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ESSAYS IN SURGERY.
44 use of instru- tion will also be directed to the globules of strict value of the blood, which certain pliysiologists clasthe results obtained. The advancement of sify as animals of the tribe infusoria. We all the other sciences has been effected are already acquainted with their form, and through the gradually increasing perfection the manner in which their movements are of their means of observation ; why should it effected. We shall pursue our inquiries not be the same with medicine? In several relative to them by examining the modificaof our experiments last year we had occa- tions, if any, to which they are subject. M. sion to employ an ingenious instrument in- Turpin has lately asserted that the globules vented by M. Poiseuille for ascertaining of the milk belong to the vegetable kingdom. the precise pressure of the blood, and the It will be worth our while to determine force of impulsion of the heart. The results whether or not any close relation may be were scarcely credible, and have overturn- shown to exist between these globules and ed all theories that might have been pre- those of the chyle or blood. viously held on the subject. Among other facts M. Poiseuille has established, by ESSAYS IN SURGERY. tneans of the hemodynamometer (for so the instrument is called), that the static force is J. M. COLEY, Esq., Senior Surgeon to By equally energetic in two animals exceedingly the Bridgnorth and South Salop Infirmary,
practicable occasions,
make
ments fitted to estimate the
disproportioned in size-a horse and a rabbit. I myself made an experiment with the instrument on two dogs of equal size and strength ; I injected the greater part of the blood of one into the veins of the other, and
No. I. PHLEGMONOUS ERYSIPELAS. THE nature and improved treatment of this found that the variation in the pressure disease are now so generally understood, by amounted only to a few millimetres. Now, the writings of Mr. Copland Hutchinson no matter how surprising these results may and Mr. Lawrence, that it may appear needbe, they are incontestable, and, indeed, the less to occupy the attention of the profession
solution of what at first appeared inexpli- any further on the subject. As, however, cable was thereby rendered extremely easy. the cause of the malady has been almost exHere it is : any notable diminution of the clusively referred to external injury or irriquantity of the circulating fluid increases tation, as a lacerated wound, puncture of the number and force of the heart’s contrac- of some fascia, or other fibrous structure, uninteresting to adduce tions, while a superabundance of blood pro- &c., it may not be it duces a contrary effect. Hence it may be facts to prove that may be occasioned by laid down as a principle, that the number cold, and that it is also subject to endemic and force of the heart’s pulsations are in the influence. Although Mr. Hutchinson was aware inverse ratio of the quantity and pressure of the blood; this increase in the frequency that it was frequently produced in the navy and power of the heart’s contractions, when by the moisture and sudden alterations of the organ is nearly deprived of blood, may temperature to which sailors are exposed, be compared to the acceleration of the move- yet he appears to believe that the external ments of a watch caused by shortening its irritation of salt and friction combine to balance. These facts show how much might promote the affection, as the following pasbe said on the effects of bloodletting, and sage implies :— " The lower extremities being the parts what a novel view might be taken of the most subject to the attacks of this disease theory of that operation. At a future period we will reconsider this subject; for the pre- among seamen may, in some manner, be atsent, suffice it to say that the removal of tributed to their legs and trowsers being blood by venesection inevitably modifies the more frequently immersed in salt-water than other parts of the body, and the constant contractility of the heart. irritation produced by the friction of such will before you Every question brought be examined in its physical, chemical, coarse materials as usually constitute the of sailors upon the naked skin."* mechanical, and vital bearings, for life is dress Mr. Lawrence, to whom surgeons are inthe result of these different modes of action. I propose devoting a considerable number debted for the satisfactory manner in which of lectures to the study of the blood, for I he has confirmed the superiority of Mr. am acquainted with no subject more deserv- Hutchinson’s mode of treatment, appears to ing of attention. We will study it not only suppose that it arises, almost exclusively, in chemical apparatuses, but in the living from external injury, or the sudden suppresanimal and in the human subject labouring sion of the discharge from an ulcerated surunder disease; we will endeavour especially face. " Phlegmonous erysipelas is more com to ascertain by what series of transformations its renewal is effected through the chyle, monly idiopathic ; it supervenes on the the materials of which, when examined sepa- wound of venesection, on injuries of the surately, are found to bear no analogy to the Some Practical Observations in Surgery. By proper constituents of the blood. Our atten- A. C. Hutchinson, 1816, page 79.
45 as those of the patella and ness, and deep red colour, which appearincised and lacerated wounds, ances were more prominent in some parts and compound fractures. An inflamed state than in others. He had fever and delirium. I made 5everal free and deep incisions of ulcers, especially in thelower extremities, is a common cause of it; this frequently through the skin and cellular membrane, comes on when large ulcers, or extensive which were followed by a discharge of wounds, are healed rapidly in persons con- blood, mixed with serous and purulent The next day the swelling was fined to bed, and allowed a full diet of meat matter. and beer. It has often been produced by greatly reduced, the fever subsided, and the delirium entirely ceased, and from this time wounds received in dissection."* The manner in which cold appears to ope- recovery rapidly proceeded. CASE 2.-Miss P. consulted me on Feb. rate in producing phlegmonous erysipelas, is by paralysing the capillary circulation 15, 1838. About a fortnight before that and inducing congestion, and ultimately time she was suddenly desired to see her coagulation of the blood ; and the series of mother who was ill in the night, during an results which follow the loss of vitality in intense frost. Not waiting to dress herself, the capillary vessels, so accurately described she walked about the house a considerable by Gendrin t in this work on inflammation, time without stockings. An inflammation are readily discoverable in the progress of in the right leg followed, and, when I visited this disease in the cellular membrane. When her, I found the back part of the leg inflamed incisions are made into this structure, soon with phlegmonous erysipelas, which was after the attack commences, the gaping proceeding upwards. The next day the skin wounds present a dark crimson colour, and was more hard and dark-coloured and painthe coagulated condition of the blood, which ful, and the inflammation was extending is the cause of this appearance, is distinctly with astonishing rapidity along the thigh. I divided the skin and subjacent adipose observable. As the inflammation advances the sections afford a gray aspect, which is substance, to the extent of three inches in produced by the separation of albumen and fourteen parts, and on the following day recoagulable lymph, and the partial disappear- peated the operation at the upper portion of ance of the colouring matter of the blood. the leg, the disease having again increased Lastly, when openings are effected, after during the night. By these means the pain, the purulent stage is complete, a mixture of swelling, and redness were relieved and pus and serum may be seen oozing from the recovery soon succeeded. disorganised cells, and all appearance of In some instances cold seems to co-operate blood is lost, except that resulting from the with inflammation previously existing in esdivision of arteries, which have escaped the tablishing phlegmonous erysipelas. Thus, destructive process. exposure to cold, especially at certain seaBefore I proceed to trace the origin of sons, will be followed by this erysipelatous phlegmonous erysipelas to the application affection during the suppurative inflammaof cold, it may be necessary for me to pre- tion in the cyst of a diseased tooth, or after mise that the disease consists in a diffuse in- the opening of other cysts, or after some flammation of the skin, terminating, when puncture or wound has been inflicted, as violent and unrelieved, in suppuration and the wound of venesection or the incision of destruction of the subjacent cellular, adipose the scarificator. and aponeurotic, or fibrous structures. That CASE 3.-1807, Dec. 25. Mr. J. D. conit may be produced by cold or moisture, in- sulted me respecting a phlegmonous erysidependently of external injury, or saline, or pelas in the integuments of the lower jaw, other irritation, is proved by the following occasioned by exposure to cold. It had been preceded by suppuration in the discases :— CASE 1.-1831, Feb. 12. S. P., was occu- eased periosteum of an adjoining tooth. On pied early all the day in rendering assist- the 31st the inflammation had extended so The ance to passengers in one of the streets in much that I was desired to visit him. this town, which was inundated by the peculiar induration, and deep red colour of river. While thus employed his feet and phlegmonous erysipelas had occupied the legs were immersed in the cold water with- whole of the neck on the side originally out any covering, and no external injury attacked, as far as the clavicle, and low fever The was sustained from accident or friction. On with muttering delirium was present. the following day he was attacked with treatment by incision not having then been phlegmonous erysipelas in the integuments made known, I punctured the integuments, of the knee. The disease increased to such where the disorganisation of the subjacent an alarming degree that it was considered parts appeared most severe, and thus rescued expedient to consult me on the case. I found my patient, notwithstanding the entire dethe upper part of the leg, the knee, and the struction of the platysma myoides. CASE 4.-1831, June 27. W. T. had been thigh enormously swollen, of a brawny hardsuffering during the last week with phleg* Medico-Chirurg. Transactions vol 14. t Histoire Anatomique des Inflammation. Par A. monous erysipelas on the cheek, which had N. Gendrin. Paris, 1821. proceeded from cold, and had been preceded
perficial bursas,
olecranon,
on
46 an aphthous ulcer on the inside of the the street, and at a short distance from the upper lip. The mucous membrane of the residence of these patients, consulted me on cheek was now occupied with what the account of an inflammation in the capsule French call muguet. The cheek was amaz- in the knee-joint. The remedies I prescribed ingly thickened by the inflammation in the consisted of scarification and cupping, an cellular membrane, and great external heat evaporating lotion, and afterwards a blister. and redness prevailed, which extended to Before this and the scarifications were quite and closed the eyelids, and disfigured the healed, the patient rode a considerable disear and throat. He had delirium and a tance in an open carriage, and took cold. rapid pulse, and had been twice bled Fever and superficial inflammation above without benefit before I saw him. Find- the knee followed, and on August 15th I ing him in this perilous state, I incised the was requested to see her. I found that cheek in three places, taking care to avoid phlegmonous erysipelas had on the 12th atthe transversalis faciei artery, and the paro- tacked the leg, and extended all down the tid duct. The incisions presented a gray inside, and across the middle of it. She had appearance, denoting a deposit of lymph nausea with frequent vomiting and confuand pus, and the advanced progress of the sion of mind. In the most diseased part disease. The delirium continued till the the skin had acquired considerable tension fifth day after the operation, when a speedy and thickness, and the induration of the adipose substance was extreme. I cut through recovery commenced. Incisions should not be practised in the the integuments to the extent of about eight face, except in such perilous cases as the inches in five or six places. All the sympone just related, where the life of the pa- toms improved till the 18th, when the intient is in imminent danger, as the marks flammation had appeared on the outside of left by them may occasion permanent disfi- the thigh, where I found it necessary to repeat the incision. On the 6th of September gurement. The following cases illustrate the ende- I had the satisfaction of receiving a commumic form which phlegmonous erysipelas nication from the surgeon informing me that occasionally assumes. The patients lived the leg and thigh were quite well, and our in the same street, and the same side of the patient’s health restored. The foregoing facts are, I trust, sufficient street, and their diseases occurred nearly at to prove that phlegmonous erysipelas is frethe same time. CASE 5.-1830, July. A lady was attacked quently, if not generally, produced by cold with phlegmonous erysipelas after venesec- or a peculiar state of the atmosphere, and tion, and died in consequence of the disease. that an antecedent wound or other external I did not see this patient, but was informed injury is not necessary for its existence in by the surgeon who bled and attended her, all cases. that every precaution had been taken to preWith respect to the seat of this disease, I vent such a result from the operation. am of the same opinion with Mr. Lawrence, CASE 6.-1830, July 29. A sister of this viz., that it is chiefly situated in the cellular lady, residing in the same house, was bled and adipose membrane, as may be seen by three weeks ago by the same practitioner. any one who observes the appearance of On the following day inflammation appeared these structures immediately after the inciat the orifice, which gradually extended from sions have been effected. The cells, as I the elbow to the wrist, and terminated in stated before, are found distended, first with erysipelas phlegmonoides. The disease atcoagulated blood; and, as the inflammation length progressed with great rapidity, and aproceeds, with lymph and pus, the red fatal termination, as in her sister, was ap- colouring matter of the blood having mostly prehended. The surgeon, therefore, on the disappeared ; and, lastly, complete disor’ 27th, made several superficial incisions,ganisation of the cellular structure is dis. which afforded some relief and evacuated a little pus and serum. An alarming exten- cernible together with the adjacent fascia, Hence the following remark of Mr. sion of the inflammation having, however, &c. taken place to-day, the surgeon requestedHutchinson is untenable:—" I have no idea, my attendance at the town in which he andhowever, that the loose cellular structure of the patient lived. I cut through the skinthe adipose substance participates much in and cellular membrane, with four long incithe inflammatory action of erysipelas phlegsions, down to the fascia, and, where that was diseased, I divided it. A branch of the moooides."—(Pt’ac. Observ. vmS’urg.,p. 81.) When the nature of this disease is ascerradial artery was wounded and required aL ligature. The case was now left to the caretained, I agree with Mr. Hutchinson, that of the surgeon in attendance, from whom Ithe sooner the incisions are made the more had the pleasure of hearing on the 31st that will the patient recover; and the recovery was rapidly proceeding. CASE 7.-Before I had left the town inbest guide for their locality and extent will which these occurrences took place, anbe the situation and dimensions of the parts elderly lady, residing on the same side off in which the inflammation predominates.
by
:
speedily
practicable occasions,
make
ments fitted to estimate the
disproportioned in size-a horse and a rabbit. I myself made an experiment with the instrument on two dogs of equal size and strength ; I injected the greater part of the blood of one into the veins of the other, and
No. I. PHLEGMONOUS ERYSIPELAS. THE nature and improved treatment of this found that the variation in the pressure disease are now so generally understood, by amounted only to a few millimetres. Now, the writings of Mr. Copland Hutchinson no matter how surprising these results may and Mr. Lawrence, that it may appear needbe, they are incontestable, and, indeed, the less to occupy the attention of the profession
solution of what at first appeared inexpli- any further on the subject. As, however, cable was thereby rendered extremely easy. the cause of the malady has been almost exHere it is : any notable diminution of the clusively referred to external injury or irriquantity of the circulating fluid increases tation, as a lacerated wound, puncture of the number and force of the heart’s contrac- of some fascia, or other fibrous structure, uninteresting to adduce tions, while a superabundance of blood pro- &c., it may not be it duces a contrary effect. Hence it may be facts to prove that may be occasioned by laid down as a principle, that the number cold, and that it is also subject to endemic and force of the heart’s pulsations are in the influence. Although Mr. Hutchinson was aware inverse ratio of the quantity and pressure of the blood; this increase in the frequency that it was frequently produced in the navy and power of the heart’s contractions, when by the moisture and sudden alterations of the organ is nearly deprived of blood, may temperature to which sailors are exposed, be compared to the acceleration of the move- yet he appears to believe that the external ments of a watch caused by shortening its irritation of salt and friction combine to balance. These facts show how much might promote the affection, as the following pasbe said on the effects of bloodletting, and sage implies :— " The lower extremities being the parts what a novel view might be taken of the most subject to the attacks of this disease theory of that operation. At a future period we will reconsider this subject; for the pre- among seamen may, in some manner, be atsent, suffice it to say that the removal of tributed to their legs and trowsers being blood by venesection inevitably modifies the more frequently immersed in salt-water than other parts of the body, and the constant contractility of the heart. irritation produced by the friction of such will before you Every question brought be examined in its physical, chemical, coarse materials as usually constitute the of sailors upon the naked skin."* mechanical, and vital bearings, for life is dress Mr. Lawrence, to whom surgeons are inthe result of these different modes of action. I propose devoting a considerable number debted for the satisfactory manner in which of lectures to the study of the blood, for I he has confirmed the superiority of Mr. am acquainted with no subject more deserv- Hutchinson’s mode of treatment, appears to ing of attention. We will study it not only suppose that it arises, almost exclusively, in chemical apparatuses, but in the living from external injury, or the sudden suppresanimal and in the human subject labouring sion of the discharge from an ulcerated surunder disease; we will endeavour especially face. " Phlegmonous erysipelas is more com to ascertain by what series of transformations its renewal is effected through the chyle, monly idiopathic ; it supervenes on the the materials of which, when examined sepa- wound of venesection, on injuries of the surately, are found to bear no analogy to the Some Practical Observations in Surgery. By proper constituents of the blood. Our atten- A. C. Hutchinson, 1816, page 79.
45 as those of the patella and ness, and deep red colour, which appearincised and lacerated wounds, ances were more prominent in some parts and compound fractures. An inflamed state than in others. He had fever and delirium. I made 5everal free and deep incisions of ulcers, especially in thelower extremities, is a common cause of it; this frequently through the skin and cellular membrane, comes on when large ulcers, or extensive which were followed by a discharge of wounds, are healed rapidly in persons con- blood, mixed with serous and purulent The next day the swelling was fined to bed, and allowed a full diet of meat matter. and beer. It has often been produced by greatly reduced, the fever subsided, and the delirium entirely ceased, and from this time wounds received in dissection."* The manner in which cold appears to ope- recovery rapidly proceeded. CASE 2.-Miss P. consulted me on Feb. rate in producing phlegmonous erysipelas, is by paralysing the capillary circulation 15, 1838. About a fortnight before that and inducing congestion, and ultimately time she was suddenly desired to see her coagulation of the blood ; and the series of mother who was ill in the night, during an results which follow the loss of vitality in intense frost. Not waiting to dress herself, the capillary vessels, so accurately described she walked about the house a considerable by Gendrin t in this work on inflammation, time without stockings. An inflammation are readily discoverable in the progress of in the right leg followed, and, when I visited this disease in the cellular membrane. When her, I found the back part of the leg inflamed incisions are made into this structure, soon with phlegmonous erysipelas, which was after the attack commences, the gaping proceeding upwards. The next day the skin wounds present a dark crimson colour, and was more hard and dark-coloured and painthe coagulated condition of the blood, which ful, and the inflammation was extending is the cause of this appearance, is distinctly with astonishing rapidity along the thigh. I divided the skin and subjacent adipose observable. As the inflammation advances the sections afford a gray aspect, which is substance, to the extent of three inches in produced by the separation of albumen and fourteen parts, and on the following day recoagulable lymph, and the partial disappear- peated the operation at the upper portion of ance of the colouring matter of the blood. the leg, the disease having again increased Lastly, when openings are effected, after during the night. By these means the pain, the purulent stage is complete, a mixture of swelling, and redness were relieved and pus and serum may be seen oozing from the recovery soon succeeded. disorganised cells, and all appearance of In some instances cold seems to co-operate blood is lost, except that resulting from the with inflammation previously existing in esdivision of arteries, which have escaped the tablishing phlegmonous erysipelas. Thus, destructive process. exposure to cold, especially at certain seaBefore I proceed to trace the origin of sons, will be followed by this erysipelatous phlegmonous erysipelas to the application affection during the suppurative inflammaof cold, it may be necessary for me to pre- tion in the cyst of a diseased tooth, or after mise that the disease consists in a diffuse in- the opening of other cysts, or after some flammation of the skin, terminating, when puncture or wound has been inflicted, as violent and unrelieved, in suppuration and the wound of venesection or the incision of destruction of the subjacent cellular, adipose the scarificator. and aponeurotic, or fibrous structures. That CASE 3.-1807, Dec. 25. Mr. J. D. conit may be produced by cold or moisture, in- sulted me respecting a phlegmonous erysidependently of external injury, or saline, or pelas in the integuments of the lower jaw, other irritation, is proved by the following occasioned by exposure to cold. It had been preceded by suppuration in the discases :— CASE 1.-1831, Feb. 12. S. P., was occu- eased periosteum of an adjoining tooth. On pied early all the day in rendering assist- the 31st the inflammation had extended so The ance to passengers in one of the streets in much that I was desired to visit him. this town, which was inundated by the peculiar induration, and deep red colour of river. While thus employed his feet and phlegmonous erysipelas had occupied the legs were immersed in the cold water with- whole of the neck on the side originally out any covering, and no external injury attacked, as far as the clavicle, and low fever The was sustained from accident or friction. On with muttering delirium was present. the following day he was attacked with treatment by incision not having then been phlegmonous erysipelas in the integuments made known, I punctured the integuments, of the knee. The disease increased to such where the disorganisation of the subjacent an alarming degree that it was considered parts appeared most severe, and thus rescued expedient to consult me on the case. I found my patient, notwithstanding the entire dethe upper part of the leg, the knee, and the struction of the platysma myoides. CASE 4.-1831, June 27. W. T. had been thigh enormously swollen, of a brawny hardsuffering during the last week with phleg* Medico-Chirurg. Transactions vol 14. t Histoire Anatomique des Inflammation. Par A. monous erysipelas on the cheek, which had N. Gendrin. Paris, 1821. proceeded from cold, and had been preceded
perficial bursas,
olecranon,
on
46 an aphthous ulcer on the inside of the the street, and at a short distance from the upper lip. The mucous membrane of the residence of these patients, consulted me on cheek was now occupied with what the account of an inflammation in the capsule French call muguet. The cheek was amaz- in the knee-joint. The remedies I prescribed ingly thickened by the inflammation in the consisted of scarification and cupping, an cellular membrane, and great external heat evaporating lotion, and afterwards a blister. and redness prevailed, which extended to Before this and the scarifications were quite and closed the eyelids, and disfigured the healed, the patient rode a considerable disear and throat. He had delirium and a tance in an open carriage, and took cold. rapid pulse, and had been twice bled Fever and superficial inflammation above without benefit before I saw him. Find- the knee followed, and on August 15th I ing him in this perilous state, I incised the was requested to see her. I found that cheek in three places, taking care to avoid phlegmonous erysipelas had on the 12th atthe transversalis faciei artery, and the paro- tacked the leg, and extended all down the tid duct. The incisions presented a gray inside, and across the middle of it. She had appearance, denoting a deposit of lymph nausea with frequent vomiting and confuand pus, and the advanced progress of the sion of mind. In the most diseased part disease. The delirium continued till the the skin had acquired considerable tension fifth day after the operation, when a speedy and thickness, and the induration of the adipose substance was extreme. I cut through recovery commenced. Incisions should not be practised in the the integuments to the extent of about eight face, except in such perilous cases as the inches in five or six places. All the sympone just related, where the life of the pa- toms improved till the 18th, when the intient is in imminent danger, as the marks flammation had appeared on the outside of left by them may occasion permanent disfi- the thigh, where I found it necessary to repeat the incision. On the 6th of September gurement. The following cases illustrate the ende- I had the satisfaction of receiving a commumic form which phlegmonous erysipelas nication from the surgeon informing me that occasionally assumes. The patients lived the leg and thigh were quite well, and our in the same street, and the same side of the patient’s health restored. The foregoing facts are, I trust, sufficient street, and their diseases occurred nearly at to prove that phlegmonous erysipelas is frethe same time. CASE 5.-1830, July. A lady was attacked quently, if not generally, produced by cold with phlegmonous erysipelas after venesec- or a peculiar state of the atmosphere, and tion, and died in consequence of the disease. that an antecedent wound or other external I did not see this patient, but was informed injury is not necessary for its existence in by the surgeon who bled and attended her, all cases. that every precaution had been taken to preWith respect to the seat of this disease, I vent such a result from the operation. am of the same opinion with Mr. Lawrence, CASE 6.-1830, July 29. A sister of this viz., that it is chiefly situated in the cellular lady, residing in the same house, was bled and adipose membrane, as may be seen by three weeks ago by the same practitioner. any one who observes the appearance of On the following day inflammation appeared these structures immediately after the inciat the orifice, which gradually extended from sions have been effected. The cells, as I the elbow to the wrist, and terminated in stated before, are found distended, first with erysipelas phlegmonoides. The disease atcoagulated blood; and, as the inflammation length progressed with great rapidity, and aproceeds, with lymph and pus, the red fatal termination, as in her sister, was ap- colouring matter of the blood having mostly prehended. The surgeon, therefore, on the disappeared ; and, lastly, complete disor’ 27th, made several superficial incisions,ganisation of the cellular structure is dis. which afforded some relief and evacuated a little pus and serum. An alarming exten- cernible together with the adjacent fascia, Hence the following remark of Mr. sion of the inflammation having, however, &c. taken place to-day, the surgeon requestedHutchinson is untenable:—" I have no idea, my attendance at the town in which he andhowever, that the loose cellular structure of the patient lived. I cut through the skinthe adipose substance participates much in and cellular membrane, with four long incithe inflammatory action of erysipelas phlegsions, down to the fascia, and, where that was diseased, I divided it. A branch of the moooides."—(Pt’ac. Observ. vmS’urg.,p. 81.) When the nature of this disease is ascerradial artery was wounded and required aL ligature. The case was now left to the caretained, I agree with Mr. Hutchinson, that of the surgeon in attendance, from whom Ithe sooner the incisions are made the more had the pleasure of hearing on the 31st that will the patient recover; and the recovery was rapidly proceeding. CASE 7.-Before I had left the town inbest guide for their locality and extent will which these occurrences took place, anbe the situation and dimensions of the parts elderly lady, residing on the same side off in which the inflammation predominates.
by
:
speedily