent vessels are diminished, or at least do not maintain their usual relation to those of the exhalants.

_Pain_ is the next symptom enumerated. Here the very common error of supposing that where there is pain there must always be inflammation may be noticed. Some diseases attended with the most acute pain, as Tic Douloureux and Cramp, are generally unattended with inflammation. Many chronic diseases, too, are accompanied with violent and long-continued paroxysms of pain, without excited circulation of the part.

This erroneous opinion often gives rise to highly prejudicial proceedings, as—the exhausting, by copious depletions, the vital powers of patients, already enfeebled by continued disease or treatment—the consequent aggravation of the urgent symptoms—and, the then only termination of the disease and of the practice, death.

Again, it is true that we must bleed, in some cases, with the view of preventing the occurrence of inflammation; yet the prophylactic treatment may be carried too far, as in cases of violent injuries, or after severe operations. In these instances, the immediate abstraction of blood, so far from being beneficial, expedites the dissolution of the patient, or at least greatly retards the cure. Pains arising from local irritations are often treated in a similar way, whilst the removal of the cause would be much more likely to restore the natural action of the parts.