Elements of Surgery

by Robert Liston

Local impressions, injuries, or irritations, though apparently of little importance, frequently produce irritation which affects the whole system, and is therefore termed constitutional. Syncope sometimes follows the passing of a bougie along the urethra. We meet with too many instances of constitutional irritation following severe injuries or operations, especially if attended with much hemorrhage. In general, there is considerable prostration of strength; the patient is anxious and restless; his sleep is disturbed; the pulse is weak and fluttering, occasionally intermittent; the tongue is white and loaded; the appetite is gone; the stomach rejects the little food which the patient is able to take; he is startled and annoyed by the slightest external impression. At this period of the disorder, rigors generally occur, and are followed by a sense of heat, and by perspiration; then the above symptoms gradually decrease, and the patient recovers; but in certain instances his breathing becomes quick and somewhat oppressed, attended with a peculiar spasmodic elevation of the nostrils; all the secretions are diminished, the intellectual functions become impaired, and there are occasional convulsive twitchings; coma supervenes, preceded by a low muttering delirium, and followed by death.

This action, as well as every other, is much modified by the importance of the part which is the source of the action, and by the constitution of the patient. It is more severe in children than in adults. The affection will be more fully detailed, when treating of local injuries, and the management of patients after severe operations.

The Causes of Inflammation come next to be considered; and first, of the proximate cause or theory. The different states of the Vessels, in their healthy and in their incited condition, have given rise to much discussion. In the first place, considerable difference of opinion exists as to the relative share which the heart, the larger arteries, and the capillaries, have in propelling the circulating fluid in a state of health. Some physiologists are inclined to attribute the principal power to the heart, the blood being propelled and returned, according to them, almost entirely by the vis a tergo; while they suppose that the arteries possess merely a degree of elasticity or tonicity. Considering the arteries as elastic tubes, performing an indispensable part in the propulsion of the blood, we will now briefly consider their state in inflammation.

Passing over the different theories of error loci, spasm, &c., which have at various times been entertained, let us first examine the condition of the capillary vessels, for these are primarily and principally concerned. In inflammation, the balance of the circulation is destroyed, but a diversity of opinion has existed as to the precise nature of the change which occurs. It has been supposed, and perhaps correctly, that the circulation is, in the first instance, much accelerated in the capillary vessels of an inflamed part; but it has been satisfactorily proved by experiment, that, after inflammation is fairly established, the blood circulates more slowly than in the healthy state of the vessels. There appears, in fact, to be, as insisted upon by some writers on the subject, a state of excitement, then of collapse, followed, if the life of the part is not destroyed, by reaction. When a part is stimulated, the circulation is accelerated, and a greater quantity of blood is transmitted by its vessels: if the excitement is speedily removed, they recover themselves, though perhaps a little dilated, and no inflammation ensues. If, for instance, a foreign body of any kind gets entangled betwixt the upper eyelid and the bulb of the eye, and it is permitted to remain a few moments only, redness of the whole surface of the conjunctiva takes place, but it is transitory, and disappears entirely some short time after the extraction of the foreign body. If, however, it is permitted to continue longer in contact with this sensible surface, the membrane reddens more and more, and becomes thickened. Violent pain, with discharge of tears, and alteration of the secretion from the mucous surface, take place, ophthalmia is, in fact, established. If the exciting cause is applied for a sufficient length of time, the extreme vessels lose their contractility, they are weakened, become dilated, and the contained blood circulates slowly. When inflammation is fairly established in a part, the capillaries become considerably dilated, and the blood is often completely stagnated in the inflammatory point. In the circumference of this focus, it is accelerated as formerly noticed: the blood is probably stagnated for two or three days in the capillaries and in the contiguous cellular tissue, when the action is at all violent. It, however, begins to move again; it loses its colouring matter, while stagnated; the fibrin is assimilated to the neighbouring parts, or rather effused, so as to cause the thickening, and the blood globules have possibly undergone a change, and been converted into those of pus. If the disease be of a limited extent, and without breach of surface, they are carried into the circulation very gradually, and in such small numbers as not to produce injury to the health; otherwise the contamination of the blood by a large quantity of pus causes inflammatory fever. It is probable that the permanent dilatation occurs in consequence of the larger vessels in the immediate vicinity being incited, and propelling more blood into the minute capillaries than they can readily return into the corresponding veins; and in consequence of so great a degree of distension being produced, the vessels are incapable of again speedily contracting; the blood, also, from being stagnant, becomes of a darker colour. The larger trunks propelling blood into the distended and comparatively inert capillaries, which are incapable of transmitting into the veins the same quantity of fluid which they receive, will cause the throbbing or pulsating sensation. The blood circulating in the parts around is sometimes apparently changed in quality; it is redder, flocculi appear floating in it, and the globules disappear. These last may have been broken down, or partial decomposition may have taken place from a loss of vital power in the vessels themselves.

The blood globules are, perhaps, merely compressed; for whenever motion is produced in the fluid, they speedily reappear. Fresh globules also find their way into the affected capillaries from neighbouring vessels. The alteration in the component parts of the blood has been supposed to depend upon the previous state of the inflamed vessels in which it is contained: it is said soon to reassume its natural appearance, when brought into a healthy vessel, and reference is made to experiments on the web of the frog’s foot. When once altered, it is, however, questionable if the blood ever reassumes its natural appearance; of course the blood which takes the place of that which was stagnated in the capillaries will be natural. If there have been extensive inflammation, and therefore much altered blood, one of two things will happen, viz., inflammatory fever and its consequences, or the discharge of the offending matter (the altered blood) as pus. We may also conclude that the blood of an inflamed part undergoes chemical changes; for when the part becomes gangrenous, the blood then loses its red colour, and assumes a yellowish-brown hue, from the absorption of its colouring matter, which necessarily implies an alteration in its chemical constitution. It seems not unlikely, that the change which is early observed in the appearance of the blood of an inflamed part is the commencement of a chemical process, which, if the vessels do not regain their contractile power, terminates in the total destruction of the ordinary properties of that fluid. It is probable that the more modern speculators in medical science have paid too little attention to the state of the fluids, and to the fact that, when diseased action occurs in a part, its secretions and supplying fluid are very considerably changed.

But the blood in inflammation also undergoes a change, observable after its removal from the circulation, and especially when the system sympathises with the part affected. The blood, it is generally believed and stated, does not coagulate so quickly as in the natural state, or else, it is said, the red globules, being increased in specific gravity, fall rapidly to the lower part of the containing vessel, so that a yellowish crust appears on the surface of the crassamentum or clot; and this appearance is termed the inflammatory or buffy coat. The blood extracted from the veins of a patient labouring under inflammatory fever often appears to coagulate very quickly; but it contains an unusual proportion of fibrin. In certain states of inflammation, this crust is also much contracted, so that its marginal circumference is at a considerable distance from the sides of the containing vessel; its margins also are elevated and inverted; its upper surface is smooth, whilst the under adheres firmly to the coagulum; and in this state the blood is said to be cupped, as well as buffed. The appearance of the buffy coat is not peculiar to the inflammatory state, but is apparently dependent on hurried circulation, however occasioned. It frequently presents itself in blood removed from the circulation during pregnancy, and in several other conditions of the system, apparently altogether unconnected with inflammatory excitement. In these circumstances, however, the contracted or cupped appearance of the coagulum is hardly ever observed. An ignorance of the above fact leads to dangerous practice, inasmuch as certain practitioners will bleed, and continue to bleed, for very equivocal inflammatory symptoms, conceiving themselves fully warranted in so doing by the presence of the buffy coat. This coat is often not so apparent in the blood first drawn as in that afterwards abstracted.

In inflammation, as was formerly remarked, a greater quantity of blood not only flows into the capillary vessels, but it also escapes from them, or is extravasated. This may occur with or without rupture of the vessels, and to a greater or less extent, according to the violence of the action, and the texture of the part.

When local inflammatory action exists to a considerable degree, the general circulation is more or less disturbed. The heart, and the larger vessels supplying the capillaries, which are more immediately concerned in the local action, subsequently sympathise with the part affected, and, acting with greater vigour than usual, propel the blood into the extreme branches; so that the inflammatory excitement may be said to be gradually communicated by the continuous sympathy, till the whole sanguiferous system becomes subject to its influence. The degree of this general excitement depends greatly on the texture and function of the part primarily affected.

The term Passive Inflammation has been applied to that state in which the larger vessels are not excited, or have ceased to sympathise with the capillary branches. The term Chronic Inflammation is properly limited to the consequence of the acute inflammatory action, the part remaining turgid and swollen, the vessels over-distended with dark blood, but with little or no pain, and without heat or throbbing. Congestion is also employed to denote fulness of the vessels, large as well as small, when no sign of excited circulation, or of decided inflammatory action, has occurred. It is most frequently used, however, when describing the condition of an internal organ. An over-distention of a particular set of vessels may certainly exist (as a consequence of inflammation, or altogether unconnected with it), unattended with inflammatory action. These two states ought to be carefully distinguished from a similar condition of the vessels, attended with inflammation; for practice, which would be beneficial in the one case, is highly prejudicial in the other, and lamentable examples of the non-attention to this distinction are every day observed.

It may here be mentioned, that some have denied the existence of vitality in the blood; and to some minds it may, perhaps, be difficult to conceive how a fluid should be possessed of this principle. But no one can either doubt or deny that the blood, in its distribution, in its manner of receiving increase, in the secretions furnished by it, and in its various morbid changes, is governed by certain laws and principles which cannot be explained by those of chemistry or mechanics, but must belong to some other power. It is allowed, and has been promulgated by all authors, that the blood is one of the most active agents in the animal economy—in repairing waste, in affording peculiar fluids necessary in that economy, in supplying organs with materials for carrying on their functions, &c.; and yet all this, according to some, is accomplished by a dead animal fluid; no one can plausibly object to the laws by which the blood is governed being referred to the power of life, and to their being called Vital Principles.