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wound area as this will give us the best result
and the minimum damage to tissue. On the (EXCLUSIVELY FOR THE MEDICAL HERALD.)
contrary, with the poor reaction of tissue, coupPATHOLOGY OF TRAUMATIC WOUNDS* led with bad treatment, gives us the maximum
damage to the tissue with ugly scars, or with 0. C. MORRISON, M. D., Carroll, Iowa
the sacrifice of the tissue or limbs of the patient. A traumatic wound is the destruction of the I have never felt that I should be so greatly epithelial covering of the body by external vio- concerned about a possible infection by gas lence, with or without the destruction of under- bacillus, pyocyaneus, or kindred infections but lying tissue. The pathological classification I should have a thorough understanding of the of this class of wounds will be limited in this action of bacteria and their toxins upon the paper to :
cellular tissues of the body and the resulting 1. Grave infected wounds.
pathology. We have spent much time in learn
ing the characteristics of the many bacteria and 2. Grave uninfected wounds.
in juggling their development to suit our fancy. We are not concerned whether the wound The life of any uni-cellular organism will serve be lacerated, clean cut, or punctured, but we are as a unit of comparison. We know that it concerned with the type of bacteria infecting it. The reaction of the wound locally is not always it excretes its own toxins or waste products.
gathers its food from the fluid in which it lives. the guide in our judgment to the severity of
It attracts another uni-cellular organism with the remote reaction. The invasion of other tis- which it fuses for reproduction. The questions sues proximal to the wound is usually by Phleg
are: "By what method does it get its nourishmonous Cellulitis.
ment, and how does it expel the waste products The remote effects are by metastasis or from its body?” In answering these questions toxemia. Phlegmonous Cellulitis is the result of logically we are forced to revert to a comparany of the pyoginic bacteria. We were taught to ison of similar actions in the inorganic world. believe that the amount of gangrenous tissues There is a force which causes the sodium ion found in a wound was due to the so-called direct to unite with an atom of chlorine or with two gangrene which was the result of the traumatism. atoms of hydrate. They unite in definite quanThe examples cited us were those with which tities and only to form a certain substance or many of you have contended. Time and again specific compound. A further study of this ion the beautiful work in the resected stump was teaches us that it is the ultimate division of made to look like a field that had been devastated matter which represents both a physical and by a German army, and the flap which you so chemical substance. We have learned that this carefully tried to preserve was found to be in a socalled ion can be driven by an electrical curstate of necrosis. This slough was in many in- rent and deposited at the respective positive and stances hastened by the rapid action of bacteria. negative pole, hence, the chlorine will be found Koch has declared that: “Bacteria secrete a solu- at one pole, the sodium at the other. ble substance which comes in contact with the
We have not learned the relationship existsurrounding tissue by diffusion, which substance ing between the socalled ion and its cargo of produces a deleterious action on the tissue cells, electricity but many chemists testify that the and they perish as a result."
size of the ion bears relationship to the quantity Should the reaction of the tissue be slow of electricity it carries. Mann says: "Îhe soand the virulence of the infective agent great, called pure ash-free proteins are chemically inert we can readily imagine that a maximum slough and in the true sense of the word are dead bodies. will be the ultimate result. Some patients will That which puts life into them is the presence Teact quickly aided by proper treatment which of electrolytes. is based upon an influx of lymph supply to the Some men have defined the ion as the small
est division of matter capable of carrying an *Read before the Medical Society of the Missouri Valat Keokuk, Ia., March 21, 1917.
electrical charge. It is not visible; it cannot be
brought to the vision nor the senses of a per- sesses for other chemical substances, namely: son excepting in one splendid illustration, that the analine dyes. Again, the proteids are placed of radium. We can see in a dark tube the ions in the body in stock solution of serum albumin of radium dissemination into the surrounding and serum globulin. These are organic comatmosphere. The ultimate division of that sub- pounds which are broken up by the ferments stance carrying with it the electrical spark is within the cell body into the various purin ring perhaps the smallest division of that strange compounds which formulate an important part substance.
of the cell, especially in muscle tissue. They Through this we reason that if radium rep- are most certainly attracted to the tissues by resents the smallest electrical ion and we think a chemical attraction. We note another very of electricity as being the basic principle of all striking truth when we observe that a dead cell matter remember that electricity plays within a paraffin mount has the same chemical through the blue ether expanse of the universe attraction for analine dyes as does the living at 'ease, as per wireless. We gather the con- cell in the frozen specimen which proves the ception that electricity is the true challenger of chemical attraction or chemotaxis which the cel! creation since it is everywhere.
possesses is chemical and not biological. The Atheist reasons, “I have my God and There are many other illustrations in medCreator. It is everywhere, permeates all things, icine; for instance, the specific action of quinine is the essential to life;" and so brings his chal
upon the plasmodium malaria, the action of lenge to the very door of creation. But we
emetine upon the entamoeba buchalis or the readily observe that in work where we are not action of salvarsan. upon the spirochaeta pallida definite,where we are not able to demonstrate the are other striking examples. We note in this actual happenings, that in this field there is that bacteria do not have the selective action to liable to originate the wildest theories and su- protect their own bodies but are subject to the perstitions. I bring this to your attention to behavior of the organic substances contained emphasize one fact; that cells have certain chem- within them. The by-products of bacteria cericals within their bodies which attracts certain tainly have a chemical composition and are atother chemical substances, both organic and in- tracted to the cells of one's body by the power organic, and by this means they obtain their food of chemotaxis. Ehrlich was unable to explain and give exodus to their waste products. Ehrlich this chemical phenomenon and did the best he has plainly demonstrated the fact that they at- could by offering his "Side Chain Theory." tract certain organic substances, when he worked Another step further in showing the attraction out his theory for staining the various substances that cells possess for each other is found in comprising the cell body.
Metchinkoff's theory of phagocytosis.
It is It is through the staining property of cells again found in the attraction the ova has for that we have been able to study them. The the spermatozoa. It is again found in the atvarious salts, potassium, sodium, etc., which the traction that many of the uni-cellular organisms cell contains are not merely dissolved in the have for each other which causes them to unite fluid of the cell but are combined in the organic for the purpose of reproducing their own type. constituents of the cell protoplasm. They are It is certainly beautifully illustrated in the atnot merely salts to the proteins but are ions, traction that the cells of the body possess for both anions and kations, and are a chemical certain bacteria and their toxins. The strepcombination of the large proteid molecule. tococcus has been found by Rosenow tó possess
The affinity of a nucleus for a basic stain a special affinity for the mucosa. On taking the depends upon the nucleic acid found within the streptococcus from an appendix or gall bladder cell. Ex.-The head of the spermatozoa con- of an animal, culturing it in artificial media tains much nuleic acid bound to simple protein and injecting it into another animal of the same and readily forms a saltlike combination with species will produce the same disease in the the basic dyes, hence the intensely stained nu- animal injected. We must make allowance for cleus. The chromaffin fibres, which are a part environment however, as the streptococcus under of the nucleus, stain lighter at all times except- one environment will produce localized abscesses, ing in karyokinesis when they stain identical under another phlegmon, another scarlet fever, with the nucleus. Marallum claims that the
Marallum claims that the another erysipelas, another septicemia, another nucleus contains no chloride since it will not osteomyelitis, another endocarditis, another peradmit of a silver nitrate stain. He further states nicious anemia (Smithies), another neuritis, anthat the nucleolus has a special affinity for an other herpes zoster, etc. All of these depend acid stain and attracts it quickly as compared upon the environment of the bacteria but the with the basic stain of the nucleus and many of basic principle is the same for the bacteria and the granules found within the cell which differen- its toxin. tiates it, especially the phagocyte, is a striking Every tissue of the body possesses its special example of the chemical attraction a cell pos- affinity for certain bacteria. The nervous tissue attracts streptococcus, tetanus, rabies, poliomye- we lay a liver out separate from an animal's litis anterior, etc. Bone tissue attracts strepto- body in aseptic media we find autolytic fercoccus and staphylococcus, pneumococcus spiro- ments present in the cells of the liver which chaeta pallida, etc. Muscle tissue attracts all causes self- digestion of these cells or autopus producing organisms, as does connective liquefaction necrosis. The cells of muscles estissue.
pecially break down by these ferments and free The blood carries all bacteria and their a very great amount of by-products composed toxins. The red cells attract the plasmodia ma- of purin ring compounds carrying the nitrogen laria especially. The lymphatics are no exception radical. We note in gluttonous persons and high to the blood stream in general. I could indulge livers that the urea output is very great. indefinitely but time does not permit. The im- In gout and diseases of metabolism the urea portant point in the application of this argument compounds are especially increased in the urine. lies in maturing our judgment in how to handle V. Norden has talked this for years. Chittenseptic wounds. Locally the wound may look ever den did a number of diatetic experiments showso encouraging but remotely we find the chronic ing us that the proteid in-take was excessive disintegration of liver 'cells, of kidney cells or in many cases and that we can get along better of heart cells and other tissue. We ask our- with a reduction in the calory in-take from V. selves as young practitioners when should we Norden's standard. amputate a compound infected arm or leg? There are two ways that we may get an When should we resort to heroic measures in excessive output of nitrogenous compound: trying to eradicate the foci of infection?
1. Excessive in-take. Now our study will apply with a great deal 2. Excessive destruction of tissue. of satisfaction and we answer, before these se- In grave sepsis we have the maximum descondary changes, of which I have just spoken, truction of cells of every kind and the nitrooccur. We have studied the destruction of cells gen output in the urine, is always increased. from chemicals and toxins from without, now In some diseases of metabolism we get an inI wish to discuss the pathology produced in crease in the non-nitrogenous purin ring comthe body by the death and the liberation of pounds within the body. In conditions where chemicals and toxins produced by ferments from great destruction of tissue is present, as per within the cells. Wells says: "The intracellular thrombosis or the destruction of trophic nerve ferment is the most important part of the cell's supply, we get an excessive amount of nitrogenmetabolism."
ous purin ring compounds within the body. I Proteids are continuously being broken down have analyzed fourteen cases where thrombosis, into urea, CO2 and water. Crile has observed traumatism or trophic nerve supply destroyed the that after unusual stimulation of the cells the tissues, causing the following symptoms in the exhaustion produces a marked acidity of the patients: cell content. Wiener says: “The reason cells
They showed a queer illness. Pulse rapid; do not digest themselves is from the fact that delirious; appetite gone; no fever; they were they are alkaline in reaction. Autolysis does very yellow and looked quite ill. The color of not begin until acids replace the normal alkalin- the wound was perfectly normal; no redness nor ity and the cell begins dying. If alkalies are swelling. added the death of the cell does not occur.” Blood: reds gradually fell to two million Jacoby says: "Heterolysis (foreign body di- cells. Whites climbed to 23,000. Hemoglobin gestion) is accomplished by the phagocytic 35 per cent (Tal). Remainder of physical exenzyme which is capable of digesting any pro
amination was negative except the urine. Sp. teid from serum albumin to cat-gut." The auto- g. 1035; a trace of albumin and urates were lytic action of any cell body is accomplished only plus. I was at a loss to know what had hapwhen the cell media is acid. The endotoxic bac- pened to my patients. They did not improve teria, as typhoid and cholera, are examples of the with time, either, and I was very much alarmed. autolytic properties of intercellular enzymes and The normal look of the wound, the lack of an their action. Some scientists claim that they increased temperature, the specific gravity of the act only when liberated after having digested urine led me to study the pathology of these cases the cell capsule.
closely. In fact, they looked like a diabetic The very interesting phase of this topic to me in coma, but there was no sugar. I well reis that of grave un-infected wounds. I refer to member the words of Prof. Chittenden: "Prowounds and tissues deprived of their ability teid decomposition products are a constant to assimilate food, no matter from what origin, menace to the well being of the body. Any whether it be traumatic, thrombosis of blood quantity of proteid beyond the real requirements supply or injury to the trophic nerve supply of the body may prove injurious. We see the evil When a cell is destroyed the nuclus disappears effects of uric acid in gout, but there are many and liquefaction necrosis supervenes. Should more nitrogenous waste-products of proteid
catabolism which with excess of proteid food, carbonate or urea. If they are set free in avaare liable to be unduly conspicuous in the fluids lanches the blood CO2 cannot care for them and of the body, and many do great harm before they float free and must react as Chittenden they are eliminated from the body through the states, or are similar in pathology to that of kidneys. Further, we must concede the terrific diabetic crises. strain upon the liver and kidneys before and There is a great deal that might here be used during the transit of their elimination. They in support of this idea but time does not peralso cause very marked disturbance in the cen- mit a long scientific discussion of this subject. tral and peripheral nervous system and must If we know that these bodies carry a nitrogen be eliminated as speedily as possible to prevent radical, we can estimate the damage done as this occurance."
the N radical will be an index in amount corFrom this statement we see that proteids respondingly larger or smaller as the amount may cause pathology, if the system is saturated of proteid destroyed within the body. I used with their end-products over a long period of Kjeldahl's method of determining the amount time. Stress has been laid on faulty elimination of nitrogen, and followed the plan of Otto Folin of proteid decomposition or their catabolism for proteid destruction. products. But few essayists have devoted time One gram of proteid will produce 1-3 gram to the increased production. Diabetes is a dis- of urea. The urea nitrogen equals 87.5 per cent ease due to acid bodies which do not carry the of the entire nitrogen output. An orderly nitrogen radical but are purin ring compounds record of his diet was kept and the nitrogen derivative of fat catabolism. The gouty diathe- balance estimated. Of the cases studied their sis is due to purin ring compounds carrying the N average output was three times the nitrogen inradical. The urate crystals deposited as tophi il- take for four weeks, when they gradually relustrate their accumulation within the system as turned to their normal balance. Their loss of a chronic deposit, and seem to be due to faulty weight was very marked. The necessity of havelimination. The acute type of acidosis is illus- ing CO2 suggested the soda treatment. They trated in gangrenous tissue deprived of its nutri- had soda by mouth, proctoclysis, hypodermoclytion from any cause, and which must be absorbed sis and intra-venus infusions of normal soluthus throwing an avalanche of amin.acids, due tions of soda until the urine reacted alkaline. to the sudden destruction of the proteid tissues Under this alkaline treatment they made a rapid of the body into the circulation. (We are here and sure recovery. I offer these cases and their dealing with the catabolism of proteid cells.) history to illustrate the fact that the essayist
We ask if the body proteid can be broken has treated many of these cases as low grade indown within the system and thrown into the cir- fection. I give the chromaffin system of accuculation as cleavage products or amin acids. A mulation and retardation and glandular secrebeautiful example is found in postmortum auto- tions, their enzyme place, and grant their influlysis of the liver, which is accomplished by the in- ence in metabolism. But the pathology of totercellular ferments, causing a liquefaction ne- morrow will be based upon the cell and its biocrosis and the liberation of amin acid. When chemistry. Tomorrow will unfold the simple, the blood supply or trophic nerve supply is cut intricate, chemical reaction and the administraoff to a certain group of muscles we all know tion of Salvarsan will no longer be done emthat the system reacts very gravely. There is pirically. something about it that has not been explained. We note that cellular catabolism products are These patients are gravely ill. There may not the same whether produced by an invading bacbe a single external symptom. You do not get
You do not get teria or by death due to some other cause. I this phenomenon if you amputate a normal limb. grant that there are other bacterial by-products If you amputate before gangrene sets in, he with which we must deal. We recognize the may suffer from something that savors of ser- influence chemistry plays in these matters. We iousness. Now and then a thrombus is over- all recognize and accept the fact that therapy come and the patient will slowly get well but will always follow the analysis pathology makes. the question is: "What happens to make this I am intensely interested in the truths unman or patient so ill?”
derlying the composition and structure of all Taylor, of Pennsylvania, says that the de- matter. The one great law of simplicity given struction of body proteids is always amin acid us by no less chemists and scientists than Curies, carrying the N radical. No matter with what Rutherford, Sir Wm. Ramsey and Prof. J. J. reagents, steam, ferments, alkalies or acids, the Thompson, who all concur in the positive and end-result is amin acid. Then by the destruc- negative balance of corpuscles necessary to fortion of large masses of proteids we must have mulate the atom of any substance of matter. an enormous increase of these acid bodies in They show that acids are pregnant with negathe circulation. We know that they unite with tive, and alkalies with positive electrical ions. the CO2 of the blood for elimination as ammonia They do not limit this great law of simplicity