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wound is glued together by fibrin, the exudate having come along the lymph-spaces from adjacent vascular areas. Organization occurs by multiplication of fixed tissue-cells and leukocytes. Divided muscle, if the ends are widely separated, unites by fibrous tissue. The ends of a divided muscle, if closely approximated, unite by fibrous tissue, which becomes filled with muscle-fibres. It is not yet definitely known whether these fibres arise by growth from the muscle-cells of the ends of the muscle, or by metamorphosis of the new connective tissue. Divided nerve, when approximated, can regenerate. The ends are first united by new connective tissue; this new tissue is a bridge for nerve-cells, and is finally converted into nerve by the growth of cells from both the

FIG. 27.-Forms assumed by a nucleus dividing (Green, from Flemming).

central and distal ends, the cells finally meeting. If the ends are not approximated, they join by fibrous tissue, the distal end atrophies, and the proximal end becomes bulbous. The above view is entertained by Mayer and Eichhorst. Waller holds that repair is effected by the central end alone. When a tendon is divided the ends retract, and the sheath, as a rule, becomes filled with blood-clot. The blood-clot is rapidly removed, embryonic tissue replacing it. This new tissue arises from the sheath, and the cut ends do not participate in the process. Granulation-tissue is formed; this is converted into fibrous tissue, and after a time the fibrous tissue becomes true tendon. If no blood-clot forms in the sheath, the walls of this structure collapse and adhere, and the separated tendon-ends are held together by a flat fibrous band formed from the collapsed sheath (Warren's Surgical Pathology). When a bone is broken a large blood-clot forms in the medullary canal, between the broken ends, below and outside of the periosteum. Granulation-tissue replaces the

blood-clot, granulation-tissue becomes fibrous tissue, and the fibrous tissue in many places becomes cartilaginous. In the second week lime-salts begin to deposit and bone forms (p. 333). Cartilage can heal as cartilage, but usually unites by fibrous tissue. When an artery is ligated, embryonic tissue forms in and around it, the walls soften and are converted into the same tissue, vascularization occurs, fibrous tissue forms and contracts, and the artery is converted into a fibrous cord. An ulcer heals in the same manner as does a wound with loss of substance-by second intention. An abscess heals by collapse of its sides and their adhesion (by third intention). The sides are embryonic tissue, which is formed into granulations, these granulations unite, and organization into fibrous tissue takes place.

V. SURGICAL FEVERS.

The surgeon encounters fever as a result of an inflammation or an aseptic wound, in consequence of infection, and in certain maladies of the nervous system. It is important to remember that, while elevated temperature is generally taken as a gauge of the intensity of fever, it is not a certain index. There may be fever with subnormal temperature (as in the collapse of typhoid or pneumonia), and there may be elevated temperature without true fever (as in certain diseases of the nervous system). It is true, however, that elevation of temperature is almost always noted.

The essential phenomena of fever, according to Maclagan, are-(1) wasting of nitrogenous tissue; (2) increased consumption of water; (3) increased elimination of urea; (4) increased rapidity of circulation; and (5) preternatural heat. Traumatic fevers follow a traumatism and attend the healing or infection of a wound. The forms are-(1) benign traumatic fever; (2) malignant traumatic fever.

Benign traumatic fever is divided into two classes-the aseptic and the septic. There is but one form of aseptic fever, the post-operation rise. The septic benign fevers are surgical fever and suppurative fever. The malignant traumatic fevers are sapremia, septic infection, and pyemia. In this section we discuss only the benign fevers.

Aseptic fever appears after a thoroughly aseptic operation and after a simple fracture or a contusion. It may appear during the evening of the day of operation or not until the next day, and reaches its highest point by the evening of the second day (100° to 102°). This elevation is spoken of as the

"post-operation rise." Besides the fever there are no obvious symptoms; the patient feels first-rate, sleeps well, and often wants to sit up; there are no rigors and there is no delirium. The wound is free from pain and appears entirely normal. Blood examination shows leukocytosis. This fever is due to absorption of pyrogenous material from the wound-area, the material being obtained from clot or inflammatory exudate, or from both. Many observers believe that the pyrogenous element is fibrin-ferment, which is absorbed from disintegrating blood-clot and coagulating exudate. Warren thinks the fever due to fibrin-ferment, and "also to other substances slightly altered from their original composition during life.” Some have asserted that the fever is due to nervous shock.

Schnitzler and Ewald have recently studied aseptic fever.1 These observers maintain that aseptic fever can exist when no fibrin-ferment is free in the blood, that fibrin-ferment can be free in the blood when there is no fever, and in consequence that fibrin-ferment is not the cause of the elevation of temperature. They rule out of consideration nervous shock as a cause, and assert that a combination of several factors is responsible, nucleins and albumoses which are set free by traumatism being looked upon as the most active causative agents. The presence of nuclein in the blood in aseptic fever is indicated by leukocytosis and by the increase of the alloxur bodies (including uric acid) in the urine. The capacity of nucleins and albumoses to cause fever is greater in the tubercular than in the non-tubercular. The diagnosis of aseptic traumatic fever is only made after a careful examination has assured the surgeon there is no obscure or hidden area of infection.

In some cases an aseptic fever may appear after an operation, and later be replaced by a septic fever. If the temperature remains high after a few days, or if other symptoms appear, the wound should be examined at once, as trouble certainly exists.

Traumatic or surgical fever is seen as a result of infected wounds where there is inflammation, but no pus. This fever is due to the presence of fermentative bacteria in the wound and the absorption of their toxic products. The most active and commonly present organisms are those of putrefaction. Fever ceases as soon as free discharge occurs, and its appearance is an indication for instant drainage. The temperature rises pretty sharply in a day or so after the operation, ascends 1 See Archiv für klinische Medicin, Bd. liii., H. 3, 1896; also statement of their views in Medical Record, Dec. 19, 1896.

with evening exacerbations and morning remissions, and reaches its height about the third or fourth day, when suppuration sets in; the temperature begins to drop when pus forms, if the pus has free exit, and reaches normal at the end of a week (see Suppurative Fever). Stitch-abscesses are often found in surgical fever. If a post-operation rise continues for an unnaturally long time, or if after it has passed away a secondary rise is noted, suspect infection and examine the wound. The wound is painful, tender, swollen, discolored, and often foul. The stitches must be cut, and the area asepticized, and packed with iodoform-gauze or drained by a tube. The fact that this fever is apt to cease when suppuration begins led the older surgeons to hope for pus and to endeavor to cause it to form.

Suppurative Fever-This fever, which is due to the absorption of the toxins of pyogenic organisms, occurs after suppuration has begun, and is found when the pus has not free exit. It can follow or be associated with surgical fever, or may arise in cases in which surgical fever has not existed. Suppuration in a wound is indicated by a rapid rise of temperature-possibly by a chill. The skin becomes swollen, dusky in color, and edematous, pain becomes pulsatile, and much tenderness develops. The wound must at once be drained and asepticized. In a chronic suppuration, such as occurs in the mixed infection of a tubercular area, there exists a fever with marked morning remissions and vesperal exacerbations, attended with night-sweats, emaciation, diarrhea, and exhaustion. This is known as "hectic fever;" it is really a chronic suppurative fever. The treatment of hectic fever consists in the drainage and disinfection if possible, the excision of the infected area, the employment of a nutritious diet, stimulants, tonics, remedies for the exhausting sweats, and free access of fresh air.

Other Forms of Fever.-Fever of Tension.-When there is great tension upon the stitches the spots where the stitches perforate ulcerate and some fever arises. To relieve the fever of tension cut one or several stitches. This fever is in some cases surgical, and in some suppurative, according as to whether the infective organisms cause fermentation or suppuration.

Fever of Iodoform Absorption (p. 27).

Malaria. It is wise to examine the blood in supposed septic fevers, for only by this means can malaria be excluded. It is more common to mistake sepsis for malaria than malaria for sepsis.

Surgical Scarlet Fever. It is maintained by some writers (notably Victor Horsley and Sir James Paget) that a child is rendered especially susceptible to scarlet fever by the shock of a surgical operation. Scarlet fever which develops after an operation is spoken of as surgical scarlet fever. Warren quotes Thomas Smith as having had ten cases of scarlet fever in forty-three operations for lithotomy in children. The puerperal state is supposed also to predispose to scarlet fever. Some writers hold that an attack of scarlet fever after an operation is a coincidence. Others maintain, and with great show of reason, that a red scarlatiniform eruption appearing after an operation rarely indicates genuine scarlet fever, but usually points to infection, as such eruptions are known occasionally to arise in septicemia.

Hoffa has discussed this subject elaborately. He concludes that four types of eruption can follow operation: (1) a vaso-motor disturbance due to irritation of sensory nerves, and manifested by a transient urticaria or erythema; (2) a toxic erythema due to absorption of aseptic pyrogenous material from the injured area-the absorption of carbolic acid, iodoform, or corrosive sublimate, or the effect of ether; (3) an infectious rash which is sometimes found in septicemia or pyemia, and due to minute emboli composed of bacteria, which emboli lodge in the capillaries; (4) true scarlet fever, with the usual symptoms and complications, the organisms having entered by way of the wound, and the eruption often beginning at the wound-edges (quoted in Warren's Surgical Pathology).

VI. TERMINATIONS OF INFLAMMATION.

Inflammation may terminate in a return of the part to health or in its death. Recovery is said to be by delitescence when the inflammation is arrested at an early stage, and by resolution when the inflammation passes on regularly to the formation of embryonic tissue and this tissue is absorbed. New formation is the termination of inflammation when there has been loss of substance or when the embryonic tissue is not absorbed. Death of a part is by suppuration (molecular death) or gangrene (molar death).

Inflammation may terminate in—(1) effusion of liquor sanguinis; (2) formation of embryonic tissue; (3) formation of pus; (4) ulceration; and (5) mortification.

Effusion of Liquor Sanguinis.-The so-called "serum" of inflammation is not serum at all, but is liquor san

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