Part 9

In Hospital Erysipelas, purging cannot be carried to any great extent with safety, and general bleeding is seldom if ever admissible unless the patients previously robust and in good health, in whom the disease has occurred in consequence of their being conveyed to a distance and during hot weather, after an accident or wound, and in whom the fever is of a violent inflammatory nature. In civil hospitals, the patients are generally in a weak state before the accession of this disease; and in their case, after the stomach and bowels are regulated, stimulants are more requisite. Great attention must be paid to cleanliness, the sores must be frequently dressed, and the same sponges must not be used for different individuals: in order to prevent contamination by the promiscuous use of sponges, it is better to clean the parts around sores with lint or tow, and to destroy immediately such dressings as have been used. The apartments must be well ventilated, and those who are affected with the disease should be separated from the rest of the patients. The local applications will vary according to the particular circumstances of each case. Strong escharotics may be required to clean the surface of the sores, and put a stop to the sloughing. The nitric acid will answer the purpose well, and is less objectionable than some remedies that have been used; such as the arsenical solution, or the red hot iron.

OF FURUNCULUS AND ANTHRAX.

Furunculi, or Boils, most generally occur in unhealthy constitutions, particularly in those individuals who are habitually addicted to the use of ardent liquors: they seem to arise from, at least they follow, disorder of the digestive organs. Their seat is in the skin and subjacent cellular tissue.

They generally occur in those parts which are possessed of little vitality, as in the back, buttocks, shoulders, the posterior part of the neck, &c. They are seldom single, are often numerous, and vary in size from a pea to a pigeon’s egg.

A boil is of a conical form, elevated above the surface of the body; its base is hard and firm, whilst its apex is acute, soft, of a white colour, and exceedingly painful; the pain experienced in the tumour is severe and burning. From the comparatively trifling nature of the affection, the assistance of the surgeon is seldom required, and hence the apex of the tumour generally gives way either spontaneously, or in consequence of being scratched by the patient, or rubbed by the clothes; the purulent matter, which is generally small in quantity, and mixed with blood, is thus discharged. This, however, is attended with but little relief in bad forms of the affection; for at the lower part of the cone is situated a considerable quantity of mortified cellular tissue, which must be evacuated before the cavity can heal.

In this unhealthy species of inflammation, resolution cannot be expected; on the contrary, suppuration is the natural termination of the disease, and must be hastened by poultices and fomentations. A simple or crucial opening, according to circumstances, must afterwards be made in the apex of the tumour, so that the sloughs of the cellular tissue may be permitted to escape readily. In the advanced stage, the sloughs are the irritating cause by which the inflammatory action is prolonged, and on their removal the cavity contracts speedily.

If there is much derangement of the digestive organ, it may frequently be found necessary to administer an emetic. If the bowels are slow and the liver torpid, calomel and antimony are highly useful, or other mercurial preparations may be given, in combination with active purgatives; if the state of the secretions is more natural, these medicines may be administered in alterative doses. The mineral acids are often usefully administered, with the view of removing the disposition to the formation of boils. Twenty minims of the aromatic sulphuric acid may be given twice or thrice a day in any convenient vehicle. Anodynes are occasionally required.

_Anthrax_ or _Carbuncle_ maybe considered as a severe form of boils. It occurs in the plague, and is a characteristic symptom. It appears in the same parts, and apparently from the same causes, as the boil. The tumour is of a more flattened form, slightly elevated above the surface, and frequently of great extent; the base is deeply-seated, hard, and unyielding. The integuments are at first of a bright colour, but afterwards assume a dark-red or reddish-brown hue. The pain is violent and burning. The process of suppuration is very tedious, and the matter that is formed is small in quantity. If the tumour is not interfered with, ulceration occurs in its surface, producing various apertures, through which the matter is evacuated, the discharge is thin and unhealthy, excoriating the neighbouring surface; and the mortified cellular tissue, remaining at the base of the swelling, keeps up the irritation. The extent of a carbuncle is frequently great, both as to width and depth; on the back, or buttocks, it not unfrequently attains an immense size. In one instance, the whole posterior part of the neck was involved; the cellular tissue, muscles, and tendons, sloughed; and the vertebræ were ultimately exposed. In another case, the whole occiput, the posterior and lateral parts of the neck, and the space betwixt the shoulders, exhibited one continuous mass of carbuncle. By making free incisions, procuring early separation of the sloughing parts, and supporting the strength of their constitutions, both patients recovered, though considerably advanced in life.

It seldom occurs in the face or head, and when it does, it generally proves fatal. In a male patient in the Edinburgh Royal Infirmary, aged forty-eight, a carbuncle of the size of a very large orange was situated in the centre of the forehead; by active local and constitutional treatment, he soon got well.

The affection is sometimes attended with typhoid symptoms, rigors, profuse perspiration, nausea, vomiting, disordered bowels, loss of appetite, anxiety, restlessness, difficult respiration, palpitations, faintings, pale-white tongue, low pulse, pale or turbid urine, headache, giddiness, drowsiness, and, in severe cases, with delirium. In old or exhausted patients, the prognosis is unfavourable.

An early and free incision must be made into the tumour; if the swelling is large or extensive, the preferable form of incision is the crucial; the ill-formed matter is thus evacuated, the slough exposed, and more readily allowed to escape. If the mortification of the cellular tissue be extensive, and the sloughs prove firmly adherent, the free employment of the caustic potass will be found of much service, the half-dead cellular substance being thereby completely destroyed, and the surrounding parts stimulated to a new and superior degree of action, necessary for the removal of the mortified parts, and reparation of the breach of surface. Poultices and fomentations may afterwards be employed, followed by the warm-water dressing, medicated or not. The stomach and bowels must be put into proper order by the exhibition of suitable medicines; and the vis vitæ may be still farther supported by the administration of tonics and stimulants. If, after the separation of the sloughs, the exposed surface shall assume an indolent or debilitated action, stimulating dressings, such as turpentine liniment, or elemi ointment may be employed.

Such practice will be found sufficient to procure a speedy and favourable termination of the disease, in this country, where we have not to combat any of those malignant diseases with which carbuncle is accompanied in other climates.

OF INFLAMMATION OF THE MUCOUS MEMBRANES.

Mucous Membranes and the skin are analogous in structure, somewhat similar in function, and sympathise closely with each other in health and in disease. Both are endowed with that peculiar degree of sensibility which enables them to bear with impunity the impressions of foreign bodies; and both are protected from the influence of these bodies by an inorganic covering; the cutis and rete mucosum by the epidermis; the corium of mucous membranes by a laminated epithelium. They are the seat of all excretions, and by them all substances are introduced from without into the system. The capillary portion of the vascular system appears to have somewhat the same arrangement in both; the distribution of blood to the mucous membranes being, however, more copious. At the commencement and extremity of the alimentary canal, they insensibly pass into each other by means of an intermediate structure, of which the prolabium may serve as an example. In particular circumstances, they change into each other, both in appearance and in function. Thus, in prolapsus of the gut or of the vagina, the discharge from the protruded mucous surface after a time subsides, the rugæ disappears, the membrane becomes thickened and indurated, and gradually assumes an appearance exactly resembling that of the skin. In natural paraphymosis, the delicate membrane which, in the healthy state of parts, lines the internal surface of the prepuce, becomes converted into a cuticular covering. In neglected and long-continued excoriation of the nates, the raw surface, which was at first tender and irritable, and discharged a serous fluid, becomes villous, less sensible, and discharges a fluid similar to a mucous secretion. In sinuses also of long duration, the secreting surface becomes changed, so as to resemble a mucous membrane, and the discharge, from being purulent or gleety, becomes mucous, or at least resembles a mucous fluid,

A mucous surface, when inflamed, has for a short time, perhaps, at first, its functions suspended; it then furnishes a secretion, increased in quantity, and but little changed in appearance from the healthy fluid; afterwards the discharge resembles purulent matter, and is termed muco-purulent. When, however, the inflammation is violent, the discharge becomes bloody, or is altogether suppressed, and the membrane is thickened. Inflammation of a mucous membrane is very apt to spread with great rapidity, in this respect resembling the corresponding affection of the skin. It is attended with a sense of itching, and a burning pain. This pain is much increased by the muscles surrounding the parts being thrown into action, as in expelling their contents, more especially if these be of an acrid quality. The membrane is thickened, and of a spongy appearance; its surface is red, and sometimes covered with flakes of lymph; occasionally it is much softened, and coated with a viscid adherent mucus; and it would appear, in many instances, that, in acute inflammation, the membrane is generally softened, whilst it becomes indurated from chronic inflammatory action. When the inflammation is violent, and consequently rapid, considerable quantities of lymph are effused either on the surface of the membrane, or into the submucous tissue: and the lymph subsequently becoming organised, the membrane is much thickened, and a contraction is the consequence. The functions of a part lined with mucous membrane are more or less deranged, in consequence of the vitiation of the secreted fluid.

In inflammation of this tissue, metastasis is also apt to occur, from one part of the membrane to another, and from the membrane to the external surface. Cynanche, for instance, often follows upon erysipelas of the face and scalp, and _vice versâ_.

The passages, the internal surfaces of which are invested by a mucous membrane, are those subservient to respiration, nutrition, generation, and the urinary secretions; in other words, the mucous surfaces are the Pneumogastric and the Genito-urinary. Their particular diseases will be treated of hereafter.

OF INFLAMMATION OF THE SEROUS MEMBRANES.

On such an extensive subject it is unnecessary to enter fully; not that the inquiry is uninteresting, or that a knowledge of the diseases of the internal cavities, and the mode of treating them, is not required of the surgical practitioner before he can enter into practice, with safety to his patients and comfort and satisfaction to himself, but we have a very important class of diseases to bring under review in a limited space, and it is properly the province of others to treat of internal disorders, and to describe the best mode of alleviating or curing them. It is, however, the duty of the surgeon to treat the inflammatory affections of some of the serous membranes, and the consequences of inflammatory action in most of them; and it is therefore highly necessary that he understand the symptoms, progress, and consequences of such actions. The affections of the serous membranes are principally under the management of the physician; but they not unfrequently follow wounds and surgical operations, and the diseases of several of them are purely surgical. Inflammation of a serous membrane is attended with heat and pain, aggravated by motion of the parts and by pressure; the natural secretion is increased in quantity, the process of exhalation being incited, and that of absorption weakened; the serous fluid accumulates. The secretion becomes altered in quality, and assumes a milky appearance; lymph is effused, generally mixed with purulent matter, and floats in the fluid, or adheres to the surface of the membrane, which is rough and flocculent. The adherent lymph becomes organised, being penetrated by numerous bloodvessels; and thus the original membrane is, in many instances, much thickened, chiefly from the addition of new matter, though also from enlargement of its bloodvessels and opening out of the primitive tissues, principally the subserous cellular. When inflamed serous surfaces, which have been altered, both in texture and function, in consequence of inflammatory action, remain for a short time in contact with each other, lymph is effused and penetrated by bloodvessels from each surface; thus the new deposit is organised, and forms a medium of connection. By this process the parts are intimately united to each other, and consolidated into one mass; or are merely approximated, and joined, at one or more points, by portions of lymph, in some cases thin and narrow, in others extensive and of considerable thickness; the adhering bands either extend in a straight direction, from one surface to another, or interlace, forming a sort of network. After adhesions of various kinds have been formed, they are often lengthened and attenuated in consequence of the motion of the parts, as is particularly the case with adhesions between the pleura costalis and pulmonalis. When they have been of considerable duration, they often resemble the original membrane from which they were deposited, becoming thin and transparent, smooth on their external surface, and furnishing a serous secretion. Not unfrequently, inflammatory action in this tissue terminates in suppuration; and the pus, secreted by the membrane, accumulates in the most dependent part of the cavity. By collections of matter, whether serous, sero-purulent, or purulent, within a serous cavity, the functions of the contained viscera are deranged, much impeded, and in many instances morbid actions are excited in them. The inflammation, whether it terminates in resolution, or proceeds to serous effusion, adhesion, or purulent secretion, is attended with constitutional disturbance, and the symptoms are proportioned to the original intensity of the action, and the extent and kind of its termination. The effusion of lymph, and consequent adhesion, is, however, in many circumstances, a highly salutary process, as in wounds and injuries of the hollow viscera: effusion of their contents being thereby prevented, and the patient being saved from the danger attending violent inflammation of those cavities and their coverings, caused by the escape of a greater or less quantity of irritating extraneous matter. Purulent collections also, in the solid internal viscera, are thus allowed to discharge themselves externally. The nature, symptoms, and consequences of inflammation of serous membrane, will be more fully considered under the diseases of particular parts.

OF INFLAMMATION OF TISSUES COMPOSING THE ARTICULATIONS.

Inflammation of the synovial surface occurs in consequence of wounds, bruises, or sprains, and often from exposure to cold; from the latter cause, the knee and elbow joints most frequently suffer, as they are generally more exposed to its influence, and not so well covered with muscular substance as the others. Constitutional diseases, such as certain fevers, are followed sometimes by effusion of serous fluid into joints. Purulent matter is also deposited in joints during certain forms of suppurative fever; and this is attended by rapid change of structure.

There is heat, throbbing, pain, and swelling of the part, sometimes redness of the surface, and great constitutional disturbance; the symptoms and appearances, however, vary much, according to the extent of the joint which is involved. When part of the capsule is affected, the inflammation spreads rapidly over all the surface; the synovial membranes resembling the serous in this respect, as well as in healthy structure and function. Like the serous, too, they are shut sacs, are smooth on their surface, and furnish a secretion, the synovial, for facilitating the motion between opposing surfaces; it is, however, somewhat more glairy than the serous. Neither, in their healthy state, are possessed of much sensibility, nor are ligaments, tendons, tendinous sheaths, and bursæ, which two latter textures resemble in every respect the synovial; when inflamed, they become most exquisitely sensible. The incited action of the bloodvessels is followed by increased discharge, which is less glairy and albuminous, partaking more of the serous character. When the incited action soon terminates, and the activity of the absorbents is diminished, the fluid accumulates within the joint, producing _Hydrops Articuli_. This accumulation of fluid in joints may take place without being preceded by any apparent inflammation, and may remain a long time without any visible change of structure in the membrane. The knee is more frequently the seat of dropsy than any other joint.

When the action is more violent, and is not actively opposed, lymph is effused on the inner surface of the membrane, or is deposited amongst the ligamentous and cellular tissues external to the joint, in consequence of which, the membrane and external ligaments become thickened, and of an almost cartilaginous consistence. Serum is effused into the more superficial cellular tissue, filling up the hollows around the joint, concealing the protuberances of the bones, and producing a globular swelling. The articulating surfaces become ulcerated, and matter forms within the capsular ligament; or the pus is deposited exteriorly to the joint, and gradually approaches the surface. But although ulceration is so prone to occur in the cartilages, the synovial membranes do not readily take on this action, unless from the progress of matter, formed within the joint, towards the surface. The synovial lining of the bursæ and sheaths of the tendons are extremely indisposed to ulcerate; and it may be remarked, that, while suppuration without ulceration is common in the synovial membranes, the cartilages, on the other hand, afford frequent instances of ulceration without suppuration, of which more particular mention will be made in the sequel. The cartilage is occasionally swelled and softened where the disease has long existed.

Along with ulceration of the cartilage, a portion of it may become dead, or either state may occur separately; and in many cases, the substance of the bone also becomes affected, of which two classes of cases may occur, viz., great inflammation on the articular surface of the bone, with separation of the cartilage by the ulcerative process in this situation; and inflammation of the medullary web, leading to atrophy of the cancelli, collections of pus therein, or even death of a portion of the spongy texture of the bone, as will be more particularly treated of in the chapter on diseases of the osseous tissue. These changes often compose the primary disease, and to them the affections of the synovial membrane and other parts succeed.

Such occurrences are attended with alarming disturbance of the constitution, with fever, and even with the most threatening and dangerous symptoms, such as delirium and coma. If the patient survive, and the matter be evacuated from the joints by openings into its cavity, hectic fever is almost certain to supervene.

An opinion has been broached lately by Mr. Key, that the ulceration of cartilage was consequent upon the increased vascularity and thickening of the synovial membrane, that the cartilage, in fact, was removed by the action of the vessels ramifying in the membrane, and the prolongations or fringes from it in its diseased condition. Occasionally these fringes correspond, in a remarkable manner, to the breach of surface in the cartilage; but again, ulceration is frequently met with far removed from the membrane. It is also seen, in cases where an opportunity is afforded of making the examination in the earlier stage of disease, that ulceration exists to some extent whilst the synovial membrane is unaffected. And certain cases, in which the cartilage is affected with hypertrophy, and the common form of atrophy of this part in old people, are altogether adverse to Mr. Key’s views. When ulceration takes place at a point removed from the attachments of the synovial membrane, it appears to proceed more frequently from the attached than from the free surface of the cartilage; then the adventitious membrane occupying the rugged spaces, and which under the microscope appears highly vascular, is connected apparently with the medullary web.