Elements of Surgery

by Robert Liston

If at any part adhesion fail, suppuration and granulation must follow. The adhesion may be prevented by any of the circumstances already mentioned, or by an unfavourable state of the constitution, the nature of the wound, exposure to bad air, the occurrence of fever, or of a flux natural or not. The wound may contain foreign matter; blood or the contents of canals may be effused into it, and many other obstacles may exist to retard, or prevent adhesion. Notwithstanding, in all cases, though the chance of union be but small, the parts should be approximated. A great point is gained if certain parts only are brought to adhere, for by their natural attachments the opposite surfaces are preserved in more direct contact than they could otherwise be, and thereby but little space remains to be filled up with granulations. If, on the contrary, the surfaces are not approximated, the flap is diminished in size, and when afterwards placed in contact with the surface from which it was detached, it is found not to correspond, leaving considerable deficiency to be repaired by the comparatively slow process of granulation. Whereas, if it had been early replaced, partial attachments would probably have been formed by adhesion, the flap thereby retained in situ, and prevented from shrinking, so that but little new matter would be required.

Sometimes union does occur, and that speedily, after the flap has remained separate for a considerable time; and in such cases it may be doubted, whether union is accomplished by adhesion, strictly so called. Most probably it is by this process that the rapid union occurs in such circumstances: the divided parts have assumed an excited action, and effused lymph; during their state of separation, the lymph will become organised when it is connected with the original parts, just as well as if the surfaces had been in contact; and when they are at length so placed, they will be agglutinated to each other by the outer part of the effused lymph, which still continues soft and unorganised. If motion be then prevented, organisation, which has already commenced in the connecting medium, will proceed undisturbed, converting the agglutination of soft unorganised lymph into firm and permanent union by means of organised tissue. In these circumstances, it is not to be wondered at if adhesion should be completed in a shorter time than when the surfaces are brought together immediately after their division; in each instance the process is the same, only in the one it has to proceed from its very commencement, whilst in the other it is previously all but perfected, and after the parts have been put together, the last stage only requires completion. It is only in a particular stage of a granulating surface, that adhesion will take place speedily, when the discharge is diminished, but healthy, and the granulations florid and firm.

When a wound is to heal by granulation, the exposed surface at first is dry, painful, and slightly swelled, and afterwards a thin discharge of bloody serum is poured out, with relief to the painful sensations; the surface is at this time covered by a thin layer of coagulated lymph, and the parts, if approximated, are in the most favourable state for adhesion. Soon, however, the vessels assume a different mode of action, and secrete a fluid which becomes purulent; the effused lymph has been organised, forms a living part of the surface from which it was deposited, and is covered and protected, in its yet delicate condition, by the purulent fluid. This new matter is disposed in numerous small conical projections of a florid colour; and these, by their own power, form others similar to themselves, at the same time discharging purulent matter; so that, in a healthy constitution, the cavity is soon filled by the granulations, which come to the same level as the surrounding integument. Sometimes they are exuberant, soft, and spongy, and in this state possessed of little sensibility, and but ill supplied with bloodvessels. At others, they are slow in approaching the surface, and then often morbidly sensible. In all cases, the new matter is very apt to be absorbed, either from the state of the patient’s health, or from the nature of the applications; and foreign substances, in a state of solution or minute division, are more readily taken into the system from the raw surface than from the sound skin. When, then, the granulations approach the skin, the sore contracts, the newly formed parts being modelled into a more firm and dense condition by the action of the absorbents. Sometimes, in superficial sores, the skin is seen spreading from several parts near the centre; but at these points portions of the original skin must have remained uninjured, though the others were destroyed, and have formed cutaneous matter as soon as they were on the same level with the surrounding granulations; for these insulated portions of skin are not a product of granulations, as some suppose, but of a substance similar to themselves. Skin is formed from skin. Thus, where a part of the integuments has been completely removed by operation, or destroyed by accident, no islands of skin are observed during the cure, but the sore is uniformly covered by skin proceeding from its margins. The margins of a healing sore are of a white colour, and adherent to the subjacent parts; but in an unhealthy one the margins are often unsupported, the subjacent granulations are absorbed, and their place is occupied by thin purulent matter; the new skin is unable to maintain its independent existence, continues of a dark colour, perhaps for a long period, then wastes away or sloughs. The recent cutaneous matter covering a sore contracts, and the neighbouring old skin is extended; the new surface is thus diminished; it assumes a slightly puckered appearance, and is termed cicatrix. This is at first pretty vascular, the vessels running straight; after a time they contract and become invisible, and scarcely admit fine injections. Frequently the scar is so far absorbed after some time, as to leave only a firm line, whiter and more dense than the surrounding integument.

If union by the first intention does not take place, then all the application to procure it must be abandoned, all sutures, plasters, compresses, &c., must be dismissed, for they now can do no good, and may be productive of harm; the attention, on the contrary, must be directed to effecting union by granulation; with this view, other means are to be chosen, so that to continue those which were formerly used to promote adhesion would be absurd, when adhesion can no longer be expected. The stitches must then be taken out, when inflammation has gone off, and œdema remains, the parts are to be supported; and by attention to position, and gentle bandaging, the size of the wound will be diminished. Inflammation must be subdued by the usual means, and suppuration encouraged by fomentation and poulticing, or warm water dressing. After inflammation has subsided, tension disappeared, purulent discharge occurred, and granulations formed, the edges of the wound are to be gently brought together, so as to render the quantity of new matter requisite for filling up the cavity as small as possible. Nature will then accomplish the union in her own way, and we can only assist and minister to her; for who thinks now of healing wounds by pure force of surgery? The dressings ought to be light, the ointment, if any is used, scanty; in some cases the application may be dry; but in many cases various lotions will be found of much advantage. These latter are used of different qualities, according to the nature of the sore; and these can be of little avail unless evaporation be prevented, by a piece of oil-silk laid on the outer surface of the dressing. In most granulating wounds, they require to be of a mildly stimulating nature, and the one which I have most frequently employed is a weak solution of the sulphate of zinc. The integuments round the wound may be occasionally washed, to prevent excoriation, but no good can accrue from washing the sore; its natural discharge is its best protection, and if superabundant, it can be removed by means of dry lint or tow from the surrounding parts.

From bruised and lacerated wounds there is little or no hemorrhage, but in proportion to the severity of the bruise, is the bleeding slight, and the danger great. The bloodvessels are so torn and twisted as to permit the spontaneous and temporary suppression of hemorrhage to occur almost immediately; and the larger arteries may escape entirely, owing to their elasticity. Sometimes after bruised wounds, such as those inflicted by gunshot, the large vessels bleed instantly and violently; often, however, hemorrhage occurs only after the sloughs separate, many days after the infliction of the injury, and then it is generally very profuse; in some instances, limbs are torn, bruised, or shot away, without hemorrhage occurring to any great degree, or at any period. Frequently the vitality of the parts surrounding the wound is much diminished; and the whole limb is apt to become gangrenous, either immediately, on account of the extreme violence of the injury, or consecutively, from greatly excited action going on in parts whose power of resistance has been much impaired: it often arises also from constitutional peculiarity. The gangrene extends often rapidly, in consequence of the infiltration of putrid serosity into the cellular tissue. In the treatment of bruised wounds, the position of the parts must be carefully attended to; they must be placed in a state of relaxation. In general, it is unnecessary to retain the margins of the wound in contact, for adhesion cannot occur—suppuration must ensue, and is to be desired—and the dead and dying parts must be loosened and discharged before union can take place. Sometimes, as when a large flap has been detached, and the parts not much injured otherwise, approximation ought to be accomplished, for the reasons already mentioned. In almost all cases, and most certainly in those in which the mechanical injury has been severe, and its effects extensive, violent inflammatory action is to be dreaded, and measures must be taken to ward it off: notwithstanding the prophylactic treatment, violent inflammation often comes on, and then recourse must be had to the means proper for the subduing of it. Blood is to be taken from the part, if necessary, and soothing applications used, in the form of fomentation and poultice. The main indications are to prevent extravasation into the substance of the limb, and strongly excited action. When the sloughs begin to separate, emollient poultices promote the suppuration and discharge of dead matter, and afterwards the sore must be dressed, according to the nature of the case, with the applications most fit for granulating sores in their different degrees of action and advancement. During the after treatment, the sides of the sore ought to be well supported, so as to prevent, as much as possible, suppuration from extending along the neighbouring cellular tissue; but, at the same time, the dressing must not be so tightly applied as to cause irritation. When abscesses have formed in the neighbourhood, the cavities should be freely exposed by incision; thus a free discharge will be given to the matter, and the cavity brought to granulate from the bottom. During the suppurating stage, the patient’s strength must be maintained by generous diet.

Punctured wounds are dangerous, from the deep and internal effusion of blood and serum which usually attends them. The effusion, which in open wounds is poured out externally, and moderates and prevents the excited action from exceeding what is salutary, is, in punctured wounds, poured into the substance of the limb to its detriment. It is followed by severe inflammatory action and profuse suppuration. In order to prevent these untoward results, it was formerly the practice immediately to dilate the wound; but this is hurtful, for if the wound be deep, as it generally is, dilatation of its whole extent is a proceeding severe in itself, and in its consequences; whilst, if the external part only of the wound is dilated, the operation will entirely fail to effect what is intended. The knife will be used in great good time where a foreign body is found to be lodged in the wound, when tension has occurred, or matter has formed. Sometimes the wound heals throughout its whole track by adhesion, without any bad symptoms being so much as threatened. Setons, recommended in this class of wounds, are of no service. It is not the narrowness of the external opening, as is sometimes supposed, that is the cause of all the mischief, but the injury and consequent inflammation of deep-seated parts.

Poisoned wounds are rare in this country. Wounds by the stings of certain trifling insects produce considerable swelling in some constitutions, and when the injury has been inflicted on a loose texture. In some parts of this country, the bite of a small adder causes pain, swelling, and unhealthy suppuration of the part, with some constitutional disturbance, but the results are seldom serious, and never fatal. In warmer climates, the bites of some snakes are followed by the most violent symptoms; in some cases proving fatal in a few hours, in others after a day or two. Great swelling occurs almost immediately, attended with excruciating pain, and extends upward along the limb; vision becomes impaired, the patient lies in a state of stupor, and ultimately succumbs under convulsions and delirium; the symptoms vary in particular instances according to idiosyncrasies and the state of the constitution when the injury is inflicted.[22] In this country, the bites of rabid animals are more dangerous than those of animals naturally poisonous. Rabies most frequently occurs in dogs, and others of that species, such as wolves, foxes, &c. They become dull, sluggish, and irritable; have unnatural appetites and cravings, devouring their excrement and urine; the stomach is generally found full of chopped straw, pieces of wood, &c. Derangement of the cerebral functions is not complete,—they know and obey their master. They are often not afraid of water, but lap it and go into it readily. From them the disease is communicated to the human subject, and to the lower animals, such as cats, sheep, cattle, and even fowls; the virus is not communicable, except by the deposition of the saliva on an abraded surface, or into a wound. It is not produced by eating the flesh of a rabid animal. During the first days of the attack, pustules are, it is said, observed under the tongue, but there is no apparent change in the glands. The symptoms of hydrophobia in man seldom appear before the twentieth day after the infliction of the wound, and in some instances they have not presented themselves till after the lapse of months. The most prominent are great restlessness, much irritability and anxiety, and convulsions of the muscles concerned in deglutition, produced either by attempts to swallow, or by fluid being presented to the patient. Ultimately, the spasms become general, are induced by the most trifling exertions or noises, and prove fatal in a few days. Frequently the patient retains his senses throughout, and is fully aware of his lamentable situation; in other instances, he soon becomes delirious, raves, and threatens his attendants. For this horrible disease we are unacquainted with any cure. In general, profuse bleedings are employed, and large quantities of opium given internally; every powerful antispasmodic, as well as every violent medicine, has been made trial of, but in vain: some certainly mitigate the symptoms, but none cure the patient. It has been even proposed to suspend or destroy the function of the nervous system for a time, by the employment of the Wourali poison, keeping up at the same time respiration by artificial means, under the expectation that thus the impression on the system might be got over. The morbid appearances usually observed after death are marks of inflammation of the pharynx and air-passages, and of the mucous surface of the stomach and intestines. It is evident that the disease ought to be prevented if possible, and for its prevention the most efficient measure is timely excision of the affected parts; and they should be cut out a long period before the constitutional affection comes on: when excision is dangerous, or wholly impracticable, and when the patient does not apply soon after the accident, the injured parts may be destroyed by some active caustic, as the potassa fusa. The nitrate of silver has been strongly recommended and extensively employed by Mr. Youatt, whose experience in this disease is very great. This application should scarcely be trusted to alone. The removal of parts wounded by snakes, even after violent symptoms have appeared, has proved successful, ammonia having been at the same time administered internally. In some instances, arsenic has been found efficacious when given in large doses, and frequently repeated.[23]

Wounds received during dissection occasionally have unpleasant consequences from the absorption of animal matter. The absorbents leading from the wounded part become swelled and painful, and in slight cases there are shivering and general indisposition for some days. The more violent symptoms arise from examining bodies which are rather recent, and in which putrefaction is just commencing, and very frequently from inspecting the bodies of females who have died of puerperal diseases. The absorption may take place from punctures made by scissors, the point of a knife, or spiculæ of bone, or from old scratches, or chops by the side of the nail or on the hand. There is little or no danger from an open and bleeding wound, as by the flow of blood the part is completely cleaned; it is generally from slight punctures that untoward symptoms need be apprehended. Effects similar to those resulting from wounds in dissection often occur in nurses and others who have pricked themselves with pins while washing foul clothes, or from handling poultices or dressings removed from bad, putrid, or sloughing surfaces. The symptoms already mentioned are soon followed by others more severe: shivering continues, and the patient is seized with vomiting; the part affected, and often the greater part of the arm, becomes red and much swollen; the cellular tissue is infiltrated with serum often dark and putrescent, abscesses form at various points along the limb to the axilla, and purulent matter is diffused throughout the unhealthy cellular tissue, which in many instances sloughs, and gives rise to extensive sores. Typhoid symptoms soon appear, and in the more aggravated cases speedily prove fatal. When such local and constitutional symptoms arise, it will generally be found that the patient was of a broken-up constitution previously to the infliction of the wound; did they solely depend on the inoculation of virus, they would be of very common occurrence, considering that wounds are so frequently received during dissection; but it is seldom comparatively that any unpleasant symptoms follow such an accident. In all cases, however, it is prudent to adopt measures in order to prevent absorption of the virus. With this view, the wound is made to bleed by means of pressure or suction, and by the latter method the exposed surface is most effectually purified; afterwards nitrate of silver maybe applied to deaden the surface, and protect it by an eschar. If such means be unavailing, the after symptoms must be encountered as they appear, local inflammation subdued, tension relieved, abscesses opened, sloughs removed, &c. General bleeding is seldom admissible, but purgatives and antimonials will prove beneficial at the commencement; afterwards the strength is to be supported, and, if the patient be much reduced, stimulants are to be liberally administered.

We shall next treat briefly of gunshot wounds; under this head are included the contused and the lacerated, caused by splinters, &c. The vitality of the injured surface is generally destroyed at once, whence bleeding seldom occurs, even after whole limbs have been shot away; in some cases, however, hemorrhage is profuse, as when a large artery has been wounded by small shot. The effects on the system are extremely various; some persons are affected with tremors, anxiety, and depression from slight wounds; while the most severe injuries are often unaccompanied by any disturbance of the nerves. The shock is generally of short duration, disappearing soon, on the patient’s being reassured and encouraged, or after his taking a little wine or opium. In gunshot wounds, those inflicted from a distance or close at hand can in general be readily distinguished. In the latter, the wound is large and lacerated, portions of the wadding are impacted, and the skin around is marked with grains of gunpowder. In the former, the wound is small and clean. When a ball passes through a fleshy part, the opening at its entrance is small and depressed; whilst that by which it escaped is open, with everted edges. When it follows a superficial course, its track is marked by a wheal, or elevation of the skin with discoloration. At one time, it was believed that the most serious consequences resulted from a ball passing close past the body without even touching it—that in this way violent concussion of the brain, proving instantly fatal, was produced; but this notion has been disproved by experience; part of the head accoutrements, of the hair, of the nose, and of the ears, have been shot away by cannon-balls, and yet no disturbance of the brain has followed either immediately or consecutively. The opinion originated from the circumstance of soldiers having been found dead without any evidence of injury; but bones are often broken and comminuted by an indirect blow, or by a spent ball, without any breach of surface or external sign remaining; internal injuries indeed—rupture of viscera—more than sufficient to cause instant death, are thus inflicted without any apparent external læsion.