Chapter 17 - Surgical Diseases
Modern Surgery
Suppuration and Abscess
Ulceration and Ulcers
Malignant Pustule
Burns and Scalds
Frost Bite
Septic Wounds
Incised Wounds
Rules for Examining and Dressing Wounds
Antiseptic Dressings
Way Wounds Unite
Punctured Wounds
Lacerated Wounds
Granulation and Scarification
Gunshot Wounds
Poisoned Wounds
Way Broken Bones Unite
Different Diseases of Bones
White Swelling
Stiff Joint
Water in the Scrotum
Blood in the Scrotum
Varicose Veins
Deformities and Irritations of the Spine
Wry Neck
Foreign Bodies in the Eye
Inflammation of the Edge of the Eyelids
Disorder of the Lashes
Chronic Inflammation of the Lachrymal Sac
Inflammation of the Cornea
Inflammation of the Iris
Weakness of Sight
Imperfect Vision
Short and Long Sight
Affections of the Ear
Inflammation of the Meatus
Wax in the Ear
Inflammation of the Tympanum, Deafness
Bleeding from the Nose
Ingrowing Toe Nail
Chafing and Excoriation
Foreign Substances
Bleeding from Wounds
Proud Flesh
Compression of Arteries to Stop the Flow of Blood
Care of the Teeth
Rotting of the Teeth
Filling Teeth
The First Teeth
Cleaning the Teeth
Ulcer of the Stomach
Riggs' Disease

17.2 Inflammation


ON this pathological basis much of surgical disease rests. Surgical inflammation is due in a great measure to the introduction into the tissues of germs which there multiply with great activity, forming as a result certain poisonous products called toxins. These toxins are deadly poisonous to the system, and when absorbed cause high fever, chills and sweats, loss of appetite and strength, and generally undermine the strength. It is as if so much mineral or vegetable poison had been introduced into the stomach. Their activity is astonishingly rapid when they are situated in tissues favorable to their development, like the peritoneum and other serous membranes, richly supplied with lymphatic vessels to convey the poison from one point to another.
There are several conditions favorable to the development of germs when introduced into the body, chief among which is moisture; hence to keep the wound dry and well drained is the constant aim of the surgeon. When bacteria are introduced into the system through a wound, they begin at once to put on their activity, and the production of toxins commences. Nature rushes, so to speak, to the field of the enemy, and a great fight at once occurs. She throws out a mass of lymph about the invaded portion of the flesh to surround the enemy and cut off his base of supplies. She forms out of her own blood antitoxins, so called. It soon becomes a question of which is the stronger form, the toxins of the germs, or the antitoxins of the serum. This battle results in a thickened, congested, painfully swollen and reddened area, which, ff nature conquers, Softens and melts away, but which, if the enemy is victorious, breaks down and forms pus. The result depends largely on the location of the struggle, the strength of the patient, and the virulence of the germ. If it be in a part poorly supplied with lymphatic vessels and soft structures, nature has the advantage, because the enemy cannot find easy access to structures beyond the field of battle; but if the neighborhood of the invasion is in soft structures, the enemy quickly seizes on some short route to a neighboring lymphatic station and there deposits its poison and thus extends its field till nature is overwhelmed. The ability of nature to manufacture antitoxins quickly and mobilize her forces to the rescue on the one hand, and the virulence of the germ or its capability to develop its poison quickly, on the other, are always deciding elements in the preservation or destruction of the part attacked. Much is now being accomplished toward eradicating germ diseases and germ inflammation by the cultivation of this natural antitoxin. Its special victory is seen in the diphtheritic antitoxin with which that disease is now so successfully fought. This antitoxin which nature throws out is cultivated in horses till such an amount is stored up that against it diphtheria no longer has any influence; this serum, so rich in antitoxin, is then introduced into the human subject as an antidote to the forming toxins of the diphtheria.
And so it is with lockjaw, rabies, and many other germ diseases. This therapeutic agency is yet in its infancy, but much may be expected of it in the future.
But not all inflammation is necessarily of bacterial origin, at least so far as is yet proven.
Every part of the body which has vessels and nerves is liable to inflammation. Where there are no nerves, it cannot exist. Many diseases are caused by it. Mechanical injuries, such as cuts, bruises, and fractures, produce it. And many other disorders, not caused by or causing it in the beginning, become entangled with it in their progress. It is very important, therefore, to understand the nature and management of inflammation. It is not always to be looked upon as a disease; it is frequently a simple process of repair, whereby nature restores injured parts to health, in which there is no germ life present.
The Signs of Inflammation are redness, pain, heat, swelling and loss of function, though in some cases these do not all appear.

Acute Inflammation. When the redness, the pain, the heat, and the swelling are clearly marked, and the inflammation is so rapid that it either subsides in a few days, or quickly brings on suppuration, or ulceration, or mortification, it is said to be acute.

Chronic Inflammation. When it is less painful, and slower in its progress, beginning very gradually, and lingering a long time, it is then chronic.
Common, or Simple, or Healthy Inflammation, is that which is not mixed up with any disease, but is established by nature for some salutary purpose, and is generally germ free.
Unhealthy Inflammation is that which has been caused by some other disease, like the poison from germ life, and is under its control.
Specific Inflammation is that which seems to vary from all ordinary cases, being dependent on a particular state of the system, on an animal poison, or a principle of contagion or infection, and a power of propagation from one person to another, such as all germ poisons.
Some of these produce such permanent effects, that those having them are not liable to a second attack.
Inflammation is Primary, or, as the doctors say, idiopathic, when it is the original disease.

Inflammation is Secondary, or Sympathetic, when it is the result of some other disorder, which goes before, and produces it.
It has been explained elsewhere that the different parts of the body are connected by little threads or nervous strings which run from one to the other. If one part of the body become injured or disordered, it uses these nervous threads as telegraphic wires, to tell other parts of its misfortune; and it sometimes happens that when the intelligence conveyed is of a sad and alarming character, the part receiving the news is so excited and distressed as to become inflamed. Nothing can be more proper than to call this sympathetic inflammation.
When the inflammation is violent, and is seated upon some important part, the sympathetic action is so great as to disturb the whole constitution; and this general disturbance is sympathetic or symptomatic inflammatory fever. On the other hand, it more frequently happens, especially in the light of modern surgical pathology, that the lymphatic system, which is in reality a delicate railroad system for the economy, leading toward the great citadel of life, the heart, carries over its tracks to the nearest station some of these germs or germ poison from the primary wound or inflamed spot, thus spreading the contagion to whatever lymphatic station the vessel happens to run.

The Symptoms are quick and strong pulse, dryness and heat of skin, parched mouth, great thirst, scanty and high colored urine, costiveness, disordered nervous system, loss of appetite, anxiety, restlessness, sleeplessness, headache, wandering and confusion of mind, and sometimes delirium. This fever John Hunter called a universal sympathy of the body with the disturbed condition of a part of it.
It is only by inflammation that a wound is healed, or a broken bone repaired.
Upon the surface of a wound nature pours out a fluid called plastic lymph. This is composed of fibrin, the material of which flesh is made, united with a little of the watery part of the blood, chiefly albumen. The watery part disappears soon after it is poured out, and the fibrin hardens into a kind of membrane. Through this, nature sends small nerves, arteries, and veins, which she uses as threads to sew up the wound. Fibrin being the chief material with which nature constructs our bodies, she of course uses it to repair them when wounded, just as a carpenter, who constructs a floor with planks, uses planks to mend it when it is broken through.

Buffy Coat of the Blood. The effects of inflammation extend to the blood. This fluid, when drawn from the veins of a person suffering from an inflammation active enough to disturb the constitution, forms a clot in the basin more slowly than usual, but the clot is harder; and a layer of fibrin is left upon the surface, of a yellowish buff color, looking like size or glue, and called the huffy coat. The clot is also Scooped out in the centre, and the blood is said to be cupped.

Coin Discs. It is another peculiarity of inflamed blood, that if a drop of it be examined under a powerful microscope, its globules, or discs, which are very numerous, will be found standing on their edges, and leaning against each other, like a row of copper or silver coins. (Fig. 152.)

Inflammation may end in one of four different ways.

I. By Resolution. Suppose a large splinter of wood be stuck into the hand of a healthy man. It causes redness, heat, swelling, and pain; and these combined are inflammation. The splinter is pulled out, and the hand well done up with a disinfectant dressing, and properly cared for. The redness fades, the heat declines, the swelling subsides, and the pain disappears; the inflammation is ended, and the hand is well. Coming to a fortunate end in this way, inflammation is said to be, resolved, or terminated by resolution.

II. By Suppuration. It does not always end so happily. The splinter may be broken off below the skin, and not pulled out; or, even f removed, germs may have been introduced from the splint or from ~he skin of the hand; these germinate rapidly and form pus, and instead of the inflammation abating, it will increase, and the centre )f the injured part will begin to rise up to a point, and grow white )n the top. This shows that there is matter formed underneath, which is lifting up the scarf skin, and seeking to come through. Fig. [53 is a microscopic view of pus corpuscles.
The pain is now very throbbing and pulsating keeping time with the beats of the heart. When the scarf skin can hold out no longer, t breaks, and yellow, cream like fluid runs out, which we call pus. The redness, pain, etc., now subside. This process we call suppuration.
At this time, if the wound have been a severe one, attended by sympathetic fever, and the discharge of pus be now large, there may be a change in the fever, marked by frequent shivering and chilliness, followed by flushes of heat, which ends in sweating. We call this hectic fever.

III. By Ulceration, or the formation of open, running sores.

IV. By Mortification. If the wounded part have been so much injured as gradually to destroy its vitality, it dies. The vivid red of the inflammation changes to a purplish, or livid, or black hue. The strained condition of the skin ceases, a bloody fluid lifts up the cuticle, the pain and feeling are all gone, the part is dead and putrid, and gives out a peculiarly offensive smell. This process is called mortification.
The mortified and dead part is called a slough; and it is separated from the living parts by a peculiar vital process which has the name of ulceration.

Treatment of Inflammation. Though inflammation sometimes ends kindly by resolution, and though it is often a salutary process, yet it is frequently very destructive, ending in suppuration, ulceration, and mortification, thickening, hardening, softening, and enlarging parts affected by it; and doing these things in textures of great delicacy, and of vital importance in the economy of life. It calls, therefore, for judicious, and, often, for very active treatment.
There are three principal things to be done, to remove the cause, if it be still active, to take the blood away from the inflamed part, and to render the part aseptic, if possible.
If a bullet be lodged in the flesh, or a thorn, or a splint of wood, or a piece of glass, it is the exciting cause of the inflammation which follows, and little can be done to advantage till the offending substance is extracted. If inflammation be excited in the bladder by the irritating presence of urine which cannot be passed, this must be drawn off with the catheter before relief can be had. If the Stomach be inflamed by improper food, or too much of it, the diet must cease to follow appetite, and take reason for its master. If ladies have excited inflammation in the bowels, or any of the internal organs, by a dragging weight of skirts, they must either put off the burden, or hang it upon the shoulders with straps.

The blood is removed from the inflamed part in two ways:
Direct Method. It is done directly by various methods which tend to take the blood out of the small vessels, which are so full and crowded as to produce pain. Cold water, ice, etc., applied to the part cause these little vessels to contract, and squeeze the blood out of themselves. These are very useful applications; and they are to be pursued as long as there is any hope of breaking up the inflammation, or causing it to end by resolution. But when this is no longer to be expected, and it is found that it will go on to suppuration, then apply warm fomentations and poultices. These will mollify and soften the parts, and cause the suppurating to go on more rapidly and with less pain.
Counter Irritation. The other method of removing the blood from the inflamed part is by what is called counter irritation.

Costiveness is always produced by the symptomatic fever which often results from inflammation. This should be removed by saline purgatives, such as Rochelle, Epsom or Glauber's salts, salts of tartar, tartrate of potassa, and the tartrate of soda (9), (7), (12), (14), (18), (20), (25), (27), (41). Sometimes more active purgatives are required, and then the compound extract of colocynth, etc. (29), will be excellent, or two compound cathartic pills, at night, followed by (299) may be used.
As a drink, cream of tartar (298) will be found cooling and refreshing. In all inflammations, the diet must be light and unstimulating.
To allay the excessive fever and pain of inflammation, some of the' coal tar products may be used, like ammonal or phenacetine, in ten grain doses, every two to four hours; but it must be remembered that inflammation is the result of poisons and not the cause of them, hence these remedies are but temporary and palliative, and must be used while the real cause is being fought by removal of the original source of the trouble.
The third method of treating inflammation is the most important, because generally it strikes home. Inasmuch as most inflammation which comes from outside causes is the result of the introduction of bacteria into the body, the most natural thing to do is to disinfect at once the injured or diseased part. Sulpho naphthol or oil of milk is a good disinfectant, and is used in strength of one half teaspoonful to a quart of water; this latter turns the water milk color.

The pressure of war conditions in Europe has compelled the search for improved methods in the treatment of wounds, the most successful of which is the discovery made by Dr. Alexis Carrel of the Rockefeller Institute. This success is not due to the miraculous properties of any new drug. The antiseptic employed is Dakin's sodium hypochlorite 0.05 per cent. It is an ideal wound antiseptic of high bacterial activity and low irritating quality. It also has the great advantage of being able to dissolve pus, old blood clots, tissue debris, etc. All shell fragments, particles of clothing, dirt, etc., are removed. The wound is painted with tincture of iodine, and the edges trimmed away. The placing of the tubes and their number varies with the nature of the wound, the guiding principle being to place the tubes so that the liquid will come in contact with every portion of the wound. Instillations of the fluid are made every two hours by releasing the adjustable clamp controlling the flow. The amount of solution employed varies with the nature and extent of the wound; for the average wound 10 c.c. are sufficient. This interrupted instillation is kept up until the wound is proved sterile. The tubes are then removed and a compress moistened with Dakin's solution is applied. The rate of instillation is from 5 to 20 drops a minute, according to conditions. The object is to moisten the wound surface and not flood the bed.

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