What happens when an unstoppable force meets an immovable object? A desert storm isn't just an operation overseas anymore. I'm used to being overlooked and passed by. There's always something to keep me busy and I do my best to stay occupied. A lightning storm only needs a moment of hesitation to strike, so I keep my head down and make sure I don't get caught off guard.
Until one otherwise uneventful day, I find myself on a ranch outside of my hometown of Witmer, owned and operated by the man I've had a crush on since high school: Scott Rowe. Scott and I didn't see eye to eye when we were younger, and I have no reason to believe that time changed him as much as it changed me.
It's just that wherever I end up, he’s already there waiting for me. Lightning doesn't strike twice and the third time is no coincidence. Even if Scott seems more interested in just being friends, I have to find out if he feels the storm brewing between us.
AUTHOR’S NOTE
This is the Witmer story of Ava and Scott, a friends-to-lovers, meetcute romance in a small-town western setting with an independent heroine, an alpha hero, a dash of humor, no cheating and a guaranteed happily ever after! There is a healthy dose of steamy scenes. There is no cliffhanger and can be read standalone but is ideally read as the third in the Witmer series as you will love the characters and want to find out what happens to them.
To get ‘Hero Of The Heart’ (Book 1 of my Witmer Warriors series) completely free instantly ($2.99 on Amazon), please take 5 seconds to subscribe to my free VIP Newsletter at JeanStokes.com, which also means you’ll get updates on my new books, more free books and Jean’s popular juicy life gossip!
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Preface
Author’s note
CLAIM YOUR FREE BOOK!
Chapter 1 - AVA
Chapter 2 - SCOTT
Chapter 3 - AVA
Chapter 4 - SCOTT
Chapter 5 - AVA
Chapter 6 - SCOTT
Chapter 7 - AVA
Chapter 8 - SCOTT
Chapter 9 - AVA
Chapter 10 - SCOTT
Chapter 11 - AVA
Chapter 12 - AVA
Chapter 13 - SCOTT
Chapter 14 - AVA
Chapter 15 - SCOTT
Chapter 16 - AVA
Chapter 17 - SCOTT
Chapter 18 - SCOTT
Chapter 19 - AVA
Chapter 20 - EPILOGUE - AVA
CLAIM YOUR FREE BOOK!
About The Author
JEAN’S OTHER BOOKS!
CONTENTS
CHAPTER 1 - AVA
Another day, another addition to the never-ending list of things to do.
Check the Virgil permit expiration date. Get groceries. Check the mail. Schedule an oil change. Email my uncle back telling him that his offers to send my mother to a nursing home are appreciated but not something I'm interested in.
One of the things I've always excelled at is making lists.
I'm task-oriented, which is a good thing when working at the town hall in administration. It also helps me keep on top of things at home, where I live with my mother. She's pretty much bedridden these days, and needs the help.
I never minded. Growing up, all we had was each other, and while taking care of her means putting a lot of my own dreams on hold, I wouldn't trade it for anything. My mother's younger brother, who moved away from Witmer the minute he could and only came back when my father died, makes offers occasionally and sends me emails with websites to nursing homes and care facilities in Florida.
But this is home, for both of us. Witmer is where we belong, and I'm not going to send her away. I couldn’t imagine life outside of Witmer. Besides, I had a nice life here.
I don't dislikemy job at the town hall. It's busy, and bureaucracy has its own kind of beauty, where every check and balance needs to be accounted for, and forms and files measured and marked. It's a lot like sewing—every stitch has its place and must be perfect to ensure the entire finished product fits effortlessly.
That's what I want to be when I have enough money. My mother's old sewing machine is as well known to my hands as staplers and keyboards at this point. I've always loved fashion, and clothes, both studying and making them.
But that kind of thing requires some pretty hefty savings. I have a list for that, too— the space I'd need, and the tools, and the fabrics to get started—tucked away in the back of my journal like a secret.
I know my mother would feel guilty, if she knew that I was waiting for her sake, so I don't tell her about it.
The day is almost done, thank God I begin to clear off my desk and put away the pending cases to deal with tomorrow. Sophia, my assistant, managed to get the signatures from Mr. Armistead for his divorce paperwork, so that's one less thing I need to take care of. Our boss is a strict no-nonsense kind of woman who doesn't tolerate any slack.
Sophia smiles at me as she leaves, and I lift my hand in a little wave, watching her shoulder her way out the front door. She's so pretty, much prettier than I am, with her tanned skin and thick, lustrious hair. My own hair is plain, a mousey brown, and my skin pale no matter how hard I try to tan.
Witmer is a sunny place and it should be full of beautiful people. In contrast, I stick out like a sore, white thumb.
I suppose it could be worse. It's not like I have any time to catch someone's eye at this point anyway, even if I wanted to. Still, it's hard not to think about it when I'm wandering around town, seeing people like Sophia, or the chiseled and fit military men that are on leave or live in the town while working at Fort Bliss. Witmer is a small town, so everyone knows everyone, and I'm the quiet, reserved girl who lives with her poor mother that nobody notices. I sigh to myself, gather my list for groceries from my desk and tuck it into my bag. Thankfully, it'll be a light haul this week, since my mother's new medications curb her appetite and she doesn't eat as much as she used to. I've been trying to cut back as well—I tend to stress eat and since I don't have much time to exercise, I have to watch what I eat to make sure I don't gain weight, undoing all of my hard work.
It's ridiculously hot outside, sunlight bouncing off the asphalt so brightly it makes me wince even behind my sunglasses. I pull out my phone as I walk to my car, praying that the tree I parked it under provided enough shade that it won't be too hot inside.
"Hi, Mom," I say when she answers. "I'm headed to the store. Any last minute requests?"
"I'm making roast for dinner," she tells me brightly. I smile, glad to hear that she feels well enough to be on her feet long enough to roast something. "Would you mind getting some fresh corn? We can have it with dinner."
"Sure," I say, biting my lower lip as I get into my car. I unlock it and open the front door, wincing at the heat that comes out. I stand, for a moment, letting it air. There's only canned corn at the grocery
store, but one thing Witmer has is a lot of land, and there are some large farms that grow fresh crops. "I'll be home in the next hour or so."
"Alright, bunny, see you soon," she says, and hangs up. Bunny— she's been calling me that since I was a kid. I used to think it was cute, but these days I'm wondering if it's because I'm so shy. I try not to be, but it's not easy making friends when no one pays attention to you.
I pocket my phone with a sigh and get into my car, turning the air conditioning on high as soon as I can. I wish— and not for the first time—that I’d splurged for the ventilated seats, but that had been an expense I couldn't stomach at the time, and the car is so old at this point it’s closer to the junkyard than an upgrade.
There are two main farms near Witmer. The first is run by the awful Burchell brothers—anyone who has been in Witmer longer than a day knows to avoid those guys at all costs. They're all giant, mean men, and honestly even the thought of driving up to their ranch makes my stomach turn.
Then, there's the ranch owned by Scott Rowe. He's retired military, used to work at Fort Bliss and lives here now along with several of his buddies.
He's . . . Well, he makes my stomach flutter for an entirely different reason.
I've had a crush on him for as long as I can remember, but he wasn't exactly nice to me in school, despite my best efforts to just stay out of his way. He wasn't aggressively mean, but I caught him making fun of me and some of the 'bigger' girls with his buddies
back in the day and that left a stinging hurt that I had yet to completely forget.
But he's a much better prospect than the Burchell brothers, and if Mama wants corn, then she'll get her corn.
I sigh to myself, bracing for the trip up to his ranch, and drive towards the horizon.
CHAPTER 2 - SCOTT
It's going to be a good harvest this year. I can feel it in my bones as I watch Paul come in with the most recent haul from one of the fields, which now has large bales of hay instead of the large stalks that had been there just that morning.
Paul rents that particular field, and I get a cut of it in exchange. It's a good trade-off, since it means a little less work on my end. As long as I supply the pesticides and let him rent out my equipment, he gets his harvest, I get my share, and everyone's happy.
I do this for several of the locals, those who mostly grow crops for their livestock instead of investing in the farming trade.
If you'd asked me if this was where I'd be ten years ago, I'd have laughed in your face. Back then, the military was my blood, sweat, and tears. But I don't regret retiring after my tour, and I definitely don't regret settling down in Witmer. It's home now. I've built this farm from the ground up, and I wouldn't trade it for anything in the world.
Paul climbs down from the combine and walks over to me, pulling the gloves off his hands. He's sweating in the heat, and gives me a big smile. "All set?" I ask.
"Yep, I'll put your cut in the barn this evening." "Thanks."
My attention is caught by a small plume of dust, coming up the long track from the main road. I frown, seeing that it's a car a small
compact, trundling determinedly over the potholes and mud. I really need to even out that road. Civilian cars don't fare well on it.
The car stops near the front of the barn, and the engine dies. From it emerges a woman, slim and pale, her round cheeks flushed from the heat and brown hair sticking to the sides of her face.
My eyes widen in recognition. If that ain't little Ava Philips!
It's been years since I've seen her this close. I could remember her from high school, quiet and reserved, more at home in the corner of home room and shyly keeping to herself.
She's . . . gorgeous.
She wasn't a runway model, but her pale skin almost glows in the sunlight, highlighting the soft brown of her hair and the brilliant glassy color of her eyes. Her blushing cheeks makes her look so sweet. Her figure is hidden by the smart blazer, suit pants and modest heels, but it gives her this put-together, business-woman kind of look that I can't stop staring at.
She closes her car door, looks around, and catches me staring. I've never been shy, so I don't look away. And, after all, this is my ranch. She bites her lower lip, and pulls her blazer around herself despite the heat, walking over to me with her head lowered.
"Mr. Rowe?" she asks, as though she doesn't recognize me at all. I'm bigger and tanner than I was in high school, but surely, I don't look all that different.
"Ava," I say, and smile at her. She blinks up at me, as though surprised I know her name. "Scott's fine. What're you here for?"
"Oh. My mom wants some corn for dinner," she says, looking down again as though she can't hold my gaze. She blinks rapidly, shifting her weight. "I know yours is the best, better than the canned store stuff."
I feel my smile widen, pride and pleasure warming my chest. "You got it, hon," I say with a wink that just makes her blush darken. She's red as cherries now. It's honestly adorable. "How much do you need?"
"I don't—" Her brow creases as she worries her lower lip again. "Just enough for two people."
"Alright," I assure her, having mercy on the poor thing. She smiles weakly, dark lashes fluttering again. I put my hand on her shoulder and subtly guide her to follow me, into the smaller stockpile where I keep the bags of corn and barley.
I hear her following behind me, like a nervous lamb being led into a new pen. Looking over my shoulder at her, she seems so nervous and shy, it instantly makes me want to make her look up at me and give her a hug. She looks like she could use a hug.
I lead her into the barn, and she sighs in relief at the cool air.
"This way," I say, and lead her towards the back.
Talia's already there—one of the newer hires my buddy Aaron had practically begged me to take on so that she wouldn't go work for the Burchell brothers. She's a tiny thing, but feisty and a good worker. I'm glad to have hired her on.
"Hey, Talia," I say, gesturing back to Ava. "Would you mind sorting out some corn for Ava here?"
"Sure," she replies with a wide smile.
I nod, and leave. I can feel Ava staring after me, and mentally curse my behavior back when we were younger. I wasn't the nicest guy during my military days, and while I had worked hard at being better, I'm sure she remembers how mean I was.
Besides, I don't have time to go chasing pretty girls these days. The crops aren't doing as great as I expected them to, and Aaron's getting more and more convinced that the Burchell brothers are doing some shady dealings under the radar. My business is everything to me, so it's better to leave Ava in Talia's capable hands than get distracted.
CHAPTER 3 - AVA
"So," Talia says, drawing my attention. She's only a little taller than me, blessed with gorgeous tanned skin and thick black hair, and cheekbones I would die for. She smiles at me. "You just need some corn?"
"Yes, just enough for two people, unless the price is good," I reply, biting my lower lip as I watch Scott leave the barn. Talia hums, drawing my attention, and I watch her open up a large burlap sack and scoop two handfuls into a smaller back.
She shows it to me. "You think this will be enough?"
"I think so," I reply. She grins and hands it over. "How much?"
"Oh, I have no idea," Talia replies, laughing. "But I'll let Scott know you owe him money and have him call you or something."
I can't help the way my cheeks heat up, thinking of Scott Rowe calling me, of having to come back to the farm and seeing again. Talia notices. Her brow arches and she gives me a lopsided, knowing smile. "Unless you'd like to go settle it in person," she adds, and gives me a playful nudge. My blush darkens and all hope of blaming it on the heat goes out the window when Talia winks.
"I don't think that will be necessary," I stutter, looking down, fingers twisting around the ties of the bag.
"But then when will you see your crush again?" Talia asks, eyes wide with false innocence. I can't help smiling. It's been a long time since
I had someone who was friendly to me, who wasn't my mother or someone I worked with. Talia's personality is strong and bubbly, drawing people to her. I didn't have a personality like that.
"I don't—"
Talia grins. "I know puppy love when I see it," she says, laughing, and tosses her hair. "You should go for it. I haven't known Scott long, but he seems like a good guy. Funny as Hell once you get him going."
"I can't just ask Scott Rowe out on a date," I reply.
"Oh, we're full-naming him," Talia says. She links her arm in mine and we walk out of the barn together. It's not as humid outside, but it's still dreadfully hot, and I fan the halves of my business jacket to try and cool down. "That means there's a story. Tell me!"
"He's . . . We went to high school together," I tell her. "But we didn't exactly run with the same crowd. He was one of the popular kids and I wasn't." A sour feeling curls in my stomach, remembering how mean and stinging his offhand comments usually were. He might not remember them, but I certainly did. "I wasn't his type, I guess."
Talia considers me, both eyebrows rising. "Ava, you're gorgeous," she says, and shakes her head when I merely shrug. "Honey, please. Okay. You go on and make dinner or whatever. What's your number? I'll give it to Scott and make sure he calls you."
It's hard to argue with someone like Talia. She has a strong personality, and isn't someone who will take 'no' for an answer. So, I sigh and recite my phone number, and she plugs it into her phone, and sends a test text my way. My phone chimes in my pocket.
"Great," she says, smiling widely and letting my arm go. "I'll see you around! Don't be a stranger."
And with another wink, she turns to leave, hips swaying from side to side in an unconsciously attractive way. She's so pretty and confident, she's exactly the kind of woman a guy like Scott would go for.
With a sigh, I get back into my car and drive home. I take the long way, victorious in my quest to get corn but my mind reeling. Seeing Scott after all these years is conjuring up feelings I thought I was over for a long time.
He's just as handsome as he was back in high school. I only saw him a few times afterwards, when he was on leave from the military and in town.
He's strong, his muscles filling out his clothes in a way that makes my stomach feel warm and my cheeks heat up. He's always had nice features—a strong jaw, brilliantly expressive eyes, and dimples when he smiles. The years haven't done anything to change that.
I sigh to myself as I pull up in front of my house. It's one of the smaller ones in Witmer, a two-story with light stone walls and a modest garden that I do my best to tend. It's difficult to find time, between my job and taking care of my mother, and the summer hasn't been kind to the more delicate plants, but it’s still a stressreliever for me and I’m glad I have it.
It's my sanctuary, when all is said and done.
I hurry into the air conditioning and sigh with relief. The smell of dinner is potent in the house, and I smile at the sight of my mother in the kitchen. The medicine she's taking has thinned her hair to the
point where she wears scarves on her head, and she's skin and bone these days. Seeing her up and about like this is refreshing and a good thing.
"Hi," I greet, setting the bag down.
"That took a while," she notes, offering her cheek for me to kiss.
"Did you run into any trouble?"
"I went out to Scott Rowe's farm, it's farther away," I explain, shrugging off my blazer and sighing with relief when the cool air slides up my arms and through my thin blouse, cooling me down.
My mother's brows rise further, and she looks at me from over the pot of boiling water as she pours in the corn. "Scott Rowe? Isn't that the boy you went to high school with?"
"I went to school with everyone in this town my age," I reply, laughing. "But yes."
She hums. "Why didn't you go to the Burchell farm?" she asks.
I sigh, and shake my head. "Scott's prices are better," I tell her, which isn't exactly a lie, because I haven't been charged yet. I don't want to talk to her about how uncomfortable the Burchell brothers make me, about the terrible rumors and that everyone knows to stay away from them. She's already got so much on her mind and there's no sense weighing her down further with trivial things like that.
She hums again. "Well, get changed and settled in. It'll be around fifteen minutes before dinner's ready."
I smile, and nod, heading to my room. I have the larger bedroom, though it's not the master bedroom. Mom has that one so that she
can get to the bathroom when she needs to, but she doesn't need as much space as I do.
I change out of my work clothes and into a loose t-shirt and jeans. Most of my clothes are too large on me these days since I lost all the weight from high school, except for what I bought for my job. I find them more comfortable and it's a nice reminder of how much progress I've made when it comes to my body.
I'll never be as effortlessly beautiful as Talia, but at least people don't make fun of how I look anymore. At least, not where I can hear.
I almost jump out of my skin when I hear my phone ring. An unfamiliar number flashing on the screen, but it's got a local area code, so I answer it. "Hello, this is Ava Philips."
CHAPTER 4 - SCOTT
I find myself watching Ava as she gets into her car and drives away. She's absolutely gorgeous, and I can't believe how I never noticed how bright and pretty her eyes are, the adorable way her cheeks dimple when she smiles, or how endearing it is when she blushes. Talia approaching me draws my attention away. She has a smile on her face that looks knowing, sly and mischievous, and my brows rise.
Talia's gorgeous too, in that bombshell kind of way. Feisty and capable, and definitely someone I'd look twice at, but I know my buddy Aaron has a thing for her, even if his head is too far up his ass to admit it yet. I can't really blame him—I have similar problems. We did things in the military, all of us did. We brought home horrors in our suitcases and keep ghosts in our skulls. No woman should have to be around that kind of bullshit.
"Hey," she greets brightly, folding her arms across her chest.
I smile at her. "How much did you charge her?" I ask.
"Well, since you didn't tell me how much to, I didn't," Talia replies with a shrug. I frown. I'm not above cutting a price for a friend, but the farm isn't doing that great this season and I can't get away with giving crops away . "But," she adds, "I got Ava's number and told her you'd call her and let her know how much everything was." She reaches into her pocket and pulls out her phone, and looks at me expectantly.
"Alright," I sigh, and let her put Ava's phone number into my phone. She hands it back with another grin, and looks down the long driveway where Ava's car is just turning onto the main road.
"She's pretty," Talia says lightly.
"Yeah," I reply, smiling a little. "She and I were in high school at the same time. Few years apart, but . . ."
Talia nods, and her lips purse. She arches a brow and looks at me again. "So, are you gonna ask her out?"
"What?" I ask, shocked. "Why would I do that?"
"Because she's pretty and cute and you guys already know each other, and she seems nice," Talia replies.
I wince, running a hand through my hair. "She doesn't want to get caught up with the likes of me," I say sullenly.
Talia's head tilts, and she frowns. "A farmer?" she asks, visibly confused.
"No, a . . ." I sigh, and shake my head again. "She can do better. I wasn't always that great a guy, to her or to anyone else." I laugh, weakly. "I was kind of an asshole."
"Was," Talia repeats. "Not now. At least, not as long as I've known you." Her head tilts, thick hair falling down her shoulder. "And even if she thinks you used to be an asshole, clearly she's gotten over it if she chose to drive all the way out here instead of getting corn at a grocery store or something."
I frown.
Talia gives me a look like I'm being stupid. I feel like I'm being stupid, but I don't quite know why. "Scott, girls don't just drive all
the way out of town for two handfuls of corn on a whim," she says gently, and puts a hand on my shoulder. "Give her a call. At least get your money's worth, and see what happens." She laughs. "Come on, soldier, don't shy away from talking to a pretty girl."
I flush, laughing weakly again. "I'll call her," I say. "Justfor payment for the corn."
Talia grins, eyes flashing with victory. "Atta boy," she says, and pats my shoulder. She turns away, heading off to work, and I shake my head and laugh. Aaron's got his work cut out for him.
I wait long enough for me to be sure that Ava was home. I open my phone and pull up Ava's number to call it. It rings twice before I hear her soft voice answer. "Hello, this is Ava Philips."
"Hi Ava, it's Scott," I reply. "Talia gave me your number so we could discuss payment for the corn."
"Oh! Of course," she says brightly. "I'm sorry I didn't wait around. I'm good for it, I just wanted to get home before my mom got too tired."
For a moment, a pulse of affection renders me silent. Of course, Mrs. Philips is sick, everyone in town knows that. Ava's care and attentiveness to her mother makes me smile.
"It's no problem," I assure her. "And it's not a big deal if you need to wait a few days to pay."
"No, really, it's fine," Ava replies. "I can come first thing tomorrow, or after work, if you're going to be around. I don't like leaving debts unpaid."
You and me both. "Alright, great," I say, and if I tell her the price that's a fraction of what I would actually charge, then that's between me and my books. "I'm here pretty much sunrise to midnight, so any time you want to come by, you can."
"Thank you, Scott," she murmurs, her voice quiet. She sounds so sweet, just as sweet as she looked. Her voice is calming and soothing even over the phone. It makes me think of how she might sound first thing in the morning, how she might smile and blush heavy with sleep, hair wispy around her kind, warm face, eyes glassy and heavy-lidded with tiredness. "I'll see you tomorrow."
"See you," I say, and hang up, a strange frantic warmth in my chest at the idea of seeing her again.
I sigh to myself, and head into my office. Balancing the books always does a good job of distracting me, and I can't let the most beautiful woman I've ever seen keep me from doing my job and running the ranch.
Besides, I meant what I said to Talia—I wasn't a nice guy when I was younger. I've gotten a lot nicer in the years in between, but there are some things I never want to burden another person with. Not just past actions, but the consequences of those actions. I used to be an—I can admit that to myself now and I don't want to let someone close in case that personality is still there. An angel like Ava deserves someone who'll be sweet and kind. Someone who'll bring her breakfast in bed and spoil her rotten. My edges are too rough for a woman like her.
No, it's better I just leave her be. I don't want to hurt her, and I couldn't bear breaking her heart.
CHAPTER 5 - AVA
I'm sick with nerves when I go back to the ranch the next day, my heart racing a mile a minute as I see the familiar barn come into view and drive up to them. The idea of seeing Scott again makes me feel like a blushing, silly schoolgirl with a first crush. So naïve and ridiculous.
He's out front when I pull up, and despite the fact that it's nowhere near as warm as it's going to get, he's already sweating. It makes his shirt cling to his muscled arms and chest, his hair flat on top of his head, cheekbones tinted red from the sun.
He looks so handsome and smiles widely when he sees me. I'm already blushing by the time I get out of the car.
"Hi, Ava," he greets warmly, as I smile.
I reach into my bag and pull out the bills to pay for the corn and hand them over. I get the feeling it's a lot cheaper than it should be, but I'm not in much of a position to refuse kindness. Mom's medicine is expensive, even with her insurance, so every penny counts.
I'm good at making lists. I budget religiously for the day when I will, eventually, have to hire twenty-four-hour care for her so that I can keep working, as well as the repairs I know are going to come on the house eventually.
He pockets the money with another smile. It looks like he wants to say something, but he physically bites his tongue and sighs. "You didn't have to get up so early to drive out here," he says.
"I don't mind," I reply. "I'm usually up this early anyway. I like to watch the sun come up."
As soon as I say it, I can feel my blush darkening.
His eyes are gentle when he looks at me. He's so tall, and smells like hay and molasses—something sweet that makes my mouth go dry. Or maybe it's just the way he smiles at me. He's always made me feel like that
But his smile widens, and he looks up to the sky. The very top of the sun just visible, a brilliant arc of orange that turns the opposite horizon pink. "I do, too," he says quietly. "Best part of my day."
I nod along with him, and then bite my lower lip. "I have to go to work," I murmur apologetically. I want to stay. I want to keep talking to him and watching the way his eyes shift and move like there's something behind them, oceans of his thoughts casting waves to draw me in.
He nods, and rubs his hand over the back of his neck. "It was good to see you," he murmurs, and smiles. "Maybe I'll see you around sometime."
"Yeah," I reply, smiling. "That would be great. I'd like that," I add. I don't want to be too eager, but Scott makes me feel eager. Makes me feel like that ridiculous bubbly schoolgirl who would do anything to get the attention of the popular kids.
He grins and squeezes my shoulder, before I walk to my car. Even the touch of his warm, wide hand on my shoulder makes my knees feel weak, my head spin like I stood up too fast. My knees are shaking, and my heart won't calm down as I get into my car and drive away.
Work is much of the same that day. There's paperwork to file andcourt appearances to organize. I allow myself to get immersed in it, trying not to think about Scott, and his smile or the weight of his hand on my shoulder.
But I can't help myself. I can't remember the last time I was this attracted to someone. Thoughts of Scott linger in the back of my skull like a persistent fly, refusing to leave me alone.
It's so inappropriate to think about at work, but I can't help myself. I push my thighs together and bite hard on my lower lip as I try not to think about how it might feel to have Scott's hands on my shoulders, cupping my neck. Running down my arms and gripping my waist. He's strong, he'd probably be able to pick me up and fling me anywhere, which is definitely not something I let myself think about when I was heavier.
I find myself lingering on thoughts of what it would be like to be kissed by him. To put my hands in his hair and scrape my nails down his strong, tan shoulders. Of how he’d able to crush me against a wall or a bed and cover me completely. Of how he would hold me as I exploded in his arms, and the feeling of his callused hands on the inside of my thighs, and—
As though summoned by my thoughts, the door opens and in walks no other than Scott Rowe himself. I feel myself blushing tomato red as he looks around and walks right up to my desk with a warm smile on his face.
"Hi, Ava," he greets.
"Hi, Scott," I reply, glad that my voice doesn't stutter. I clear my throat and straighten the papers on my desk, needing something to
do with my hands. "Are you alright? Can I help you with something?"
"Yeah, actually. I filed a permit last week here and was wondering if there’s any update," he tells me.
I nod, and turn to my computer and filing cabinet. "What was the nature of the permit?"
"Zoning, I think it's best classified as," he replies. "Or maybe subletting. I'm not entirely sure." He smiles sheepishly, and for a moment he looks like he did in high school, boyish and charming. My treacherous heart skips another beat and I suck in a breath.
"Alright, give me a minute," I tell him. He nods, and then just stands on the other side of my desk, perfectly content to wait. My fingers tremble as I open my computer and pull up his case file. As a business and land owner in Witmer, Scott has to file a lot of paperwork with the town hall, and one might think it had any kind of organization worth a damn, but between my frazzled state and the outdated sorting system, it takes me a while to find what he's looking for.
He’s also staring at me the whole time. I can feel his eyes on my face and it just makes my blush worse and my heart pound faster. I know I'm off my game from thinking about him so much, and it feels like he can see right into my mind and knows, which of course just makes the shaking worse.
Finally, I manage to find what he was looking for. "Your lease agreement with Mr. Jackson for rental of one of your fields?" I ask, and look at him just long enough to see him nod. I press my lips
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the term “lymph gland” has been carefully excluded and the more accurate and far preferable term “lymph node” has been substituted. This seems to be a suitable place to explain the substitution and the reason therefor.
PA R T I . SURGICAL PATHOLOGY.
C H A P T E R I .
HYPEREMIA: ITS CONSEQUENCES AND TREATMENT.
The reactionary results of injury to various tissues and the first local appearances due to the surgical infectious diseases are indicated by certain appearances, which, for a few hours at least, are in large measure common to both. Their beginnings being pathologically similar, their results depend not alone on the violence or intensity of the process, but also, and in predominating measure, upon the primary influences at work. The consequences of mere mechanical injury—such as strain, laceration, etc.—are in healthy individuals promptly repaired by processes which will be taken into consideration in the ensuing chapters. They are throughout conservative and reparative, and are directed toward restoring, as far as possible, the original condition. The consequences, on the other hand, of the surgical infections are more or less disastrous from the outset, although the extent of the disaster may be localized within a very small area, as after a trifling furuncle, or they may be so widespread as to disable a limb or an organ, or they may even be
fatal. It is of the greatest importance, not alone for scientific reasons, but also because treatment must in large measure depend upon the underlying conditions, to differentiate between these two general classes of disturbance, which we speak of as—
A. Those produced by external or extrinsic disturbances, i. e., traumatisms, sprains, lacerations, etc.; and
B. Those produced by internal and intrinsic causes, which, for the main part, are the now well-known microörganisms, such as cause the various surgical diseases.
These latter disturbances may be imitated or simulated in the presence of certain irritants within the tissues, such as the poisons of various insects and plants; the irritation produced by foreign bodies, minute or large; and possibly the presence within the system of certain poisons whose nature is not yet known, such as that of syphilis, or certain others whose chemistry is fairly well understood, but whose presence cannot be easily explained, as uric acid, etc.
Clinically, all these disturbances are manifested by certain phenomena common to each, which may present themselves at one time more prominently, at another less so. These significant appearances have been recognized from time immemorial as the calor, rubor, dolor, tumor, et functio lesa of our ancestors, or as the heat, redness, pain, swelling, and loss of function of our common experience. When one or more of these are present, the surgeon cannot afford to disregard the fact, while he should, moreover, be able to account for each on general principles which should to him be well known.
To their more exact study we must, however, make some preface in the way of general remarks concerning a phenomenon everywhere easily recognized, but as yet incompletely understood. This phenomenon has reference to an undue supply of blood to a part, and is commonly known under two terms which are practically synonymous, namely, congestion and hyperemia. To begin with these, then, we must note, first of all, that congestion and hyperemia may be—
A. Active; and B. Passive.
They may also be spoken of as—
1.
2.
Acute
; and
Chronic.
Considering first the two latter distinctions, it will be found that the acute hyperemias are met with most often in consequence of sharp mechanical disturbances. The chronic hyperemias, on the contrary, are conditions which in many individuals are more or less permanent. Note accurately here the proper significance of certain terms. Hyperemia means, in effect, an oversupply of blood to the given part; the term should have only a local significance. When the entire body seems to be too well supplied with blood, the condition is known as plethora, the counterpart of which term is usually anemia. The direct counterpart of the term hyperemia should perhaps be ischemia, meaning a perverted blood supply in reduced amount. With plethora and anemia as terms implying general conditions, with hyperemia and ischemia implying local conditions, there should be little room for confusion in phraseology.
The active form of hyperemia used to be called “fluxion,” a term now rarely used. Active hyperemia means an increased supply of arterial blood. In passive hyperemia the oversupply is rather of venous blood. In the former case the condition seems due to overactivity of the heart, with such local tissue changes as permit it to occur. In passive hyperemia the blood current is slower—there is a tendency toward, and sometimes an actual, stagnation; all of which is usually due to obstruction of the return of blood to the heart. The conditions permitting these two results may be widely variant.
Active Hyperemia.
—Active hyperemia may be produced by purely nervous influences, even those of emotional origin. The flushing of the face which is known as “blushing” is, perhaps, the most common illustration of this fact. It is well known also that this is, in some degree at least, the result of division of certain nerves which have to do with the regulation of the blood supply. The cervical sympathetic is the best known and most often studied of these, and the consequences of division of this nerve in the neck are stated in all the text-books on physiology. So also by electrical stimulation of certain nerves the parts supplied by them can be made to show a very active hyperemia, which will subside shortly after discontinuance of stimulation, providing this has
not been kept up too long. In active hyperemia there is absolute increase of intra-arterial tension, and under these circumstances pulsation may be noted in those small vessels in which commonly it is not seen nor felt. This is the explanation of the throbbing pain complained of under many actively hyperemic conditions. This hyperemia affords the explanation of the clinical signs to which attention has already been called. The increased heat of the part is the result of greater access of blood, which prevents cooling by radiation and evaporation; the peculiar redness is due to the greater filling of the capillaries with the blood, which gives the peculiar hue to the skin and visible textures; while to the increased pressure upon sensory nerves is also due the pain. The minuter changes occurring within the congested part call for more accurate description. Whether or not there is actual dilatation of capillaries under these circumstances is a matter still under dispute, but of the dilatation of the larger vessels there can be no possible question.
As hyperemia is to such a great extent brought about by action of the nervous system, it is well to divide it more accurately into the hyperemia of paralysis, or neuroparalytic congestion, which is the result of a paralysis of the constrictor fibers of the vasomotor system, and into the hyperemia of irritation, or neurotonic congestion, which is due to the irritation of the dilators (Recklinghausen). Physiologists are fairly well agreed that as between the dilating and the constricting apparatus of the vasomotor system there is ordinarily preserved a certain degree of equilibrium; to which fact is probably due that normal condition of affairs inaugurated after temporary disturbance, since overaction in one direction succeeds reaction in the other. As Warren has illustrated this, our common treatment of frostbite by cold applications is a concession to this fact, since by the cold applications we endeavor to limit the reaction which would otherwise follow after thawing out the frozen part.
The best examples of the hyperemia of paralysis are perhaps to be met with after certain injuries to nerves, as, for instance, flushing of the face and hypersecretion of nasal mucus, tears, etc., after injury to the cervical sympathetic. Such, too, in its essentials is that form of shock known as brain concussion, which is often followed by
nutritive disturbances among the brain cells, with consequent perversion of brain function.
Waller’s experiment of placing a freezing mixture over the ulnar nerve at the back of the elbow is also significant, the result being congestion and elevation of surface temperature of the fingers supplied by this nerve. Congestion and swelling have also been observed after fracture of the internal condyle of the humerus, by which this nerve was pressed upon; and similar phenomena may be noted in fingers or toes as the result of injuries of other nerves.
Hyperemia due to paralysis of the perivascular ganglia is observed sometimes in transplanted flaps, in the suffusion of a limb after removal of the Esmarch bandage, in the congestion of certain sac walls after tapping, in the hyperemia of, perhaps even hemorrhage from, the bladder wall after too quickly relieving its overdistention, and in the swelling of the extremities when they begin to be first used after having been put at rest because of injury.
The hyperemias of dilatation are more acute in course and manifestation. Along with them go sharp pain, hypersecretion of glands, edema, and sometimes desquamation of superficial parts. The facial blush due to effusion; the temporary flushing due to indulgence in alcohol; the suffusion of the conjunctiva, perhaps the face, with hyperlacrymation, accompanying facial neuralgia or hemicrania; and the hyperemia consequent upon herpes zoster, urticaria, etc., are illustrative examples of this form. The erythema due to nerve irritation or injury, the swelling of the joints which appears after similar lesions, and that condition described by Mitchell as erythromelalgia, probably also belong here. In fact, almost all the reflex hyperemias are hyperemias of dilatation.
The forms of hyperemia considered above belong mainly to the designation of active.
Passive Hyperemia.
—Passive hyperemia is most often a mechanical consequence of obstruction of the return of blood, which can be imitated at will, and which is not infrequently the result of carelessness, as when an injured limb is bandaged too tightly. Experiment shows that when such mechanical obstruction has taken place there is temporary increase of intravenous pressure, which soon returns to the normal standard,
such readjustment meaning that blood has found its way back by collateral circulation. Only when such rearrangement is possible do we have anything like permanent passive hyperemia. In organs with a single vein, such as the kidneys, the question of obstruction may assume a very important aspect. Under these circumstances the appearance of the involved part, when visible, is spoken of as cyanotic, while its surface, instead of being abnormally warm, is the reverse, due to impeded access of warm blood and more rapid surface cooling. The blood under such conditions is often darker than natural, because, remaining longer in the part, it absorbs more carbonic dioxide, or at least gives up more of its oxygen. As long as actual gangrene is not threatened, the blood column has a communicated pulsation, at least in the large veins. Escape of corpuscular elements may occur after the phenomena above noted have been present for some time; but the corpuscles rarely, if ever, escape until there has been more or less copious transudation of the fluid portion of the blood—i. e., the serum. When anatomical changes can be grossly, yet carefully, observed, as in the fundus of the eye, it is seen that under these circumstances the arteries become smaller, although whether this is a primary or secondary change is not to be determined. Discoloration of the integument is the frequent result of leakage of blood corpuscles and their pigmentary substance into the tissues, and is consequently a frequent accompaniment of chronic passive edema. It is seen often in connection with varicose veins of the legs.
Another form of passive congestion or hyperemia is that due to enfeeblement of the heart’s action by serious injury or wasting disease. When under these circumstances the lung has become more or less infiltrated with fluid, with hemorrhagic extravasation, the condition is known as hypostatic pneumonia—a misnomer, nevertheless indicating a condition which is only too frequent in the aged and feeble.
RESULTS OF HYPEREMIA AND CONGESTION.
These may be—
1. Speedy subsidence of all hyperemic phenomena— resolution.
2. Acute swelling.
3. Chronic swelling.
4. Gangrene.
5. Nutritional changes—atrophy and hypertrophy.
1. Resolution.
—The speedy subsidence of hyperemic phenomena is known as resolution—a term which has also been applied to the retrograde phenomena after a genuine inflammation. For present purposes it implies, first, the subsidence into inactivity of the exciting cause or its complete removal. This may include the passing of an emotion, the removal of an irritant, the loosening of a bandage, the resort to certain applications or to constringing or astringing measures by which the effect is counteracted. A particle of dust in the conjunctiva may within a few moments produce an active congestion of the conjunctival vessels, which, ordinarily scarcely visible, becomes prominent and easily noted. The removal of the offending substance permits a return to their original size in perhaps a half-hour. This is an example of the speedy subsidence of the hyperemia of dilatation after removal of the cause. Should the hyperemia not subside promptly, it is well to use cold applications, or in this instance an astringent collyrium, or some agent whose physiological effect it is to produce vascular contraction, as cocaine, adrenal extract, etc.
2. Acute Swelling.
—When the effusion above referred to takes place into loose connective tissues the condition is spoken of technically as edema, while when it occurs into a previously existing cavity, such as that of a joint, it is known as an effusion. The amount of blood thus effused will be influenced by the anatomical and mechanical conditions existing about the part. It may be presumed, as a general rule, that when the extra vascular pressure equals the intravascular pressure little or no more fluid may escape. As a matter of fact, it is seldom that the former rises to the degree of the latter. Conversely, one method of treating such edemas and effusions is by some device which shall make the extravascular pressure exceed the intravascular, when the fluid is, as it were, forced back into the vessels, and is made to resume its
proper place within the same. This is often done by taking advantage of elastic compression, as when a rubber bandage is applied about the part. In certain parts of the body it may be done by pressure brought about by some other device. Pressure may be used for two purposes:
A. To so increase extravascular pressure as to limit the possible amount of an effusion, as when it is put on early after an injury; or,
B. When it is used as a later resort for the purpose of reducing swelling which has already occurred.
3.
Chronic Swelling.
—This is something more than the swelling alluded to under Acute Swelling. Chronic swelling implies either a continuous passive hyperemia, or, what is more common, a positive increase in tissue elements as the result of an oversupply of nutrition brought by the blood, which itself was furnished to the part in a degree far in excess of its needs. The result is a more rapid reproduction of cell elements, with result in the shape of tissue thickenings or tissue enlargements, known as hypertrophy, or, more properly speaking, hyperplasia, of a part, and to the laity as “overgrowth.” This chronic swelling or chronic enlargement is in some degree also connected with the phenomena of escape of white corpuscles from the bloodvessels and mitotic division of certain tissue cells, which have up to this time been usually regarded as a feature of the true inflammatory process.
4. Gangrene.
—This may be the result of hyperemia—for the most part the passive forms—though most instances of gangrene due to intrinsic causes are inseparable from the presence of infectious microörganisms. The gangrene which is spoken of here includes that due to the pressure of tumors, tight dressings, or any natural or intrinsic agency, and that due to pressure from without when not so pronounced as to produce immediate and total loss of circulation in a part. It includes the formation of many bed-sores and so-called pressure-sores, which may be due to an enfeebled heart, to an obstructed pulmonary circulation, or to external pressure in conjunction with cardiac debility. While insisting, then, that gangrene should be recognized as a possible result of hyperemia, it may be added that it is in effect a tissue death, and that dead tissue is always and everywhere practically the same thing, no matter by what
causes brought about. Consequently, the subject of gangrene will be considered under a separate heading. will be considered later.
5. Nutritional Changes
The consequence of persistent hyperemia is transudation—i. e., escape of blood plasm from the vessels into body cavities and tissue interspaces. This leads to consideration under a distinct heading of—
TRANSUDATES AND EXUDATES.
Exudation may occur in vascular and non-vascular, in firm and soft tissues, in, under, and upon membranes. With respect to location, exudates are described as free, when found upon free surfaces or within natural cavities; interstitial, when found between the tissues or parts of tissues; and parenchymatous, when they are situated within the tissues themselves, particularly in epithelial and glandular cells of any kind.
Exudates are serous, mucous, fibrinous, or mixed, the mixed forms including the so-called seropurulent, the mucopurulent, the croupous, and the diphtheritic.
When any exudate contains red globules in sufficient quantity to stain it, it is called hemorrhagic.
Serous transudates from free surfaces are sometimes spoken of as serous catarrhs; when into cavities, as dropsies; when into tissues, as edema; when occurring beneath the epidermis they form serous vesicles or blebs or bullæ.
Fibrinous exudation refers to the fluid which coagulates soon after its exit from the vessels within those spaces into which it has oozed. When flocculi of coagula float in serous fluid it is known as a serofibrinous exudate. Pure fibrinous exudate occurs rarely, save in and upon mucous membranes. The extent to which exposure to the air is responsible for the firm coagulation of the fibrin previously held in solution is uncertain. The most potent factors in producing such coagulation are bacteria, but it is not yet disproved that coagulation may occur without their aid. When such coagulation occurs upon the surface of a mucous membrane it has been spoken of as croupous. When the epithelial covering as well as the basement membrane,
and often the submucous tissues, are involved, so that the membrane cannot be stripped off without tearing across minute bloodvessels, the exudate has been known as diphtheritic. These terms may possibly be still retained in an adjective sense as implying the exact location of a surface exudate, but are scarcely to be used in any other significance.
The following table illustrates significant differences whose full importance cannot be impressed before a study of inflammation has been carefully entered upon:
Hyperemic Transudates. Inflammatory Exudates.
Poor in albumin. Rich in albumin.
Rarely coagulate in the tissues. Usually coagulate in the tissues. Contain few cells. Contain numerous cells.
Low specific gravity.
High specific gravity. Contain no peptone.
Contain peptone (product of cell disintegration).
TREATMENT OF CONGESTION AND HYPEREMIA.
These disturbances are to be combated, first of all, by insisting upon physiological rest. This, perhaps, is the most important measure of all. The profession is indebted to Hilton for the decided advance which he made in the treatment of congestive and inflammatory affections by insisting upon this principle in his celebrated work on Rest and Pain, which every young practitioner should read. Aside from this first and underlying principle, the treatment must, in some measure at least, be based upon the time at which we are called upon to treat the case. If seen at once, before exudation has been excessive or the other disturbances marked, we may carry out a certain line of treatment for the purpose of limiting all these unpleasant features. On the other hand, if seen late, when exudation has been copious and when pain and other disturbances are due to its presence, a distinctly different course will be adopted.
Toward the end first mentioned—namely, the limitation of hyperemia—we may adopt local and general measures. Local measures include graduated pressure, providing this is not
intolerable to the patient, so equalized that outside of the vessels it shall equal that inside. This may be done by careful bandaging, extreme care being taken that the pressure be applied from the very extremity of the limb; otherwise, passive exudation might be augmented and gangrene be precipitated. Elevation of a limb will often accomplish the same purpose. Cold, which is in effect an astringent and which tends to contract bloodvessels, is another measure in the same direction, and if applied early will do much to limit the degree of the attack. This may be applied as dry or moist cold, and should be gradually mitigated as the congestion subsides. It acts through the vasomotor system, and is a measure to be resorted to with caution. An efficient way of applying dry cold can be extemporized by a few yards of rubber tubing, held in place by wire or sewed in place to a piece of cloth, through which a stream of cold water is permitted to pass.
Heat is another efficient means, acting, however, in a rather different way. Heat is a measure to be employed to hasten the disappearance of exudation—in other words to quicken resorption, which it does by equalizing blood pressure, dilating the capillaries, stimulating the lymphatic current, and in every way helping to clear the tissues of that which has left the bloodvessels.
It is necessary also, at least in extreme cases, to employ some detergent or derivative measures, including bloodletting, to which we do not resort sufficiently often. When used for this purpose, depletion should be applied at the area involved, if possible. This may be done either as venesection, by leeching, either with the natural or the artificial leech, or by a series of minute punctures or incisions, which give relief to tension, permit the rapid escape of fluid exudate, and often save tissues from the disastrous effects of strangulation. In some cases of deep-seated congestions these measures are inapplicable, and venesection at the point of election—say the cephalic vein in the arm—may be followed by great benefit. Another method of depletion is by administration of cathartics, such intestinal activity being stimulated as shall lead to copious watery evacuations. The salines rank high as measures directed to this end, but in emergency much stronger and more drastic drugs may be administered, such as jalap, calomel, elaterium, etc. Diaphoretics
and diuretics help to reduce temperature and in some degree to deplete, but their action is usually slow. When exudation is considerable in amount and confined to some one of the body cavities, it is often best combated, if at all obstinate, by the method of aspiration. This includes any suitable suction apparatus by which the fluid may be withdrawn through a small needle or cannula, the operation being trifling in difficulty, but one to be performed under strictest aseptic precautions, lest infection of an exudate already at hand be permitted.
Certain individuals, especially the neurotic, will need more or less anodyne, particularly when local applications fail to give relief. Sometimes a small dose of morphine administered hypodermically will act magically in making efficient those measures which would otherwise be inefficient. In little children some anodyne or hypnotic will be of great service. Under all circumstances it is well to keep the lower bowel empty, and certain elderly individuals with weak and enfeebled hearts will need the stimulation to be afforded by digitalis, quinine, and alcohol, or preferably strychnine administered subcutaneously.
In cases of chronic hyperemia and its consequent hyperplasias (induration, thickening, etc.) there is no one measure so generally applicable and effective as the continued use of cold-water dressings. These are generally spoken of as “cold wet packs,” and may be continued—constantly or intermittently—for many days.
Massage is also an invaluable agent in the reduction of swelling and tissue overproduction. It promotes absorption, even of acute effusions, by equalizing the blood and hastening the lymph circulation, and under its scientific application it is surprising how firm exudates and old adhesions seem to disappear.
ATROPHY AND HYPERTROPHY, AND THE CONSEQUENCES OF ALTERED, DIMINISHED, AND PERVERTED NUTRITION.
As a consequence of increase of nutrition we have a condition known commonly as hypertrophy, more accurately as hyperplasia. Hypertrophy literally means overgrowth, whereas hyperplasia more accurately describes that which constitutes hypertrophy—namely,
numerical increase of constituent cells. Common usage has made the more inaccurate name “hypertrophy” cover nearly all these conditions. Hypertrophy, or hyperplasia, means enlargement of a part or of an organ beyond its usual limits, and as the result of increased function or increased nutrition. It is to be distinguished from gigantism, which means inordinate enlargement as the result of a congenital tendency or condition. Hypertrophy is—
A. Physiological1. Compensatory;
From deficient use.
B. Pathological -
Local;
General;
Senile;
Congenital.
Congenital hypertrophy: gigantism of both lower extremities (Case of Dr Graefe [Sandusky] )
A. Physiological Hypertrophy.
—1. This includes many of the compensatory enlargements of an organ or a part when extra work is put upon it, owing to deficiency of some other organ or part. This is spoken of as compensatory enlargement. Illustrative examples may be seen in the heart, which becomes larger and stronger when the bloodvessel walls are
diseased and their lumen narrowed, or when other obstructions to circulation are brought about; again, in enlargement of one kidney after extirpation of the other, or of the wall of the stomach when the pylorus is constricted or obstructed; again, of the fibula after weakening or more or less destruction of the tibia, or of the shaft of any bone when it has been weakened at some point by not too acute disease; or, again, of the walls of bursæ after constant friction.
2. The best examples of physiological hypertrophy owing to deficient use are perhaps seen in some of the lower animals; as, for instance, in the teeth of such rodents as beavers when kept in captivity and prevented from natural use.
B. Pathological Hypertrophy.
—3, 4. Instances of this are everywhere and every day are met in the results of so-called chronic inflammation, a term which is a complete misnomer and should be expunged from text-book use. So-called chronic inflammation simply means increase of nutrition owing to a certain degree of hyperemia, which may have been produced in the first place as the result of traumatism, which may have come from chemical irritants circulating in the fluids of the part —as, for example, uric acid, etc.—or which is brought about as the result of perverted trophic-nerve influence. Instances of local pathological hypertrophy may be seen in the thickened periosteum after injury, in the enlargement of a phalanx known as the “baseball finger,” and in numerous other places; or they may be general, in which case they are brought about mainly by some irritating material in the general circulation. The unknown poison of syphilis generally provokes such nutritive disturbances.
5. Senile hypertrophy is connected with nutritional disturbances characteristic of old age, as to whose remote causes we are still uncertain. Instances of senile hypertrophy, however, are common, particularly in the prostates of elderly men, which are liable to undergo extensive enlargement.
6. Of congenital hypertrophy and that of unknown origin we see, for instance, examples in certain rare cases of hypertrophy of the breast, in leontiasis, perhaps even in acromegaly, etc.; and these are to be distinguished from gigantism, because in most instances of the former type the hypertrophic tendency is not manifested until youth
or adult life, whereas gigantism is a condition in which the tendency was apparent even before the birth of the individual.
ATROPHY.
Atrophy implies impaired nutrition, and means diminution in the size of an organ or part, and is the converse of hypertrophy. It is necessary to make plain that in atrophy nutrition is only impaired and not arrested, since complete arrest of nutrition means necrosis—i. e., gangrene or disappearance of parts. It may be—
1. From disuse without disease;
A. Physiological -
2. Biological or developmental;
3. Senile.
4. Result of acute tissue losses;
B. Pathological -
5. Result of phagocytic activity;
6. Result of continuous pressure;
7. Specific.
A. Physiological Atrophy.
—1. This is always the result of disuse or impaired function from any cause. Its evidences are generally seen in the fatty structures and muscles— i. e., in the soft parts. It is true, however, even of the bones, or, of greater interest, even in the brain cells. We see evidences of it also in minute organs; as, for example, in the digestive glands in certain cases where diet is restricted. Again, we see it in the diminution of the size of the heart after hip amputation, less being required of that organ, and also in the entire structure of the rectum after colostomy.
2. Examples of the developmental type are best seen in the natural disappearance of the hypogastric arteries, the ductus arteriosus, the vitelline duct, the Wolffian bodies, and in the various generative ducts (Gärtner’s, etc.) shortly after the birth of the human individual. We sometimes see it also in the prostate after orchidectomy. Equally illustrative is the disappearance of the tail and gills of the tadpole, the eyes of animals living in caverns, and, in a
general way, of organs which become useless owing to a different environment.
3. Senile atrophy is seen equally well in the hair follicles, the teeth, the bones, and the sexual organs of elderly people—in fact, in all their tissues, even in the brain.
B. Pathological Atrophy.
—4. Acute atrophy of surrounding tissues is the necessary accompaniment of destruction by suppurative or other disturbances; that is, parts disappear by absorption which have not been interfered with by pyogenic organisms. So complete may atrophy occur under these circumstances as to cause disablement of an organ or part. This kind of senile disappearance is merely an expression of phagocytic activity, although not now a question of bacteria.
5. The same is true of that variety spoken of above as biological or developmental, since phagocytes are the active agents in producing the disappearance of the tadpole’s tail.
6. A more slow form of pathological atrophy is seen in the gradual disappearance of tissues in the neighborhood of advancing tumors, enlarging cysts, etc. This is perhaps but another expression of atrophy from continuous pressure. But a still better illustration is the atrophy which comes from immobilization of a part without pressure. This is usually the case when splints or orthopedic apparatus have to be kept in place for some time.
7. Specific forms of pathological atrophy are largely connected with disturbances in the central nervous system. They are often referred to as trophoneurotic. Their exact mechanism is not yet understood, and cases may be confused under this head whose remote causes are widely different. Here should be included, for instance, the atrophy of a deep bone which occurs after extensive burn of the surface; also that peculiar form of atrophy of tissues in the stump which produces the so-called conical stump. These cases are of a more complicated character, for if pressure is removed from the bone end, especially in young people, the bone tends to grow faster than it should, while the soft parts disappear, partly as the result of mere disuse or loss of function. In this way conicity is produced, which sometimes calls for subsequent re-amputation. Under this head might also be included the so-called “trophic
inflammation” (misnomer) of some writers, such, for example, as ulceration of the cornea after division of the trigeminus. The general subject of atrophic elongation also belongs here, referring to the fact that as a result of disuse, or sometimes of active disease, the bones, while showing atrophic changes in other respects, actually increase in length. Should such increase occur in one bone of those portions of the limbs which are supplied with two, the result would be posture deformity and displacement of the terminal portion.
CHAPTER II.
SURGICAL
PATHOLOGY OF THE BLOOD
The part played by the constituent elements of the blood in inflammation, suppuration, and other still more disastrous conditions is so great and so important that, before proceeding to discussion of these lesions, it seems necessary to set forth a resume of facts illustrating the importance of accurate knowledge concerning this most important fluid.
The total amount of blood in the human body has been variously estimated at from oneeleventh to one-twenty-fifth of the body weight, the average being about one-sixteenth. The amount which the body may lose and still retain vitality is very vague and differs not only with individuals, but very greatly under various conditions. Severe loss of blood is one to be atoned for as quickly as possible, and is to be prevented as far as it can be after accidents or during operation. For this reason the so-called bloodless method of operating upon limbs, by the use of the rubber bandage, constituted a great advance in surgery For the same reason the use of hemostatic forceps is of equal value in operating upon other parts of the body; other things being equal the quickest and most satisfactory recoveries follow the bloodless operations, and it is an advantage to conserve this vital fluid as far as possible.
It has been roughly estimated that the blood is divided about as follows, between the different parts of the body: the heart, lungs, and large vessels holding one-fourth, the skeletal muscles one-fourth, the liver one-fourth, the remaining quarter being distributed over the balance of the body
The blood varies within wide limits in its coagulability, and this variation occurs apparently even within conditions of health. In some patients the blood may be seen to coagulate almost as rapidly as it collects upon the surface, while in others the exposed parts continue to ooze, and the checking of hemorrhage is a difficult, sometimes almost impossible, matter. There are certain diseases in which the blood is known to have reduced power in this direction; for example, in the toxemias, especially those connected with biliary obstruction and jaundice. There were not a few of these cases of slow bleeding to death in days gone by, simply because the capillary hemorrhage could not be controlled. Recently, it has been shown that calcium chloride administered internally has a marked effect in favoring coagulation, and when opportunity is afforded it should be given for several days previous to operating and as part of the necessary preparation. It may be administered in doses of from 1 to 2 Gm., and should be given three or four times, at least, in twenty-four hours.
A test of the coagulation time, normally three to five minutes, but lengthened under circumstances like those mentioned above, even to an hour, will often prove of great value.
There are certain albumoses whose effect on coagulation of the blood is very suggestive and very mysterious. A very minute dose of cobra poison, for instance, will make the blood of an experimental animal remain fluid for days, unless this animal has been previously immunized against it, in which case coagulation takes place even more rapidly than normally A trace of serum from an immunized rabbit is enough to prevent the fluidifying effect of the cobra poison, but quite insufficient to neutralize its toxic effects. The surgeon practically never desires to reduce coagulability of the blood, but frequently to increase it. When it is increased by natural conditions or those not easily controlled, then it may lead to thrombosis and produce trouble in that way
Fibrin.
—Increase of fibrin, hyperinosis, accompanies the leukocytosis of inflammation and suppuration. It may be approximately estimated on the cover-glass by noting the closeness of the network resulting after fifteen minutes’ exposure. The inflammatory indication of leukocytosis may, therefore, be inferred from its determination, while the leukocytosis of
