150 CASE OF COMPOUND DISLOCATION OF THE ANKLE 



first place, there must necessarily be a considerable discharge of blood and 

 serum during the first twenty-four hours, and hence this is the period in which 

 there is greatest risk of putrefaction spreading into the wound, so that it does 

 not seem wise to interpose anything that can interfere in the slightest degree 

 with the antiseptic action of the dressing. And, in the second place, there is 

 no chance of a suppurating sore being established by the direct action of the 

 antiseptic upon the wound for a single day only. This leads me to speak- of 

 a condition of suppuration to which I have not before had occasion to advert — 

 viz. the element of time. When the tissues are in a healthy state, no stimulus 

 can induce them to suppurate. It appears that it is only when the tissues have 

 been gradually degraded, under the influence of protracted abnormal stimula- 

 tion, into the most imperfect of all tissues, which, when we see it at the surface 

 of a sore, we term granulations, that they are in a condition, if further stimulated, 

 to give birth to the still lower progeny of pus-corpuscles. In other words, 

 granulation must precede suppuration, and it is a process which requires days 

 for its completion.^ Thus it is a familiar fact to all surgeons that a recent wound 

 in healthy tissues does not suppurate for three or four days when subjected to 

 ordinary treatment — that is to say, the stimulus of putrefying material must act 

 for three or four days upon the tissues before it can induce them to suppurate ; 

 and when the first-formed pus is wiped from the wound, granulations ma}'' be 

 seen upon the surface. 



The same holds with regard to the inflammatory stimulus. Inflammation 

 does not produce suppuration in a day. Whether acute or chronic, it must 

 first degrade the tissues to granulations before it can occasion the formation of 

 pus. This is well illustrated by a common boil, which is a limited inflammation 

 of the cutis vera, so severe at the centre as to destroy the vitality of a portion 

 of the tissue, and gradually shading off to the state of health in the vicinity. 

 Here, though all possible degrees of intensity of inflammation are present, 

 between the centre and the circumference, no pus is produced till some days 

 have elapsed. Then the ' core separates ', as it is said, and the slough is found 

 detached from the neighbouring living tissues, and surrounded by a few drops 

 of odourless pus. But when the slough and the pus are removed, the cavit}' 

 in which they lay is seen to be lined with granulations. The inflammatory 

 stimulus, like the putrefactive, had induced granulation as a preliminary to 

 suppuration. 



^ An exception to this statement must be made for the case of the epitheUum of some mucous mem- 

 branes, the cells of which, originally of simple structure, soon form pus-corpuscles under shght abnormal 

 stimulation. While thus adopting the language of the ' Cellular Pathology ', elaborated by Virchow 

 and others following the path first opened up by Goodsir, I may remark that my own experience has 

 tended to convince me of the truth of that doctrine. 



