Surgery, a practical treatise with special reference to treatment / by C.W. Mansell Moullin ; assisted by various writers on special subjects.

Mansell-Moullin, C. W. (Charles William), 1851-1940

Date:: 1893

Credit: Surgery, a practical treatise with special reference to treatment / by C.W. Mansell Moullin ; assisted by various writers on special subjects. Source: Wellcome Collection.

Provider: This material has been provided by the Augustus C. Long Health Sciences Library at Columbia University and Columbia University Libraries/Information Services, through the Medical Heritage Library. The original may be consulted at the the Augustus C. Long Health Sciences Library at Columbia University and Columbia University.

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$sloughing parts with the forcei)s and scissors, and the appUcation of bromine sohition as strong as may be necessary.] In connection with this, it is noteworthy that sloiigliing celluHtis of the most intense description occurs in some cases of snake-bite, and in some forms of post- mortem poisoning, and, what is very significant, not always in the neighborhood of the wound. In the former of these at least it is practically certain that the gangrene is due to the virulence of an alkaloid, which, though it is not sufficient to kill the tissues at once, lowers their vitality to such an extent that they fall an easy prey to the micro-organisms that enter from time to time into the blood. In the latter—when, for example, all the cellular tissue on the side of the thorax becomes gangrenous forty-eight hours after a punctured wound of the finger—the same explanation is highly probable ; and it does not seem unlikely that hospital gangrene is really due to saturation of the blood with the scarcely less virulent poison thrown off by the lungs in cases of overcrowding. PHLEGMONOUS INFLAMMATION. Diffuse inflammation of the cellular tissue and skin, the so-called phlegmon- ous erysipelas, is another product of the ordinary micrococci of suppuration acting under peculiarly favorable circumstances. In many respects it resembles true erysipelas, especially in the conditions under which it occurs, but in its nature it is essentially different. Like erysipelas, it usually spreads from a wound ; those who are broken down in health from intemperance, exposure, and particularly Bright's disease, are much more prone to it than others ; and in a very large pro- portion of cases a streptococcus is found in connection with it. But, on the other hand, it is not infectious, although it is in the highest degree contagious ; it always ends in suppuration and sloughing; it may follow injuries of the most varied description—post-mortem wounds, bites of reptiles, or the sting of a wasp ; it attacks deep-seated parts of the body, such as the pelvic cellular tissue, after parturition or lithotomy ; and it is never accompanied by the characteristic, well- defined rash always present in true erysipelas. The affection of the skin is an altogether secondary complication, which may or may not be present, according to the original seat of inflammation. Further, the streptococcus, which is undoubtedly the ordinary S. pyogenes, is not confined to the lymphatics, as in the case of the S. erysipelatis, but migrates freely beyond into the cellular spaces, and penetrates through the adventitia of the vessels into their interior. Causes.—In some rare cases diffuse inflammation originates without a wound. Nearly always, however, an injury of this kind is present, opening up the submu- cous or the subcutaneous cellular tissue, or the deeper planes among the muscles or round the bones. When there is none, the germs—as in acute infective osteomy- elitis—gain access to the part through the blood. Occasionally the inflammation commences some little distance from the seat of infection ; and exceptionally it does not attain any great degree of severity until this is healed. The predisposing conditions are general and local. The former are those already mentioned in connection with gangrene—diabetes. Bright's disease, the consequences of exposure, intemperance, starvation, and, briefly, everything that tends to interfere with the elimination of waste product or impair the general nutrition. Overcrowding and bad ventilation are very important in this respect; probably their influence is due to the poisonous substances exhaled from the lungs, which, even when breathed for a short time, produce the most extreme depression. The local conditions are very simple : imperfect drainage, especially if there is a cavity filled with extravasated blood, is sure to cause it. It is for this reason that diffuse inflammation of the most disastrous character is so common after com- pound fractures or penetrating wounds of joints. Decomposition occurs under high tension before the tissues are able to protect themselves in the least, and the products are driven into the loose cellular interspaces, poisoning and destroying$