Clinical lectures on subjects connected with medicine, surgery, and obstetrics

Contents

ACUTE SPLENIC TUMOUES. By Prof. Dr. N. Friedrich, of

Heidelberg. Translated by Dr. T. P. Smith ... 1

MENSTRUATION AND DYSMENORRHEA. By Prof. A.

I

When, in the year 1536, a strong army of the " great King Francis " entered Piedmont by the Mont Cenis, it was accompanied by an inexperienced surgeon nineteen years old — still very " doux de sel," as he himself says — the afterwards so celebrated Ambroise Pare. The storming of the small mountain fortress Villane, near Susa, probably gave him for the first time full occupation, and he followed in all things the example of his older colleagues. Like these, although hesi-

F tatingly, lie poured into the gun-shot wounds boiling oil o£ elder to destroy the poison, but the oil fell short, and thus he was compelled to dress the other wounded men with an ointment of oil of roses and turpentine. Fearing that the latter would soon become victims of the wound-poison, he passed a sleepless night, got up early to see the ill consequences, but was greatly surprised to find those he had half given up free from pain, and without inflammation or swelling, while those who had been treated with the boiling oil lay in a state of fever, with great pain and much swelling. He therefore determined, as he tells us, never again to burn the poor subjects of gun-shot wounds so cruelly.

Pare's treatise on gun-shot wounds, in which he asserts the non-poisonous nature of them, and in which the above account is included, first appeared in Paris* in 1551, fifteen years later. A part of this interval he passed in Italy, and it is supposed that he became acquainted there with the investigations of the learned doctor of Bologna, Bartholomew Maggi, and adopted his line of argument against the poisonous nature of gun-shot wounds. Maggi's treatise appeared a year later at Bologna.f

However the question of priority may stand, it is certain that it required all the respect which Pare enjoyed in riper years, especially in regard to military surgery, to obtain gradually consideration for the new view. In much later years we still encounter the old error.

How this error could gain such strength and extension can be proved with difficulty, however, in single instances. It is certain that gun-shot wounds were at first regarded as contused wounds, and were therefore treated, according to custom, with warm and moist applications. But since gun-shot wounds from their very nature, especially when complicated by fractures, are disposed to take a bad course, and since this bad course must have become more frequent as the number of such lesions has become greater since the introduction of small-arms, while the precautions formerly taken for the welfare of the wounded were insufficient, experience at the bed-side could but lead to

and confirm a very unfavourable view of the especially dangerous nature of such wounds. Cases of acute sepsis, developing itself in the course of the wound and agreeing in essential points with the consequences of the bite of a poisonous snake , will have given rise to the idea. Even during the late war, cases of the kind occurred which now and then excited a suspicion in the minds not of laymen alone that the enemy made use of poisoned missiles.

Thus in the beginning of the sixteenth century Johannes de Yigo had only to put into a dogmatic form the already established view of the physicians of the time. A gun-shot wound is a contused wound, he says, for the bullet is round ; it is burnt, for the bullet is heated ; it is poisoned, for powder is poisonous. The poisoning is the essential condition, therefore the treatment must be directed above all to counteract this. And thus, in consequence of the great reputation of J. de Vigo, the fate of sufferers from gun-shot wounds was determined for many years. Amongst various escharotic methods employed against the poisoning, the pouring of boiling oil into the fresh wounds was that which recurred most frequently.

All this is rather far-fetched, it will be said, when we are speaking of the present state of things in reference to the treatment of wounds, but the distance of three centuries and a half is only apparently a great one. The theoretical error is no doubt removed, but the fact which it sought to explain is not removed with it. We no longer look for the poison in powder and lead, but we speak, as they did formerly, of a poisonous action of the wound upon the body : this poisonous condition forms now as then the main point of our therapeutic endeavours, in fact, J. Lister's first method of cauterising the fresh wound with concentrated carbolic acid has no doubt reminded many of the burning out of gun-shot wounds in the fortress of Villane.

The next step was that a poisonous substance may develop itself or settle in the wound, and especially in gun-shot wounds, a substance which has nothing to do with powder or lead. Pare himself adopted this view. When he took part in the siege of Rouen, many wounds sloughed and had a cadaverous smell, and on opening the bodies of those who died, numerous collections of pus were found in different parts of the body, full of greenish, ill- smelling ichor. Besiegers and besieged believed themselves to be wounded with poisoned bullets. Pare looked for the cause in a deterioration of the air by the large quantity of decomposing substances, and since he admitted of a caustic treatment of the wounds in such, cases, cauterisation with unguentum segyptianum (equal parts of alum, verdigris, and sulphate of copper), he appears to have assumed, as is done at this day, a direct action of the so-called deteriorated air upon the wound itself.

The evil influence of air vitiated by the products of decomposition, not upon wounds only, but upon the organism generally, has never been lost sight of by physicians since that time. That rotten straw, decomposing bodies of men and animals, surfaces saturated with excrement, and overcrowding of badly ventilated hospitals give rise to infectious fevers and an unhealthy state of wounds, is not a result of modern observation only. That it was a question of processes of fermentation which became communicated to the body by means of the excitors of fermentation contained in the air, was a view frequently adopted. To quote one only out of many : John Pringle, in bis " Observations on the Diseases of the Army," published in 1775, devotes a chapter especially to 'Diseases resulting from Bad Air/ and his forty-eight experiments on septic and antiseptic substances contain numerous hints at attempts resembling those made at the present day to determine the antiseptic power of certain things.

No advance was made, however, beyond vague surmises concerning the nature of the excitors of putrefaction, and they were for the most part looked for amongst the volatile, ill-smelling products of decomposition, and were believed to be extremely subtle gaseous matters. It is now known, and this knowledge has become public property through the modern literature on fermentation and putrefaction, that it was reserved for the investigations of the present day to obtain possession of these substances, and I can therefore treat this part of the subject briefly. These investigations were directed first to the generatio equivoca. That in a fluid capable of putrefaction, which had been exposed a considerable time to a boiling temperature and brought into contact with air previously heated or passed through sulphuric acid, not even the minutest organisms appear, was first shown by Fr. Schulze*, Schwannf, Helmholtz+, and further that under these conditions putrefaction does not take place. If the organic character of the excitors of putrefaction was proved hereby, they might still be regarded as possibly gaseous substances. The decisive experiment of Schroder and Dusch§ put an end to this doubt, since it showed that it was indifferent for the success of the experiment whether the air was heated, submitted to the action of sulphuric acid, or passed through cotton. Since cotton can have no other effect upon the air except that of retaining the matters contained as dust in it, the excitors of putrefaction were to be sought for in these. In connection herewith stand the experiments of Pasteur, || which now, amongst Gferman authors also, are the only ones usually mentioned.

The matters removed from the atmosphere by the cotton in Schroder's experiment, or by the bent tubes in that of Pasteur, consist partly of detritus of all kinds, partly of extremely minute organisms, and as regards their production it appears to me to be proved that the micro-organisms which make their appearance in boiled infusions come from the air, and it also appears to be proved that these micro-organisms exert a decisive influence upon the decomposition of their infusions. It is quite otherwise with the assertion frequently heard that decomposition can be caused and carried out to its final products by micro-organisms only ; here at once the doubt presents itself whether the atmospheric ferment-dust, seeing that the micro-organisms can only reach the air through the drying up of their infusions, does not also contain fragments of this dried fluid, and whether these fragments are not also capable of setting up a decomposition. We are acquainted with physiological ferments which, even if' arising in cells, are soluble in water,

* Preliminary communication in Poggend. Annal., B. 29, p. 487.

t Preliminary communication concerning experiments on wine fermentation and decomposition. Poggend. Annal., 1837, B. 41, p. 184.

X On the nature of decomposition and fermentation. Mull. Arehiv, 1843, p. 453.

§ Schroder and Dusch, On nitration of the air in connection with putrefaction and fermentation. Annal. der Chem. und Pharm. 1854, Bd. 89, p. 232. Schroder, loc. citat. 1859, Bd. 109, p. 35. 1861, Bd. 117, p. 273.

70 CLINICAL KESULTS OF THE LISTER TREATMENT

and when dried retain their ferment properties, and why should such soluble ferments not also exist in putrefaction-fluids ? So long as we do not succeed in separating the micro-organisms completely from their infusions, or in isolating them from the atmospheric dust, or so long as we possess no method of destroying the micro-organisms in a fluid capable of putrefaction, without modifying the albuminates, we must leave this an open question.

Sufficient for the purpose of this treatise is the fact that the atmosphere always contains putrefaction-ferments in the form of dust, and that, therefore, when we speak of foul air and pure air, this only means a difference in the quantity, perhaps also in the quality of these ferments.

So far as I know, Lister was the first to refer the long-known essential difference in the behaviour of open and subcutaneous wounds to this fact, while one had previously been content to assume that the difference between subcutaneous and open wounds depended upon the access or non-access of oxygen to the fluids of the wound. It being once established that the atmosphere always and everywhere contains ferments, it was evident that the secretions of wounds contained just such combinations as are especially liable to be changed by ferments. In this sense, every wound exposed to the air must become infected or poisoned, and to obviate this poisoning and effect an aseptic course must be accepted as the chief object in the treatment of wounds.

Lister argued that if we succeed in destroying the ferments which have entered into the open wound before they come into activity and during the healing of the wound admit only disinfected air, i.e. air in which the ferments have been destroyed, the wound will run an aseptic course like a subcutaneous wound.

One of these questions concerns the behaviour of the atmospheric ferments contained in the healthy organism, for on account of their minuteness and their distribution in air and water, they must be regarded as always present in the organism. Do they undergo destruction there, or are they merely latent ? Billroth* inclines, on the ground of his investigations, to the

* Investigations of the vegetation-forms of coccobacteria septica, &c. Vienna, 1874. — Billroth's surmise that these latent resting spores, so soon

"belief in their latent presence in the healthy body, and the experiments of Tiegel* serve to confirm, this view. But if they are merely latent, they will be brought by the circulation from behind to the wound, will find in the secretions of the wound, air having access, matter fitted for their activity, and little will be gained by the prevention of their free access from the atmosphere.

The second question is, how do the unformed ferments coming from the organism, which are contained in all the albuminous fluids of the body, including the secretions of wounds, comport themselves when brought into contact with air which has been deprived of its ferments ? Certainly otherwise than in subcutaneous wounds to which access of the oxygen of the atmosphere has also been prevented. In the Lister treatment also a continued antiseptic influence upon the secretions of the wound is kept up, and no one can doubt that the constant presence of carbolic acid in the neighbourhood of the wound, which is one of the essential characteristics of the Lister treatment, must have an important influence on the chemistry of the secretions of the wound. In the Lister treatment the oxygen of the atmosphere has access to the wound and the secretions of the wound are under the action of carbolic acid : the wound, therefore, is not placed under the conditions o£ a subcutaneous wound.

Another question is, whether Lister has succeeded in rendering the healing process aseptic without otherwise exposing the patient to danger. Lister is constantly endeavouring to improve his method and render it milder. Carbolic acid continues to be his most important means of disinfection. Instead of the original cauterisation of the surface with concentrated carbolic acid, he washes it with diluted carbolic acid, or with a solution of chloride of zinc in the proportion of 1 : 8. Carbolic acid spray is employed to destroy ferments "entering into the wound during the operation, as well as when the dressing is renewed. The tying of the arteries with carbolised catgut was an important addition, and instead of the pasteas some pathological process furnishes them with a fitting soil, may at once start into activity, appears to me to be of great importance.

* On coccobacteria septica (Billroth) in the bodies of healthy vertebrate animals, by Dr. E. Tiegel. Virchow's Arch., 1874, Nos. 3 and 4, p. 453.

dressing, that with, carbolised gauze is used, which permits the easy escape of the secretions. This escape is further facilitated, when it appears desirable, by the introduction of carbolised india-rubber tubes. Thus originated the Lister dressing, to which the objection that it endangers the patient can no longer be made, and which is now strictly carried out in many places, e.gr. in the hospitals of Halle, Basle, and Leipzig, and the steps of which are accurately described in the treatises of Dr. A. W. Schultze* and Dr. L. Lesser, t which I assume to be already known to the reader.

The results of the Lister method at the bed-side were certainly of a nature to attract at once the attention of all those who, not content with their previous success, wished to prevent the deaths resulting from pyaemia, septicasmia, and hospital gangrene. Lister's* comnmnications made an impression of reality, and all that one heard of him from those who went to see him at Glasgow, and afterwards in Edinburgh, sounded favourably. I was the more inclined to employ the Lister method from the first, because the Leipzig Hospital at that time (1867) was still in the old Jacob's Institution, one of the worst of hospitals, and I confess that I was one of those who, in accordance with the original instruction, cauterised the cavity of the wound in cases of compound fracture with concentrated carbolic acid. It unfortunately happened sometimes, that •without effecting an aseptic course in all cases, sloughing of tissues of serious extent occurred. With the present method there is no fear of this. Our results have constantly improved with the development of the method and with our technical experience. They are not so good, it is true, as those of Lister himself, or of Yolkmann, but I feel justified in recommending the method, and am of opinion that it ought to be tried impartially, more than has yet been done, if only

* R. Volkmaim's Collection of Clinical Lectures. No. 52. 1872.

t Deutsche Zeitschr. fur Chirurgie, by Hiiter and Luke, 1873, p. 402.

% Those of Lister's publications to which I have as yet had direct access were contained in the Lancet in 1867 — March 16, 23, 30, April 27, July 27, and in a paper in the Microscopical Journal for October, 1873. The rest I know, in so far as they have been made use of by Schultze and Lesser. The work by Dr. A. Thamhayn, " The Lister Dressing," Leipzig.. 1875, contains all Lister's articles, but, unfortunately, did not reach me in time. I 'trust, however, that I have not missed anything essential.

OP WOUNDS. — BY C. THIERSCH. 73

because the methods of treating wounds hitherto leave much to he desired.

An attempt to give a comprehensive description of the modes of dressing which were in use, or are so still, presents much difficulty on account of the variety and quantity of the material. The best way appears to be to obtain a general view by determining how each of these modes answered to the chief requirements of a practical treatment of wounds. As such chief requirements may be regarded : rest of the wounded parts from the first moment, unimpeded escape of the secretions of the wound, prevention or arrest of septic processes. For simplification I will confine myself to large amputation- wounds and compound fractures, partly because these most frequently lead to those evil results which we seek to prevent, and partly because what holds good for them holds good for less severe wounds also. Of injuries of the cavities and their organs, I shall not speak here. Neither shall I allude to the influence of warmth and cold beyond observing that the latter will be chiefly of use where it is a question of the immediate mechanical change occasioned by the injury alone, not of septic complications. As an antiseptic it is of little value.

The open treatment of wounds, as being the most simple, must here be spoken of first. "When it was first carried out methodically, and recommended to others by the Yienna surgeon Vincenz von Kern in the beginning of this century, it appeared to the majority of surgeons to be sheer heresy, and although Ph. v. Walther warmly recommended it, and Jiingken reported favourably of what he had seen in Kern's practice, it was not admitted to the larger hospitals, so strong was the prejudice that a wound must be defended from air and required certain local medical treatment for its cure. The great ascendancy of French surgery at that time, which adhered to ancient traditions, was no doubt the chief impediment.

Stromeyer returned to the principles of Kern, and I saw under his management, during the Danish war of 1850, many gun-shot wounds with fracture and amputation-wounds treated successfully by the open method, and also during the last war I saw a patient with mortified leg, the spontaneous separation of which under the open treatment Stromeyer awaited, and, as I afterwards heard, with good success. It naturally requires the soft, tender, and patient hand of a Stromeyer for the success of such an attempt, and the never-to-be-forgotten example "which he gave us younger men in 1850, was witnessed once more by me twenty years later. In the fifth and sixth decade of this century, Vezin, Bartscher, and A. Burow also adopted this method. In July, 1866, I saw in the Assembly Room of Kissingen stumps treated by Burow alongside of others, and so far as I can remember, all suffered equally under the unfavourable conditions present. I have myself made many attempts therewith, and so, doubtless, have many others, but the real value of this method was first established statistically by the report of Dr. R. U. Kroenlein* on the results attained by the strict carrying out of this method by Rose in the Zurich Hospital, as compared with the close dressing formerly in use.

"Whether the wound lies quite free, or is covered with a piece of oiled silk, or with a water compress cold or warm, does not appear of importance, if free escape of the secretions is not prevented thereby ; we may also add irrigation without changing its character, and the permanent water-bath may also be of use.

It affords the wounded parts perfect rest and obviates all retention of the secretions, meets therefore two of the chief requirements completely, and also antiseptically is not without effect ; for while the wound is placed by the rest in a condition to close itself towards the exterior by sealing up of the cavities of the cellular tissue, and any products of decomposition which may be formed in the wound are not retained, so can also retained, decomposed blood or secretions not be pressed into the still unclosed or re-opened cavities of the cellular tissue, which is certainly the most frequent starting-point for septic and pyeemic processes. I have repeatedly seen large wound-surfaces, e.g. those of amputations of the thigh with extensive sloughing eschars, proceed to cleansing and granulation without a trace of fever, which is certainly the best proof how completely the putrid fluids run off externally. The superficial mortification which even the cleanest incised wound must undergo when exposed to the air need not be taken into con-

* The open treatment of wounds from experiences in the surgical wards at Zurich, 4, 1872.

sideration, since healing by the first intention was never expected.

In opposition to the great advantages of the open treatment of wounds stand as disadvantages, — that it permits the formation of products of decomposition on the surface of the wound, which may sometimes find their way into the circulation before the granulation of the surface of the wound takes place, or through a wound in the granulating surface ; that it presents an undefended surface for the deposit of the infectious matter of hospital gangrene ; and that it also, in cases otherwise favourable therefor, partly or entirely gives up any attempt to effect the immediate healing of the wound.

To obviate the first of these disadvantages, Bardeleben's method combines the open treatment with antiseptic irrigation of the surface of the wound.

Since the leaving open of the wound does not always in itself alone permit the free escape of the secretions, especially in cases of compound fracture, and since such free escape is one of the most important points in this treatment, the various precautions and measures which facilitate escape serve for its completion : dilatations by incision, opening of fluctuating points, counter- openings previous to, or after deposits of pus ; drainage in the place of the dossils of lint and setons formerly in use, etc. ; also the free opening of wounded joints and resection of them, may be included here.

A contrast to the open treatment of wounds is presented in the attempts to place the wounds under the shelter of a firm eschar dried in situ, whereby the access of air is prevented and the condition of a subcutaneous wound approached. Exclusively of slighter and superficial lesions, this method has furnished good results in the case of compound fractures of a slighter kind with small skin wounds, and a remarkable instance how, under the defence of a closely adherent eschar consisting of wadding, blood, and chloride of iron, sprinkled with carbolic acid, denuded cranial bones became converted into granular tissue without appreciable suppuration, is given in Trendelenburg's treatise, " Cure of injuries to bones and joints under an eschar."* This method served Lister as the starting-point for his first method, and indeed, if the formation of the eschar is * Archiv, fiir klin. Chirurgie, 1873, vol. xv. p. 461.

preceded by the disinfection of the wound and the eschar prevents access of the atmospheric ferments, the preliminary conditions of an aseptic course are given. In the usual method, however, recommended by A. Cooper, of letting the eschar of blood and lint dry without previous disturbance of the wound, or of forming the eschar by the addition of glutinous or coagulating substances, suppuration will take place in severe and deep contused wounds generally on the third or fourth day at the bottom of them, with swelling, pain, and fever, and it will be fortunate if this disturbance pass away with the removal of the retained pus. The method has this advantage, that it insures perfect rest for the wound during the first few days, and may, under some circumstances, effect an aseptic course, but since, in cases of deep-seated suppuration, it checks the escape of the pus, it may cause grave complications.

It has not been used, so far as I know, in large amputation-wounds, but we may mention here the treatment of amputation-wounds with the ecraseur and the red-hot wire, and the cauterisation of the fresh surfaces of amputation- wounds with wadding steeped in chloride of iron, as was practised occasionally by French army surgeons during the last war. This was done under the notion that with the defence of an eschar produced by compression, actual cautery, or cauterisation, the surface of the wound becomes closed more readily externally, before decomposition takes place, than in an incised wound left entirely to itself. But as there is no probability that these interesting experiments will be adopted generally in practice, I content myself with remarking that wounds so treated are exposed to the same dangers as other such wounds healing slowly by granulation.

We may also name here Jules Guerin's hermetically closed india-rubber dressing with suction apparatus. In 1765 the Florentine, Yacca, published a work, "Liber de inflammations raorbosae, quse in humano corpore fit, natura, causis, et curatione," and Yacca, who knew that decomposition is only possible when air has access, spoke in detail of various antiseptic measures, and, ended with the proposal to cover the amputation- stump with lint and oiled linen, to place over this a leather cap, and then to enclose the whole in a glass bell with air-tight rim. The air enclosed would do no harm because in small quantity. To pump it out was not advisable, because the stump ought to remain under normal atmospberic pressure. This proposal has probably never been carried out, but it shows how long the idea of the deleterious effect of air has occupied the attention of surgeons.

Here belongs also Alph. Gruerin's dressing with wadding, in which, by covering the wound with a thick layer of wadding to be left on for a considerable time, the infectious matters of the air are excluded, and since Oilier sprinkles the wadding used in this dressing and the wound itself with carbolic acid, this is a close dressing which may act antiseptically, not only by excluding atmospheric ferments, but also by destroying any ferments contained in the wadding or in the wound.

What has been said of treatment under an eschar holds good also for these close dressings. The rest which the wounded part enjoys for some time is certainly favourable, but the antiseptic action is not much to be relied on, and if sufficient care be not taken to allow of the escape of the secretions, evil results from their retention are to be feared.

The dressings for amputation- wounds and compound fractures which are probably now most widely used, consist, as is known, in covering the wound with an absorbent porous substance, formerly exclusively lint, now frequently wound-wadding, either laid immediately upon the wound, or with interposition of a mild salve. This dressing was to be regarded as a step in advance, as it took the place of continuous irritation of the wound-surface by strong ointments, corrosive solutions, and liniments. But when there is much discharge, it requires to be changed frequently, which interferes with the rest for the wound, and it not unfrequently causes retention of pus, and facilitates decomposition of the secretions of the wound. It therefore decidedly does not meet the three chief requirements : rest, free escape of secretions, and antisepsis, and unless I am mistaken, has already passed the maximum of its extension. In amputation-wounds, in which healing by the first intention is aimed at, it so frequently leads to a superficial healing of the edges of the skin, while septic matters are developed deeper in, that the healing of the wound by the first intention, although recommended by the greatest surgeons of England and Germany, has never been generally adopted ; it was thought better to abstain from the attempt than to risk failures so often accompanied by evil consequences.

Information concerning the at present prevailing views of French hospital surgeons is furnished by a discussion which took place on March 25, 1873, at a sitting of the "Association francaise pour l'avancement des sciences," at Lyons. The occasion for this was a communication from Dr. Azam of Bordeaux, in which he most warmly recommended the exact union of amputation-wounds. In his method the wound is carefully closed by a deep-seated and a superficial row of sutures, while the retention of the secretions is provided against by drainage. Over this is placed a dressing of wadding. "Water and the sponge are not used at all. The sutures are removed on the third and fourth day, the drainage-tube on the tenth. The dressing is moistened with alcohol. Complete healing of stumps of the leg on the eleventh and thirteenth day, of the thigh on the fifteenth and sixteenth, are reported in recommendation of the method. Verneuil, without meeting with any opposition, formally declined all such experiments for the large hospitals, " autant de necropoles assermentees," for which the slow healing of amputation- wounds is exclusively adapted.* In reference hereto, Alphonse Guerin, at a meeting of the Surgical Society, December 26, 1872, showed a stump (model ?) the flaps of which had united under his wadding dressing in fourteen days. One can therefore, he says, effect the healing of such wounds by the first intention in the hospitals of Paris. Guerin was unable to show the patient himself, who had died of embolic pysemia resulting from suppuration of the spinal cord. It was, therefore, only a fallacious, superficial healing which was boasted of at that meeting as something particular, f