■ "■■■»vwwww^n«»*H*aMw*i*^qB«MHpB«p«||HpnavQHiMi mvvwnm 'iMtH ««p«|w/,;;;'y-'' ' y~.' ???::':■?■ ■ '---■• - - - - .-....,-,.^-..t,^, ^,. U ^-J.ILll^'.jf |-,ttll- JL^ :; ::-;.■:»> ■'■;■'•' N^'d_^' "V^^OtO^i? ( ,■■. \ t * « ' ...,-•/ f H hvrz'r... . f * V % V . K —TTWicA St._ ...... J* hiitffz 'kz,U ._TU\r«\ St.— THE PRINCIPLES AND PRACTICE MODERN SURGERY. ^f THE CW*PRINCIPLES AND PR.AfiTlfiR^^^tf? PRINCIPLES AND PRACTICE —'VVitA St. — of M OD E RN SURGE R Y. v BY ROBERT DRUITT. " Id potissiinum agens, lit omipsis hypotbesibus, in praxi nihil adstruat quod tnultiplici cxpe- ricntia non sit roboratum." Act. Erud. Lips., 1722. SECOND LONDON EDITION. Xllustratett tofth iffttg s^ootr KnsraWuas. ♦ WITH NOTES AND COMMENTS BY JOSHUA B. FLINT, M.D.—M.M. S.S. LECTURER ON THERAPEUTIC AND OPERATIVE SURGERY IN THE " LOUISVILLE ACADEMY OF MEDICINE, AND LATE PROFESSOR OF SURGERY IN THE MEDICAL INSTITUTE OF LOUISVILLE." rirTLAUELPHiA: LEA & BLANCHARD. 1842. V ; >W\\ *A vVO Entered according to Act of Congress, in the year one thousand eight hundred and forty-two, by LEA &, BLANCHARD, \;a the Clerk's Office of the District Court of the Eastern District of Penney Ivania. GRIGGS & CO., PRINTERS. TO CHARLES MAYO, Esq. SENIOR SURGEON TO THE WINCHESTER HOSPITAL. IN ADMIRATION OF HIS SOUND JUDGMENT AND SKILL IN SURGERY, AND r IN GRATEFUL ACKNOWLEDGMENT OF EARLY KINDNESS, THIS WORK IS DEDICATED BY HIS AFFECTIONATE NEPHEW (VND OBEDIENT SERVANT, ROBERT DRUITT. 6, Bruton Street, Berkeley Square, June 1st, 1841. PREFACE TOTHE SECOND EDITION. A long preface is not necessary to explain the purport of this work. Suffice it to say, that it is meant to afford a short but complete account of modern surgery; to contain every thing that is essential to the right un- derstanding of its principles, and to embody the experience of the highest authorities as to the best rules lor practice. Short books have in general one of two faults. Either they are made short by the omission of much that is important, insomuch that they are very bad guides for the student, and utterly useless to the advanced'practi- tioner; or they are made short by condensation, and are so crabbed and intricate in style, that some cannot understand them, and others will not take the trouble to read them. I cannot expect this work to be entirely free from both these faults; but yet the favourable reception which the former edition met with from readers and critics leads me to hope that it answered its intended purpose; and that by adhering to the most rigid method, and by making, where possible, a numerical division of the sub- jects, I succeeded in rendering it tolerably complete, readily comprehen- sible, and not difficult of retention by the memory. I have added a hun- dred pages to the practical department of the present edition, which I be- lieve contains every novelty in surgery that deserves mention; but let me add, that in conformity with the motto on my title-page, I have carefully excluded all new-fangled modes of treatment that appeared to me to be contrary to the rules of sound English practice. The arrangement of a work of this kind ought not, as I conceive, to be regarded as a matter of mere indifference, or at most of convenience, but it ought to embody in it something of a principle; and I believe that the arrangement of this work may be useful to the student, by showing him in what order he may best prosecute his researches into the principles of his profession. Of the five parts into which it is divided, the first two are more espe- cially devoted to the principles, and the three others to the practice of suro-ery. The first part treats of the disturbances of the constitution at PREFAi E. with large, that maybe produced by injury or disease of apart; beginning the simple faintness or collapse that follows a blow, and proceeding to consider the varieties of fever and tetanus. The second part describes what may be called the elements of local disease; that is to say, those morbid changes of structure or function, which are produced either immediately by external causes, or seconda- rily, through some deviation from health. And this part includes not only the common changes of structure which may be produced, almost at will, in any constitution; but those diseases also, such as cancer and scrofula, which require some peculiarity of the system for their development, and which are consequently termed specific. Had my limits permitted, I would gladly have made this part of the work more complete, and have included in it an abstract of general pathology; speaking more fully both of local changes, and of the manners in which they are modified by dif- ferent kinds of health. Let me observe here that the man who looks upon inflammation as a mere hydraulic derangement of the blood-vessels, or as something red, that must be bled and starved, may be what is vulgarly called simple and decisive in his practice, but is not very rational and cannot be very successful. The third part treats of the various kinds of injuries, beginning with the simplest mechanical injuries; then proceeding to the effects of chemical agents, and lastly, considering the effects of animal poisons. "With regard to the last-mentioned class of morbific agents, I may observe, that with- out a knowledge of hospital gangrene, dissection wounds, and glanders, no one can have very clear ideas on the subjects of infection and conta- gion, or of the action of those other morbid poisons, whose effects come within the so-called domain of physic. The fourth part considers the various tissues, organs, and regions of the body in order, and describes the various accidents they are liable to, and such of their diseases as are commonly assigned to the care of the Burgeon. The fifth part describes such of the operations as were not included in the former parts. So much for the arrangement of the work; from which I have never hesitated to deviate in slight paiticluars, for the purpose of avoiding repetition, or of not separating subjects that might be better treated of in connexion. To the whole is appended a collection of formulae, the number of which is very much increased in this edition. R. D. 6, Bruton Street, Berkeley Square, June 1, 1841. PREFACE TO THE AMERICAN EDITION. The American Editor of the present volume can claim but little parti- cipation in the merits of it beyond what is due to an early appreciation of the excellencies of Mr. Druitt's book, and an earnest and successful effort to procure its republication. Upon a thorough examination of it with a view to this undertaking, it appeared that its author had been so eminently successful in collecting and arranging whatever could be introduced into such a work with advantage, as to forbid any aspira- tions for the honours of authorship to a revising Editor, even in the hum- ble offices of annotation and commentary, and he engaged in the enter- prize ambitious only to be instrumental in introducing to his profession in this country, and especially in the west, the best compend of the princi- ples and practice of surgery extant. The only work of the kind, to be compared with it, is the admirable Dictionary of Mr. Samuel Cooper, and though a high compliment, it is not an undeserved one to this volume, to say that, in view of its final purpose and uses, it is, in many respects, entitled to a preference. Mr. Cooper's disquisitions—historical and speculative—on various subjects, though always learned, ingenious and interesting, are frequently too ela- borate and discursive for a book of practical reference, and the substance of them may generally be found in brief and comprehensive paragraphs, by Mr Druitt, and accompanied by such ample biographical references as will enable the surgical student to prosecute his inquiries under the light of all the best guides and authorities which the science can supply. The systematic and methodical arrangement of topics in one volume, while it may be a little less convenient in a manual tor the practitioner, than the alphabetical order of the -Dictionary," nevertheless contributes essentially to its excellencies as a text-book for the student. In this re- snect it will be found to answer an important desideratum in the appara- tus of teaching, and cannot fail to become a favourite as well with Profes- sors of Surgerv as with their pupils. V full course of surgical instruction, of which this should be an epi- tome or synopsis, would be as nearly a complete one, both in arrange- Zi -d matter, a, the present state of the science and the didactic .renins 'of the best teachers, could produce. ' The extensive circulation which such claims cannot tad to secure to a ,rk of this kind, among the teacher, and practitioners of our art, in this worl 9 IX PREFACE TO THE AMERICAN EDITION. country, offered a tempting opportunity lor the Editor to introduce to their notice such views and principles of practice, on the various surgical topics, as his own observation and reflection had contributed to establish and render favourite and important ones, in his own estimation. Among these results of his personal investigation are certain conclusions respect- ing the natural history of calculous affections, and the causes of their greater frequency on this than on the other side of the Alleghenies, which it would have been particularly agreeable to him to have communicated to the profession in this way. and which probably would have been in- teresting to most medical readers. But, a fear of rendering the book too voluminous for its peculiar uses, inability to find a single chapter or sec- tion in the original which could be dispensed with, and, especially, a reluctance to violate its rigid eclecticism determined him to abstain in the present reprint, from any such additions. A few brief notes of a practical character, the transposition of two or three sections, and the change of name, from " The Surgeons Vade Mecum" to the one now substituted—comprise the only material alte- rations on which he has ventured. The latter alteration was made partly as a matter of taste, but chiefly upon considerations of significancy and pertinence. " Vade Mecum " is a title by no means expressive of the true character of this work—it indicates indeed, the modesty of its author, but is far from comporting with the real dignity and merit of his produc- tion. " The Principles and Practice of Modern Surgery " is certainly a significant title for a book which, like the present, is a faithful codifica- tion of the opinions and practice of Hunter, Pott, B. Gooch, Abernethy, the Bells, Physick, Dupuytren, Hennen, Macartney, Larrey, the Coopers, Scarpa, Lawrence, Liston, Guthrie, Mayo, Brodie, Carmichael, Warren, Wardrop, Key, Travers, Dudley, Breschet, Tyrrell, Green, Dieffenbach, Civiale, Leroy, Arnott, Barton, Ricord, Colles, Stanley, and most of the other distinguished surgeons who have flourished since the commence- ment of the Hunterian epoch. Without any of the adventitious aids to which most publications of the present day owe their success—the pre- vious heralding, and subsequent puffing which are usually in requisition at a literary debut—without the prestige of rank or official distinction on the part of its author, the "Vade Mecum" has secured an extraordinary popularity in Great Britain, and the most flattering commendations of medical critics. Such testimony to its intrinsic merits has encouraged its republication here, and will bespeak for it a favourable reception among the practitioners of our country, to whom it is respectfully commended, by Their Friend and Brother, J. B. F. Louisville, April 5th, 1842 CONTENTS. PART I. OF THE CONSTITUTIONAL EFFECTS OF LOCAL INJURY AND DISEASE. Chapter I. Of Prostration or Collapse - - - 17 II. Of Prostration with Excitement - - 20 III. Of Fever - - 21 Section 1. Of Fever generally - - ib. 2. Of Inflammatory Fever - - 22 3. Of Irritative Fever - - 27 4. Of Hectic Fever - - - 28 5. Of Typhoid Fever - - 30 IV. Of Tetanus - ' - - - - 32 PART II. OF THE PRINCIPAL PROCESSES OF LOCAL DISEASE. Chapter I. Of the General Phenomena of Inflammation - 45 II. Of Acute Inflammation - - - 52 III. Of Chronic Inflammation - - - 59 IV. Of Effusion of Serum 61 V. Of Adhesion or the Production of New Tissues - 62 VI. Of Haemorrhage 66 VII. Of Suppuration and Abscess - - - 67 Section 1. Of the Theory of Suppuration and Properties of Pus - - ib. 2. Of Acute Abscess - - - 73 3. Of Chronic Abscess - - 77 4. Of Diffused Abscess, or Diffuse In- flammation of the Cellular Tissue 81 Of the Diseases of the Skin - - 82 5. Erysipelas - - - ib. Xn CONTEXTS. Chapter VIII. Of Ulceration - - - - - 87 Section 1. Of the Pathology of Ulceration ib. 2. Of the Varieties of Ulcers - - 90 IX. Of Mortification - 10i Section 1. Of the Pathology of Mortification - ib. 2. Of the Symptoms and Treatment 106 X. Of Scrofula - - - - - H2 XI. Of Malignant Diseases - - - 120 Section 1. Introductory - - -lb. 2. OfScirrhus, or Carcinoma Simplex 122 3. Of Medullary Sarcoma, and Fungus Iloeinatodes - - - 126 4. Of Gelatiniform Cancer, Melanosis, and other rarer varieties of Malig- nant Disease - - 128 PART III. OF THE DIFFERENT SPECIES OF INJURIES. Chapter I. Of Incised Wounds .... 129 II. Of Punctured Wounds - - - 133 III. Of Lacerations and Contusions ... 134 Section 1. Of Contusion and Ecchymosis - ib. 2. Of Lacerated and Contused-Wounds 137 IV. Of Gunshot Wounds - - - 138 V. Of the effects of Heat, Burns, and Scalds - 150 VI. Of the Effects of Cold - - - 157 VII. Of the Effects of Mineral and Vegetable Irritants - 160 VIII. Of the Effects of the Poison of Healthy Ani- mals, and of the Treatment of Poisoned Wounds generally - - - 162 IX. Of the Poisons contained in Dead Human Bodies and of Dissecting Wounds - - - 167 Section 1. Of the Poisons contained in Dead Bodies, and of the Influence of Dis- section on the Health - - ib, 2. Of Dissecting Wounds - . 170 X. On the Effects of Poisons generated by Diseased Animals - j~g Section 1. Of Hydrophobia - . ^ 2. Of the Glanders - . jgg XI. Of the Venereal Disease - jao Section 1. Of its General History and Pathology ib. CONTEXTS. Xlll Section 2. Of Gonorrhoea - - - 193 3. Of Primary Syphilitic Ulcers - 201 4. Of Treatment of Primary Syphilis - 205 5. Of Bubo - - - 210 6. Of Secondary Syphilis - - 212 PART IV. OF INJURIES AND SURGICAL DISEASES OF VARIOUS TISSUES, ORGANS, AND REGIONS. Chapter I. Of the Diseases of the Cellular Tissue - - 216 Section 1. Carbuncle and Boil - - ib. 2. Tumours - - - - 217 i. Tumours - - 219 n. Malignant and Semi-malignant Af- fections - - - 221 III. Of Diseases and Injury of Muscles, Tendons, and Bursae - - - - 223 IV. Of the Diseases and Injuries of the Lymphatics - 230 V. Of the Diseases and Injuries of Bone - 231 Section 1. Of the Diseases ... ib. 2. Of Fracture generally - - 238 3. Of Non-union and False Joint - 242 4. Of Compound Fracture - - 243 5. Of Particular Fracture - - 245 VI. Of the Diseases and Injuries of Joints - 262 Section 1. Of the Diseases of the Synovial Mem- brane - ib. 2. Inflammation of the Cellular Tissue - 266 3. The Ligaments - 266 4. The Cartilage - - 267 5. Articular Caries, - - - 269 6. Anchylosis - - - - 270 7. Of Disease of the Hip Joint - 271 8. Wounds of Joints - - - 274 9. Of Dislocation generally - 274 10. Of particular Dislocations - - 275 VII. Of Injuries and Diseases of Arteries - - 285 Section 1. Of Wounds of Arteries - - ib. 2. Of Inflammation of Arteries - 290 3. Of Aneurism - - - 291 4. Of Aneurism by Anastomosis and Naevus - - - 296 VIII. Of Injuries and Diseases of Veins - - 299 CONTEXTS. Chapter IX. Of Injuries and Diseases of the Nerves - 303 X. Of Injuries of the Head - - - - 307 Section 1. Wounds of the Scalp - - ib. 2. Concussion of the Brain - - 308 3. Compression from Extravasated Blood- - - - 310 4. Fractures of the Skull - - 311 5. Wounds of the Brain, Hernia, Cere- bri, &c. - - 312 6. Inflammation of the Brain - - 313 7. Trephining and Paracentesis - 315 XI. Of the Diseases and Injuries of the Spine - 317 XII. Of the Injuries and Diseases of the Eye - 324 Section 1. Of Wounds and Foreign and Bodies 324 2. Diseases of the Eyelids - - 325 3. Diseases of the Lachrymal Apparatus 326 4. Of Inflammation of the Eye, gene- rally, and of the Diseases of the Conjunctiva- - - 328 5. Of the Diseases of the Cornea - 338 6. Diseases of the Sclerotic - 336 7. Inflammation of the Anterior Cham- ber, or Aquo-Capsulitis - 336 8. Of the Diseases of the Iris - - 337 9. Inflammation of the Capsule of the Crystalline Lens - - 340 10. Of Cataract - - - 340 11. Of the Diseases of the Vitreous Hu- mour ... 347 12. Inflammation of the Choroid and Retina .... 347 13. Of Amaurosis - - - 348 14. Of Short and Long Sight - - 352 15. Of Squinting - 353 16. Of Malignant Disease of the Eye - 356 XIII. Of the Diseases and Injuries of the Ear - 358 XIV. Of the Diseases and Injuries of the Face and Nose ----- 362 XV. Of the Surgical Diseases and Injuries of the Neck 380 XVI. Of the Surgical Diseases and Injuries of the Chest 394 XVII. Of the Surgical Diseases and Injuries of the Ab- domen ----- 398 XVIII. Of Hernia - - - . - 404 Section 1. Of the Nature and Treatment of Hernia generally - . {0 CONTENTS. XV Section 2. Of Inguinal Hernia - - - 412 3. Of Femoral or Crural Hernia - 416 4. Of the Umbilical, Ventral, and other remaining Species of Hernia - 418 Chapter XIX. Of the Surgical Diseases and Injuries of the Rectum and Anus ... 420 XX. Of the Diseases of the Urinary Organs - - 430 Section 1. Of Stricture of the Male Urethra ib. 2. Of certain Consequences of Stric- ture and other Affections of the Male Urethra - - - 435 3. Of the Diseases of the Prostate - 437 4- Of the Diseases of the Bladder - 440 5. Of Diseases of the Kidney, Haema- turia, and Suppression of Urine 443 6. Of Urinary Deposites, Gravel, and Stone; and of the Diatheses, or States of Constitution which give rise to them - - - 448 7. Of Stone in the Kidney and Ureter - 451 8. Of Stone in the Bladder - 452 9. OfLithotrity - - - 455 10. Of Lithotomy - - 458 XXI. Of the Diseases of the Male Genitals - - 464 Section 1. Of the Diseases of the Penis - ib. 2. Of the Diseases of the Testis and ' /; Scrotum- ... 465 3. Of Impotence - - - 470 XXII. Of the Surgical Diseases of the Female Genitals - 471 XXIII. Of the Diseases of the Breast - - 473 XXIV. Of Clubfoot, and other Deformities of the Limbs - 477 PART V. OF THE OPERATIONS OF SURGERY. Chapter I. Of Operations in general, and of the Extirpation of Tumours - - - - - 481 II. Of the Minor Operations - - - 483 III. Of the Amputations • - - - 488 IV. Of the Ligature of Arteries - - - 502 Appendix of Formulae - - - - - -513 PART I. OF THE CONSTITUTIONAL EFFECTS OF LOCAL INJURY AND DISEASE. CHAPTER I. OF PROSTRATION OR COLLAPSE.* Definition.—We shall use the terms prostration, or collapse, in the present chapter to signify that general depression of the powers and ac- tions of life, which immediately follows any severe injury. Symptoms.—The usual symptoms are, shivering; coldness of the sur- face and extremities; rapid, feeble, and tumultuous pulse; hurried and sighing respiration; dilated pupil, and oppression of the mental faculties. But these symptoms are liable to great variety; for they not only differ in degree, but the principal functions are unequally disordered in different cases. Sometimes depression of the vascular system predominates, and the patient lies in a state of perfect syncope, with the pulse and respiration imperceptible. Sometimes the nervous system is chiefly affected, the pa- tient being bewildered and incoherent, as though intoxicated; or even comatose, as though he had taken a narcotic poison. Nausea and vomiting, hiccup, and suppression of urine; and in children, convulsions, are also extremely frequent symptoms. Terminations.—The process of recovery from collapse is commonly called reaction: and the manner in which the case may terminate must depend on the nature and degree of that reaction. Thus, First, if it is healthy and moderate, and especially if the collapse arise merely from concussion (or violent shaking) of an organ, without actual injury to its structure, it will lead to complete recovery. Thus it very often happens that a slight blow on the testicle, or particularly on the stomach or liver, causes an extreme degree of sickness and faint- * The principal authorities to be consulted on the subject of the first two chap- tera, are Travers on Constitutional Irritation, third edition, and Hunter on the Blood, chap. ii. 3 18 PllO.-^l ItAlTtlN OR tOU.AI'sl . ne>d, which, however, passes off gradually, and leaves no ill conse- quences. Secondly. If reaction be excessive, the state of collapse will be gra- dually succeeded by fever, symptomatic of the inflammation to which the local injury has given origin. Thirdly. If reaction be imperfectly developed, it will be converted into the state of prostration with excitement, of which we shall speak in the next chapter. Fourthly. If reaction be altogether wanting, the collapse will termi- nate in death. And death may occur immediately on the receipt of the injury, if it be of extreme severity; or otherwise the patient may die more slowly, the pulse at the wrist becoming fainter, and finally ceasing; and the respiration more and more slow and oppressed, till life is gradu- ally extinguished. Causes.—These symptoms may be caused by every variety of injury to which the body is liable. Great and sudden extremes of grief, or joy, or fear, or cold;—.large doses of any active poison, such as arsenic, or sulpheric acid, or tobacco;—the sudden impression of miasmata, or of morbid poisons, as the plague;—great loss of blood, and mechanical in- juries. It is most important that the surgeon should know what injuries are most likely to be followed by fatal collapse, in order that he may have proper materials for giving his prognosis. They are, First, those of organs that are necessary to life, as the stomach and brain; and it is well known that a severe concussion of either of these organs may extinguish life instantaneously. Secondly. Injuries of organs which do not easily admit of reparation; as the joints. Thirdly. Injuries that are severe in their nature; as punctured, lace- rated, contused, and especially, gunshot wounds. Fourthly. Injuries of great extent, although they may be trivial in de- gree;—as extensive burns. Lastly. Injuries occurring to young infants or to the very aged; or to constitutions that are enfeebled by excess* and intemperance,! or by long standing bodily disease or mental depression. From this it will be learned, that the slightest injury, or surgical operation, the removal of a tumour for instance, may prove fatal to persons labouring under chronic organic disease, such as tubercles in the liver or lungs, or continued anxiety and despondency of mind; so that in almost any case, a firm persuasion that recovery is impossible, is almost sufficient to render it so. *---------" Tibi quidnarn accedct ad istani Quam puer et validus praesutnis molliticm, seu Dura valetudo incident, seu tarda senectus ?" Hor. Sat. ii. 2, 86. t Those who always live above par, says Hunter, are extremely liable to sink PROSTRATION OR COLLAP3E. 19 Treatment.—The indication is to excite the vital organs to a mo- derate and healthy reaction. This is to be fulfilled by the use of diffu- sive stimulants, such as hot brandy and water, aether, and ammonia; and putting heated bricks or bottles of hot water under the axillae and between the thighs, and covering the patient warmly till the circulation is restored, and the pulse has acquired permanent strength and firmness. Vomiting may be allayed by a large dose of solid opium (gr. ii.— iii.,) or by a large dose of calomel, (gr. v.) and opium (gr. ii.) or by an opiate enema (vide Formula 48) if the bowels are relaxed, or an aperient enema, especially of turpentine, (F. 49) if they are confined; or by effervescent draughts containing one or two minims of diluted hy- drocyanic acid, with ten of Battley's sedative, every hour. Counter- irritation to the epigastrium, by means of very hot water or a mustard poultice, (F. 44) is also highly useful.—Hiccup may be relieved by a teaspoonful of sp. setheris comp., or by sipping very frequently gruel, or some other bland fluid, and keeping very silent and quiet.—Convul- sions delirium and coma, are to be treated according to the state of the circulation; by ammonia and stimulants whilst it is depressed, but by a very cautious bleeding, or leeching, or purging, or application of cold to the head, if they remain after the circulation is restored and the pulse has become firm.—One remedy that it might be well worth while to try in an extreme case, is the wrapping a patient in the skin of a sheep, or of any other animal, stripped off immediately after its death. Baron Larrey had seen this done by certain humane Esquimaux, with the greatest benefit, to some shipwrecked Frenchmen that were half dead with cold, fatigue, and hunger; and he put it in practice with equal success in the case of Marshal Lannes, Due de Montebello, when he was dangerously bruised by a fall from his horse during one of Napo- leon's Spanish campaigns. Cautions.—Care must be taken on the one hand to continue the use of stimulants long enough, and to desist from them gradually if there is any fear that the collapse may return; and, on the other, not to carry them too far—for if the action of the heart is excited beyond its powers it will be more liable to be permanently exhausted. Besides, if the patient be over stimulated, the succeeding fever and inflammation from the injury will be aggravated; and the danger of haemorrhage will be increased from any blood-vessels that may have been ruptured. Finally, the vulgar and mischievous habit of bleeding patients immedi- ately after an injury, before they have recovered from a state of faintness and depression, needs only to be mentioned to be condemned. when attacked by disease or injury; for as they are habitually at the full stretch of living, their powers cannot be excited farther to meet any casual emergency.—On the blood, chap. ii. sect. 1. ( *' ) CHAPTER II. OF PROSTRATION WITH EXCITEMENT. Definition.—" Prostration with excitement, and excessive reaction," is the term used by Mr. Travers to signify a state which sometimes fol- lows the collapse from a severe injury; in which there is a violent but transient excitement of the nervous and vascular systems, without the development of that more permanent and sthenic action which constitutes inflammatory fever. Symptoms.—The symptoms vary extremely in different cases, although they present the uniform character of extreme and exhausting excitement, without genuine febrile action. There is great anxiety about the region of the heart: the respiration is oppressed and sighing; the pulse exceed- ingly rapid and bounding, but soft and compressible; the face is flushed, and there is vomiting. But, in the majority of these cases, the principal feature is the excitement of the nervous system, which is manifested by a peculiar delirium (delirium traumaticum) precisely similar to the de- lirium tremens.* The tongue is moist and tremulous; there is a gene- ral tremor of the muscles; the patient is totally sleepless, irritable in his temper, answers questions in a snappish, or peevish, or incoherent man- ner; is often anxious to call himself perfectly well; and as the malady in- creases, he becomes restless, impatient, and talkative; wishes, perhaps, to get out of bed, and attempts to injure his attendants, and soon becomes most furiously maniacal. In some cases, however, the delirium is of a milder cast; the patient is haunted with extravagant ideas and spectral il- lusions; or fancies himself busied in his ordinary avocations, and talks perpetually about them. Terminations.—The prognosis will be the more unfavourable, in pro- portion as the excitement is violent, as it cannot fail to lead to exhaustion, the pulse becoming irregular, the aspect livid and haggard, the extremi- ties cold, and coma supervening, which is soon followed by death. There will be some hope, however, if the pulse becomes more tranquil and firm, and especially if the patient sleeps. Causes.—The exciting causes of this state are (surgically considered) the various mechanical injuries before enumerated;—acting on constitu- tions that are weak, and consequently irritable;! that have " an increased • Copland's Diet. Pract. Med. Art. Delirium with Tremor. t Omne infirmum, naturi querulum. FEVER. n disposition to act, without the power to act with." Some examples of it occur in children, especially after burns; but they are most frequently met with in the case of persons of middle age and plethoric habit, who habitually indulge in excess of food and spirituous liquors, and who, as is well known, often die from many injuries and accidents which more temperate persons might have recovered from without difficulty. Treatment.—The indications are to moderate the excitement, and support the strength. If there be violent delirium, with heat and dry- ness of skin, and the pulse very sharp, the scalp should be shaved and kept wet with evaporating lotions; the bowels should be evacuated with a dose of calomel combined with camphor, followed by an aperient draught, or by enemata if there be much vomiting; taking care, however, not to purge so freely as to reduce the strength. At the same time hyos- cyamus should be given in moderate doses every hour or two; such as gr. v. of the extract or TT[ xxx. of the tincture—and if these means fail, one large dose (gr. ii.—iii.) of solid opium, or TT[ xl.—lx. of Battley's solution may be given after the bowels are opened. If, however, there be greater debility and restlessness, opium may be given in small doses, (gr. |—3 2nda, vel 3tia, quaque hora,) carefully watching its effects, and giving it up if it seem rather to augment cerebral excitement, or to induce coma. Enemata containing 3ft of laudanum may be preferable in some cases; or combinations of camphor and henbane with musk and anti-spas- modics. The strength should be carefully supported by beef-tea, arrow- root, &c: and if the patient have been accustomed to ardent spirits or opium, they may be allowed with great advantage in considerable quan- tity. The patient must be confined, if necessary, in order to prevent injury to himself or others; and he should be treated with calmness and indulgence, but yet with firmness. In the last stage, when coma super- venes, counter-irritation by means of sinapisms or blisters to the scalp, or feet, or calves of the legs, may be tried, but scarcely any means will avail. CHAPTER III. OF FEVER. SECTION I.--OF fever generally. General Description.—Fever may be described as a state in which all, or most of the functions of the body are deranged. The nervous 22 inflammatory fever. system is shown to be deranged, by the headach, pain in the back, lassi- tude, muscular weakness, mental torpor, and confusion of the perceptive senses. Chilliness or burning heat, testify to disorder of the function by which animal heat is produced or regulated. Respiration and circula- tion are either slow and embarrassed, or performed with preternatural frequency and force. Digestion and nutrition are suspended, hence the rapid emaciation. The secretions are either deficient, or, if abundant, are depraved; hence the thirst, dry skin, scanty urine, and costiveness or diarrhoea. Moreover, the fluids have a tendency to be vitiated, and the solids to be diseased, as shown by congestion and effusion in either of the three great cavities. Fevers are often divided into two grand families; the idiopathic and the symptomatic. The former arise from agents operating on the blood or nervous system; ague and typhus are examples. The latter are called symptomatic, because produced by disease or injury of some part. It is with these that the surgeon has to deal; and there are the following varieties, which we shall treat of successively. (1.) If there be acute inflammation in a healthy system, the fever will be inflammatory, which is commonly called symptomatic fever. (2.) If there be acute inflammation in a weakened or cachectic system—or if the inflammation arises from certain specific causes of a depressing ten- dency, such as morbid poisons,—or if it attack certain structures, as the veins;—the fever is generally called irritative. (3.) If the inflammation have terminated in an exhausting suppuration, or if there be a permanent disease which the constitution has no power to vanquish, hectic fever will be established. (4.) When the vital powers are entirely exhausted, the fever assumes what is called a typhoid type; which, in the emphatic language of Hunter, is termed dissolution. (5.) Lastly, fever, even when arising from a local cause that is permanent, may be intermittent; that is, may occur in definite paroxysms, with intervals of health.—This is often the case in diseases of the urinary organs, such as stricturescind fistulae in perinaso: and sometimes in worms or other states of irritation of the intestinal tube. section ii.—of inflammatory fever. Syn.—Synocha, Cullen. General Description.—This fever accompanies every acute inflam- mation which arises from a severe and considerable injury, or affects parts of great sensibility and importance in healthy subjects. And it is almost a natural and necessary concomitant. " Nature," says Hunter " requires to feel the injury; for where after a considerable operation inflammatory fever. 23 there is rather a weak quiet pulse, often with a nervous oppression, with a seeming difficulty of breathing and loathing of food, the patient is in a dangerous way. Fever shows powers of resistance; the other symptoms show weakness, sinking under the injury."* Symptoms.—Slight shivering ; succeeded by increased heat of skin :t preternaturally frequent, hard, and vibratory pulse ;—pain and aching in the head, back, and limbs, with a sense of lassitude and muscular weak- ness;—general deficiency of the secretions; dry skin; dry and white tongue; thirst; nausea and loss of appetite; constipation; scanty and high- coloured urine;—the blood generally buffed and cupped;—slight aggrava- tion of the symptoms in the evening, often delirium in the night, and slight remission in the morning. Terminations.—(1.) If the patient recover, the urine becomes more copious, and deposites a lateritious sediment;:}; the tongue becomes moist and clean, the skin cool and perspiring; the local inflammation either is resolved, or proceeds to a healthy suppuration; and the return of the appetite and of the other natural functions indicate the patient's recovery. The formation of pus often appears to be a natural crisis.§ (2.) But if from the irreparable nature of the disease or injury, or from the irrita- bility of the system, life is destined to be destroyed, the pulse becomes continually more frequent, and subsequently weak, irregular, and inter- mittent, the extremities cold, and life soon ceases with the failure of the circulation. Treatment.—The treatment of this fever is included in that of acute inflammation, of which it is the shadow. But it must be observed in this place, that when it is symptomatic of an inflammation that is un- avoidable, (as after a compound fracture, and most other severe injuries,) it cannot be cut short, although its undue violence may be abated;—and that great care should be taken not to weaken the patient too much by depletion, especially if the part injured be not of vital importance, and its reparation will require time and strength. The indications are, to allay vascular action and nervous irritation, and to restore the secretions. And the means are, rest, low diet, aperient and febrifuge medicines, ano- dynes at bed-time when the bowels have been cleared, and general or local bleeding if demanded by the exigencies of the case. * On the blood. Chap. iv. sect. 6. t From increased determination of blood to it, and deficiency of the secretion which naturally carries off the heat. In ordinary symptomatic fever, the real heat of the blood does not rise more than three or four degrees above the natural stan- dard; but in scarlet fever it has risen as high as 1160. t Lateritious, like brick-dust, from later, a brick. § K/>/«f, any important phenomenon in a disease (mostly an evacuation of some sort) by which the patient's safety or danger may be judged of. 24 inflammatory i ever. Caution.—Although it is always expedient to open the bowels, yet purging should be avoided when it is likely that the disturbance which it occasions may be detrimental to any diseased or injured part, as a com- pound fracture, or the like. Of the Pulse.—It may be convenient to say a few words in this place about the pulse. The elements of the pulse are three; namely, first, the contraction of the heart, which propels blood into the arteries;—secondly, the yielding and dilatation of the artery, which when felt constitutes the pulse s*—and, thirdly, the return of the artery to its former caliber. Now some of the properties of the pulse depend on the heart, and some on the arteries. Thus its frequency and slowness correspond to the number of the heart's contractions in a given time. Its quickness (or sharpness) depends on the velocity and impetus with which each individual contrac- tion is made. On the other hand, hardness of the pulse depends on the resistance offered to the ingress of the blood, by the constant tonic con- traction of the contractile coat of the arteries; but if that contraction is trifling, so that the vessel yields readily to the impulse of the blood, or the pressure of the finger, the pulse will be soft. The vibratory feel, or thrill, or jar, is caused by an irregular dilatation of the artery, which dilates with an innumerable number of stops and interruptions. The full and small pulse depend in some measure on the quantity of blood in the system, but principally on the state of the vessel, for if that does not dilate freely, the pulse will be small. A small hard pulse is a much safer indication for bleeding than a full soft one. In the fever accompanying acute inflammation of any common part, such as skin, cellular tissue, or muscle, or of the eye, dura mater, or pleura, the pulse is generally frequent, hard, and full. During acute inflammation, however, of the brain and stomach—parts most essential to life—or of the peritoneum, testicle, and kidney, which are most intimately connected with the stomach by the sympathetic nerve, the vital powers seem to be more depressed, and the pulse is frequent, hard, and small. Again, during acute inflammation in a very weak and irritable constitu- tion, or after great loss of blood, the pulse may either be very frequent, smalt, and soft, or frequent, large, soft, and jerking; the soft jerking quality indicating an almost passive yielding to the heart's impulse, and being caused by an absence of that contractile tone which renders the pulse small and hard.t * If the artery is perfectly straight, and the circulation tranquil, the dilatations will not be so great as to be perceptible to the eye, and can only be appreciated by compressing the vessel slightly between the fingers; whereas if it is curved each impulse of the blood will slightly straighten it, and cause a sensible motion. t Wilson Philip. Experimental Inquiry into the Laws of the Vital Functions p. 323, 3d edition. See also Hunter on the Blood, Chap. iii. sect. 8. inflammatory fever. 25 Buffy Blood.—The reader need scarcely be reminded, that after healthy blood has coagulated, it divides into two portions, serum and crassamentum;—that the serum is a watery solution of the albumen and salts, whilst the crassamentum consists of the fibrine and red particles;— and that the fibrine, which by itself is yellowish white, derives a uni- formly red tinge from the equal diffusion of these particles. But, on the other hand, the crassamentum of inflammatory blood has on its surface " a buffy coat,'''' that is, a yellowish white layer of fibrine free from red particles;—which layer may vary from one line to one third of the clot in thickness, and is frequently so strongly contracted as to make its sur- face concave or cupped, and its edges fringed. We have therefore to inquire, first—what change in the blood causes this deviation from its ordinary appearance;—and secondly, what states of the system produce this change in the blood. (1.) With regard to the first inquiry, there are four changes in the state of the blood which, together or singly, may be possibly concerned in the production of the buffy coat. First, a slow coagulation, so that the red particles have time to sink, and leave the upper surface of the clot colourless. Secondly, an increased specific gravity of the red parti- cles, so that they have an unusual tendency to subside quickly. Thirdly, a disposition of the fibrine to separate itself from the mass of the blood. Fourthly, an increase in the quantity of the fibrine. Now the first of these conditions, namely, the slow coagulation, gene- rally exists in inflammatory fever, " when the powers of life are unim- paired, the circulation rapid, and the blood drawn in a full stream."* But still, as Hewson says, " something more than merely a lessened dis- position to coagulate is necessary for forming the crust or size,"t because, in the first place, if blood be confined by ligatures in a vessel of a living animal, or if an animal die a sudden and violent death, although in both these cases the blood will coagulate very slowly, it still will be free from the buffy coat, and, in the second place, inflammatory blood sometimes coagulates very quickly. So that slow coagulation cannot be admitted as the essential cause.J The second condition, namely, increased gravity of the red globules, was supposed to be proved by an experiment of Hunter's;§ but as it was soon after disproved by Hewson, who repeated Hunter's experiments with a totally opposite result, no great weight can be laid upon it. The third alleged cause, the spontaneous separability of the fibrine, is * Copland, Diet., Art. Blood. t Hewson; Experimental Inquiry into the Blood. Lond. 1772. Chap. ii. pp.34 ct seq. t Mailer's Physiology by Baly, 2d edition, vol. i. p. 129. § Hunter says also that the scrum is specifically lighter than usual. 1 2(i inflammatory fever. established on better evidence. " The blood in inflammation," says Hunter, " more readily admits of a separation of its visible parts." In fact the fibrine (which was assumed by Hewson to be highly attenuated) may be seen to rise to the surface of inflammatory blood very soon after it is drawn, giving it a bluish appearance. The fourth condition, the increased quantity of the fibrine, has been proved to exist, by the experiments of Thackrah,* Andral, and others. But whilst some authors assert that it is increased at the expense of the albumen of the serum, and that the serum of inflammatory blood contains less albumen than usual; others, as Gendrin, affirm that the serum is pre- ternaturally albuminous.t From a due consideration of these circumstances, it appears most proba- ble that the buffy coat depends partly on some change in the vital properties of the blood, by which the fibrine is disposed to separate itself from the liquor sanguinis;—and partly, perhaps, on a diminished viscidity and slow coagulation, which permit the red particles to subside quickly.^ The cupping is easily accounted for by the strong contraction of the buff; for the crassamentum of inflammatory blood is always extremely dense and firm, although there may be no buffy coat whatever. (2.) In the second place, we have to consider by what states of the system these changes in the blood are produced. Hunter says that they are produced by an increase of the powers of life, and by an increase of the disposition to act with those powers. And we have both positive and negative evidence that this is correct. For the buffy coat is found on the blood of healthy pregnant women and animals, in whom the powers and actions of life are augmented without doubt; and it is always most conspicuous when the circulation is rapid, and when the blood is drawn in such a manner as to preserve its vital properties; that is, in a full rapid stream, into a deep vessel, the temperature of the apartment being high. On the other hand, the buff will be deficient, when the blood is drawn in such a manner as to deprive it speedily of its life; that is, in a small slow stream, into a flat and shallow basin, the temperature being low. It is remarkable, that the buffy coat is occasionally absent at the com- mencement of some inflammations, especially of the lungs, whilst the circulation is slow and labouring and embarrassed, and whilst it may be * Thackrah, C. T. on the Blood. Lond. 1834. Andral, in Dublin Med. Press, t Albumen and fibrine are almost identical in chemical composition; and the former, when coagulated, can scarcely be distinguished from the latter. } Davy's Experimental Researches. Lond. 1839, vol. ii. This eminent physiolo- gist den.es that the quantity of fibrine is increased, and advocates Hewson's doc trine, that tne fibrine is attenuated, and the blood lc viscid, during inflammation irritative fever. 27 supposed that the nervous system is oppressed by the intensity of the inflammation; and that it may make its appearance as soon as that oppres- sion is removed by bleeding. Thus, during one venaesection, it has hap- pened that the blood first drawn has not been buffed, owing, as we»pre- sume, to the embarrassed circulation;—the buff has appeared in a second portion when enough has been drawn to relieve that embarrassment; — and has again disappeared in a third, when the circulation has become languid at the approach of syncope. Finally, the buffy coat, considered as an evidence of fever or inflamma- tion, is, like every other symptom that our conjectural art presents us with, not to be depended on invariably. For, in the first place, it may be present when there is no inflammation;—as in pregnant women; in the plethoric; in persons accustomed to be periodically bled, or who are habitually exposed to the night air.* Again, its quantity is by no means proportioned to the intensity of inflammation; for it is constant to the last in rheumatism, even when subdued by bleeding. And there are certain inflammations of great intensity in which it does not exist at all; as in the commencement of sundry cases before mentioned;—in inflamma- tions that have little of the adhesive tendency, as those of mucous mem- branes, or diffuse inflammation of the cellular tissue; and in the in- flammations arising from certain morbid poisons, as glanders, or in the course of typhus fever.t when the blood, having lost its vital qualities, scarcely coagulates at all. section hi.—of irritative fever. General DEseRipnoN.—The term Irritative Fever seems to be con- ventionally assigned to a form of violent and dangerous constitutional disturbance, which apparently combines the characters of inflammatory fever and of prostration with excitement; and which is scarcely to be distinguished from the early stage of typhoid fever.£ Or perhaps it may be more convenient to describe it as the set of constitutional symptoms which attend phlebitis, diffuse inflammation of the cellular tissue; the disease arising from glanders, and from wounds poisoned during dissec- tion;—also severe phlegmonous erysipelas and inflammations in which there is great pain from the confinement of matter;—all of which cases * Samuel Cooper. First lines of Surgery. t Palmer's edition of Hunter. Vol. iii., p. 39, note. t Some authors state that the blood is most buffed when there is an inflammation with considerable tendency to effusion of fibrine, as pieurisy or pericarditis; others state that it is most buffed when the inflammation has no adhesive tendency, as acute rheumatism, so th:it the fibrine cannot escape from the blood: a curious in- stance of contrary deductions from the selfsame facts, when partially viewed and hastily generalized. 28 HECTIC FEVER. exhibit a combination of violent local inflammation, great febrile commo- tion, and great depression of the vital powers. The Symptoms and Treatment will be particularized under the head of tike various local affections which this fever accompanies. The lead- ing features are great restlessness and anxiety, debility, depression of spirits, weight at the prtecordia, oppressed respiration; frequent rigors; rapid and sharp pulse, but variable in force; death, preceded by low delirium, and signs of great exhaustion. The treatment must, as a general rule, be directed to the invigoration of the vital powers by cordial stimulants and tonics, the evacuation of depraved secretions, and the removal of pain and irritation, and of local disease, by whatever measures are most ap- propiiate.* SECTION IV.—OF HECTIC FEVER.t Definition.—Hetic fever is an habitual disorder of the system, when irritated by some long-standing disease, or source of weakness which it is unable to remove. It is a remittent fever, and is accompanied by a general tendency to increase of one or more secretions. Symptoms.—Emaciation and debility; tongue morbidly clean and red, especially at the tip and edges; appetite often inordinate; disposition alternately to diarrhoea and profuse perspiration;!: pulse frequent and small;—a febrile exacerbation comes on every evening (or oftener, especi- ally after meals) with slight chills, followed by heat of skin, burning of the soles of the feet and palms of the hands, and a circumscribed flush in the cheeks;—thirst and restlessness, preventing sleep till after the mid- dle of the night, when the patient falls asleep, and suddenly wakes in a profuse perspiration;—often buoyancy of spirits and hope to the last. Terminations.—(1.) If it be about to terminate fatally, the debility increases; the diarrhoea and perspirations become more profuse and ex- hausting; the legs become oedematous; aphthae form; and greatpain; griping and tenesmus attend the diarrhoea, owing to an inflammatorv or ulcerated condition of the intestines. The patient may expire suddenly, the heart failing from mere debility; or death may be preceded by typhoid symptoms. And thi3 fatal termination may be owino- either to the con- tinuance of the original disease, or to the induction of secondary disease in the lungs or mesenteric glands. (2.) Recovery from hectic is often remarkably rapid, if the causes be removed; provided that no secondary disease has commenced. Causes.—Any chronic organic incurable disease;—whether incurable » Vide part ii. chap. vii. sect. iv. on Diffuse Inflammation of the Cellular Tissue; and part iii. chap. ix. sect. ii. on Dissection Wounds. t From e|/c, sxt<;:oc, habit, habitual. t Called colliquative; (liquo, I melt;; because they exhaust the system. HECTIC FEVER. 29 from its nature, as scirrhus, tubercle;—from its seat, as the lungs or mesentery;—from its extent:—or from constitutional debility; also ex- haustion from profuse suppuration;—or from any other great and con- tinued discharge;—as prolonged lactation, leucorrhoea, and so forth. Hectic is so frequently caused by profuse suppuration, that an absorption of pus was formerly deemed to be its invariable and efficient cause. Hunter denied this theory—1st, because hectic may arise from organic disease, or from excessive discharge of any secretion when there is no suppuration; 2ndly, because pus may be absorbed (as it often is from chronic abscesses and buboes, which are discussed without being opened) without the production of hectic* It is certain, therefore, that absorp- tion of pus is not the only cause of hectic. But it is equally certain that pus is absorbed from extensive suppurating surfaces; and it is probable that its presence in the blood adds to the hectic and constitutional debility; and that (especially if it be vitiated or decomposed) it tends greatly to the production of colliquative diarrhoea and ulceration of the intestines.f For the injection of pus or putrid matter into the blood almost invariably causes diarrhoea;^:—an effect also which is notoriously produced among students who absorb the putrid vapours of the dissecting-room. Treatment.—The indications are (1) to remove the local cause; (2) or if that be impracticable, to enable the system to support it. The first indication may often be fulfilled by an amputation or other operation; and it is well known that hectic patients often bear operations extremely well, recovering from them rapidly, and making but one step as it were from death's door to perfect health.§ In cases not admitting oi requiring an operation, local mischief must be remedied, and profuse discharges re- strained as far as possible. As for the second indication, the strength must be maintained by a mild nutritious diet; that is, as much food may be given as the stomach can digest with comfort; and wine, porter, or beer, may be allowed in order to assist digestion; but the quantity of animal food and of spirituous liquors must be regulated, so that they may not add to the excitement, nor increase the heat of the skin, thirst, and perspirations. Arrowroot and other farinaceous preparations; jellies, Iceland and carragee moss, are useful as mild nutritives occasionally, when there is an excess of heat and feverishness; but these slops should not be given at such times or in such quantities as to interfere with the di- « On the Blood. Ch. ix. sect. 1. + Copland ; Diet. Prac. Med., Art. Hectic, p. 965. t Vide part ii. ch. vii. of this work. § « The removal of a diseased part which the constitution has become accustomed to, and which is rather fretting the constitution, is adding less violence than the re- moval of a sound part in harmony with the whole." Hunter on the blood. Ch. ii. sect. 2. 30 TYPHOID FEVER. gestion of more solid food, if there is an appetite for it. Tonics may be given to support the strength; such as bark, quinine, or cascarilla; or sometimes the preparations of iron; but if at any time, in the varying pro- gress of the disease, excitement appear to prevail, the pulse being more accelerated, and pain aggravated, tonics and animal food must be for a time exchanged for saline medicines and farinaceous or milk diet. Di- gitalis, a remedv much used in hectic, may be of service at such times, if given in a few moderate doses, for not too long a time. Ten minims in a saline draught, at bed-time, are a proper dose. Sleep must be procured, and pain allayed, by sufficient doses of opium. Change of air is always advantageous. Profuse perspirations may be checked by dilute sulphuric or nitric acid, with tonics, as F. 1. As it will be recollected that the diarrhoea often depends on an inflamed or ulcerated condition of the in- testinal mucous membrane, reason will suggest that attempts to stop it by port wine and large doses of catechu, or other stimulants and astrin- gents, will often be not only unavailing, but irritating and mischievous;* although good enough in cases of mere debility. If, therefore, the diar- rhoea is attended with tenderness, much pain, and tenesmus, the proper remedies are demulcents and anodynes; rest in bed; occasionally a poul- tice of bran with one fifth of mustard, applied to the abdomen, and suf- fered to remain till it causes slight smarting and redness;—the very mild- est diet of milk, arrowroot, &c, enemata of starch, containing from twenty to sixty minims of laudanum (F. 48;)—Dover's powder at bed-time, and small doses of chalk mixture, with a few minims of laudanum, during the day; and one or two grains of blue pill, with three or four of rhubarb occasionally, if the liver is inactive. It may be added, that copious injec- tions of warm water give great relief in all cases of diarrhoea; soothing the irritating membrane, washing away acrid secretions, and enabling the patient to pass easily at once what otherwise would occasion several painful dejections. SECTION V.--OF TYPHOID FEVER.t Gkneral Description.—This fever is an acute form of constitutional disturbance, occurring when the powers of life are much exhausted or depressed. It may be a sequel of the hectic; or of the state of pros- * The author has known large doses of catechu purge violently, when adminis- tered to a young woman for passive monorrhagia. t The pathological student, will not confound the affection spoken of here and else- where, in the volume, as "typhoid fever," with the dothinenteritis of modern phy- sicians. Mr. Druit and other surgeons still employ the term to indicate a sympathe.' tic febrile affection, with adynamic symptoms, a Typhus-like condition or simulated synochus. F. TYPHOID FEVER. 31 tration with excitement; or it may supervene very soon after an injury. Symptoms.—Pulse very frequent and weak, often quick and jerking in the early stages; skin hot and very dry; all the secretions deficient; tongue dry, brown, and tremulous; lips parched;—if there be a wound, it becomes dry, livid, and glassy, and ceases to suppurate. Terminations.—(1.) If the patient is to die, the pulse becomes more rapid, thready, and tremulous, and at last is imperceptible at the wrist; the eyes look dull and glassy and sunken; the temples and nostrils are pinched from atony of their muscles;—the patient lies on his back, and sinks towards the foot of the bed;—there is frequent hiccough; the abdo- men is tightly distended with flatus, and the sphincter is relaxed, so that stools are passed involuntarily; the patient dozes imperfectly, awaking with a start; he picks imaginary objects on the bed clothes, and mutters to himself;—there is starting or twitching of the tendons; at last the skin becomes cold and clammy, respiration slow and laborious, and coma supervenes, soon followed by death. (2.) If recovery occurs, the surest sign of amendment is a diminution of the frequency and increase of the firmness of the pulse, with sound sleep; the patient being sensible and composed, the eyes brighter, the tongue cleaning, and above all, sup- puration returning, if there be a wound. Causes.—Typhoid fever may be caused (1) by some circumstances producing immediate and direct depression of vital power; such as trau- matic gangrene; a wound poisoned during dissection; or a severe injury or operation suffered by an habitual drunkard. (2.) It may be caused by some disease of long standing, which has completely exhausted the constitutional powers—as profuse suppuration with hectic. And both these conditions may be, and frequently are, combined with a third; (3) namely, contamination of the blood by putrid or other poisonous matter. Thus it is sure to supervene if putrid pus be confined in an abscess, or if putrid urine escape into the cellular tissue of the perinaeum. M. Bon- net has proved incontestably that the hydrosulphate of ammonia, the pro- duct of putrefaction, is absorbed in these cases, and is one cause of the typhoid fever.* Prognosis.—The prognosis will of course be always doubtful; but there may be a chance of recovery, if the cause is of recent existence, and admits of removal by operation or otherwise; whilst there can be scarcely any, if the constitution has been exhausted by its long continuance.* Thus, if this fever come on in erysipelas or small-pox, diseases of no long continuance, the constitution may rally;—or if it is caused by a re- cent injurv, or by extravasation of urine, it may be removed perhaps by * See part ii. ch. vii. sect. iii. 32 TETANl S. an amputation, or incisions in the perinaeum: but it will scarcely be cured if caused by chronic abscess or disease of a joint, and preceded by hectic. And thus, if the hectic has been suffered to pass into the typhoid state, the season of amputation and hope of recovery are also past. " It is," says Hunter, " the more incurable, as it is more connected with the past than with the present." Treatment.—The indications are to remove the cause; allay irrita- tion, and support the strength. If the removal of the cause by operation is likely to be successful, upon the principles just laid down, it should be done without delay; and even if not, it may be better to try a doubtful remedy than none at all. As for the general treatment, opium or some of its preparations should be given in small doses, repeated frequently, or in a large dose at once, according to the judgment of the practitioner, for the relief of restlessness and delirium. The most potent tonics, especially quinine, should also be freely given. The author can particularly recommend F. 2. 3. 26. Moderate quantities of concentrated forms of nutriment, jellies, broths, beef-tea, arrowroot, &c, and wine or hot brandy-and-water, need not be spared, if the patient will take them. Hiccough is best relieved by a tea- spoonful of sp. aether, c; and flatulence by an enema of turpentine. The catheter should be used if the patient cannot pass his water—a point that should always be most scrupulously inquired into. CHAPTER IV. OF TETANUS. Definition.—Tetanus is a disease manifested by tonic* spasm and rigidity of some, or many, of the muscles of voluntary motion. Divisions.—There are several varieties of tetanus. (1.) It is divided into the idiopathic, or that which arises solely from some disorder of the system, and the traumatic, or that which is caused by a wound. (2.) It may be acute or chronic; the former arising suddenly, and soon termi- nating, generally affecting the whole body, and often fatal; the chronic • being of less intensity and of longer duration, usually partial in its extent, and mostly terminating in recovery. (3.) Tetanus may be general or * Spasms are of two kinds; the tonic (tiw», Istretch) in which the rigidity is per- manent, and the clonic, (x.\ovo;, commotion,) in which contraction alternates quickly with relaxation, as in epilepsy and hysteria. TETANUS. 33 partial; and when partial it is mostly confined to the neck and jaws, con- stituting trismus, or locked jaw. (4.) It may be divided according to the set of muscles predominantly affected: being called opisthotonos, when the body is curved backwards so as to rest on the occiput and heels, which it most commonly is; emprosfhotonos, when it is curved forward from a preponderance of the abdominal muscles;* and pleurosthonotos, when it is drawn to one side, this being the most uncommon.t (5.) The trismus infantum, or neonatorum which attacks children soon after birth, is usually made a distinct species. (6.) Tetanus may in its type, be intermittent, when it is caused by marshy miasmata, as it may be occa- sionally like almost every other nervous affection. Premonitory Symptoms.—(1.) In the true traumatic tetanus, there are seldom any premonitory symptoms, except sometimes severe shoot- ing pains in the wound;—(2.)the genuine idiopathic is mostly preceded by foul tongue, loss of appetite, disturbed sleep, dejected spirits, and fugitive spasms in various parts;—(3.) and in one well-marked set of cases that will be more fully alluded to hereafter, the attack is preceded by shivering, pain in head, back, and limbs, and other symptoms of inflammatory fever. Symptoms.—The patient first complains of stiffness and pain of the neck and jaws, as from a cold; and his countenance is observed to have a peculiar expression, because the corners of the mouth and eyes are distorted and puckered by incipient spasm of the facial muscles. In the next place, the muscles of mastication and deglutition become fixed and rigid, with spasm, so that the mouth is permanently closed, and there is great difficulty of swallowing, especially liquids. To these symptoms succeed a fixed pain at the epigastrium, and convulsive difficulty of breath- ing, indicating that the diaphragm and muscles of the glottis are affected; and the spasm now extends to the other muscles of the trunk and limbs, rendering them completely fixed and rigid. The abdomen feels remark- ably hard; there is obstinate constipation, and frequently difficult mictu- rition from spasm of the perinaeal muscles; the pupils are contracted, and the saliva flows from the mouth, because the patient is unable to swallow it. This spasm never ceases; but it has occasional remissions of violence, alternating with aggravated paroxysms, which are easily induced by the slightest irritation or disturbance. Meanwhile the in- * Larrey conceived that the curvature of the body was determined by the situation of the wound ; that if the wound was on the posterior surface, there would be opis- thotonos, and so forth. But although this is sometimes the case, it is quite as fre- quently otherwise. (Clinique Chirurgicale, Paris, 1829, p. 85.) t A case of acute tetanus, affecting one side only, is given in the Med. Gaz., May 12th, 1838. No mention is made of the pulse. J 34 tellects are undisturbed, and the pulse may be natural, except during a severe paroxysm, which quickens it, and causes perspiration and thirst. Terminations.—(1.) If the case is about to end fatally, the paroxysms become more frequent and violent, and the breathing more and more embarrassed by spasm of the diaphragm and of the muscles of the glottis; and at last the patient dies, either from exhaustion or from suffocation; the nervous system being either worn out by the violence of the spasm, or the respiratory action being suspended long enough to cut off the necessary supply of arterial blood from the brain, and so induce insensi- bility. The most usual period of death is the third or fourth day; some- times it is postponed till the eighth or tenth, but rarely longer. On the other hand, there is the case* recorded of a negro who injured his hand, and died of tetanus in a quarter of an hour; and cases of death within twenty-four hours are by no means uncommon. (2.) When acute tetanus terminates favourably, still the patient's recovery is not complete for weeks or months—partly because of the strainings and lacerations which the muscles have suffered,—partly because of the remaining ten- dency to spasm, which very slowly yields, and is apt to be temporarily aggravated by very slight causes, especially cold and damp. But in some rare instances the disease has been removed almost instantaneously by the removal of its exciting cause. Prognosis.—The prognosis in acute tetanus is extremely unfavourable, especially if traumatic; it is more favourable in the idiopathic, and the chronic most generally gets well of itself. Death very seldom occurs after the twelfth day. Dr. Panyt attempted to found a prognosis on the state of the pulse, and thought that if on the fourth day it was under 100 or 110, the patient being an adult, the prognosis was favourable;—but if above 120, unfavourable. But although it is true that the pulse is in general accelerated towards the close of the malady, still some fatal cases have occurred in which it never rose above 80 or 90. As a general rule it may be said that the prognosis is favourable if the complaint be par- tial;—if it do not affect the muscles of the glottis;—if it has lasted some days without increasing materially in severity;—if it is sensibly mitigated by the remedies employed;—if the pulse is not much accelerated;—if the patient sleep; and if he have been subject to it before in an intermittent form. On the other hand, the prospect will be unfavourable, if the spasms continually increase in severity, and especially if they affect the muscles of the glottis. Diagnosis.—Tetanus resembles hydrophobia in the difficulty of swallowing and aggravation of the spasms by slight external irritants; * Rees's Encyclopedia, Art. Tetanus. t Caleb Hillier Parry, M. D. Cases of Tetanus and of Rabies Contagiosa. Bath 1814. TETANUS. 35 but it may be distinguished by the spasms being continuous, and by the patient being sensible in general and calm to the last;—whereas in hydro- phobia, there are fits of general convulsions with perfect intermissions, and the patient is mostly delirious, with a peculiarly wild haggard ex- pression of countenance. Inflammation of the spinal cord, or its mem- branes, resembles tetanus in having opisthotonos and spasmodic difficulty of swallowing; but it may be distinguished by the pain in the back, and fever being more predominant than in any case of mere tetanus, and by the paraplegia and coma which supervene in most cases. Morbid Anatomy.—The morbid appearances that have been found in different cases are as follow. Increased vascularity of the membranes and substance of the spinal cord, with or without effusion of serum;— more rarely the same appearances have been found in the cranium; flakes of cartilage and spiculae of bone deposited in the membranes of the spinal cord;*—vascularity of the nerves leading from the wounded part;—vas- cularity of the mucous membrane of the stomach; —of the sympathetic ganglia;—and congestion of the lungs. But there is not one of these morbid changes that is constantly, and, except the first, there is not one of them that is even frequently found. The muscles are extremely rigid after death, and ecchymosed or ruptured in many parts;—the blood is mostly coagulated. Predisposing Causes.—The best established predisposing causes are;—changes of temperature from warm to cold or damp;—a disordered state of the stomach and bowels;—the presence of worms, or of undi- gested food, or vitiated secretions in the intestines;—the existence of the above-named osseous or cartilaginous deposites, or of any other perma- nent cause of irritation near the spinal cord;—fear, anxiety, or fatio-ue, or any other circumstances that depress either mind or body. Tetanus is much more prevalent and fatal in warm than in cold or temperate cli- mates; and men are much more frequently subject to it than women. Exciting Causes.—The exciting causes of tetanus may, for the sake of convenience, be arranged under three heads—the first two comprising the causes of the idiopathic, and the third, those of the traumatic variety. Theirs/ consists of causes which operate on the nervous system gene- rally, as cold and damp; the poisons of nux vomica, of the cicuta aqua- tica, and other narcotico-acrid poisons, especially a certain Javanese poi- son called che/ik. The second comprises causes which affect organs supplied with gan- glionic nerves, especially the stomach or bowels; and there can be little doubt but that many of the cases which are styled traumatic, because there exists a wound, are in reality caused by visceral irritation, without which the tetantus could not have arisen. Thus in a case, which occurred * Refer to the cases at p. 38. 36 TEIAM'S. in St. Bartholomew's Hospital, ten days after a wound on the toe, and proved fatal in a fortnight, no morbid appearances, not even an increase of vascularity, were found in the spinal cord; but almost all the intes- tinal canal was inflamed, and there were ulcers in the ilium and ccecum.* Dr. Dicksont and Mr. M'ArthurJ relate cases in which the intestines were filled with a peculiar unhealthy yellow viscid secretion;—Mr. Aber- nethy§ commemorates the peculiarly unhealthy stools, like sloughs, in a case which he observed;—Mr. Travers|| strongly suspects that dysentery and ulcers of the intestines may be coincident causes;—and some authors^ have affirmed that intestinal worms are a strongly predisposing, if not really efficient, cause. But besides, cases might be quoted, from various authors, in which there was no wound at all,—gastro-intestinal irritation was the only cause. Thus Andral relates a case produced by gastritis; Lehman,** a case of partial tetanus by hernia; and another instance is related,^! in which it was caused by the irritation of an emetic on a sto- mach disordered by habitual drunkenness. But although irritation of the stomach and bowels is the most frequent of this class of causes, still irri- tation of other organs may produce the disease. Begintt states that it has arisen from pericarditis; Gooch|J gives a case produced by disease of the breast; and Farr** knew it caused by pulmonary abscess. Uterine irritation is by no means an uncommon cause. Whytt** gives the case of a girl, aged twenty, who caught cold during the menstrual period, and died of tetanus in eighteen hours; and the case related in the adjoining note gives a good example of fatal trismus from irritation of the womb.§§ * There were vascularity and serous effusion in the cranium, brought on most likely by the large doses of opium which the patient took. Med. Gaz. vol. i. p. 646. t Med. Chir. Trans, vol. vii. p. 459. t Ibid. vol. vii. p. 474 et seq. § Lectures on Surgery. Renshaw, London, 1835, p. 23. || Travers. Farther Inquiry concerning Constitutional Irritation. London, 1835, p. 397. IT Laurent. Vide F. Pescay, Diet, de Sc. Med. Paris, 1821, vol. lv. p. 9. ** Quoted in Wenceslai Trnka de Ki'zowitz, Commcntarius de Tetano, Hndo- boni